泌尿系统肿瘤泌尿内科内科八年制英语教学课件

Urogenital Trauma Urogenital Trauma Renal 10-15% of trauma patients with abdominal injuries have GU involvement. Renal Injury Renal Injury Renal injuries constitute 45% of all GU injuries; Most renal injuries (80%) are minor and do not require surgical intervention; Renal trauma can happen in both blunt or penetrating trauma; Renal injuries are most commonly from motor vehicle accidents (MVAs); Renal Injury Scale Renal Injury Physical examination: Flank ecchymosis or mass indicates a retroperitoneal process but is not specific to renal injuries and rarely occurs acutely. The most important indicator of renal trauma is gross or microscopic hematuria. The absence of hematuria, although rare, does not exclude renal injury because it is absent in 5% of patients. Radiographic Staging IVP - double dose CT Scan - best method of staging - radiographic study of choice Ultrasound Angiography - used for suspected renovascular injury Renal Injury CT Staging for Renal Injury Right renal stab wound (Grade IV) Left renal laceration Management of Renal Injury Surgical Management for Renal Injury Ureteral Injury Ureteral Injury Ureteral injuries after external violence are rare, occurring in less than 4% of cases of penetrating trauma and less than 1% cases of blunt trauma. Ureteral injuries after external violence, unlike renal injuries, are difficult to detect with the usual array of diagnostic tools. Ureteral Injury Excretory urography demonstrating extravasation in the upper right ureter consequent to stab wound (Arrow) Surgical Management for Ureteral Injury Bladder Injury Bladder injuries classified into contusions, extraperitoneal and intraperitoneal ruptures ; Intraperitoneal (20%) Extraperitoneal (80%) Rupture A full bladder is more likely to become injured than an empty one. Bladder Injury mostly occur in blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures; 15% occur with penetrating trauma and blunt mechanism without a pelvic fracture (ie, full bladder blowout). gross hematuria in the trauma setting requires imaging of both upper and lower urinary tract Bladder Injury Diagnosis Cystogram and CT are helpful diagnostic tools. Cystogram (left) shows extraperitoneal bladder rupture with extravasation into scrotum. CT(right) reveals intraperitoneal bladder rupture with contrast material surrounding bowel loops Surgical Mangement of Bladder Rupture Urethra Injury Urethra Injury Almost exclusively in male Most common in straddle injure Significant morbidity Stricture Incontinence Impotence Foley catheter implication Urethra Injury Gross hematuria in 98% Inability to void Blood at urethral meatus Pelvic / suprapubic tenderness Penile / scrotal / perineal hematoma Boggy / high-riding prostate/ ill-defined mass on rectal examination. More common than posterior Direct trauma Usually NO pelvic injury Blood at meatus Unable to micturate Penile/Scrotal/Perineal Contusion Hematoma Fluid collection Posterior Urethra-Anterior Urethra- Urethra Injury EXTRAVASATION OF URINEHigh Riding Prostate on DRE Diagnosis Urethrogram is the best diagnostic tool- Urethrogram Contrast extravasation + Contrast in bladder Contrast extravasation only Urethrogram PARTIAL Tear COMPLETE Tear retrograde urethrography via meatus Extravasation of contrast medium with the “missing” bladder indicates a complete tear of the urethra Urethrogram Management of Urethral Injury Partial tear careful passage of 12-14 Fr. Foley. If any resistance: Urology Complete tear: Urology + suprapubic cath. If Foley already there and suspect tear: LEAVE FOLEY IN PLACE Initial urethral repair is not recommended Initial urethral repair is not recommended because of risk of hemorrhage, impotence, and because of risk of hemorrhage, impotence, and infection of pelvic hematoma. infection of pelvic hematoma. Management of Urethral Injury Surgical RepairBanks Method Penis Penetrating, skin avulsion and amputation repaired surgically “fracture” repaired and drained surgically Scrotum/testes Hematocele and contus