Transcript Slide 1

INJURIES TO THE
GENITOURINARY
TRACT
S.Vahidi
Special examination
A.Catheterization and assessment of injury
1-catheterization
2-CT scan
3-retrograde cystography
4-urethrography
5-arteriography
6-IVP
B.Cystoscopy and retrograde urography
C.Abdominal sonography
Injuries to the kidney
-most common injuries of urinary system
-kidney with existing pathologic condition are more
readily ruptured
Etiology
-Blunt trauma(80-85%)
-Penetrating truma to the flank area should be
regarded as a cause of renal injury until proved
otherwise
-Associated abdomial visceral injuries are present in
80% of renal penetrating wounds
Pathology & classification
A-early pathologic finding
1)-grade I (the most common)renal contusion
microscopic hematuria
2)-grade II renal parenchymal laceration
perirenal hematoma
3)-grade III laceration extending into the renal medulla
large retroperitoneal hematoma
4)-grade IV laceration extending into the renal
collecting system-artry injuries
5)-grade V multiple gIV –renal pedicle avulsion
main renal artery or vein from penetrating
trauma
Pathology & classification
(continue)
B-late pathologic findings
1-urinoma
2-hydronephrosis
3-arteriovenous fistula
4-ranal vascular hypertension
Treatment
A.Emergency measures
B.Surgical measures
1)Blunt inguries
85% no operation require
operation indicated in:
-persitent retroperitoneal bleeding
-Urinary extravasation
-non viable parenchyma
-renal pedicle injuries
Treatment(continue)
2)Penetrating injuries
exploration is needed
rare exception:minor parenchymal
injury with no U. extravasation
in 80% of cases:associated organ
injury
Treatment(continue)
C.Treatment of complications:
urinoma & abscass:drainage
malignant hypertention:vascular repair
or nephrectomy
hydronephrosis:surgical correction or
nephrectomy
prognosis
-excellent prognosis
-IVP & BP monitoring is needed
Injuries to the ureter
Etiology:
-iatrogenic:tul-pelvic surgery
-deceleration accident:avulse the ureter
Clinical finding:
-signs & symptoms:fever- flank pain-nausea &
vomiting-urinary leakage
(within first 10 postoperative days).ileus
Lab exam:hematuria.
Imaging
o IVP-retrograde ureterography-spiral CT:
extravasation
hydronephrosis
o Sonography:hydronephrosis-urinoma
o Radionuclide examining:delayed excretionaccumulation in renal pelvis
Differential diagnosis
Bowel obstruction
Peritonitis
Fever
deep wound infection
acute pyelonephritis
Treatment
o The best opportunity:in the operating roomuntil 7-10 days
o Lower ureteral injuries:reimplantationureteroureterostomy-bladder tube flap-transureteroureterostomy
o Midureteral injuries:ureteroureterostomy or
trans u. ureteostomy
o Upper ureteral injuries:ureteroureterostomyauto transplantation-bowel replacement
o Stenting
o Prognosis:excellent
Injuries to the bladder
o Usually due to external force
o Often associated with perlvic fracture(15% of
pelvic fractures)
o iatrogenic injury
Clinical findings
o Pelvic fracture : crepitus-painful
o Unable to urinate- Hematuria
o Hemorrhagic shock
o D.R.E.: distinct landmarks
Lab:Hematuria
X-ray:pelvic fracture-extravasation
Complications:pelvic abscess-peritonitisincontinency(partial)
Treatment
o Extraperitoneal:foley cath
(bladderneck injury-large bloodclots→surgical
management)
o Intraperitoneal:surgical repair
o Prognosis :excellent
Inguries to the urethra
Clinical findings:lower abdominal paininability to urinate-blood at the uretheral
meatus-prostate displacement-perineal
hematoma
X-Ray findings:pelvic fracture-extravasation
Complications:stricture-impotencyincontinency
Treatment
o Immediate management : cystostomy
o Delayed urethral reconstruction
urethroplasty.
o Immediate urethral realignment