Genitourina Ry Trauma: Skdi 3B

Genitourina
ry Trauma
SKDI 3B
Renal Trauma
Epidemiology:
Most common among genitourinary trauma
1-5% of all trauma
Mechanism:
Blunt trauma (motor car accidents, assaults, falls,
contact sports)
Penetrating trauma (stabs, high velovity gunshots)
Blast effect (low velocity gunshots)

Renal Trauma
Presentation
Hematuria (gross or microscopic)

Microscopic = 5 RBCs/HPF
May be absent
Shock (hypotension, tachycardia, oliguria)
Flank bruising/mass
Flank pain/tenderness
Renal Trauma
Indications for Imaging
Penetrating injuries
Blunt injuries in association with:

Gross hematuria
Microscopic hematuria and shock (SBP < 90)
Microscopic hematuria in children
Microscopic hematuria in patient with solitary kidney
Absence of hematuria but high clinical index of suspicion of renal
injury based on Hx, Px and AXR
Rapid deceleration injury
Lower rib #
Transverse process #
Loss of psoas shadow
Renal Trauma
Options for Imaging
Consider the need for both anatomic and functional information

IVP - Single-shot intra-op
U/S - Confirm 2 kidneys
Angiography - Used for embolization
These modalities have a limited role and have been essentially

replaced by CT scan
Renal Trauma
CT Scan
Provides valuable anatomic and functional information
Provides the most definitive staging information
Provides information on associated injuries
Imaging modality of choice for renal trauma

Renal Trauma
Classification
AAST
Pediatric Renal Trauma
Considerations
Occupies proportionately larger space
Less perirenal and subcutaneous fat
Renal capsule, Gerotas fascia and perirenal fat less

developed (? less fixation)
Vascular pedicle more susceptible to shearing forces
Higher catecholamine output after trauma

Pediatric Renal Trauma
Summary
Shock not a useful parameter

Hematuria may not be present ~10%
High index of suspicion based on mechanism
Liberal use of imaging studies
Renal Trauma
Non-operative Management
Conservative management for:

90-98% of blunt renal trauma
Up to 50% of penetrating renal trauma
ABCs
Admission
Bedrest until gross hematuria clears
Close clinical observation
Serial vital signs, CBC
Renal Trauma
Indications for Surgical Exploration
ABSOLUTE RELATIVE
Persistent renal bleeding Penetrating injuries
with hemodynamic
instability Extensive urine
extravasation
Expanding perirenal Grade 5 injury
hematoma Shattered kidney
Pedicle injury
Pulsatile perirenal Non-viable tissue

hematoma (>20%)
Arterial injury (main
or segmental)
Bladder Trauma
General Considerations
Relatively uncommon
Often in association with multi-system organ injury

Significant mortality rate (10-20%)
Have high index of suspicion of urethral disruption
injury
Bladder more susceptible to injury when full
Bladder Trauma
Etiology
Blunt
Penetrating
Iatrogenic
Spontaneous rupture
Bladder Trauma
Etiology
BLUNT
Most common type of bladder injury
Usually motor vehicle accidents
2/3 contusions, 1/3 ruptures
Associated with pelvic #
10-25% of pelvic #s have associated bladder injury
85-90% of bladder injuries have associated pelvic #
PENETRATING
Less common
Often associated with major organ injuries
Bladder Trauma
Etiology
IATROGENIC
Open or laparoscopic pelvic surgery
Gynecologic, vascular, urologic or general surgery
SPONTANEOUS RUPTURE
Underlying pathology
Cancer, obstruction, XRT, TB, sensory neurologic deficit
Bladder Trauma
Presentation
Hematuria
95% blunt injuries have gross hematuria
Inability to void
Abdominal pain
Abdominal bruising
Pelvic mass
Peritoneal signs
Shock
Bladder Trauma
Imaging
Cystogram
AP films obliques
Remember drainage films
10% of bladder ruptures detected on drainage films
CT Cystogram
Often more efficient since most patients need CT anyway

Provides additional helpful information about other organs
Bladder Trauma
Practical Classification
Contusion
Most common
Often diagnosis of exclusion
Laceration/rupture
Extraperitoneal
vs. This is what we really need to know
Intraperitoneal
Bladder Trauma
Management
GENERAL PRINCIPLES
ABCs
Establish urinary drainage/diversion
Antibiotics
CONTUSION
No specific therapy required
Bladder Trauma
Management
EXTRAPERITONEAL RUPTURE
Conservative, catheter drainage x 7-14 days, cystogram
Indications for surgical repair:

Patient already in O.R. for another reason
Associated rectal perforation or open pelvic fracture
Bone fragments projecting into bladder
Multiple/large ruptures
Bladder Trauma
Management
INTRAPERITONEAL RUPTURE
Surgical repair
Midline laparotomy/cystotomy
Multi-layer closure of bladder injury
Bladder drainage
Foley catheter suprapubic catheter
Perivesical drain
Bladder Trauma
Complications
Intraperitoneal
Urinary frequency
Shock
Peritonitis
Azotemia
Extraperitoneal
Shock
Pelvic abscess
INJURIES Of THE URETHRA
Urethral injuries are uncommon and

occur most often in men, usually
associated with pelvic fractures or
straddle-type falls.
Various parts of the urethra may be
lacerated, transected, or contused.
Management varies according to the
level of injury.
The urethra can be separated into 2
broad anatomic divisions: the
posterior urethra, consisting of the
prostatic and membranous portions,
and the anterior urethra, consisting of
the bulbous and pendulous portions
Clinical Findings
Symptoms:
Patients usually complain of lower abdominal pain and inability to

urinate. A history of crushing injury to the pelvis is usually obtained.
Signs:
Blood at the urethral meatus is the single most important sign of

urethral injury (Urethroragia).
Suprapubic tenderness and the presence of pelvic fracture are noted

on physical examination.
A large developing pelvic hematoma may be palpated.
Perineal or suprapubic contusions are often noted.
Rectal examination may reveal a large pelvic hematoma with the

prostate displaced superiorly.
Clinical Findings
Laboratory Findings:
Anemia due to hemorrhage may be

noted.
Urine usually cannot be obtained

initially, since the patient should not
void and catheterization should not
be attempted.
Clinical Findings
Instrumental Examination:
The only instrumentation involved

should be for urethrography.
Catheterization or urethroscopy
should not be done, because
these procedures pose an
increased risk of hematoma,
infection, and further damage to
partial urethral disruptions.
X-Ray Findings
Fractures of the bony pelvis are

usually present.
A urethrogram (using 20-30 ml

of watersoluble contrast
material) shows the site of
extravasation.
Ordinarily, there is free

extravasation of contrast
material into the perivesical
space.
Incomplete
prostatomembranous disruption
is seen as minor extravasation,
with a portion of contrast
material passing into the
prostatic urethra and bladder.
X-Ray Findings
Treatment
Conservative therapy is effective

for patients with recent
nonpenetrating damage of
urethra: rest, cool compresses,
and antibiotics.
Within 7-8 days after trauma

thermal procedures and
resorption agents are prescribed.
Shock and hemorrhage should be

treated.
Treatment
Surgical Measures:
Urethral catheterization should
be avoided.
Initial management should
consist of suprapubic
cystostomy to provide urinary
drainage.
A midline lower abdominal
incision should be made, care
being taken to avoid the large
pelvic hematoma.
The bladder should be opened
and carefully inspected for
lacerations. If a laceration is
present, the bladder should be
closed with absorbable suture
material and a cystostomy tube
inserted for urinary drainage.
The suprapubic cystostomy is
maintained in place for about 3
months. This allows resolution of
Treatment
Urethral reconstruction
-Reconstruction of the urethra
after prostatic disruption can
be undertaken within 3 months.
Before reconstruction, a
combined cystogram and
urethrogram should be done to
determine the exact length of
the resulting urethral stricture.
The preferred approach is a
single-stage reconstruction of
the urethral rupture defect with
direct excision of the strictured
area and anastomosis of the
bulbous urethra directly to the
apex of the prostate.
A 16F silicone urethral catheter
should be left in place along
with a suprapubic cystostomy.
Catheters are removed within a
Complications
Stricture, impotence, and incontinence as complications of
prostatomembranous disruption.
Stricture following primary repair and anastomosis occurs in about

one-half of cases. If the preferred suprapubic cystostomy approach
with delayed repair is used, the incidence of stricture can be reduced
to about 5%.
The incidence of impotence after primary repair is 30-80% (mean,

about 50%). Incontinence in primary reanastomosis is noted in one-
third of patients.
Delayed reconstruction reduces the incidence to less than 5%.

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Genitourina

1-5% of all trauma

Blast effect (low velocity gunshots)

Hematuria (gross or microscopic)

Shock (hypotension, tachycardia, oliguria)

Blunt injuries in association with:

Consider the need for both anatomic and functional information

U/S - Confirm 2 kidneys

Angiography - Used for embolization

These modalities have a limited role and have been essentially

Provides valuable anatomic and functional information

Provides the most definitive staging information

Provides information on associated injuries

Imaging modality of choice for renal trauma

Occupies proportionately larger space

Less perirenal and subcutaneous fat

Renal capsule, Gerotas fascia and perirenal fat less

Higher catecholamine output after trauma

Shock not a useful parameter

Conservative management for:

Pulsatile perirenal Non-viable tissue

Often in association with multi-system organ injury

Often more efficient since most patients need CT anyway

Establish urinary drainage/diversion

Indications for surgical repair:

Urethral injuries are uncommon and

Patients usually complain of lower abdominal pain and inability to

Blood at the urethral meatus is the single most important sign of

Suprapubic tenderness and the presence of pelvic fracture are noted

A large developing pelvic hematoma may be palpated.

Perineal or suprapubic contusions are often noted.

Rectal examination may reveal a large pelvic hematoma with the

Anemia due to hemorrhage may be

Urine usually cannot be obtained

The only instrumentation involved

Fractures of the bony pelvis are

A urethrogram (using 20-30 ml

Ordinarily, there is free

Conservative therapy is effective

Within 7-8 days after trauma

Shock and hemorrhage should be

Stricture following primary repair and anastomosis occurs in about

The incidence of impotence after primary repair is 30-80% (mean,

Delayed reconstruction reduces the incidence to less than 5%.

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