URINARY TRACT

TRAUMA
Basuki B Purnomo, Besut Daryanto, Kurnia Penta Seputra
Department of Urology
Saiful Anwar General Hospital / Medical Faculty Brawijaya Univesity
Malang
STANDARD KOMPETENSI DOKTER
INDONESIA (KKI 2012)
Tingkat kemampuan yang harus dicapai (standard
Kompetensi)
1.Mengenali dan menjelaskan
2.Mendiagnosis dan merujuk
3.Mendiagnosis, melakukan penatalaksanaan awal, dan
merujuk
A.Bukan gawat darurat
B. Gawat darurat
4.Mendiagnosis, melakukan penatalaksanaan secara
mandiri dan tuntas
A. Kompetensi yang dicapai pada saat lulus dokter
B. Profisiensi (kemahiran) yang dicapai setelah selesai
internsip dan/atau Pendidikan Kedokteran Berkelanjutan
(PKB)
STANDARD KOMPETENSI DOKTER
INDONESIA

The Current Clinical Development of Trauma

22 November 2008 Care
Incidence of UG Trauma

Urogenital trauma
Bladder Genitalia
(41 cases) (11 cases) Ureter
23% 6% (5 cases)
3%

Urethral
(50 cases) Kidney
28% (72 cases)
40%
KIDNEY TRAUMA
Kidney (Renal) trauma
 Kidneys are retroperitonel organs those are
protected by surrounding organs
 Renal trauma accounts for approximately 3% of all
trauma admissions and as many as 10% of
patients who sustain abdominal trauma.
 :  = 3 : 1
Majority of renal traumas are mild and can be managed
conservatively
Advanced of imaging study
 more accurate staging of renal injury: decrease
surgical intervention and increase renal preservation
Epidemiology
Most of renal trauma are blunt type

Grade II
4%
Grade V
Grade IV 7%
Grade III 3%
4%

Grade I
81%
Mode of Injury

Blunt In rural areas:

trauma 90-95 %

Stab
Mechanism In urban: wounds
Penetrating
of renal trauma up to 20
Gunshot
injury %
wounds

Rapid
renal artery
deceleration occlusion
injuries
Diagnosis
Initial Emergency Assessment
Securing of the airway
Controlling any external bleeding
Resuscitation of shock

Decide : Haemodynamic stability !

 Initial Assessment
History:
○ Direct, witnesses or emergency
personal
○ Possible indicators of renal injury :
 a rapid deceleration event
 high speed motor vehicle accident
 direct blow to the flank
 penetrating (stab/gunshot) along the line of
kidneys
 Urinalysis
 basic test for renal injury

 Serial Haematocrit
 indicate blood loss

 Creatinine
 reflects renal function prior to the injury
Imaging Examination

1) Ultrasonography
2) Intravenous Pyelography (IVP)
3) Computed Tomography (CT scan)
4) MRI
5) Angiography
Indication
1) Gross haematuria
2) Microscopic haematuria and shock
3) The presence of major associated
injuries
4) Rapid deceleration injury
5) Penetrating wound suspected passing
the kidney
IVU (intravenous urography)
IVU revealed :
 the presence of contra lateral
kidney
 define the renal parenchyma
 out line the collecting system

Extravasation of contrast
CT Urography
Grading and Treatment of Kidney
Trauma
 Goal of management :
Minimize morbidity
Preserve renal function

 The question of renal trauma

management
Explore or observe ?

Influenced by the associated abdominal injuries

Grading Renal Injury

Grade I and II are managed conservatively

Grade III and IV injuries are now managed conservatively
Operative: salvage or nephrectomy
Conservative management

Observation
• T
• N Exploration
• Hb
• Hematuria
• Flank mass 
Complication
 Early complication  Late complication

⇛ Bleeding/delayed bleeding ⇛ Delayed bleeding

⇛ Infection ⇛ Hydronephrosis
⇛ Perinephric abscess ⇛ Urolithiasis
⇛ Sepsis ⇛ Chronic
⇛ Urinary fistula pyelonephritis
⇛ Urinary extravasations ⇛ Hydronephrosis
⇛ Urinoma ⇛ Hypertension
⇛ Hypertension ⇛ AV Fistula
⇛ Pseudoaneurysms
URETERAL TRAUMA
Etiology

Gynecologic: 73% (247

cases )
Iatrogenic:
75% General surgery: 14% (46
cases)
(340 cases )
Ureteral urological surgery: 14% (47
Blunt: 18% cases)
injuries
(81 cases)
(452 cases)
Penetrating:
7%
(31 cases)

(Dobrowolski et, BJU Int 2002, 89 : 748-751)

Location of Injury

(Dobrowolski et, BJU Int 2002, 89 : 748-751

Diagnosis
Should be suspected for ureteral trauma :
In all cases of penetrating abdominal injury
(especially gunshot wounds)
Deceleration trauma
Signs of upper tract obstruction, urinary fistula
Sepsis after trauma
Flank pain
Vaginal leakage After gynecological pelvic
surgery
Septic
Suspected ureteral injury durante operation
inject methylene blue I.V.
IVP
Retrograde pyelography
Management
1. Partial injuries (grade 1 and 2)
Ureteral stenting antegrade or retrograde ( 3
weeks)
Nephrostomy to divert urine
Both need fluoroscopic guidance
Grade 2 and 3 detected at surgery
(iatrogenic)
Primary closure and stent
Placement a non suction drain peri ureteral
Indwelling catheter for 2-3 days to avoid
reflux during voiding
2. Complete Tears :
Principles of repair for grade 3-5 :
Debridement of ureteral ends to fresh tissue
Spatulation of ureteral ends
Placement of internal stent
Watertight closure of reconstructed ureter with

absorbable suture
Placement of external, non-suction drain
Isolation of injury with peritoneum or omentum
Prevention ureteral injury before
operation
IVP, before :
Gynecological malignancy operation
 Advanced endometriosis
 Pelvic inflammatory disease
Introducing
Careful dissection, identified ureter
No panic in case of arterial bleeding during
dissection
Use a traumatic vascular clamp
BLADDER TRAUMA
ETIOLOGY
 Full bladder is vulnerable for trauma
 Trauma patients 10% involving genitourinary
tract
 2% of abdominal injury requiring surgical repair
involve bladder
 Blunt trauma accounts for 67-86%
 Penetrating trauma accounts for 14-33%
 In 70-97% of bladder injuries: (pelvic fracture +)
 In pelvic fracture: (30% bladder injury +)
 CLASSIFICATION OF BLADDER INJURY

BASED ON THE TYPE OF TRAUMA

CLASSIFICATION ASSOCIATED
MECHANISM OF INJURY
OF INJURY INJURIES
Blunt pelvic trauma with Pelvic fractures
Extra
laceration by bone fragments(s)
peritoneal
Shearing at ligamentous Other long bone
(80-90%)
attachment(S) fractures
Blunt trauma
High velocity blunt lower High rate of
Intraperitone abdominal trauma associated intra-
al (10-20%) High intravesical pressure with abdominal injuries
rupture at dome High mortality
Direct injury to the bladder wall Associated injury
Penetrating
to ohter organs is
trauma
common
DIAAGNOSIS
 Gross haematuria 82%
 Abdominal tenderness 62%
 Inability to avoid
 Bruises over the suprapubic region
 Swelling in the perineum, scrotum and
thighs, as well as a long the anterior
abdominal wall due to urine extravasations
 An urethral catheter does not return urine
Cystography
 Is considered as standard
diagnostic procedure?
 Accuracy rate 85–100%
 Injected contrast identified
outside the bladder
 Instillation of 350 ml
contrast media with gravity
 Exposing film :
Plain film
Filled film
Post drainage film

Intraperitoneal bladder rupture

Treatment
. Blunt trauma with extraperitoneal rupture :
Catheter drainage
- 86% ruptured bladder healed in 10 days
- 100% healed in 3 weeks
Surgical intervention
- debridemant and closure
- healed faster
2. Blunt trauma intraperitoneal rupture :
Always manage by surgical exploration
Abdominal organ should be inspected and urinoma must be
drained
3. Penetrating injuries :
Should undergo emergency exploration and repair
URETHRAL TRAUMA
Etiology :
Pelvic fracture
Male : 3,5 – 19%
Female : 0 – 6%
In 10 – 17% associated with bladder rupture
In 8% associated with rectal fistula
Modus of pelvic fracture :
Blunt trauma : 90 %
Traffic accidents (70%)
Fall from a leight (25%)
In 27% as associated with multi organ injuries
DIAGNOSIS
 Triad signs of urethral disruption :
Blood at the urethral meatus (positive in 37-
93% cases)
Inability to urinate
Palpably full bladder
 The signs of pelvic fracture clinically and
radiographically
 High riding prostate (complete urethral
disruption)
 only in 34%  pelvic haematoma obscures the prostatic
contour
POSTERIOR URETHRAL INJURY
Management
 Initial management :
Resuscitation of the patient for associated
possibly life threatening injuries
 Definitive treatment of posterior urethral
injuries is remains controversial due to :
Variety of injury patterns
Associated injuries
Treatment potions availability
Urethral catheterization is contraindicated
Urethrography
 Technique :
 A 14-Fr foley catheter is
placed 1-2 cm into the
fossa navicularis
 inflate the balloon with
1-2 ml water
 Introduce 10 ml 30% /
anna contrast solution
with catheter tip syringe
 Films taken in the lateral
decubitus position
 Study under fluoroscopy
when available

Contrast extravasation on urethrography

Complication of Posterior Urethral
Injury
 Erectile dysfunction :
 13 – 30% (catheter only)
 48 – 78% (open repair)
 Incontinence
 Stricture
Anterior Urethral Injury
 Rare: 10% of lower urinary tract injuries
(Mitchell, BJU: 40, 648, 1968)
 Mostly isolated injury
 Etiology :
Straddle injury
Penetrating/gunshot
Intercourse related injury
Anterior urethral Injury

 Iatrogenic
 Straddle Injury
 Bulbous Urethral
crushed (pressed)
between pubic
bone and hard
object
 Butterfly hematoma
 Positive causative factor

 Blood in the meatus

 Large haematoma or swelling in
the perineum / scrotum

Urethrography
 Management Anterior Urethral Injury

 Blunt Trauma :
Suprapubic catheter: 4 weeks
 urethrography
Urethral catheterization
Large haematoma/swelling
 multiple incisions
 Open / penetrating injury :
Immediate exploration
○ Urethral suturing
Perioperative antibiotic
Cystourethrography after 2 weeks
THANK YOU