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
<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
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
30/M blunt trauma, ureteral injury left on CT UROGRAM –> delayed
nephrogram, ureteral nonopacification or extravasation
what to do next?
explore ureter
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
