Surgery Report Urology Trauma Oct.27

8/6/2019 Surgery Report Urology Trauma Oct.27

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This is a 61-slide presentation.Brace yourselves.


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UrologyUrology|Traumaby Alegro, Orbino, Ranario, Relatorres

Urology

Trauma

Trauma

Tra

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U

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gy

Traum

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OUTLINE OF TOPICS

I. Infections

II. Malignancies

III.TraumaIV. Emergencies

V. Lower Urinary TractObstruction


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You still remember this, right?

Kidneys

Ureters Urinary bladder

Urethra


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KIDNEY


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Facts

Approximately 10% of traumasinvolve the urologic system,most commonly the kidneys

(9th ed. Schwartz).

Renal injuries are more common

during blunt trauma,accounting for 90% ofinjuries to the kidney (8th ed.Schwartz).

The best study for evaluatingthe kidneys is a helical

abdominal CT scan with IVcontrast.

A CT scan should be performedfor all penetrating traumas.


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Who should undergo RadiographicImaging of the Kidneys?

Adult and Pediatric patientswith major decelerationinjury, shock, gross ormicroscopic hematuria

and systolic bloodpressure less than 90 mmHg at any point during thetransport andresuscitation.

All patients with penetratinginjuries to the flank orabdomen and lower ribfractures, (exception) ifunstable and requiringimmediate exploration.

*From Schwartz 8th and 9th Ed.


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Blunt Renal Trauma

.) , /A Left Kidney w severaldeep

lacerations in the collecting.system

.Large perirenal hematoma

(Bicycle Accident)

.)B CT image @ 45 daysshowing significant

improvement in the

appearance of the kidney


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Classification of Trauma

staging system for renal injury was developed by the American Associatio


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Classification of Trauma

Renal injuries are classified by extent ofdamage .

Approximately 95% of renal traumas are grade 1.

Approximately 98% of renal injuries can bemanaged nonoperatively.


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Indications

The only absolute indications for surgicalmanagement of a renal injury are persistentbleeding resulting in hemodynamic

instability or an expanding perirenalhematoma.

Relative indications for surgical management

include major urinary extravasation,vascular injury, and devitalized parenchymaltissue.


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Indications


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Studies show that even large urinary

extravasations will resolve with conservativemanagement.

Smaller vascular injuries resulting in devitalizedtissue also can be managed without surgery;however, if the amount of devitalized tissueexceeds 20% of the renal tissue, surgicalmanagement leads to quicker resolution of the

injury and to fewer subsequent complications.


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When do we manageconservatively?

Blunt traumatic injuries -Managed conservatively

Urinary extravasation - does not require exploration,but reimaging is necessary and, if persistent leakageis present, astentornephrostomy tube is indicated.

High-grade renal injuries are associated with significantbleeding, but patients who are stable and without apulsatile or expanding hematoma can be observed.

Most grade IV injuries can be managed nonoperatively.

Patients typically are placed on restricted activityuntil hematuria resolves.


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When do we do exploration?

Penetrating renal injuries Exploration

All Grade V vascular injuries should beconsidered for immediate exploration, a

delay of several hours greatly decreases therisk of renal salvage.

If the IVP is abnormal or the hematoma is

pulsatile. When the renal hilum is controlled.


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Remember!

Surgical exploration should be performed througha midline approach.

The renal vessels should be identified andcontrolled prior to opening Gerota's fascia, inorder to allow the vessels to be rapidly occludedif massive bleeding is encountered.

Injuries to the collecting system should berepaired by a watertight closure.

Devitalized tissue should be excised andmeticulous hemostasis should be obtained byligating open segmental vessels.


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Remember!

If immediate operative exploration for other injuries isrequired, renal injury staging can be performed while inthe operating room.

If concern exists over renal injury or the presence of aretroperitoneal hematoma, a single-shot, 10-minutedelayed IV pyelogram (IVP) (2 mL/kg contrast) is usefulat assessing the presence of two functional kidneys andextent of injury.

Although rarely necessary, temporary control of the renalhilum may decrease the need for nephrectomy when a

significant injury is found on exploration. Complete exposure is necessary to evaluate the extent of

injury.


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Remember!

All nonviable tissue should be dbrided and segmentaland intralobar arteries ligated with 4-0 chromic orpolydioxanone sutures.

If the collecting system is injured, it should be repaired

immediately A stent and percutaneous drain should be considered to

prevent urinoma formation.

A partial vascular injury to the renal vein or artery canbe repaired with 5-0 or 6-0 Prolene sutures.

A complete injury may require dbridement, and if anend-to-end anastomosis cannot be performed, avascular graftmay be required.


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URETER


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URETER


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The retroperitoneallocation of the ureterprotects it from

external trauma, andblunt injury is rare butcan occur with rapiddeceleration injuries.

The ureter also is frequently

injured intraoperatively,most commonly fromopen and laparoscopicsurgical proceduresincluding hysterectomy,

low-anterior colonicresections, or aorticsurgery.

Any penetrating traumainvolving the

retroperitoneum shouldunder o evaluation with


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Epidemiology Ureter is involved


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Surgical repair depends onlocation and extent of injury

a)Partial injuries can be primarily repaired,

although all devitalizedtissue must be dbrided toavoid delayed tissuebreakdown and urinoma

formation. Ureteral stents should be

placed in this situation tofacilitate healing withoutstricture.

The main complications withureteral stents aredislocation, infection andblockage by encrustation.Recently stents withcoatings, such as heparin ,

were approved to reduce


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b.) Lower ureteralinjuries(below

the iliac vessels) are best treated

with ureteralreimplant, as theblood supply canbe tenuous, andstrictures aremore commonwith a distaluretero-


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c.) Midureterallevel injuries

can be treated witha uretero-ureterostomy if aspatulated,tension-freerepair can beachieved.


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For longer defects, the bladder can bemobilized and brought up to the psoas

muscle (psoas hitch).

For additional length, a tubularized flap of

bladder (Boari flap) can be created andanastomosed to the remaining ureter.Renal mobilization with nephropexy byanchoring to the psoas muscle can

provide additional length.


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Bladder


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Bladder injury can occurfrom penetrating andblunt trauma.

Bladder injuries often areassociated with pelvicfractures and may

frequently occur inconjunction with urethralinjuries.

A delayed presentation can

be associated withintoxication, but it alsomay occur as a result ofiatrogenic injury

Radiographic evaluation


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Epidemiology Blunt trauma with

bladder injury is

associated withpelvic fracture inmore than 95% ofcases.

Intraoperativebladder injuriesaccount for:

a.Laparoscopic injuries(0.28.3%)

b.Intraperitoneal (3840%)c.Extraperitoneal (54

56%) of injuriesd.Laparoscopic injuries

diagnosed: 53.2%intrao erativel

Symptoms andsigns of Bladderinjury :

suprapubic pain Dysuria/ Anuria/

Hematuria

Anorexia, lethargy Progressive

dehydration. Abdominal

distension . Fever.


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Types of injury management:

a)Extraperitoneal

bladder injuries can typically be managed

with catheter drainage for7 to 10 days drainage if

urine is draining freelyand the bladder neck isspared.

If the bladder neck isinvolved, surgicalexploration and repair arerequired.


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a)Intraperitonealbladder injuries

should be exploredimmediately andrepaired.


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All injuries, especially those managednonoperatively, should be followed upby a cystogram to document healingbefore catheter removal.


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URETHRA


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Urethral injuries can be classified into 2 broadcategories based on the anatomical site of

the trauma:1.Posterior urethral injuries

- located in the membranous and

prostatic urethra - these injuries are most commonly

related to major blunt trauma such as motorvehicle collisions and major falls, and most

of such cases are accompanied by pelvicfractures


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2. Anterior urethral injuries

- located distal to the membranous urethra

- most anterior urethral injuries are caused

by blunt trauma to the perineum (straddle

injuries), and many have delayed

manifestation, appearing years later as a

urethral stricture


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External penetrating trauma to the urethra israre, but iatrogenic injuries are quitecommon in both segments of the urethra.

Most are related to difficult urethralcatheterizations.


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( )osterior urethra 5 cm( - )rostatic 3 4 cm( - )embranous 1 2 cm

( )nterior urethra 15 cm( )ulbar 7 cm( )enile 6 cm( )avicular 2 cm


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ETIOLOGY

As with many traumatic events, the etiology ofa urethral injury can be classified:

1. blunt

2. penetrating


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1. Posterior Urethra

- almost always related to massivedeceleration events such as falls from some

distance or vehicular collisions - these patients most often have a pelvic

fracture involving the anterior pelvis

Blunt Injuries


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2. Anterior Urethra

- most often results from a blow to thebulbar segment such as occurs when

straddling an object or from direct strikes orkicks to the perineum

- blunt anterior urethral trauma is

sometimes observed in the penile urethra inthe setting of penile fracture

Blunt Injuries


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- most often occurs to the penile urethra - etiologies include gunshot and stab wounds

Iatrogenic injuries to the urethra occur whendifficult urethral catheterization leads to mucosalinjury with subsequent scarring and strictureformation.

Transurethral procedures such as prostate and tumorresections and ureteroscopy can also lead tourethral injury.

Penetrating trauma


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- pain with voiding and inability to void - perineal, scrotal, and penile ecchymosis, edema, or both - a high-riding prostate on rectal examination

Blood at the urethral meatus is the mostimportant sign of a urethral injury.

SYMPTOMS and SIGNS


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Imaging Studies

Retrograde urethrography: The retrograde urethrography is thestandard imaging study for the diagnosis of urethral injury.It is performed using gentle injection of 20-30 mL ofcontrast into the urethra. Examination is made forextravasation, which pinpoints the existence and location ofthe urethral tear.

Cystography: The static cystography allows for concurrentbladder injury to be excluded in the acute setting. When adelayed repair is being considered, voiding cystography(performed through the suprapubic catheter) demonstratesthe bladder neck and prostatic urethral anatomy and allowsfor proper surgical planning.

WORKUP


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, .Urethra trauma Normal retrograde.urethrogram Pericatheter

retrograde urethrogram is negative

for urethral trauma and showscontinuous filling of contrastmaterial through the extent of theurethra and into the bladder

.without extravasation

, .Urethra trauma Retrogradeurethrogram reveals a tight

,stricture a common morbidity of

urethral injuries treated with.delayed repair


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, .Urethra trauma Cystogram reveals stricture of theurethra in a patient treated with delayed repair

( ).same patient as in the previous image Thecystogram and retrograde urethrogram together help

.define the length of the stricture


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Contusions can be safely treated with 10days of indwelling transurethralcatheterization.

Partial disruptions are best treated withbladder drainage via suprapubiccystostomy.

In selected cases of posterior partial

disruptions, primary urethralrealignment using catheterization maybe attempted; if successful, thisapproach limits subsequent urethral

strictures.

TREATMENT


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Complete disruptions are treated with bladderdrainage via suprapubic cystostomy. This option issimplest and can be used safely in all patients.

Definitive surgery is deferred for about 8 to 12 wk

until the urethral scar tissue has stabilized and thepatient has recovered from any accompanyinginjuries.

Selected penetrating urethral injuries and blunt

urethral injuries that occur with penile fracturesmay be sutured primarily.

TREATMENT


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TESTES


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TESTES Testicular injury

blunt injuries(common)

Ultrasound testicular blood

flow testicular

contusionsIntratesticular

hematomas

Hematoceles disrupted tunica

albuginea.

Goal of surgery

To avoid delayedcom lications


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Hala

sorry!

A g e h !


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...last but not the least


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PENIS


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Read


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PENIS

Rare injuries

butterfly sign

exploration

Retrograde

urethrogram


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A.) Patient with a penile fracture.


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B.) Intra-operative finding of bilateral corporalbody ruptures (arrows) along the ventral penile

surface.


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The End

Surgery Report Urology Trauma Oct.27

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