Retroperitoneal Collections;Retroperitoneal Collections; Causes , Diagnosis and Causes , Diagnosis and

ManagementManagement

Dr Maha Khalid AL MadiDr Maha Khalid AL MadiUrology ResidentUrology Resident

KFHU – Khobar – Saudi ArabiaKFHU – Khobar – Saudi Arabia20102010

Objective…

Retroperitoneal anatomy Interfascial planes Interfascial plane extensions Retroperitoneal collections & extension Retroperitoneal Hematoma

- Causes- Approach to RPH- Diagnostic imaging- Management

Retroperitoneal Anatomy

Retroperitoneal Anatomy

The retroperitoneum is conventionally divided into three distinct compartments:

Retroperitoneal Anatomy

1 . Posterior pararenal space,

Fat

connective tissue nerves

Retroperitoneal Anatomy

2 . Anterior pararenal space

Colon

Pancreas

Duodenum

Retroperitoneal Anatomy

3. Perirenal space

Kidneys

Adrenal glands

Upper portion of ureters

 

Interfascial Planes

Interfascial Planes

• Tricompartmental anatomy does not completely explain the spread of fluid collections.

• Collections tend to escape site of origin into expandable interfascial planes.

Interfascial Planes

• These interfascial planes are represented by

- Retromesenteric

- Retrorenal

- Lateroconal interfascial plane,

- Combined interfascial planes

Interfascial Planes

The Retromesenteric plane

Expansile plane located between the APR and PRS

Interfascial Planes

The Retrorenal plane

Between the PRS and PPS

Interfascial Planes

The lateral conal interfascial plane

Between layers of the LCF. It communicates with the RMP and RRP at the fascial trifurcation.

Interfascial Planes

The combined interfascial plane

formed by the inferior blending of the RMP and RRP . It continues into the pelvis.

Interfascial Planes

The fascial trifurcation

The point at which the RMP, RRP, and LCF planes communicate mutually

Interfascial Plane Extensions

Interfascial Planes

Medial Extension

• RMPs and RRS are continuous across the midline.

Interfascial Planes

Right superior extension

• The superior PRS is in continuity with the bare area of the liver

Interfascial Planes

Left superior extension

• The RMP ,RRP and PRS on the left extend to the left hemidiaphragm

Retroperitoneal collections & their

extensions

Types of Collections

- hemorrhagic

- bilious

- uriniferous

- enteric

- infectious

- inflammatory

- malignant

Extension of fluid collections

• Fascial planes/adhesions confine retroperitoneal fluid collections to their compartment of origin

• Large or rapidly developing fluid collections may decompress along retroperitoneal fascial planes

Extension of fluid collections

Fluid originating from the APS

Pancreatitis Pancreatic injury Appendicitis abscess of the colonic wall

Extension of fluid collections

Fluid originating from the PRS

Ruptured AAA

Renal injury Hge/urinoma

Extension of fluid collections

Fluid originating from the PPS

bleeding after spinal trauma/surgery

Extension of fluid collections

Pelvic Extension

By the infrarenal retroperitoneal space

RetroperitonealHematomas

Causes

factor IX ,X deficiency, von Willebrand APL syndrome anticoagulation*

*0.6-6.6% of patients undergoing therapeutic anticoagulation.Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: nt J Clin Pract. 2008;

Injury ( to bony structures, major vessels, intestinal or retroperitoneal viscera)

Iatrogenic

Great Vessel Injuries

Rupture of AAA

• Most bleed posteriorly confined by the psoas space or extend into the retrorenal interfascial plane behind the left kidney.

Great Vessel Injuries

IVC Injury

• Often found to bleed directly into the right retrorenal space.

Perirenal Hematomas

• Renal trauma (incidence 5%)*• Helical CT is the imaging modality of choice in

stable patients

* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: nt J Clin Pract. 2008;

Perirenal Hematomas

• Hematoma from the PRS spreads by bridging septa to the interfascial planes

• From there can spread upward near the esophagus or downward to the pelvis

Pelvic fracture w/ Hematoma

2 Routes of spread are possible

- from the PPS into the combined interfascial plane,

- from the prevesical space to the combined interfascial plane.

Pelvic fracture w/ Hematoma

• Can then ascend within the combined interfascial plane into the

RRS

RMP

Approach to RPH

Approach to RPH

• The location and mechanism of injury guide the decision to explore

• the midline retroperitoneum (zone 1)

• the perinephric space (zone 2)

• the pelvic retroperitoneum (zone 3)

Approach to RPH

ZONE 1

ZONE 2

ZONE 3

Approach to RPH

zone IMandates exploration for both penetrating and blunt injury because of the high likelihood of major vascular injury in this area.

zone I (central) retroperitoneal hematoma with active extravasation from ruptured AAA

Approach to RPH

zone IIinjury to the renal vessels or parenchyma and mandates exploration for penetrating trauma

A nonexpanding stable hematoma resulting from a blunt trauma mechanism is better left unexplored

 Large zone II (lateral) retroperitoneal hematomaFrom renal injury

Approach to RPH

zone III

• Penetrating trauma mandates exploration

• Blunt trauma are usually with pelvic fractures management is based external fixation or angiographic embolization

Approach to RPH

Clinical Presentation

• Is varied ,may be vague, and diagnosis is often missed

• Patients initially exhibit subtle clinical signs of hypotension and mild tachycardia that transiently improves with administration of fluids.

Approach to RPH

Clinical Presentation

• Patients may present with back, lower abdominal or groin discomfort and swelling,

May progress to haemodynamic instability.

Approach to RPH

Diagnostic Imaging

• Plain abdominal /pelvic XRAY may demonstrate ;

loss of the psoas shadow unstable pelvic ring fracture

Approach to RPH

Diagnostic Imaging

• Ultrasound is often limited

• Free fluid often passes into the abdominal or pelvic cavity, and can be detected as free abdominal fluid on US

Approach to RPH

Diagnostic Imaging

• CT (type, site and extent of fluid collections(

• CT Angio shows the site of the bleed and contrast outside the vessels

Approach to RPH

Diagnostic Imaging

• In haemodynamically unstable, digital subtraction angiography with selective embolisation or placement of a stent graft is indicated.

Approach to RPH

Management

• Controversial.

• all patients should initially be managed in an intensive care unit with careful monitoring, fluid resuscitation, blood transfusion and normalization of coagulation profile

Approach to RPH

Management

• If the patient is haemodynamically stable with no evidence of on-going bleeding, conservative management is recommended *

* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: Iatrogenic Retroperitoneal Bleed by .C. Chan,1 J.P. Morales,1 J.F. Reidy,2 and P.R. Taylor 1

Int J Clin Pract. 2008;

Approach to RPH

Management• In spontaneous RPH the mainstay of

management remains conservative,

withdrawal of anticoagulation

correction of coagulopathy

volume resuscitation

* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: Iatrogenic Retroperitoneal Bleed by .C. Chan,1 J.P. Morales,1 J.F. Reidy,2 and P.R. Taylor 1

Int J Clin Pract. 2008;

Approach to RPH

Endovascular Treatment

• Selective intra-arterial embolization OR stent-grafts.

• Indication: HD instability despite ≥ 4 units of blood IN 24 h, or ≥ 6 units in 48 h

Approach to RPH

Open Surgery

• Indications

- the patient remains unstable

- interventional radiology is not successful or unavailable.

- patient develops abdominal compartment syndrome

Approach to RPH

• RPH (Zone 1) after penetrating trauma implies injury to the great vessels and always requires urgent surgical exploration.

Approach to RPH

• RPH in other zones should be evaluated by CT and/or angiography; ongoing hemorrhage may respond to therapeutic embolization

Thank Thank YouYou

References…•Comprehensive reviews of the interfascial plane of the retroperitoneum: normal anatomy and pathologic entitiesSu Lim Lee & Young Mi Ku & Sung Eun Rha28 April 2009 Soc Emergency Radiol 2009

Cameron: Current Surgical Therapy, 9th ed. By JOHN L. CAMERON, MD, FACS, FRCS

Sabiston Textbook of Surgery, 18th ed by Beaughamp,Evers, Mattox

Management of Retroperitoneal Haemorrhage, Y.C. Chan; J.P. Morales; J.F. Reidy; P.R. Taylor, Int J Clin Pract. 2008http://www.medscape.com/viewarticle/582645

•Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings1 October 2008 RadioGraphicsKevin P. Daly, MD, Christopher P. Ho, MD,