外科学--泌尿系统损伤

1、泌尿系统损伤 Urologic Trauma,General Considerations,Iatrogenic Injury External Trauma,Renal Trauma,Anatomy Iatrogenic Renal Injury External Renal Injuries Spontaneous Retroperitoneal Hemorrhage,Reasons,Blunt renal injuries most often come from motor vehicle accidents, falls from heights, and assaults. Pen

2、etrating renal injuries most often come from gunshot and stab wounds. Percutaneous Renal Procedures,deceleration injury,Presentation,Hematuria is the best indicator of traumatic urinary system injury However, the degree of hematuria and the severity of the renal injury do not correlate consistently:

3、 in up to 36% of renal vascular injuries from blunt trauma, hematuria is absent,Classification,I 挫伤 肉眼或镜下血尿 其他泌尿系检查正常 血肿 包膜下血肿 II 血肿 腹膜后肾周血肿 撕裂伤 1cm的肾皮质裂伤，无尿外渗及集合系统损伤 IV 撕裂伤 肾皮质、髓质和集合系统全层裂伤 血管 肾动脉或静脉主干损伤伴出血 V 撕裂伤 肾碎裂 血管 肾蒂撕脱伤，肾无血供,Indications for Renal Imaging,all blunt trauma patients with gross he

4、maturia and patients with microscopic hematuria and shock (systolic blood pressure 90 mm Hg any time during evaluation and resuscitation) should undergo renal imaging, usually CT with intravenous contrast. Patients with microscopic hematuria without shock can be observed clinically without imaging s

5、tudies. Penetrating injuries with any degree of hematuria should be imaged. Ultrasonography is a popular imaging modality in the initial evaluation of abdominal trauma.,Nonoperative Management,indeed, 98% of blunt renal injuries can be managed nonoperatively. Grade IV and V injuries more often requi

6、re surgical exploration. Patients with high-grade injuries (grades III to V) selected for nonoperative management should be observed closely The isolated renal injury, without significant associated injuries, occurs more commonly from blunt trauma and in most circumstances can be managed nonoperativ

7、ely. The exception is major grade V vascular pedicle avulsion injuries. Isolated renal injuries with parenchymal lacerations and even segmental arterial injury can have active bleeding well controlled by angiographic embolization.,Operative Management,Absolute indications include evidence of persist

8、ent renal bleeding, expanding perirenal hematoma, and pulsatile perirenal hematoma 绝对适应症包括：持续性肾脏出血、肾周血肿扩大及肾周搏动性血肿 Relative indications include urinary extravasation, nonviable tissue, delayed diagnosis of arterial injury, segmental arterial injury, and incomplete staging. 相对适应症包括：尿外渗、组织坏死、延迟诊断的动脉创伤、

9、肾段动脉创伤及分级不明确,Renal Exploration,Renal Reconstruction,Renal Reconstruction,Indications for Nephrectomy,Grade V renal injury(77%) The unstable patient, with low body temperature and poor coagulation, cannot risk an attempt at renal repair if a normal contralateral kidney is present (23%),Complications,

10、Persistent urinary extravasation can result in urinoma, perinephric infection, and renal loss. Delayed renal bleeding can potentially occur several weeks after injury but usually occurs within 21 days. Perinephric abscess -Percutaneous drainage Hypertension :1) renal vascular injury, leading to sten

11、osis or occlusion of the main renal artery or one of its branches; 2) compression of the renal parenchyma with extravasated blood or urine; 3) post-trauma arteriovenous fistula. In these instances, the renin-angiotensin axis is stimulated by partial renal ischemia, resulting in hypertension,Ureteral

12、 injuries,Iatrogenic Ureteral Injury External Ureteral Injury,Iatrogenic Ureteral Injury,Open Surgery Laparoscopic Surgery Ureterorenoscopy Radioactive injury,External Ureteral Injury,Ureteral injuries after external violence are rare Open injury blunt trauma patients with ureteral injuries are subj

13、ect to extreme force applied over the entire body. The great degree of energy imparted to the victim is associated with such uncommon injuries as fractured lumbar processes and thoracolumbar spinal dislocation,Diagnosis,Intraoperative Recognition Imaging Studies Excretory Urography Computed Tomograp

14、hy Retrograde Ureterography Antegrade Ureterography,Treatment,Treatment,Bladder Trauma,The most common associated injury is pelvic fracture, associated with 83% to 95% of bladder injuries obstetric and gynecologic complications are the most common etiology of Iatrogenic bladder injuries,diagnosis,耻骨

15、上区疼痛或触痛 不能排尿或尿量减少 尿中有血块 CT或超声提示腹腔内游离液体 会阴或生殖器外伤体征 无反应、醉酒或感知异常 腹部膨胀或肠梗阻,Radiographic Imaging,Treatment,The usual treatment of uncomplicated extraperitoneal bladder ruptures, when conditions are ideal, is conservative management with urethral catheter drainage alone complications such as fistula, absc

16、ess, and prolonged leak,INDICATIONS FOR IMMEDIATE REPAIR OF BLADDER INJURY,外伤导致的腹腔内损伤 穿刺伤或医源性非泌尿外科损伤 膀胱引流不畅或尿中有血块 膀胱颈损伤 直肠或子宫损伤 开放性骨盆骨折 骨盆骨折需要复位和内固定 由于其他原因行剖腹探查的稳定患者 骨碎片插入膀胱内,Urethral Trauma,Posterior Urethra Anterior Urethra,Posterior Urethra,Straddle fractures” involving all four pubic rami open f

17、ractures, and fractures resulting in both vertical and rotational pelvic instability are associated with the highest risk of urologic injury,diagnosis,Urethral disruption is heralded by the triad of blood at the meatus, inability to urinate, and palpably full bladder urethral catheter cannot be plac

18、ed; misplaced into pelvic hematoma. impalpable prostate Urethrography,Treatment,Suprapubic Cystostomy Primary Realignment Delayed Reconstruction: At 3 months, scar tissue at the urethral disruption site is stable enough to allow posterior urethroplasty to be undertaken safely, provided that associat

19、ed injuries are stabilized and the patient is ambulatory,Primary Realignment,Delayed Reconstruction,Transurethral cutting-to-the-light procedure,Anterior Urethra,The majority occur after straddle injury and involve the bulbar urethra In 20% of the cases of rupture of corpora cavernosa, the urethra is involved,Injuries of the genitalia,Penis (Fracture, Gunshots and Penetrating In