Presentation on theme: "Doc. MUDr. Robert Grill PhDr."— Presentation transcript:
1Doc. MUDr. Robert Grill PhDr. Urologická klinika 3. LF UK a FNKVUrological TraumaDoc. MUDr. Robert Grill PhDr.
2Renal trauma-aetiology and pathogenesis Penetrating trauma( stab wounds, gunshots injuries)Blunt trauma( 80-85% of all kidney´s traumas)- direct blunt impact- deceleration injuriesIatrogenic(parenchymal injury during surgery , ESWL, percutan extraction of concrement )abMechanisms of renal injury a) direct blunt impactb) deceleration
3Renal injury classification AAST renal injury grading scaleGrade 1 - Contusion or non-expanding subcapsular haematoma, no lacerationGrade 2 - Non-expanding peri-renal haematoma, Cortical laceration < 1 cm deep without extravasationGrade 3 - Cortical laceration > 1 cm without urinary extravasationGrade 4 - Laceration through corticomedullary junction into collecting system or segmental renal artery or vein injury with contained haematoma, or partial vessel laceration, or vessel thrombosisGrade 5 - shattered kidney or renal pedicle or avulsion.
4Renal injury- symptomatology Haematuria ( at 80-90% renal trauma)- no correlation between level of haematuria and degree of injury / 1/3 of wounded does not suffer by haematuria /Abdominal tenderness extended during palpationAbdominal abrasionsRibs fractureNausea, vomiting, blockage of the intestine , acute abdomen signsSymptoms of hypovolemic shock ( systolic pressure < 90mm Hg, P > 90/min, decreased or no urine output, pale skin color, cool, clammy skin …..).
5Diagnosis of renal injuries Haemodynamic stability of patient is the fundamental criterionHistory of accident - background of injury (rapid deceleration, direct blow to the flank, the size of the weapon in stabbings…)Patient´s medical history – focusing on pre-existing kidney dysfunctions and diseases( hydronephrosis, nephrolithiasis, kidney cysts, kidney tumors, kidney surgeries )Physical assessment - haematuria, flank abrassions, flank palpable pain, palpable mass in the kidney area, abdominal distension, acute abdomen signs, fractured ribsLaboratory evaluation - urinalysis, regular haematocrit controlling, creatinine baseline
6Diagnosis of renal injuries Imaging – criteria for radiographic assessment - gross or microscopic haematuria and shock, associated major injuriesUltrasonography - provides a quick, non-invasive, low-cost means of detecting peritoneal fluid collections, can detect degree of renal injury, eliminate solitary kidney, dopplers assessment of functional state of kidney, indication for other radiological examinationStandard IVP - offers basic information about kidney functionality, nowadays supplied by contrast CT examination. Unstable patients selected for immediate operative intervention / ,,one-shot“ IVP/ are exception for using Standard IVP.Computed tomography – CT is a standard method used on stable patients. It is more sensitive and specific than IVP, USG and angiography. CT detects the location of injuries, evaluates details and functionality of kindneys, defines pre-existing abnormalities and associated traumas.Magnetic resonance imaging - MRI has no advantage in compare with CT, it requires a longer imaging time, increases the cost, and limits access to patients when they are in the magnet during the examination. MRI is therefore useful in renal trauma if patient suffers with iodine allergy or renal insuficience.Angiography - has been largely replaced by CT as the use of angiography is less specific, more time-consuming and more invasive. Angiography may be preferable when planning selective embolisation for the management of persistent or delayed haemorrhage from branching renal vessels .
8Treatment and prognosis in renal injuries Non-operative therapy – choice for the majority stable patients with renal injuries grade 1-4(bed-rest, hydration, antibiotics, continuous imaging examinations, hemostyptic therapy, monitoring of vital signs ).Surgical managementIndications – haemodynamic instability- exploration for associated injuries- expanding or pulsatile peri-renal haematoma identified during laparotomy- grade 5 injury- incidental finding of pre-existing renal pathology requiring surgical therapy
9Early and delayed complications at renal trauma Early complications - occur within the first month after injury and can be bleeding, infection, peri-nephric abscess, sepsis, urinary fistula, hypertension, urinary extravasation, and urinoma.Delayed complications - include bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension ( less than 5% patients ), arteriovenous fistulae, hydronephrosis and pseudoaneurysms.
10Ureteral trauma-aetiology and pathogenesis Very rare and accounts for only 1% of all urinary tract trauma.Blunt trauma 18%Penetrating trauma 7%Iatrogenic 75%- gynecological 73% ( hysterectomy, ovarectomy, gynecologic laparoskopy surgery…)- surgical 14% ( colorectal surgery, abdominal vascular surgery….)- urological 14% ( ureteroscopy, insertion of ureteral catheter )
11AAST ureteral injuries classification Grade 1: Haematoma onlyGrade 2: Laceration < 50% of circumferenceGrade 3: Laceration > 50% of circumferenceGrade 4: Complete tear < 2 cm of devascularisationGrade 5: Complete tear > 2 cm of devascularisation
12Ureteral trauma symptoms Varies according to aetiology and difficulty of injury :Abdominal and flank painHaematuria in different levelsFaebriliaDecreased urine outputNausea, vomitingUrosepsisAcute abdomen signs
14Ureteral trauma-IVPUrinary extravasation from the middle third of the left ureter /after ureteroscopy/
15Therapy of ureteral trauma Treatment depends on the extent and the location of uretal trauma :Grade 1 and 2 can be managed non-surgical with ureteral stenting or nephrostomy.Grade 3 to 5 need a reconstructive repair. The type of reconstructive repair procedure depends on the nature and the site of the injury.The options for repair of ureteral injuries- Uretero-ureterostomy- Ureterocalycostomy- Transuretero-ureterostomy- Boari flap and reimplantation- Ureterocystostomy- Psoas hitch- Ileal interposition
16Complications at ureteral trauma UrinomaPeriureteral abscessFistulaStrictura
17Bladder trauma - aetiology and pathogenesis 2% of all abdominal injuries, often associated with pelvic fractureBlunt trauma - caused by direct impacts at the pelvic area or lower abdominal at patients with the full bladder, % of patiens suffer pelvic fractures at the same timePenetrating trauma- gunshots, stub woundsIatrogenic trauma-1/2 of all bladder traumas (transuretral operation of prostatis, bladder, gynaecological operations, hernioplasty)
18Bladder injury classification Classification of bladder injury according to AASTGrade 1 - ContusionGrade 2 - Intraperitoneal bladder wall lacerationGrade 3 – Intersticial injuryGrade 4 - Extraperitoneal bladder wall laceration- simple- complicatedGrade 5 – combination of injuries intraperitoneal and extraperitonealExtraperitoneal bladder wall laceration
19Bladder trauma symptoms Lower abdominal painGross haematuria most common signsNausea, vomitingParalytic ileusPeritonitisInability to voidBruises over the suprapubic regionHaemoragic shock
20Diagnosis of bladder traumas Physical assessment – lower abdominal pain, crepitations and instability of pelvic ring, abrassions…..Laboratory examination – urianalysis and blood examinationImaging- Retrograde ureterocystography : standardly used method, sensitivity of 100%, it is neccessary to fill the bladder with a minimum of 350 ml of dilute contrast material- CT cystography : this procedure should be performed using retrograde filling of the bladder with dilute contrast material- IVP : is inadequate for evaluation of the bladder trauma ( dilution of the contrast material within the bladder, too low resting intravesical pressure to demonstrate a small tear )
21Bladder trauma- Retrograde cystography Intra and extraperitoneal bladder wall lacerationExtraperitoneal bladder wall laceration
22Therapy of bladder traumas Extraperitoneal bladder ruptures - managed by catheter drainage alone, ATB treatmentIndications for surgical repair :- intraperitoneal bladder ruptures- bladder neck injuries- the presence of bone fragments in the bladder wall- entrapment of the bladder wall by bone fragments- associated injuries that require surgical intervention, are managed by interdisciplinary cooperation
23Urethral trauma Male urethral injury The posterior urethra - prostatic and the membranous urethra.The anterior urethra - bulbar and penile urethra.
24Urethral trauma – aetiology and pathogenesis 1. Posterior urethral injuriesMostly the result of pelvic fractures/ height falls, traffic accidents /2. Anterior urethral injuriesBlunt traumaPenetrating injuriesIatrogenic injuriesAutomutilation
25Classification of urethral injuries Classification of blunt anterior and posterior urethral injuryGrade 1 : Stretch injury. Elongation of the urethra without extravasation on urethrographyGrade 2 : Contusion. Blood at the urethral meatus, no extravasation on urethrographyGrade 3 : Partial disruption of anterior or posterior urethra. Extravasation of contrast at injury site with contrast visualised in the proximal urethra or bladderGrade 4 : Complete disruption of anterior urethra. Extravasation of contrast at injury site without visualisation of proximal urethral or bladderGrade 5 : Complete disruption of posterior urethra. Extravasation of contrast at injury site without visualisation of bladderGrade 6 : Complete or partial disruption of posterior urethra with associated tear of the bladder neck or vagina
26Symptoms of urethral trauma Lower abdominal painUrethrorrhagiaInability to voidPerineal haematoma
27Urethral trauma diagnosis Physical assessment – lower abdomen pain,urethrorrhagia, crepitations and instability of pelvic ring, ecchymosis, high-riding prostate, perineal haematomaLaboratory examination – urinalysis and blood testingImaging- retrograde urethrography – gold standard for evaluating urethral injury- CT and MRI : used in defining distorted pelvic anatomy after severe injury and assessing associated injuries of other organs- USG : useful in determining the position of pelvic haematomas, or the exact location of the bladder when a suprapubic catheter is indicated.
28Urethral trauma- retrograde urethrography Normal retrograde urethrographyDisruption of posterior urethra
29Therapy of urethral traumas I. Anterior urethral injuries therapyGrade 1 – no treatment is neccessaryGrade 2 and 3 - urethral catheterisation or suprapubic cystostomyMore complicated injuries -suprapubic derivation, delayed optic uretrotomy, urethral dilatation, longer defects of the anterior urethra should be repaired by an end-to-end anastomosis, defects over 1cm by flap urethroplastyOpen injuries- primary urethral suturing- defects of more than 1 cm in length a two-stage urethral repairII. Posterior urethral injuries therapyPartial urethral rupture - suprapubic or urethral catheter.Complete urethral rupture - primary endoscopic realignment, immediate open urethroplasty ,- delayed primary urethroplasty,- delayed formal urethroplasty,- delayed endoscopic incision
30Female urethral injuries Only the posterior urethra exists in the femaleRare injuries due to length and limited connection to pubic boneMost often during the delivery, iatrogenic trauma, pelvic fracture, fracture of ventral part of pelvic ringSymptoms are similar to male urethral traumaIn diagnostic,urethroscopy is prefered to technically hard performed urethrographyMost female urethral disruptions can be sutured primarily either transvaginally or transvesically
31Complications at urethral trauma Urinary incontinenceErectile dysfunctionUrethral strictureFistulae or urethral pseudodiverticula
33Penile trauma Aetiology Blunt trauma – penile fracture, ischemic gangrene, thermal and chemical injuriesPenetrating trauma – gunshots wounds, stab, cutsSympthomsPain, haematoma, inability to void, bleedingDiagnosisPhysical assessment /palpable tenderness, haematoma, haematuria /USG, Retrograde urethrography / to eliminate an injury of urethra/TherapyIn penile fracture- surgical interventionReimplantation in case of total penile amputationIn associated injury of urethra-epicystostomia, urethral catheterisation
34Prostate and seminal vesicles trauma AetiologyInjury of the prostate and posterior urethra associated with pelvic traumaIatrogenic-prostate biopsySymptomsrectorrhagiaPerineal painUrethrorrhagia, hematuriaFever, septic shockDiagnosisPhysical assessment -digital rectal examination/pain, oedema, fluctuation /USG, NMR true PelvisTherapyATB, hemostyptic drugs, rectum tamponade, incision and drainage of prostatic abscess
35Scrotal trauma Aetiology Blunt trauma Penetrating trauma / rare injuries /Iatrogenic traumaSymptomatologyDepends on the extent of the injury / pain, bleeding, swollen /DiagnosticPhysical assessment –inspection, palpationUSG, CT, NMRTherapyDepends on the extent of the injury / from conservative management to reconstruction of scrotum /ComplicationsPost-traumatic testicular atrophyTesticular cancer
36Adrenal trauma-aetiology Vary in infants and adultsBlunt traumaPenetrating traumaIatrogenic traumaInfants post-delivery trauma
37Adrenal trauma - symptoms Haemoragic shockPalpable resistanceAcute adrenal insufficiency /tachypnoe,fever, petechiae and purpura, metabolic collapse, abdominal pain, vomiting and diarrhoea, spasm and cyanosis/ most common in infants with bilateral adrenal injury
39Adrenal trauma-therapy Conservative management with blood loss compensation, corticoid substitute, correction of metabolic interferenceSurgical intervention in cases unable to treat non-operative – exploration, nephroadrenalectomy
40Thank you for your attention Literature - Traumata urogenitální soustavy Doc. MUDr. Robert Grill, Ph.D. - Urologie 2009 Kawaciuk et kolektív - Všeobecná urologie 2006 Emil A. Tanagho, Jack W. McAninch - EAU Guidelines on urological trauma N. Djakovic, E. Plas, L. Martínez-Piñeiro, et kol. -http://www.health-reply.com/urethral-injury-classification/ -Teaching Atlas of Urologic Imaging Older / BassignaniThank you for your attention