Upper Urinary Tract Trauma Flashcards
The best indication of significant urinary system injury is gross hematuria. However, the absence of hematuria does/does not exclude a significant GU injury.
gross hematuria
does not
- Evaluation of urologic trauma in children differs from adults in that children: (3).
(1) are at greater risk for renal trauma,
(2) often do not become hypotensive with major blood loss,
(3) have a higher propensity for renal anomalies.
Rapid deceleration from a fall from height or a high-velocity impact may result in injuries at points :
RAPID DECELERATIOn
points of fixation such as the ureteral pelvic junction and the renal hilum (renal artery intimal disruption).
. The degree of hematuria and the severity of renal injury are/are not consistently correlated.
The degree of hematuria and the severity of renal injury are not consistently correlated.
Criteria for radiologic imaging include (5)
(1) all penetrating trauma,
(2) high-impact rapid deceleration trauma,
(3) all blunt trauma with gross hematuria,
(4) all blunt trauma with microhematuria and hypotension, and
(5) pediatric patients with hematuria.
TF Adult patients with microscopic hematuria without shock may be observed without imaging studies.
true microscopic hematuria
Findings suggestive of a major renal injury on CT include: (5)
- MEDIAL LACERATION
- PERINEPHRIC HEMATOMA SIZE
- INTRAVASCULAR CONTRAST EXTRAVASATION
- MEDIAL URINARY EXTRAVASATION
- DEVITALIZED RENAL FRAGMENTS
TF Nonoperative management for renal injuries is preferred in the hemodynamically stable patient, particularly with grades I to III renal injuries.
TRUE
Exploration of low-velocity renal gunshot wounds is not mandatory in selected cases. Such patients with isolated __ with stable and contained h___ who are hemodynamically stable, with no ____ injury, may be observed expectantly.
renal parenchymal lacerations
hematomas
no intra-abdominal organ injury
- Absolute indications for renal exploration are: (4)
(1) hemodynamic instability with shock
(2) expanding or pulsatile hematoma,
(3) suspected renal pedicle avulsion,
(4) uncontained retroperitoneal hematoma.
relative indications for intervention for renal trauma: perinephric ___ size, intravascular ___, ___ renal fragments, arterial ___, and ___ contrast extravasation
Perinephric hematoma size, intravascular contrast extravasation, devitalized real fragments, renal thrombosis
__ is the management technique of immediate control of bleeding, and fecal and urinary leak only, in the unstable patient. ___ is deferred until the patient is stable and fully resuscitated. For ureter injuries this entails __,__, __ and __.
At a staged/planned laparotomy, the ureter is __
“Damage control” is the management technique of immediate control of bleeding, and fecal and urinary leak only, in the unstable patient. Definitive reconstruction is deferred until the patient is stable and fully resuscitated. For ureter injuries this entails ligation and nephrostomy, externalizing, or stenting. At a staged/planned laparotomy, the ureter is later repaired.
___ - Hypertension from renal parenchymal injury
PAGE KIDNEY- Hypertension from renal parenchymal injury
When repairing ureteral injuries, the ureteral tissue should be debrided back to a __ to remove all ___.
When repairing ureteral injuries, the ureteral tissue should be debrided back to a bleeding-edge to remove all traumatized microvascular damaged tissue.
T/F Placement of vascular graft aneurysms in proximity of the ureter may cause a periureteral inflammatory reaction and ureteral injury/stenosis.
TRUE,be cautious when placing vascular grafts near ureter!!!
Ureteral injuries to the proximal and mid ureter can often be managed by __. The gap being bridged is based on ureter ___ and ___.
URETROURETEROSTOMY
MOBILIZATION AND ITS ELASTICITY
In the stable trauma patient, distal ureteral injuries should be ___ into the bladder. In select cases, a ___ can be considered. If the gap is large, then __ or ___ is the better management.
In the stable trauma patient, distal ureteral injuries should be reimplanted into the bladder. In select cases, a ureteroureterostomy can be considered. If the gap is large, then psoas hitch or Boari bladder flap is the better management.
For delayed ureteral injury, the best diagnostic radiographic test (in the stable patient) to confirm injury, is a ___
RETROGRADE UROGRAM
Ureteral transections should be repaired ___ of the injury, or the repair should be delayed for___
WITHIN A WEEK
6 weeks or more
It is prudent to isolate the ureteral repair from other injured organs (such as colon) with __ and __
OMENTUM OR PERITONEUM
Ureteral injury noted during ureteroscopy should be managed by ___. When a stent cannot be placed or inadequately diverts the urine, then a ___should be placed.
ureteral stent placement
nephrostomy tube
Ureteral injury occurring during vascular surgery should be repaired and ___ from the graft with normal tissue such as __.
Ureteral injury occurring during vascular surgery should be repaired and isolated from the graft with normal tissue such as omentum.
The basic mechanisms for arterial hypertension as a complication of trauma are (1) renal vascular injury, leading to stenosis or occlusion of the ___ or one of its branches (__ kidney)
(2) compression of the renal parenchyma with extravasated blood or urine (___ kidney);
(3) post-trauma ___ fistula.
In these instances, the ___ axis is stimulated by ___, resulting in hypertension
GOLDBLATT KIDNEY -> stenosis or occlusion of the MAIN RENAL ARTERY or one of its branches
PAGE KIDNEY–> Compression of the renal parenchyma with extravasated blood or urine
Post trauma arteriovenous fistula
In these instances, the reninangiotensin axis is stimulated by partial renal ischemia, resulting in hypertension
40 / M Blunt injury, noted hematuria (microscopic) then on BP <90 SBP–> abdominal exloration done, on assesment of retroperitoneal hemtoma noted pulsatile hematoma –> next process
RENAL EXPLORATION INDICATED
The indications are uncommon for shot ivp is uncommon, such as
surgeon encounters an ___ hematoma surrounding a kidney during abdominal exploration in an ___ patient without a ___, and are contemplating renal exploration or nephrectomy.
unexpected retroperitoneal
UNSTABLE TRAUMA
CT SCAN
The main purpose of the one-shot IVP is to assess the presence of a functioning contralateral kidney.
functioning contralateral kidney
ONE SHOT IVP Only a single film is taken 10 minutes after IV injection (IV push) of 2 mL/kg of contrast material. The study can also be helpful in assessing for ____extravasation. If the study is normal, exploration of the injured side may ___. If findings are not near normal, ___ is recommended or the kidney explored to complete the ___
10 minutes
2 mL/kg of contrast material
may be avoided
further imaging
staging of the injury
Anterior axillary line injury –> possible damage to : ___
(renal hilum and pedicle)
•Posterior axillary line –> __
parenchymal renal injury
<1 cm parenchymal depth laceration of renal cortex without urinary extravasation on bilateral kidneys
grade 3! Grade 2 ang injury but…
ALWAYS ADVANCE ONE STAGE FOR BILATERAL INJURIES
___ observation is warranted for patients with renal injury and urinary extravasation such injuries often resolve spontaneously in over 90%, unless (what kind of avulsion) is present.
Medial extravasation of contrast from the kidney, with lack of contrast in the distal ureteral on delayed CT imaging, ____
initial
renal pelvis avulsion or proximal ureteral avulsion injury
UPJ AVULSION
Urinomas can be distinguished from hematomas by their radiographic characteristics: urinomas range from ___(HU), whereas hematomas typically are __(HU)
0 to 20 Hounsfield units (HU)
greater than 30 HU
Surgical exploration of the acutely injured kidney is best by a ___, which allows complete inspection of intra-abdominal organs and bowel.
transabdominal approach
URETERAL INJURY GRADING:
Complete transection with <2 cm devascularization bilateral ureter
GRADE 4 only
bilateral ureteral injuries are upstaged up to grade iii only
Patients with penetrating trauma with any __
or a wound pattern that suggests the possibility of genitourinary injury __
degree of hematuria
should be imaged
__ with delayed images is the best study for detecting ureteral injuries
CT urography with delayed images is the best study for detecting ureteral injuries
__ is the most sensitive radiographic test for ureteral injury Although accurate in demonstrating site, presence, and location of extravasation, retrograde ureterography is often __ Thus, it often has a limited role in the __, especially if the patient is unstable. Retrograde ureterography is most commonly used to ___ because it allows the simultaneous placement of a ureteral stent if possible.
Retrograde ureterogram is the most sensitive radiographic test for ureteral injury Although accurate in demonstrating site, presence, and location of extravasation, retrograde ureterography is often time consuming and cumbersome. Thus, it often has a limited role in the acute trauma setting, especially if the patient is unstable. Retrograde ureterography is most commonly used to diagnose initially missed ureteral injuries, because it allows the simultaneous placement of a ureteral stent if possible.
In cases in which ureteral injury is discovered, and retrograde stent placement is not possible (usually secondary to a large gap in the two ends of the transected ureter), __ and stent placement at the time of __, should be performed, when possible
In cases in which ureteral injury is discovered, and retrograde stent placement is not possible (usually secondary to a large gap in the two ends of the transected ureter), anterograde ureterography and stent placement at the time of percutaneous nephrostomy placement, should be performed, when possible
PRINCIPLES OF URETERAL REPAIR
- Mobilize the injured ureter carefully, __, so as not to __ the ureter further.
- Debride the ureter minimally but judiciously ___, especially in high-velocity gunshot wounds.
- Repair ureters with __, ___, ___ anastomosis, using fine ___ sutures and ___ drainage afterward.
- Retroperitonealize the ureteral repair by closing peritoneum over it if possible.
- Do not tunnel ureteroneocystostomies but rather create a widely ___ nontunneled anastomosis.
- With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider __ to isolate the repair when possible.
- If immediate repair is not possible, or the patient hemodynamically unstable, one management option is to ____ with long silk or polypropylene suture, and plan to repair it later, or place a nephrostomy tube after ICU resuscitation (damage control). The other option is a temporary cutaneous ureterostomy over a single-J stent or pediatric feeding tube with a suture tied around the ureter proximal to the injury site, in order to secure the stent in place, and to prevent urinary leakage.
- Mobilize the injured ureter carefully, sparing the adventitia widely, so as not to devascularize the ureter further.
- Debride the ureter minimally but judiciously until edges bleed, especially in high-velocity gunshot wounds.
- Repair ureters with spatulated, tension-free, stented watertight anastomosis, using fine absorbable sutures and retroperitoneal drainage afterward.
- Retroperitonealize the ureteral repair by closing peritoneum over it if possible.
- Do not tunnel ureteroneocystostomies but rather create a widely spatulated nontunneled anastomosis.
- With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition to isolate the repair when possible.
- If immediate repair is not possible, or the patient hemodynamically unstable, one management option is to ligate the ureter with long silk or polypropylene suture, and plan to repair it later, or place a nephrostomy tube after ICU resuscitation (damage control). The other option is a temporary cutaneous ureterostomy over a single-J stent or pediatric feeding tube with a suture tied around the ureter proximal to the injury site, in order to secure the stent in place, and to prevent urinary leakage.
30/M blunt trauma, ureteral injury left on CT UROGRAM –> delayed
nephrogram, ureteral nonopacification or extravasation
what to do next?
explore ureter
most common associated injury with bladder trauma is
pelvic fracture
•-triad of blood at the meatus, inability to urinate, and palpably full bladder –> next step
URETHRAL INJURY
urethral meatus –> RUGM
•PRIAPISM: Unwanted erection of
> 4 hrs
•Indicators of bladder injury
- Suprapubic pain
- Free intraperitoneal fluid
- Inability to void or low urine output
- Clots in urine
- Enlarged scrotum
- Abdominal distention or ileus
Extraperitoneal Bladder imaging
- Do not forget to (1)
- Properly done (2)
- Inflate bladder with at least (3)
- At least 3 films, (4)
•
- CT cystogram
- Bladder (5)
(6)
•(7) not required
Extraperitoneal Bladder imaging
- Do not forget to assess upper tracts
- Properly done cystogram
- Inflate bladder with at least 350cc
- At least 3 films, plain, with contrast, drainage
•
- CT cystogram
- Bladder filled via catheter
•2-4% dilution
•Drainage film not required
•Open repair of extraperitoneal bladder rupture is done in the presence of complicating features that may result to complications such : (3)
fistula, abscess and prolonged leakage.
Intraperitoneal Rupture
- Generally results in large rent in __
- Formal surgical repair with __
- __ only applicable in minimal iatrogenic (e.g. Resectoscopic) injuries
Intraperitoneal Rupture
- Generally results in large rent in dome
- Formal surgical repair with absorbable suture is the standard of care
- Catheter drainage alone only applicable in minimal iatrogenic (e.g. Resectoscopic) injuries
___- all four pubic rami
•Fractures resulting in vertical and rotational pelvic instability
à Highest risk of urologic injury
•“Straddle Fracture”-
20/M came into er from penetrating injury, palbable bladder unable to void, noted blood at meatus, RUGM DONE showed partial anterior urethral injury,what is next step?
Primary uretrhal repair
penetrating,always primary open repair,if unable then STC
•Initial __ is the treatment of choice for major straddle injuries involving the urethra
suprapubic cystotostomy
___ is the treatment of choice for major straddle injuries involving the urethra
•Initial suprapubic cystostomy is the treatment of choice for major straddle injuries involving the urethra
GSW Injury to urethra
- Low velocity: ___
- High velocity: ___
- Low velocity: Primary surgical repair
- High velocity: Initial suprapubic urinary diversion , delayed reconstruction
what to do with amputated penis?
§Amputated portion, cleaned and placed in a double bag with ice
§Reconstruction of the urethra and corporeal bodies with microsurgical repair of dorsal penile vessels and nerves
•Penile Fracture mgt
•Immediate surgical exploration, repair of tunica albuginea tear
penile fracture
A rolling sign is the___ over the site of rupture,may be felt as a discreet firm mass over which the penile skin may be rolled. Patients with a rupture of the ___ of the penis can present with findings similar to those of a penile fracture
penile fracture
A rolling sign is the palpation of the localized blood clot over the site of rupture,may be felt as a discreet firm mass over which the penile skin may be rolled. Patients with a rupture of the deep dorsal vein of the penis can present with findings similar to those of a penile fracture
Clssification of priaprism
ISCHEMIC, NON-ISCHEMIC and STUTTERING
ISCHEMIC, NON-ISCHEMIC and STUTTERING
•Ischemic/ Low Flow blood gas
PO2, PCO2 and PH
- Ischemic/ Low Flow blood gas
- PO2= <30 mmHg
- PCO2= >60 mmHg
- pH-below 7.25
*non ischemic/HIGH FLOW:
PO2= >90 mmHg
PCO2= < 40 mmHg
pH= 7.4
Mixed venous blood
PO2= 40 mmHg
PCO2= 50 mmHg
Ph= 7.35
Medical management priapism
•Evacuation of blood and irrigation of the corpora cavernosa along with intracavernous injection of an ____ agent
___ is the agent of choice
- Medical management
- Evacuation of blood and irrigation of the corpora cavernosa along with intracavernous injection of an alpha adrenergic sympathomimetic agent
•Phenylephrine is the agent of choice
surgical management priapism
- Surgical management
- Distal shunting (Winter’s or El Ghorab)
- Proximal shunting (Quackles or Sacher)
