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( Lecture ) Trauma in Urology
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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)
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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
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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
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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,...)
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Complications Early: Haemorrhage, retroperitoneal urinoma, haematoma, abscess Late: Hypertension, AV fistula, calculi, PNF, late bleeding
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Ureteral injuries Pelvic surgery (uro, gyn, gen.s.)
Pelvic/abdomninal masses PID post RT Penetrating injury
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Clinical findings Flank pain, tenderness Sepsis Hydronephrosis!!
Paralytic ileus VV / UV fistula / watery discharge via vagina/ Labs /CRP,Leu,urinalysis,creatinine/
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Imaging USG IVU / enhanced CT ! APG Radionuclide scanning
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Treatment First-line urinary diversion !!! (nephrostomy, ureteral stenting) Reconstructive surgery /reanast., reimpl., substitutions, crossed diversion, autoTPL…/
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Bladder injuries direct external force, road accidents
iatrogenic / gyn-obs, uro, sur/
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intraperitoneal disruption
extraperitoneal disruption
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Clinical finding Haematuria
Pelvic , abd. pain (pelvic fracture presented in 90% of bladder inj.) Haemorrhage, Shock Acute abdomen !!! (intraperit)
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Imaging Pelvic & Abdominal USG Cystography (300ml) ! CT cystography
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Treatment Extraperit. – bladder drainage (epi, catheter)
Intraperit. – open surgery required!
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Urethral injuries Posterior/ Anterior urethra
Laceration, transection, contusion External forces (falls astride an object, perineal blow, …) Iatrogenic (catheter, uro )
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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 !
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X- Ray (pelvic fracture)
Urethrography !!
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Treatment drainage (suprapubic cystostomy)
immediate surgery (suspected bladder lacerations, disruptions, massive pelvic bleeding, etc.) delayed surgery (>3 months after the injury)
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Complications after delayed surg.repair
Incontinence % Stricture %
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Anterior urethra straddle injury iatrogenic instrumentations
self-instrumentations
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Clinical findings perineal, penile, scrotal haematoma
urethral bleeding normal DRE
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Diagnosis Urethrography
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Treatment suprapubic cystostomy
surgical repair (in case of urethral laceration, bleeding w/o extravasation) follow-up (stricture!)
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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)
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