外科学教学课件：Urologic Trauma

UrologicTraumaCLASSIFICATIONRenalTrauma:

KidneysareprotectedbyGerotaFasciaandRibs

OftencomesfromexternalforceUreteralTrauma:

IatrogenicinjuryBladderTrauma:

Deeplocationinthebonypelvis

PelvicfractureUrethralTrauma:

Posteriorandanteriorurethralinjuries

MostcommonurologicinjuryOthers:ExternalgenitaliaandadrenalClinicalsymptomsaremostlyassociatedwithhemorrhageandurinaryextravasation-Clinicalsymptoms--Specialexamination-KUBUltrasoundCatheterizationHigh-doseintravenouspyelogramComputedtomographyUrethrographyMRIRenoarteropgraphy-Treatment-Anti-shocktreatmentNon-operativemanagementSurgeryBlunttrauma(motorvehicleaccident,fallfromheights,assaults)Penetratinginjury(gunshotstabwounds)IatrogenicinjuryThekidneysarelocatedhighintheretroperitoneumandprotectedbythepsoasandquadratuslumborummusclesandanteriorlybytheperitoneumandabdominalviscera.RenalTrauma-Etiology-ClassificationofrenalinjurybyGradeDiagnosisShock

occursinseverelacerationandavulsionofrenalhilum

HematuriahoweverthedegreeofhematuriaandtheseverityoftherenalinjurydonotcorrelateconsistentlyPainandabdominalmassFever-ClinicalManifestation-DiagnosisUltrasoundComputedtomographyintravenouspyelographyEvaluatethefunctionofcontralateralkidney

MRIAdvantagesinimaginghematomacomparedwithCTscanRenoarteriographySuspectedrenalpedicleinjury-Specialexamination-TreatmentAclearunderstandingoftheimportanceofthehistoryandphysicalexamination,theinfluenceofdifferingmechanismofrenalinjuryforpenetratingversusblunttrauma,andtherelationtothefrequencyandseverityofrenalinjuryisessentialfortreatmentplanning.TreatmentAnti-shockandResuscitationEvaluatingthecombinedinjury-Emergencytreatment--Non-operativemanagement-Hospitaladmissionandbedrestfor2~4weeksBecloselymonitoredforbleeding,withvitalsigns,serialhematocritreadings,andpulseratesFluidinfusionAntibioticsSedative-Operation-RenalExplorationNephrectomyRenalReconstructionEmbolizationofrenalarteryMassivebleedingPersistencehematuriaMultiple-injurytraumaPenetratingtraumaTheindicationforoperationTotalnephrectomywouldbeindicatedimmediatelyinextensiverenalinjurieswhenthepatient’slifewouldbethreatenedbyattemptedrenalrepairandthenormalcontralateralkidneyispresent.Urinoma/perinephricinfection/renalloss:

systemicantibiotics;placementofaninternalureteralstentDelayedrenalbleeding:

bedrestandhydration;angiographyandembolizationPerinephricabscess:

percutaneousdrainageHypertension:

renalarterystentingComplicationandTreatmentUreteralinjuriesafterexternalviolencearerare;Mostlyoccursinsurgicalproceduresorureteroscopy.-Etiology--Diagnosis-History:pelvissurgeryorureteroscopySymptoms:hematuria;urinaryextravasation;urinaryfistula;obstructionSpecialexamination:

excretoryurography;‘retrograde

ureterography;CTUreteralinjuryManagementUreteroureterosomyInternalStentingAutotransplantationBowelInterpositionPsoasBladderHitch………Directforce:suddenforceappliedtoafullbladderleadtointraperitonealbladderruptures.Indirectforce:mostcommoncauseispelvicfracture,whichisasscociatedwiththeextraperitonealbladderruptures.-Etiology-IntraperitonealExtraperitonealBladdertraumaDiagnosis-ClinicalIndicatorsofBladderInjury--Examination-Catheterizationtest

300mlsalineinjectionintobladderviacatheterandejectionafterwards,givingthedifferenceoftheliquidintakeandoutputvolum.CystographySuprapubicpainortendernessFreeintraperitonealfluidonCTorultrasoundexaminationInabilitytovoidorlowurineoutputClotsinurineorclotsnotedinbladderonCTEnlargedscrotumwithecchymosisAbdominaldistentionorileusTreatmentEmergencytreatmentConservativemanagementTheusualtreatmentofuncomplicatedextraperitonealbladderruptures,whenconditionsareideal,isconservativemanagementwithurethralcatheterdrainagealoneOperationSurgicallyrepairtherupture;cleanurineleakageandbonefragment;Suprapubictubedrainageorurethralcatheterdrainage.A,Denseflame-shapedpatternofcontrastextravasationinpelvisduetoextraperitonealbladderrupture.

B,Repeatedcystograminsamepatientafter2weeksofcatheterdrainageshowscompletelyhealedbladder.UrethralinjuryBulbarurethraPenileurethraProstaticurethraAnteriorUrethraMembranouspartofurethraPosteriorUrethra-ClinicalManifestation-AnteriorUrethralinjuryBloodatthemeatusPerinealhematomaGrosshematuriaUrinaryretentionUrinaryextravasation:(location)Bulbarurethra:scrotumperineum;tentumabdominalwallPenileurethra:tentum-Principleoftreatment-Anti-shocktherapyAnti-infectionRetentioncatheterizationInitialsuprapubiccystostomyAnastomoticurethroplastyAnteriorUrethralinjury-ClinicalManifestation-Shock(mostlycausedbythefracture)Bloodatthemeatus,Inabilitytourinate,Palpablyfullbladder.“High-riding”prostateUrinaryextravasationandhematoma(location)Intacturogenitaldiaphragm:retroperitonealspaceandaroundperi-bladderDamagedurogenitaldiaphragm:perineum;scrotumposteriorUrethralinjury-Principleoftreatment-

Anti-shocktherapyImmediatesuprapubictubeplacementremainsthestandardofcare

AnattemptatprimaryrealignmentofthedistractionwithaurethralcatheterisreasonableinpatientswhoseconditionisstablePosteriorurethroplasty

Associatedrectalinjuriesrequireopenexploration,repair,irrigation,andplacementofdrains.posterior