Urological Trauma Presentations

8/18/2019 Urological Trauma Presentations

1/15

RENAL TRAUMAINCIDENCE• Most common injured organ in trauma, 1% trauma cases, 50% genitourinary trauma• Blunt. 4% significant, Penetrating. 70% significant• Kids 50 RBC, Penetrating >5 RBC)2. Shock + Blunt trauma 5. Suspicious injuries3. Major deceleration injuryDIAGNOSIS THE INJURY Aims: Diagnose and grade injury, Identify any pre-existing anomalies/ pathology (4-19% of adults)

Indications Requirements Pros Cons ONE SHOT IVP OT, Unstable pt 2ml/kg of 60% IV contrast

Single shot 10 mins laterQuickLow radiation

Shock → delayed uptake → false negHigher contrast load

CT SCAN Stable pt Triple phase delayed film Stages 90%Quick +Non-invasive

Tunnel of deathIV contrast + delayed films required

ULTRASOUND CT not available

Fast scan + F/U

Low radiation

Cheap

Less anatomy , Time consuming

Operator dependentANGIOGRAM Isolated renal injury Tertiary centre Ability to embolise High contrast load

Grade:GRADE DESCRIPTIONI Subcapsular, not expandingII 1 cm of renal cortex, not involving collecting system

IV Laceration into collecting system or Main artery or veinV Completely shattered kidney or avulsion of kidney

TREATMENT- SURGICALABSOLUTE INDICATIONS

1. Persistent, life threatening haemorrhage2. Expanding pulsatile retroperitoneal haematomaRELATIVE INDICATIONS1. PUJ avulsion2. Devitalised parenchyma or GSW. Higher risk of re-bleed/ urinoma. (esp if open abdomen)3. Single kidney or poor renal function + Renal artery occlusion (30% to 15% 5. Debride 3. Watertight +/- stent 6. Omental interpositionNephrectomy = Last resort. Risk if: Penetrating or GSW, Unstable + major injury (~100%), Main renal artery injury (65-86%), Main renal vein injury (25-56%)TREATMENT - CONSERVATIVE• Grade IV → spontaneous resolution 87.1%, Non-viable tissue >20% → increased complication rate• Bed rest until urine clears, Monitor: Obs, Hb, Urine, Consider BT, Re-image, Watch for complicationsCOMPLICATIONS Grad e d ep end en t , u sua lly w i th in 1 mo n th

Bleed Grade III or IV, 25% risk of delayed bleeding, 2-36 days, AV fistula = risk factor Bloodvessel Hypertension 37 days - years later (mean 34 mths), Little to suggest surgical intervention avoids

Urinoma (1%) 3 weeks up to 34 years later, 80-90% resolve spontaneously or with conservative Rx Collectingsystem PUJOInfection Abscess

Follow-upGrade I - III: No follow-up imaging required if patient stable and minimal devitalized kidneyGrade IV + V

Initial CT scan 36-72 hr Worsening urinary extravasation, Ongoing haemorrhage, PseudoaneurysmSubsequent Less clear guide lines

(US, CT, Nuclear med)Fever, Flank pain/ mass, Bleeding, ?Hypertension


2/15

CASE SUMMARY: RENAL TRAUMASue Min Ooi, Perth, [email protected] for queries

History32 year old male cycling home 2230 hours @ 40 km/hr. Fell onto tar road, no LOC.Presented at local hospital at midnight with right flank pain and macroscopichaematuria. No known medical illness.

ExaminationAwake and responsive. Haemodynamically stable. R flank tenderness, bruising.Macroscopic haematuria. 2º survey - 3 cm chin laceration.

Action: IV access and fluids, ADT vaccine, bloods, CT organized. IDC –U/A blood, protein.

Progress1 hour later, pale, clammy, SBP 90-100. 2L stat crystalloid. CT – large retroperitonealhaematoma with active arterial bleeding. Right renal laceration. HR 80, SBP 100, Hb129, UEC 140/4.7/4.3/88.

Action: Blood transfusion commenced. Transferred to tertiary centre.

FBP 106/28.8/231 after 3 units packed cells. SBP 100-110. CT (arterial, venous,excretory phases) – large retroperitoneal haematoma displacing kidney anteriorly, GdIV lower pole laceration, no urine leak.

Action: Angiography, super-selective embolisation Cook 2mm x 3cm coil.

Day 3-4 Central chest pain, desaturation to 60% RA. CXR – bibasal consolidation. CTPA – 3filling defects R UL pulmonary artery, L LL segmental arteries.

Action: IV heparinisation commenced.

Day 5-6 Hb 75. Persistent chest and abdominal pain. CT abdomen – increased size ofhaematoma. Selective angiography – no abnormalities, occluded posterior segmental

branch. Action: IV heparin ceased. Pneumatic calf device applied. 4 units packed cellstransfused. IV Timentin.

Days 7-24Haemodynamically stable. Discharged day 24.

Action: Mobilisation, physiotherapy. Oral Augmentin Duoforte. Serial CT. Reintroduction of heparin SC heparin 5000 units tds and IV heparin low dose.Commenced warfarin day 18. Target INR 1.8 - 2.0.

Representation 3 weeks laterIncreasing pain in right abdomen and groin over last 5 days. P/A fullness R flank, mildtenderness, R thigh swelling. Doppler US lower limb negative. CT showed largeloculated collection.

Action: Ultrasound guided aspiration 2.4 L haemoserous fluid drained. Creatininenegative. Symptoms resolved post-procedure.

Outpatient review 3 months later VQ scan negative. CT abdomen – haematoma almost resolved. Small interpolar defectin right kidney. GP to monitor BP, renal function.

ISSUES1. Grade IV renal laceration with segmental arterial bleeding

a. Stabilisation b. Exploration vs embolisation

2. DVT prophylaxis in trauma patienta. Subcutaneous heparin? (bleeding risks > DVT?)

b. TEDS and pneumatic calf compression device

3.

Pulmonary embolism secondary to IVC compression and traumaa. Heparinisation +/- IVC filter4. Large retroperitoneal haematoma

a. Compression of structures (IVC, external iliac vein) b. Liquefaction – long resolution time vs aspiration

5. Medium to long-term implicationsa. Page kidney, hypertension, renal impairment


3/15

URETERIC TRAUMAS. Jaboub/NSW 2007

Incidence: Relatively rare


4/15

Flank pain( +/- Haematuria),mass& incontinence in female (UVF),Vague abdominal pain&Ureteric tissue presence in specimen .

DiagnosisExternal injuries

- High index of suspicion Iatrogenic injuries - Early 7days ≤ days

- Delayed (days → yrs)Diagnostics Studies

Laboratory: ( FBC,EUCUA, Drain ↑Cr.& ↑S-Cr.) Imaging:( RGP Ureteropyeloscopy)

Special Studies :( CT-scan A/P & IVP)

Special Studies:( Indigo carmine & Methylene blue )

Intraoperative DiagnosisA. Endoscopic:Contusions & Perforation → C/E RGP+JJ stent

B. Intraoperative open Surgery Single shot IVP&Optimal exposure,Packing Bowel,Control bleeding,Goodlight,B/L examination of both Ureters. Initial Management: ABCDE ATLSHaemodynamic stability

Associated InjuryDetermine location extent & severity of injury( Preoperative-&Intraoperative)

Surgical Options( open vs minimal invasive)When to Delay Repair ?Delay Repair in : 1. Unstable Pt. for Prolonged Surgery& GA 2. Evidence of active infection e.g. urinoma & abscess 3. Significant oedema& inflammation 4. Rx : Drainage,IV ABS → Apyrexial

Definitive MX of Ureteric InjuryOptions Depend on: 1.Immeiate Recognition 2.Level & Extent 3. Associated InjuriesSurgical Options:

:Upper Ureteral Injuries1.Ureteroureterostomy2.Autotransplantation.3Bowel Interposition

:Midureteral Injuries1.Ureteroureterostomy 2.Transureteroureterostomy3. ureteroureterostomy with renal

mobilization:Lower Ureteral Injuries


5/15

1.Ureteroneocystostomy 2.Psoas Bladder Hitch 3.Boari Flap Follow up

Open Repair C/E,R/O JJ Stent &RGP → 2-3 Wks

Endoureterotomy C/E,R/O JJ Stent &RGP → 6-8 Wks

IVP +Lasix → 6 Wks, 6/12 & 18/12


6/15

Upper Ureteric Trauma -Case PresentationPascal Mancuso

Mechanism8yo BoyPassenger in MVATravelling at 80km/h

T-barred on passenger side of vehicle – collision with tree on driver’s sideRapid deceleration

PresentationAirway: patentC-Spine: hard collar placed at scene by ambulanceBreathing: Decreased AE at R baseCirculation: Haemodynamically stable

Secondary SurveyPain at R lower ribs posterolaterally

Tender R loinSoft abdomenIDC inserted: easily passed into bladder. UA shows large blood

Trauma Series:- C-Spine and Pelvic XRay normallCXR: #Rib10, no haemo or pneumo-thoraxCT abdomen/pelvis with IV contrast arranged – normal kidneys, free retroperitoneal

fluid adjacent to upper ureter. No other solid or hollow visceral injury

ManagementTaken to OT for R RPG and attempt at R ureteric stent – RPG shows contrast

extravasation from the proximal ureter Not possible to pass retrograde stent Radiologist unable to insert an antegrade stent

Intraoperative Findings1cm defect in the ureter 2cm distal to PUJIncomplete transection – approx 75% circumferential defectPink, bleeding edges

ProcedurePrimary ureteroureterostomy with spatulation of both ends of ureterSingle-length stent inserted

Interrupted 3/0 monocryl sutures used for anastomosisPrinciplesTension freePreserve peri-ureteric adventitia

Post-opIDC for 24-48 hoursDrain to remain in for at least 24 hours after IDC removed – longer if large drainage

seenStent removal and RPG at 6-8/52


7/15


8/15

NMC: Nov 2007

Bladder TraumaClassification by mechanism of injury: Blunt, penetrating, iatrogenic

Clinical Features• Gross haematuria (>95%)• Suprapubic pain/tenderness• Inability to void• Signs of pelvic/perineal trauma

• Delayed presentation: Abdo distension, ileus, urinary ascites, Cr,acidosis, sepsis

Asses sment : Indications for Imaging (Plain or CT cystogram)• Absolute: Gross haematuria with pelvic # (rupture ~30%)• Relative:(Incidence of bladder rupture


9/15

Bladder Trauma – Case presentation summary – Dr. R. Tong

22 year old maleMCA: Driver vs Tree, 100km/hrNo past history

Primary survey: Airway clear, Spont. breathingHaemodynamically stable.Retrograde amnesia, GCS 15

Secondary survey:Lacerations to scalpLower abdominal pain and pelvic painNo blood at meatus – IDC inserted by emergency-> Easy passage-> Macroscopic haematuria

Investigations:Pelvis XRay: Fracture bilateral pubic rami, Left acetabulum, Right sacral ala.CT Abd/Pelvis:Extensive intraperitoneal fluid, small splenic laceration, Kidneys normal, bladder dome defect.

Bloods:Hb 143, WCC 30.7, Plt 218Na 143, K 3.5, Cl 108, HCO3 26, Cr 210, Urea 9.0

Laparotomy:Findings: Free urine, Mild bowel contusions, Organs normal, 3cm perforation of bladderdome, Ureteric orifices normal.Closure: 2 layers, 2/0 chromic catgut

Urethral catheter, Extravesical drain.

Day 10 retrograde cystogram- No leak- Successful trial of void

24/24 IV antibiotic


10/15

Urethral Trauma

Posterior urethral injuries• Male urethra involved in up to 19% of pelvic fractures• Female urethra rarely injured (0-6% of pelvic fractures)• 90% of posterior urethral injuries occur with blunt trauma• Shearing forces disrupt the prostatomembranous junction

o Studies have shown that this is usually distal to the membranous urethra (but may involve themembranous urethra and in severe trauma the prostatic urethra)

Pelvic fractures• Type of fracture associated with different risk of urethral trauma

o Straddle fractures with SIJ disruption have the highest incidence of associated urethral trauma

Types of injury and assessment on retrograde urethrogram• Contusion: Blood at the meatus with normal RUG (no treatment required)• Stretch: Contrast into the bladder with elongated urethra (SPC or IDC)• Partial rupture: Contrast into the bladder with some extravasation (SPC or IDC)• Complete disruption: No contrast into the bladder with extravasation into the perineum

o Can be subdivided into 2cm disruptiono Requires open or endoscopic treatment, primary or delayed

Diagnosis and initial management• Primary survey and resuscitation• If there is no blood at the meatus, urethral injury is very unlikely• H&P and appropriate imaging• Retrograde urethrogram for suspected urethral injury

Management• Primary repair

o Poor visualisationo High impotence and incontinence rates (56%, 21%)*o Restricture rate 49% (most managed endoscopically*

• Delayed primary repairo SPC placed at presentationo Repair performed when patient stable (10 - 14 days)o Stricture free rate of up to 80%*o No data on incontinence or erectile dysfunction

• Primary realignmento Urethroplasty simplified in aligned urethrao Early series showed higher rates of erectile dysfunction and incontinence when compared to

delayed repairo EAU meta-analysis of 20 series*:o Erectile dysfunction 35.3%o Incontinence 5.2%o Restricture rate 60.2%

• Delayed urethroplastyo Requires placement of SPCo Minimum 3 months post injuryo Stricture rate 97% # o Restricture rate after delayed repair 10%*o Incontinence 4% # o Erectile dysfunction 19% #

• Delayed endoscopic optical incisiono “Cut to the lighto Restricture rate of 80%o Low incidence of erectile dysfunctiono Only recommended for short strictures with good urethral alignment

• Delayed urethroplasty versus primary realignmento All patients will require complex urethral surgery following SPC for delayed urethroplastyo Most strictures following primary realignment can be managed endoscopicallyo 1.6 vs 3.1 procedures in favour of primary realignment $ o Similar rates of erectile dysfunction and incontinence in both groups

Conclusions• Delayed repair historically considered the gold standard• Primary realignment similar incidence of incontinence and erectile dysfunction in recent series• Primary repair poor outcomes• Delayed primary repair inferior option to primary realignment• Endoscopic “cut to the light” should only be considered for small defects

References• * EAU Guidelines on urologic trauma January 2006 39-63• # Koraitim J Urol 1996; 156(4): 1288 – 1291• $ Mouraviev et al J Urol 2005; 173(3): 873-876• AUA Update Series Lesson 2005 30 Volume 24: Primary realignment of the traumatic urethral distraction


11/15

1

1 Urethral TraumaCase PresentationNick BuchanBrisbaneTrainee WeekVictoria 2007

2 The Case! 23 year old male.! MVA. Seat belted.! High speed frontal impact.! Car completely destroyed. Airbag deployed.! Other driver killed.! Patient conscious at the scene.

3 Initial presentation to Hospital.! A: Clear. C-spine protection. On backboard.! B: A/E symmetric. O2 sats n. No crepitus. Trachea central.! C: BP:100/60 HR:100.! D: GCS=15 PERL.! Pt exposed.C/O lower abdominal as well as right hip and leg pain.

4 Secondary Survey! Mild suprapubic tenderness.! Pelvic instability.! Probable right tibial #.! Blood at the meatus.! DRE normal.

5 Initial Management! Fluid resus. Stabilized vital signs.! Plain X-rays trauma series.

C-spine, CXR normal.! Pelvis unstable #. With fractures through the pubic symphysis, pubic rami

on the right and SI joint.! Mid tibial fracture.

6 Retrograde Urethrogram- Key points.1. Plain film to reveal

fractures.2. Supine slightly oblique

positioning.


12/15

2

3. 14-16 Fr Foley.2mls in balloon. 2cmsinside urethra.

4. 50-100mls of water soluble contrast under gentle pressure. Need to distend urethra.5. Fluoroscopy if possible.6. Post void x-ray.

7 RUG - Complete Posterior Urethral Tear.8 Mechanism of Injury.

! Shearing injury through the membranous urethra.

9 Partial Urethral Tear ! Extravasation.! Contrast in bladder.

10 Initial Urological Management! Supra-pubic catheterization.

! Subsequently transferred to theatre for external fixation of pelvis.11 Definitive Urological Management.

! The supra pubic catheter remained in-situ for four months.! A delayed end to end bulbo-prostatic anastomotic urethroplasty was

undertaken.

! Crural seperation was required.12 Delayed Urethroplasty.13 Follow Up at 6 weeks.

! Catheter removed at 2 weeks following a peri-catheter urethrogramshowing no leak.

! No erectile function at present.! No significant LUTS.! Back to work as School Teacher.


13/15

Penetrating genital injuries Exclude other life threatening injuries in field of missile Urethrography and pelvic CT essential.

Penis • Superficial wounds – irrigate and close • Deeper structures: SPC, immediate exploration,

haemostasis, debridement of necrotic tissue and primary reconstruction

Testis • Penetrating trauma bilateral in 30% • Management is surgical exploration with debridement of

dead tissue and primary reconstruction where possible • Complete spermatic cord transection can be repaired if

patient stable. Penile amputation

Usually self inflicted during episode of acute psychosis. Not uncommon Reattachment possible if


14/15


15/15

Anthony Hutton NSW section

Genital Trauma – Blunt Scrotal TraumaCase Presentation

History

24 yo male jockeyBucked from horse with associated straddle injuryImmediate right testicular pain and swellingWearing helmet, no HI, no LOC, no other injuriesPresented to ED 3hrs post injury

Examination

Obvious discomfortABCDE and secondary survey NADScrotum

- left testicle normal- right hemiscrotum dusky, large tender mass upper scrotum c/w haematoma

No meatal blood, no perineal bruising

Investigations

Urine microscopy – no microscopic haematuriaScrotal ultrasound – Right testicle mixed echogenic appearance, with minimal normalappearing testicular tissue. Moderate right haematocoele. No intratesticularvascularity.

Treatment

Proceeded to scrotal exploration – consented for possible orchidectomy.At operation

- scrotal approach- moderate haematocoele- large intra-testicular haematoma- superior pole rupture with extrusion of seminiferous tubules- following debridement – extensive intra-testicular haematoma – non-

viable- Proceeded to orchidectomy

Post-op

Uneventful recoveryFinal pathology – confirmed intra-testicular haematoma with diffuse interstitialhaemorrhage, very small rim of viable tissue. No evidence of malignancy.

Urological Trauma Presentations

Documents

Transcript of Urological Trauma Presentations