A6- Urological Trauma Flashcards
1
Q
Renal trauma is most common in….
A
young males
2
Q
What are the common mechanisms of injury in renal trauma
A
- Blunt injuries: MVAs, falls, sporting injuries, and assault
- Penetrating injuries: stab and gunshot wounds
3
Q
effects of blunt injuries
A
- The kidney and/or hilar structures are directly crushed as a result
- Less commonly, sudden deceleration may result in an avulsion injury affecting the vascular structures of the hilum or the pelvoureteric junction (PUJ)
4
Q
effects of Penetrating injuries: stab and gunshot wounds
A
- Tend to be more severe and less predictable than blunt trauma.
- Prevalence is higher in urban settings
- High-velocity bullets - greatest parenchymal destruction/ multiple-organ injuries
5
Q
Special considerations for renal trauma
A
- Known hydronephrosis or renal abnormality
- Single kidney
6
Q
: Indications for Renal Imaging
A
- visible haematuria
- non-visible haematuria and one episode of hypotension
- a history of rapid deceleration injury and/or significant associated injuries
- penetrating trauma
- clinical signs suggesting renal trauma e.g. flank pain, abrasions, fractured ribs, abdominal distension and/or a mass and tenderness.
7
Q
CT in renal trauma - 3 phase
A
- arterial phase: assesses vascular injury and presence of active extravasation of contrast
- nephrogenic phase: optimally demonstrates parenchymal contusions and lacerations
- delayed phase (5 minutes): identifies collecting system/ureteric injury
8
Q
What is the Renal injury grading scale
A
9
Q
Principles of management renal trauma
A
The initial management – ATLS principles
- Polytrauma should be managed in major trauma centres
- Damage control – limiting: hypothermia, coagulopathy and acidosis
10
Q
Management of Blunt Trauma
A
- Haemodynamically stable patient conservative management is preferred treatment option
- Bed rest, serial Hb and renal function, regular observations and repeat imaging
- Primary conservative management is associated with lower rate of nephrectomy and no increase in immediate or long term morbidity
11
Q
Blunt trauma grades management
A
- Grade 1 - 3 non-operatively
- Grade 4 - conservative, but intervention is higher urinary extravasation stent and/or percutaneous drainage
- Grade 5 - haemodynamic instability and major associated injuries There is thus a higher rate of exploration and nephrectomy
12
Q
What are some Reasons for surgical management
A
- Persistent haemodynamic instability or grade 5 vascular injury
- May require nephrectomy or debridement and partial nephrectomy
- Selective embolisation may have a role
13
Q
Complications of renal trauma
A
- Early (< 1 month) : bleeding, infection, perinephric abscess, sepsis, urinary fistula, hypertension, urinary extravasation and urinoma.
- Delayed : include bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension, arteriovenous fistulae (AVF), hydronephrosis and pseudo-aneurysms.
14
Q
Classifciation of bladder trauma?
A
- Intraperitoneal / Extraperitoneal / Combined
- Non iatrogenic / Iatrogenic
15
Q
Non iatrogenic mechanisms of injury
Extraperitoneal:
A
- associated with pelvic fractures
- shearing of the anterolateral bladder wall near the bladder base (at its fascial attachments), or by a contrecoup at the opposite side
- Rarely directly perforated by a sharp bony fragm
16
Q
Non iatrogenic mechanisms of injury
• Intraperitoneal:
A
- sudden rise in intravesical pressure of a full bladder – dome ruptures
- penetrating injuries rare except in conflict zones
17
Q
Iatrogenic Injury
examples
A
- Intra-operative: visible laceration, visible bladder catheter, and blood and/or gas in the urine bag during laparoscopy
- During TURBT / TURP: cystoscopic identification of fatty tissue, dark space, or bowel, inability to distend the bladder, low return of irrigation fluid, or abdominal distension
- Post-operatively: missed bladder trauma is diagnosed by haematuria, abdominal pain, abdominal distension, ileus, peritonitis, sepsis, urine leakage from the wound, decreased urinary output, or increased serum creatinine
18
Q
Indications for imaging - Trauma
A
• visible haematuria and a pelvic fracture or non-visible haematuria combined with high-risk pelvic fracture
- inability to void or inadequate urine output
- abdominal tenderness or distension due to urinary ascites, or signs of urinary ascites in abdominal imaging
- uraemia and elevated creatinine level due to intraperitoneal reabsorption
- entry/exit wounds at lower abdomen, perineum or buttocks
19
Q
Imaging for bladder trauma
A
• Cystogram:
Cystoscopy
20
Q
Prevention for bladder trauam
A
- Catheterisation: should be catherised in surgical procedures etc
- GA and muscle relaxation at TURBT
21
Q
Management for Bladder Trauma
A
- Recognise it
- Extraperitoneal Rupture • catheter, antibiotic prophylaxis
- Intraperitoneal – • small injuries managed conservatively but might require drainage • closure with absorbable sutures • Leave catheter for 5-10 days
22
Q
Ureteric Trauma
Iatrogenic/Non Iatrogenic
Which more common mechanism of injury
A
Iatrogenic
23
Q
Ureteric Trauma
Iatrogenic Injury causes
A
24
Q
Ureteric Trauma
Ix?
A
- Suspect it and exclude it
- Post operative clinical signs: flank pain, urinary incontinence, vaginal or drain urinary leakage, haematuria, fever, uraemia or urinoma.
- Early diagnosis is the key
- CTU in trauma or post op setting
- Retrograde pyelogram in the intra operative setting
25
Ureteric Injuries
Management of Minor injuries
* Small fistulae
* Ligation injuries
* May be managed with ureteric stenting
* May be antegrade or retrograde
26
Ureteric Injuries
Management of Major injuries
* Immediate repair if injury is recognised and patient is stable
* Nephrostomy drainage if not
27
What are the Principles of ureteric repair
* Debridement of necrotic tissue
* Spatulation of ureteral ends
* Watertight mucosa-to-mucosa anastomosis with absorbable sutures
* Internal stenting
* External drain
* Isolation of injury with peritoneum or omentum
28
Urethral Trauma
Male causes
_Anterior (Bulbar)_
* bulb compressed against pubis
* astride / kick / stab / bite
* Iatrogenic – catheterisation related
_Posterior_
* Mostly MVA related
* Significant risk of other major injury
29
Urethral Trauma
Female causes
* Birth related most common
* Less common in pelvic fracture
* Sling procedures complicated by injury in 0.2-2.5%
30
Ix for Urethral Trauma
* Blood at the meatus (introitus) / inability to void / extravasion
* Rectal examination for high riding prostate
* Urethrography
* Flexible Cystoscopy
* USS – useful for insertion of suprapubic catheter
31
Urethral Damage
Management – bladder drainage
* Attempt a gentle passage of urethral catheter
* Insertion of a suprapubic catheter but BEWARE
* bladder displaced by the pelvic haematoma
* poor bladder filling due to haemodynamic shock or concomitant bladder injury
* a suprapubic catheter should be placed under US guidance or under direct vision for example, during laparotomy for associated injuries
Small injuries may be repaired early particularly in women
• A wide variety of treatment strategies
32
Testicular trauma'
causes
* Blunt trauma occurs when there is compression of the testis against the inferior pubic ramus or symphysis
* Rupture of tunica albuginea
* In conflict zones from stepping on land mines
33
Ix for testicular trauma?
History – immediate pain, nausea, vomiting and sometimes feinting
• Ultrasound is investigation of choice
34
Management for testicular trauma
Early surgical exploration to preserve viable tissue
35
common mechanisms of injury for Penile trauma
* Most commonly when the penis is erect • Sexual intercourse • Forced flexion • Masturbation • Rolling over
* May be part of other major trauma
36
Ix for penile trauma?
* History • Sudden cracking or popping • Pain • Immediate detumescence • Local swelling
* MRI is imaging modality of choic
37
Penile trauma
Management
* Surgical intervention with closure of the tunica albuginea
* 5% have urethral injuries
* Monitor and treat erectile dysfunction
