1. ( Lecture )
Trauma in Urology

2. Renal injuries RI account for 1-5% of all traumas
BLUNT – car, sport accidents –majority!
PENETRATING –gunshots, stab wounds
AAST classification (American Associaton for the Surgery of Trauma)

3. AAST classification (American Associaton for the Surgery of Trauma)
Contusion, non-expanding subcapsular haematoma, no laceration
Non-expanding perirenal haematoma, cortical laceration < 1 cm deep, no urinary extravasation
cortical laceration > 1cm, no u.extravasation
Laceration: through corticomedullary junction into collecting system OR vascular: segm. renal artery or vein injury with contained haematoma
Shattered kidney OR major vascular injury (renal pedicle injury or avulsion)
1,2 = minor injuries – 85-95% ,4,5 = major injuries

4. Diagnosis
Trauma history, past renal injury, surgery or renal abnormalities
examination (haematuria, flank pain, flank abrasions, rib fractures, abd.tenderness)
Urinalysis, blood count, creatinine
Primary imaging -> USG!!
Enhanced abdominal CT !
Intraoperative one/shot IVP
Second/line imaging – MRI,Scinti,Angiography

5. Treatment WW – grade I-III in stable patients
Surgery (all penetrating injuries, in blunt injuries if: major blood loss, unstable patient, urinary extravasation, nonviable kidney, pedicle avulsion,...)

6. Complications
Early: Haemorrhage, retroperitoneal urinoma, haematoma, abscess
Late: Hypertension, AV fistula, calculi, PNF, late bleeding

7. Ureteral injuries Pelvic surgery (uro, gyn, gen.s.)
Pelvic/abdomninal masses
PID
post RT
Penetrating injury

8. Clinical findings Flank pain, tenderness Sepsis Hydronephrosis!!
Paralytic ileus
VV / UV fistula / watery discharge via vagina/
Labs /CRP,Leu,urinalysis,creatinine/

9. Imaging
USG
IVU / enhanced CT !
APG
Radionuclide scanning

10. Treatment
First-line urinary diversion !!! (nephrostomy, ureteral stenting)
Reconstructive surgery /reanast., reimpl., substitutions, crossed diversion, autoTPL…/

11. Bladder injuries direct external force, road accidents
iatrogenic / gyn-obs, uro, sur/

12. intraperitoneal disruption
extraperitoneal disruption

13. Clinical finding Haematuria
Pelvic , abd. pain (pelvic fracture presented in 90% of bladder inj.)
Haemorrhage, Shock
Acute abdomen !!! (intraperit)

14. Imaging
Pelvic & Abdominal USG
Cystography (300ml) !
CT cystography

15. Treatment Extraperit. – bladder drainage (epi, catheter)
Intraperit. – open surgery required!

16. Urethral injuries Posterior/ Anterior urethra
Laceration, transection, contusion
External forces (falls astride an object, perineal blow, …)
Iatrogenic (catheter, uro )

17. Posterior urethra
assoc. w/ pelvic fractures - > prostate avulsion from the membranous u. -> apical displacement of the prostate - > Pelvic urinoma, haematoma
DR Exam. !
blood at the urethral meatus !

18. X- Ray (pelvic fracture)
Urethrography !!

19. Treatment drainage (suprapubic cystostomy)
immediate surgery (suspected bladder lacerations, disruptions, massive pelvic bleeding, etc.)
delayed surgery (>3 months after the injury)

20. Complications after delayed surg.repair
Incontinence %
Stricture %

21. Anterior urethra straddle injury iatrogenic instrumentations
self-instrumentations

22. Clinical findings perineal, penile, scrotal haematoma
urethral bleeding
normal DRE

23. Diagnosis
Urethrography

24. Treatment suprapubic cystostomy
surgical repair (in case of urethral laceration, bleeding w/o extravasation)
follow-up (stricture!)

25. Penile & Scrotal injuries
Penile fracture (sex. intercourse -> disruption of the tunica albuginea -> haematoma, CAVE: urethral injury)
Penile constriction – rings
Penile amputation
Scrotal injury (hematocele, testicular disruption, torsion, skin avulsion, traumatic amputations)