CLINICAL

SCIENCE SESSION
TRAUMA
UROGENITAL
FITRI SEPTIANI 12100113028
YANUAR YUDHA SUDRAJAT 12100113020
SMF BEDAH RS AL ISLAM
2014

KIDNEY

KIDNEY
Renal injuries are common during blunt
trauma, accounting for 90% of injuries to the
kidney.
Any patient with a major deceleration injury,
shock, or gross hematuria should undergo
radiographic imaging of the kidneys.
All patients with penetrating injuries to the
flank or abdomen must undergo imaging
unless unstable and requiring immediate
exploration

 Renal injuries are classified by extent of

damage
GRADE

INJURY TYPE

DESCRIPTION

contusion

Microscopic or gross hematuria with normal

imaging

hematoma

Subcapsular, nonexpanding without parenchymal

laceration

hematoma

Non expanding perirenal hematoma confined to

renal retroperitoneum

<1 cm in depth without urinary extravasation

3

laceration

>1 cm in depth without collecting system rupture

or urinary extravasation

laceration

Parenchymal laceration through cortex, medulla

and collecting system

vascular

Main renal artery or vein injury with contained

hemorrhage

laceration

Completely shattered kidney

laceration

Avulsion of renal hilum leading devascularized

kidney

 Blunt traumatic injuries -> conservatively

Penetrating renal injuries -> exploration
All grade V vascular injuries -> immediate
exploration -> delay -> renal salvage
High grade renal injuries are associated with
significant bleeding
Most grade IV
nonoperatively

injuries

can

be

managed

Indication for Surgical

Intervention for Renal Trauma
Absolute
Persistent,
life
threatening
hemorrhage
from
probable renal injury
Renal padicle avulsion
(grade V injury)
Expanding, pulsatile or
uncontained
retroperitoneal
hematoma

Relative
Large laceration of the renal pelvis or avulsion of the
ureteropelvic junction
Coexisting bowel or pancreatic injuries
Persistent urinary leakage, postinjury urinoma, or perinephric
abscess with failed percutaneous or endoscopic management
Abnormal intraoperative one-shot IV urogram
Devitalized parenchymal segment with associated urine leak
Complete renal artery thrombosis of both kidneys or of a
solitary kidney when renal perfusion appears preserved
Renal vascular injuries after failed angiographic management
Renovascular hypertension

URETER

URETER
The retroperitoneal location of
protects it from external trauma

the ureter

Blunt injury is rare but can occur with rapid

deceleration injuries
Penetrating trauma may occur but a high index
of clinical suspicion is required to make the
appropriate diagnosis

 Any
penetrating
trauma
involving
the
retroperitoneum should undergo evaluation
with intraoperative inspection, IVP or CT
urogram
Most sensitive -> retrograde pyelogram
The
ureter
also
is
frequently
intraoperatively -> hysterectomy,
resections, aortic surgery

injured
colonic

Management
Surgical repair depends on location and extent
of injury
Partial injuries
debrided

->

primarily

repaired

->

Uretral stents should be placed in this situation

to facilitate healing wothout stricture
Lower uretral injuries (below the iliac vessels)
are best treated with ureteral reimplant
Midureteral
level
ureterostomy

injuries

->

uretero-

BLADDER

BLADDER
Bladder injury can occur from penetrating and
blunt trauma
The diagnosis should be entertaine for any
lower abdominal or pelvic trauma
Intraperitonel ruptures are less common than
retroperitoneal ruptures but may seen in the
setting of a full bladder before injury
Bladder inuries often are associated with pelvic
fractures and may frequently occur in
conjuction with urethral injuries.

 Patient -> gross/microscopic hematuria

A delayed presentation can be associated with
intoxication or iatrogenic injury
These
patients
often
have
electrolyte
abnormalities
such
as
metabolic
derangements, azotemia and leukocytosis from
urine absorption
Patients clinically
prolonged ileus.

present

with

fevers

or

 Radiographic evaluation begins with either a

fluoroscopic or CT cystogram
It is vital to avoid underfilliing, as it may lead to
a false negative study
It is important to have postdrainage film to
assess for persistent contrast which may
indicate a rupture

Management
Extraperitoneal bladder injuries can typically
be managed with catheter drainage for 7-10
days
If intraoperative exploration is to occur for
other injuries, repair can be performed at that
time.
Intraperitoneal bladder injuries should
explored immediately and repaired

be

All
injuries,
especially
those
managed
nonoperatively, should be followed up by a
cystogram to document healing before
catheter removal

URETHRA

URETHRA
Urethral injuries can be divided by anterior
(penile and bulbar urethra) and posterior
(membranous and prostatic) location
Any patient with blunt pelvic trauma, blood
present at the urethral meatus, hematuria,
inability to void or perineal hematoma should
be considered to have a urethral injury until
proven otherwise
Urethral injuries should be anticipated with
pubic ramus fractures and occur in 10% of
unilateral and 20% of bilateral injuries

Staging
Staging
is
urethrography

performed

by

retrograde

Partial urethral injuries can have an attempt at

catheter placement
Those with complete disruptions should have a
placement of suprapubic tube

 Anterior injuries often are related to blunt

sraddle inuries and penetrating trauma
Blunt anterior urethral injury can be managed
in multiple ways and only small series are
available in the literature to compare methods
Immediate surgical repair is not recommended
in the acute setting
If the patient is stable with minimal hematoma
formation, repair should be considered

 Small defects -> debrided, spatulated and

anastomosed in an end to end, watertight
fashion
Large defects -> grafts/ flaps
Complete disruption -> suprapubic tube
Stricture at the site of injury may ensue

 Posterior urethral injuries usually result from

pelvic crush injuries and shearing forces
causing a prostatomembranous disruption
The patients other injuries dictate urologic
management
Open surgical exploration -> avoided ->
anatomy -> bleeding, incontinence and ED
from injury of adjacent nerves
Management -> suprapubic tube & delayed
repair

 Urethral strictures can be caused by trauma or

inflammatory conditions
Staging -> retrograde urehtrography or VCUG
Short defects -> dilatation or cystoscopic
urethrotomy
Open repairs -> location, length, severity
Long defects -> grafting

TESTES

TESTES
Testicular injury most commonly occurs with
blunt injuries when the testicle is forcibly
compressed against the thigh or pubic bone
with enough force to rupture the tunica
albuginea
For patients with scrotal trauma, USG is the
preferred modality for staging the extent of
injury
USG -> testicular blood flow, testicular
contusions,
intratesticular
hematomas,
hematocele, disrupted tunica albuginea

 The goal of surgery is to salvage as much

parenchyma as possible and to avoid delayed
complications such as ischemic atrophy or
abscess formation
Large hematocele -> drainage
Ruptured tunica albuginea
primarily & debrided

->

repaired

Penetrating trauma -> immediate exploration

-> orchiectomy

PENIS

PENIS
Penile fractures are rare injuries that involve a
traumatic rupture of the tunica albuginea,
usually occurring during sexual intercourse.
The engorged penile corporal bodies can
rupture if sufficient force is generated against
the partner's pubic symphysis or perineum.
Men may notice an immediate audible "pop"
and experience rapid penile detumescence.
Immediate swelling develops.

 If Buck's fascia is disrupted, swelling and

ecchymosis can be noted throughout the
perineum ("butterfly sign").
At
presentation,
a
classic
"eggplant"
appearance of the penis is often, although not
always, seen.
Exploration by a circumcising incision and
repair of the defect offers the best chance at
avoiding permanent ED and penile deformity
while also minimizing the risk of infection.

 A retrograde urethrogram should be performed to rule out

urethral injury at the time of surgery.
Alternatively, the urethra can be manually occluded
intraoperatively at the penoscrotal junction and a dilute
methylene blue solution injected under pressure into the
urethral meatus with a catheter-tip syringe.
Leakage should be visualized if there is a urethral disruption.
If present, the urethra should be repaired, taking care not to
significantly narrow the lumen.
A Foley catheter is left in place for several days after surgery.
Any penetrating injury to the penis must undergo exploration
to repair any injuries to the corporal bodies or the urethra.