A6- Urological Trauma Flashcards
Renal trauma is most common in….
young males
What are the common mechanisms of injury in renal trauma
- Blunt injuries: MVAs, falls, sporting injuries, and assault
- Penetrating injuries: stab and gunshot wounds
effects of blunt injuries
- The kidney and/or hilar structures are directly crushed as a result
- Less commonly, sudden deceleration may result in an avulsion injury affecting the vascular structures of the hilum or the pelvoureteric junction (PUJ)
effects of Penetrating injuries: stab and gunshot wounds
- Tend to be more severe and less predictable than blunt trauma.
- Prevalence is higher in urban settings
- High-velocity bullets - greatest parenchymal destruction/ multiple-organ injuries
Special considerations for renal trauma
- Known hydronephrosis or renal abnormality
- Single kidney
: Indications for Renal Imaging
- visible haematuria
- non-visible haematuria and one episode of hypotension
- a history of rapid deceleration injury and/or significant associated injuries
- penetrating trauma
- clinical signs suggesting renal trauma e.g. flank pain, abrasions, fractured ribs, abdominal distension and/or a mass and tenderness.
CT in renal trauma - 3 phase
- arterial phase: assesses vascular injury and presence of active extravasation of contrast
- nephrogenic phase: optimally demonstrates parenchymal contusions and lacerations
- delayed phase (5 minutes): identifies collecting system/ureteric injury
What is the Renal injury grading scale
Principles of management renal trauma
The initial management – ATLS principles
- Polytrauma should be managed in major trauma centres
- Damage control – limiting: hypothermia, coagulopathy and acidosis
Management of Blunt Trauma
- Haemodynamically stable patient conservative management is preferred treatment option
- Bed rest, serial Hb and renal function, regular observations and repeat imaging
- Primary conservative management is associated with lower rate of nephrectomy and no increase in immediate or long term morbidity
Blunt trauma grades management
- Grade 1 - 3 non-operatively
- Grade 4 - conservative, but intervention is higher urinary extravasation stent and/or percutaneous drainage
- Grade 5 - haemodynamic instability and major associated injuries There is thus a higher rate of exploration and nephrectomy
What are some Reasons for surgical management
- Persistent haemodynamic instability or grade 5 vascular injury
- May require nephrectomy or debridement and partial nephrectomy
- Selective embolisation may have a role
Complications of renal trauma
- Early (< 1 month) : bleeding, infection, perinephric abscess, sepsis, urinary fistula, hypertension, urinary extravasation and urinoma.
- Delayed : include bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension, arteriovenous fistulae (AVF), hydronephrosis and pseudo-aneurysms.
Classifciation of bladder trauma?
- Intraperitoneal / Extraperitoneal / Combined
- Non iatrogenic / Iatrogenic
Non iatrogenic mechanisms of injury
Extraperitoneal:
- associated with pelvic fractures
- shearing of the anterolateral bladder wall near the bladder base (at its fascial attachments), or by a contrecoup at the opposite side
- Rarely directly perforated by a sharp bony fragm
Non iatrogenic mechanisms of injury
• Intraperitoneal:
- sudden rise in intravesical pressure of a full bladder – dome ruptures
- penetrating injuries rare except in conflict zones
Iatrogenic Injury
examples
- Intra-operative: visible laceration, visible bladder catheter, and blood and/or gas in the urine bag during laparoscopy
- During TURBT / TURP: cystoscopic identification of fatty tissue, dark space, or bowel, inability to distend the bladder, low return of irrigation fluid, or abdominal distension
- Post-operatively: missed bladder trauma is diagnosed by haematuria, abdominal pain, abdominal distension, ileus, peritonitis, sepsis, urine leakage from the wound, decreased urinary output, or increased serum creatinine
Indications for imaging - Trauma
• visible haematuria and a pelvic fracture or non-visible haematuria combined with high-risk pelvic fracture
- inability to void or inadequate urine output
- abdominal tenderness or distension due to urinary ascites, or signs of urinary ascites in abdominal imaging
- uraemia and elevated creatinine level due to intraperitoneal reabsorption
- entry/exit wounds at lower abdomen, perineum or buttocks
Imaging for bladder trauma
• Cystogram:
Cystoscopy
Prevention for bladder trauam
- Catheterisation: should be catherised in surgical procedures etc
- GA and muscle relaxation at TURBT
Management for Bladder Trauma
- Recognise it
- Extraperitoneal Rupture • catheter, antibiotic prophylaxis
- Intraperitoneal – • small injuries managed conservatively but might require drainage • closure with absorbable sutures • Leave catheter for 5-10 days
Ureteric Trauma
Iatrogenic/Non Iatrogenic
Which more common mechanism of injury
Iatrogenic
Ureteric Trauma
Iatrogenic Injury causes
Ureteric Trauma
Ix?
- Suspect it and exclude it
- Post operative clinical signs: flank pain, urinary incontinence, vaginal or drain urinary leakage, haematuria, fever, uraemia or urinoma.
- Early diagnosis is the key
- CTU in trauma or post op setting
- Retrograde pyelogram in the intra operative setting
Ureteric Injuries
Management of Minor injuries
- Small fistulae
- Ligation injuries
- May be managed with ureteric stenting
- May be antegrade or retrograde
Ureteric Injuries
Management of Major injuries
- Immediate repair if injury is recognised and patient is stable
- Nephrostomy drainage if not
What are the Principles of ureteric repair
- Debridement of necrotic tissue
- Spatulation of ureteral ends
- Watertight mucosa-to-mucosa anastomosis with absorbable sutures
- Internal stenting
- External drain
- Isolation of injury with peritoneum or omentum
Urethral Trauma
Male causes
Anterior (Bulbar)
- bulb compressed against pubis
- astride / kick / stab / bite
- Iatrogenic – catheterisation related
Posterior
- Mostly MVA related
- Significant risk of other major injury
Urethral Trauma
Female causes
- Birth related most common
- Less common in pelvic fracture
- Sling procedures complicated by injury in 0.2-2.5%
Ix for Urethral Trauma
- Blood at the meatus (introitus) / inability to void / extravasion
- Rectal examination for high riding prostate
- Urethrography
- Flexible Cystoscopy
- USS – useful for insertion of suprapubic catheter
Urethral Damage
Management – bladder drainage
- Attempt a gentle passage of urethral catheter
- Insertion of a suprapubic catheter but BEWARE
- bladder displaced by the pelvic haematoma
- poor bladder filling due to haemodynamic shock or concomitant bladder injury
- a suprapubic catheter should be placed under US guidance or under direct vision for example, during laparotomy for associated injuries
Small injuries may be repaired early particularly in women
• A wide variety of treatment strategies
Testicular trauma’
causes
- Blunt trauma occurs when there is compression of the testis against the inferior pubic ramus or symphysis
- Rupture of tunica albuginea
- In conflict zones from stepping on land mines
Ix for testicular trauma?
History – immediate pain, nausea, vomiting and sometimes feinting
• Ultrasound is investigation of choice
Management for testicular trauma
Early surgical exploration to preserve viable tissue
common mechanisms of injury for Penile trauma
- Most commonly when the penis is erect • Sexual intercourse • Forced flexion • Masturbation • Rolling over
- May be part of other major trauma
Ix for penile trauma?
- History • Sudden cracking or popping • Pain • Immediate detumescence • Local swelling
- MRI is imaging modality of choic
Penile trauma
Management
- Surgical intervention with closure of the tunica albuginea
- 5% have urethral injuries
- Monitor and treat erectile dysfunction
