INJURIES TO THE GENITOURINARY

TRACTS.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 urographyC.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 hematuria2)-grade II renal parenchymal laceration perirenal hematoma3)-grade III laceration extending into the renal medulla large retroperitoneal hematoma4)-grade IV laceration extending into the renal collecting system-artry injuries5)-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

TreatmentA.Emergency measuresB.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 ureterEtiology: -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 excretion- accumulation in renal pelvis

Differential diagnosis

Bowel obstruction deep wound infectionPeritonitis acute pyelonephritisFever

Treatment o The best opportunity:in the operating room-until 7-10 dayso Lower ureteral injuries:reimplantation-

ureteroureterostomy-bladder tube flap-trans- ureteroureterostomy

o Midureteral injuries:ureteroureterostomy or trans u. ureteostomy

o Upper ureteral injuries:ureteroureterostomy-auto transplantation-bowel replacement

o Stentingo Prognosis:excellent

Injuries to the bladdero Usually due to external forceo Often associated with perlvic fracture(15% of

pelvic fractures)o iatrogenic injury

Clinical findingso 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-peritonitis-

incontinency(partial)

Treatmento Extraperitoneal:foley cath

(bladderneck injury-large bloodclots→surgical management)

o Intraperitoneal:surgical repair

oPrognosis :excellent

Inguries to the urethraClinical findings:lower abdominal pain-

inability to urinate-blood at the uretheral meatus-prostate displacement-perineal hematoma

X-Ray findings:pelvic fracture-extravasation

Complications:stricture-impotency-incontinency

Treatment o Immediate management : cystostomy

o Delayed urethral reconstruction urethroplasty.

o Immediate urethral realignment