1. بسم الله الرحمن الرحيم

2. Injuries to the male urethra Injuries to the male urethra By Dr.Zaid Saadeldin khudher MBChB,FIBMS,FEBU

3. Anatomy

4. Rupture of the bulbar urethra History of a blow to the perineum usually due to a fall a stride a projecting object Clinical FeaturesClinical Features :The triad of signs is retention of urine, perineal hematoma & bleeding from the ext. urinary meatus

6. Preliminary assesment & treatment Analgesic Drugs Discourage patient from passing urine& if bladder is full perform percutaneous suprapubic cystostomy((this will reduce the likelyhood of urinary extravasation &allow appropriate investigations to establish the full extent of urethral injury))

7. Kit for percutaneous suprapubic drainage of the bladder.

8. Treatment of rupture bulbar urethra Its controversial,the main warry is that injudicious catheterisation will convert partial into complete transection of the urethra more information obtained by ascending urethrogram or flexible cystoscopy to asses the inj. If complete tear of the urethra then leave suprapubic catheter until repair

10. Treatment..(cont.) Some surgeons advocate early open repair of urethra with excision + spatulation + end to end anastamosis of the urethra Other surgeons wait longer

11. Complications Subcutaneous extravasation of urine in complete rupture if the patient attempt to pass urine. stricture is common sequel whether there is partial or complete tear infection

12. Rupture of the Membranous Urethra Intrapelvic rupture of membranous urethra occurs near the apex of the prostate

13. Clinical Features Two types of fracture pelvis.. 1.hemipelvic displacement 2.butterfly fracture about 10-15%of cases of fractured pelvis have associated urethral inj. There is often multiple trauma with inj to head thorax & abdomen

17. Clinical features (cont.) The type of ureth. inj. can often be deduced from the plain radiograph There may be associated inj. to the bladder with either intra or extra peritoneal rupture Intraperitoneal rupture associated with peritonitis

18. Clinical features (cont.) Extra peritoneal rupture of the bladder cause symptoms like rupture memb.urethra if the prostate is displaced it may be impossible to reach or appear to be very high on DRE

19. Treatment : ABC..to keep patient a live the ureth. Inj.can be managed in the short term by inserting a suprapubic cath. Intraperit. rupture of UB=exploration &repair of UB Extraperit. rupture ofUB=repair +suprapubic cath.+retroperit. drain

20. Complications: 1.Urethral stricture 2.Urinary incontinence: if the ext. urethral sphincter is destroyed continence will depend upon competence of bladder neck mechanism 3.Impotence..this is the result of damage to the nerve supply of penis 4. Extravasation of urine

21. Renal Transplantation

22. One of the early Boston recipients of a kidney transplant from an identical twin, shown here with her twin sister and their children.

23. Types of graft rejection Hyperacute Immediate graft destruction due to ABO or pre-formed anti-HLA antibodies. Characterised by intravascular thrombosisAcute Occurs during the first 6 months T-cell dependent, characterised by mononuclear cell infiltration Usually reversible

24. Chronic Occurs after the first 6 months Characterised by myo-intimal proliferation in graft arteries leading to ischaemia and fibrosis

25. Patient selection Renal transplantation is the preferred treatment for many patients with end- stage renal disease because it provides a better quality of life than dialysis.

26. Evaluation of potential recipients for organ transplantation Determine presence of comorbidity Exclude malignancy and systemic sepsis Evaluate against organ-specific criteria for transplantation

27. Causes of allograft dysfunction EarlyEarly Primary non-function (irreversible ischaemic damage) Delayed function (reversible ischaemic injury) Hyperacute and acute rejection Arterial or venous thrombosis of the graft vessels Drug toxicity (e.g. calcineurin toxicity) Infection (e.g. CMV disease in the graft) Mechanical obstruction (ureter/common bile duct

28. LateLate Chronic rejection Arterial stenosis Recurrence of original disease in the graft (glomerulonephritis, hepatitis C) Mechanical obstruction (ureter,common bile duct)

29. Immunosuppressive agents CorticosteroidsCorticosteroids : Widespread anti-inflammatory effects. Azathioprine:Azathioprine: Prevents lymphocyte Proliferation. Ciclosporin:Ciclosporin: Blocks IL-2 gene transcription

32. Thank you for your attention