injuries尿路损伤课件

Urethralinjuries Introduction Urologicalinjuriesoccurinapproximately10 ofpatientswhopresentfollowingbluntorpenetratingtraumaOfthese anumberinvolvetheurethra 65 arecompleteand35 partialUrethralinjuriesbythemselvesareneverlife threatening except Itisofnosurprisethatthehighestincidenceofurethralinjuriesisinadultsaged15 25years Urethralinjuriescanrangefromamildcontusionwithpreservationofepithelialcontinuity toapartialtearoftheurethralepitheliumorafullurethraltransectionanddisruption Theycanalsobeclassifiedbysiteintoanteriorurethralinjuriesandposteriorurethralinjuries whichisprobablythebestwaytoconsiderthem sincebothsitesareexposedtodifferentmechanismsofinjury Anatomy Themaleurethraisdividedintotheanteriorandposteriorsectionsbytheso calledurogenitaldiaphragm TheposteriorurethraconsistsoftheprostaticandthemembranousurethraThelatterisenclosedintheurogenitaldiaphragm Itextendsfromthebladdernecktothedistalsphinctermechanismforalengthof3cm Theanteriorurethraconsistsofthebulbarandpenileurethraandisa15cmcanalextendingfromtheendofthemembranousurethratotheexternalmeatus Thebladder necksphincterisfunctionalfromtheinternalmeatusdountotheleveloftheverumontanum inmalesitisreliablycomptent provideditisnotsurgicallydamagedorrenderedincompetentbyunstabledetrusorcontractions Thedistalsphinctermechanismisabout2 5cmlong butitisonly3 4mmthick itformsthewholethicknessofthemembranousurethraandextendsupwards throughtheapicalprostaticcapsule totheverumontanum Thecompetenceofthisdistalurethralmechanismis infact entirelydependentonthesphinctermuscleswithinthe3 4mm Anteriorurethralinjuries Straddleinjury Posteriorurethralinjuries Unfortunately thetermposteriorurethralstricture isstillwidelyusedtoincludesimplesphincterstrictures subprostatecpelvicfractureurethraldistractiondefects andstricturesfollowingradicalprostatectomy Thisisconfusingbecausetheyandtheprinciplesoftheirsurgicalresolutionareentirelydifferent Urethralinjuriesassociatedwithpelvicfractures Pelvicfracturesarecommonlycausedbyroadtrafficaccidents crushinjuriesorfallsfromaheight andmostcommonlyoccurinyoungmen Posteriorurethralinjuriesclassicallyoccurinassociationwithpelvicfracturesandaretheresultofshearingoftheprostatefromitsconnectiontotheanteriorurethraattheapexoftheprostate Between3 and25 ofurethralinjuriesaresaidtobecausedbypelvicfractures About27 arealsoassociatedwithotherintra abdominalinjuries Theincidenceofdoubleinjuriesinvolvingtheurethraandthebaldderrangesbetween10 and20 ofmales thesemaybeintraperitoneal 17 39 orextraperitoneal 56 78 orsometimesboth Becausetheforcesinvolvedinpelvicfractureshavetobeextremelygreat urethralinjuriesassoviatedwithpelvicfracturestendtobeassociatedwithmultipleandlife threateninginjuries Attentiontoresuscitationtendstopredominateintheearlymanagementofthesepatients Diagnosisofurethralinjury Thediagnosisofanyurethralinjuriesrequiresahighindexofsuspicion particularlyinthetraumapatient shouldbeexcludedbeforeaurinarycatheterisinserted oftenbyanexperiencedpersonintheemergencyservice Anteriorurethralinjuriescanpresentwithbloodatthemeatusinabilitytopasswater therapiddevelopmentofaperinealurinomaorheamatomaformingdownasleeveofBuck sfascia Urethralinjuryistobesuspectedinanypatientwithafractureofthepelvis Theriskofurethralinjuryincreaseswithbloodattheurethralmeatus difficult ties inabilitytovoid pelvichaematoma characteristicbutterflypatternofbruisingoftheperineum highridingpristate althoughthismightbedifficulttoappreciateinthepresenceofapelvichaematoma andfracturesinvolvingdisplacementofthepubicramirelativetotherestofthepelvis Althoughtheclassictradofbloodattheexternalurethralmeatus inabilitytopassurineandadistendedbladderisfairlyindicativeofurethralinjuries itmustbenotedthataveryhighlesionabovetheexternalsphinctermaynotproducebloodatthemeatusandadistendedbladdermayberelatedtoasphincterspasmasaresultofpainratherthanacompleteurethralrupture Rectalexaminationhelpstoexcludeadislocatedprostatebutswillingandoedemamaymaskthepresenceofanormallypositionedprostate Rectalexaminationismoreimportantasatooltoscreenofrrectalinjuries whichcanbeassociatedwith5 ofpelvicfractures Bloodontheexaminationfingerishighlysuggestiveofsuchaninuury Urethrocystography Urethrocystographyistheinvestigationofchoiceifaurethralinjuryissuspected Ifthepatientdevelopsretentionandaurethralinjurycannotbeexcluded asuprapubiccatheterisinsertedandasimultaneouscystogramandascendingurethrogramcanbecarriedoutatalaterdate Anendoscopeexaminationbyatrainedandexperiencedurologistusingacystourethroscopecanbeperformedasapreliminaryprocedure Simultaneoussuprapubiccystographyandascendingurethrograms theso called up and downogram aretheinvestigationofchoiceinassessingthesite severityandlengthofurethralinjuries Thisisusuallydonewithinaweekofinjuryifdelayedprimaryrepairiscontemplatedorat3monthsifadelayedorlaterepairisconsidered Ultrasonographyisnotaroutineinvestigationintheinitialassessmentofurethralinjuriesbutcanbeusefulindeterminingthepositionofthepelvichaematomas Thefirstchoicefortheevaluationofintra abdominalurinarytracttraumareliesupontheuseofcomputerizedtomographyscanningorspiralcomputerizedtomography Ultrasound althoughitprovidesrenalimaging doesnotgiveanyinformationonrenalfunctionandcanbedifficulttointerpretinthepreserceofileusbecauseofgasdistendedbowelloops Intravenousurographyisasecondbesttocomputerizedtomographybutispreferabletoultrasound sinceitprovidesinformationontherenalexcretionofcontrastandcanbeperformedwithasingleabdominalfilmintheemergencyroom Managementofurethralinjuries Managementofurethralinjuriesremainscontroversialbecauseofthevarietyofinjurypatterns associatedinjuriesandtreatmentoptionsavailable inadditiontotherelativerarityoftheinjuriesandhencethelimitedexperienceofmosturologists Theinitialmanagementofallurethralinjuriesisresuscitationofthepatientasaresultofassociated Possiblylife threatening injuries Thisisparticularlythecaseforposteriorurethralinjuries Thenextstepinacutemanagementistoobtaindrainageofthebladder Thiswillpreventfurtherextravasationintosurroundingtissuesandallowassessmentoftheurineoutput Suprapubiccystostomybyapercutaneousoropenrouteisthetreatmentofchoiceinsuchasituation sinceitbypassestheareaoftheurethrathatisdamagedandallowsforasimultaneousstudytobecarriedoutatalaterdate Definitivesurgicalinterventioncanbeconsideredundertheheadingsofmmediatetreatment delayedprimarytreatment 10 14days andaltetreatments 3monthsormore Primaryurethralrepairtechnique Immediateurethralrepaircanbeattemptediftheinjuryiscompleteanterior penetratingoropen providedthepatientisstableandthehaematomaminimal Immediaterepairoftheacutelytraumatizedanteriorurethracanbetechnicallydifficult Itshouldberestrictedtoonlythosepatientswithpenetratingurethralinjurieswhoarehaemodynamicallystablewithoutanysignificantinjuriestonon genitalorgans forwhomsimpleurethralclosurecanbeperformed Theseincludedefectsofupto2cminthebulbousurethraand1 5cminthepenileurethra Longerdefectsrequireurethralreplacementwithgraftsorflapsandshouldbeavoidedintheacutetraumasetting Bothurethralendsarespatulatedandanoverlappedanastomosisiscompletedovera12 14Frenchcatheter asuprapubiccatheterisalsoessentialtoguardtheurethralrepair At10daysto2weeks acystourethrogramisobtainedwiththeurethralcatheterinsituandprovidedthatthereisnoleakageattheanatomoticsitetheurethralcathetercanberemoved IfthereisleakagethenthecatheterisleftlongerandtheX raystudyrepeatedaweeklater Adelayedelectiveprocedureisusuallycarriedoutaminimumof3monthsafterinjury Completeposteriorurethralrupturescanbemanagedbyimmediaterepair delayedprimaryurethroplasty orlateurethroplasty Immediateopenrepairofposteriorurethralinjuriesisusuallyassociatedwithahigherincidenceofstrictures incontinenceandimpotence Difficultyinidentifyingstructuresandplanesasaresultofhaematomaformationandoedemaalsohamperadequatemobilizationandsubsequentsurgicalapposition Websteretal reviewedtheworldliterature whichatthetimeincluded301patientsin15reportedseries andconcludedthaturethralrealignmentwasassociatedwithrestricturein60 impotencein44 andincontinencein20 ofcases Morerecently ElliotandBarrett 13 havereportedanaseriesof57patientswhounderwentprimaryendoscopicurethralrealignmentwithameanfollow upof10 5rears Twenty onepercenthadsomedegreeoferectiledysfunction 3 7 hadmildstressincontinence 685hadpostalignmentstrctures 13oftheserequiredatotalof20proceduresundergeneralanaesthesia TheresultsofthevarioustechniquesarereviewedbyKoraitiminapersonalseriesof100patientscombinedwithareviewof771patientsfrompublishedreports Immediateandearlyrealignment n 326 wasassociatedwitha535stricturerate a5 incontinencerateanda36 impotencerate Primarysuturing n 37 wasassociatedwitha49 stricturerate a21 incontinencerateanda565impotencerate Incomparison insertingasuprapubiccatheterbeforeadelayedrepair n 508 wasassociatedwitha97 stricturerate a45incontinencerateanda19 impotencerate Onthebasisofsuchevidenceitisevidentthatdelayedurethralrep