block 15:

nephrology, urology, and body fluids

fakultas kedokteran universitas tadulako May 3rd 2012

trauma OF THE KIDNEY, URETER,

BLADDER, AND URETHRA
dr. Untung Tranggono, MS, SpB, SpU, PA(K)

Sub Bagian Urologi Bagian Ilmu Bedah FK UGM

/ SMF Urologi RS Sardjito
Yogyakarta
Trauma ginjal. . .
Mau di- apa-kan?
Ruptured kidney
 Kinds of injury
• Blunt
• Penetrating
–Gunshot
–Stab
 UROLOGIC INJURIES
Urologic Injuries
• Occur in less than 5% of trauma pts
• 80% of these are renal injuries
• Mechanism is predominantly blunt
• Majority of these injuries do not
require operative intervention
• Regions: costovertebra, flank, costal
fracture
• Grading (American Asscociation for
the Surgery of Trauma)
• Grade 1, grade 2, grade 3, grade 4,
grade 5
 Organ involved
• Kidney
• Ureter
• Bladder
• Urethra
• Penis
• Scrotum
• Testis
• Vulva
• Vagina
Pain, blood, vulnus, tumor ?
 Urologic Pain
• Important symptom
• The most common reason to visit doctor
• Accompany with
– Hematuria
– Pyuria
– Cloudy urine
– Vomite, cold sweating, hypotension

• Strong analgesics
 Pathophysiology
• Distention of UT
• Increase of intraluminar pressure
• Intra PCS: 0 – 10 cmH2O
• When obstructed: 50 cmH2O
• Distention velocity > obstrution degree
• Acute: RBF > (prostaglandin)
• ≥ 2 hours: RBF < (tromboxane, RAA)
• CVA: distended renal capsule, ischemia
 Pain location
• Part of UT • Region
• Pyelum • CVA
• Upper ureter • Flank
• Mid ureter • Mid-inferior
inguinal
• Lower ureter • Suprapubic
 Causes of UT distention
• Internal Distal obstruction
– Stones
– Clott
– Tumor
– Stenosis / stricture / fibrosis
• External compression
– Tumor
– Retroperitoneal hematome
 American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Kidney[*] Grade[†]
Type Description

• I. Contusion Microscopic or gross hematuria, urologic studies normal

Hematoma Subcapsular, nonexpanding without parenchymal laceration
• II. Hematoma Nonexpanding perirenal hematoma confined to renal
retroperitoneum Laceration <1 cm parenchymal depth of renal cortex
without urinary extravasation
• III. Laceration >1 cm parenchymal depth of renal cortex without
collecting system rupture or urinary extravasation
• IV. Laceration Parenchymal laceration extending through renal cortex,
medulla, and collecting system Vascular Main renal artery or vein injury
with contained hemorrhage
• V. Laceration Completely shattered kidney Vascular Avulsion of renal
hilum, devascularizing the kidney *
• Data drawn from Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: Spleen, liver, and kidney. J Trauma 1989;29:1664-
1666. † Advance one grade for bilateral injuries up to grade III.
 AAST GRADING SYSTEM
Grade I
• Contusion: hematuria without X-Ray
Abnormalities
• Subcapsular hematoma: No parenchymal
laceration
 AAST GRADING SYSTEM
Grade II
• Perinephric hematoma confined to
retroperitoneum
• Laceration < 1 cm in depth of renal cortex
 AAST GRADING SYSTEM
Grade III
• Laceration > 1 cm in depth
Grade IV
• Laceration through collecting system
 AAST GRADING SYSTEM
Grade IV
• Vascular injury with contained hemorrhage
Grade V
• Vascular avulsion
• Shattered Kidney
•

Figure 39-1 Classification of renal injuries by grade (based on the organ injury scale of the
American Association for the Surgery of Trauma [based on Moore et al, 1989
• I. Contusion
Microscopic or gross
hematuria, urologic
studies normal
Hematoma
Subcapsular,
nonexpanding
without
parenchymal
laceration
• II. Hematoma
Nonexpanding
perirenal hematoma
confined to renal
retroperitoneum
Laceration <1 cm
parenchymal depth of
renal cortex without
urinary extravasation
• III. Laceration >1
cm parenchymal
depth of renal
cortex without
collecting system
rupture or urinary
extravasation
• IV. Laceration
Parenchymal
laceration
extending through
renal cortex,
medulla, and
collecting system
Vascular Main renal
artery or vein injury
with contained
hemorrhage
• V. Laceration
Completely
shattered kidney
Vascular Avulsion of
renal hilum,
devascularizing the
kidney
 Penegakan diagnosis
• Trauma pada daerah kostovertebra
• Nyeri dan jejas
• Massa retroperitoneal,
• bulging, flattening pada flank
• Hematoma, urinoma
• Peritoneal sign
 Penegakan diagnosis - 2
• Syok
– Awal tindakan  eksplorasi
– Single shot IVU waktu resusitasi
• Hematuria  IVU
– Trauma tumpul + mikrohematuri + syok
– Trauma tajam + gross/mikro-hematuri
• Penunjang
– IVU
– CT scan
– Arteriografi
 Tampilan pada IVU

• Ekskresi kontras kurang dibanding

kontralateral
• Psoas line atau renal contour
menghilang
• Scoliosis ke arah kontralateral
• Ekstravasasi kontras
 Keuntungan CT scan

• Laserasi ginjal
• Kerusakan arteri
• Ekstravasasi
• Hematoma retroperitoneal
• Jaringan ginjal non-vital
• Trauma penyerta
 Tampilan pada arteriografi

• Ekstravasasi
• Bagian ginjal yang avaskuler
• Oklusi total arteri renalis
 INDIKASI OPERASI
• Syok yang tidak teratasi, syok berulang
• Hematoma yang extensif dan pulsatif
• Pada IVU
–Ekstravasasi kontras
–Ada bagian ginjal yang tak tervisualisasi
 Teknik operasi
• Approach transperitoneal
– Mengatasi trauma abdominal lain
– Isolasi vasa renalis
• Prosedur Mc Aninch
• Rekontruksi
• Observasi / post-operative care
Retroperitoneum  3 zona
(Blaisdell dan Trunkey, 1982)
Isolasi vasa renalis - 1
Isoloasi vasa renalis -2
Isolasi vasa renalis - 3
Utamakan keselamatan pasien
 CT-scan
• Football player
• 15 yo male
• Left kidney
• Ruptured
parenchyme
• Urinoma
Subcapsular hematome ?
Ruptuted PCS ?
Multilacerations of parenchyme
 EXPOSURE
• Medial rotation of intestinal structures
• Vascular control either by isolating the hilar
vessels first or by medially rotating the kidney
 TREATMENT
• Grade I
– Observation
 TREATMENT
Grade II & III
• Observe in stable blunt injury pts
• Renorrhaphy with capsular approximation
• Pledgeted sutures or mesh wrap
 TREATMENT
Grade IV & V
• Closure of calices during repair or partial
nephrectomy
• Absorbable interrupted suture
• Prevents urinoma
• Perinephric drain
 TREATMENT

Grade IV & V
• Stable patient
– Repair
– Partial nephrectomy
– Nephrectomy
 TREATMENT
Grade IV & V
• Unstable patient
– Nephrectomy
– ureterectomy
 ASSESSMENT OF CONTRALATERAL
KIDNEY
• Presence
• Size
• Injury
• IVP
• Methylene Blue
• FAST
 REIMPLANTATION
• Bench to repair
• Preservation of vascular pedicle and ureter
• Four hour warm ischemic time limit to allow
meaningful function
 URETERAL INJURY
Exposure
• Locate ureter at the level of the iliac
bifurcation then trace proximally and distally
 URETERAL INJURY
Treatment
• Repair with interrupted suture over double
J stent
• Drain adjacent to repair
• IVP prior to removal of stent
 URETERAL INJURY
Complete transection
• Debride to viable tissue
• Primary repair with spatulation over stent
• Interrupted absorbable suture
TREATMENT OF URETERAL INJURY
 URETERAL INJURY
TREATMENT OPTIONS
• Proximal ureter
– Transureteroureterostomy
• Put the uninjured kidney at risk
• Not recommended
 URETERAL INJURY
TREATMENT OPTIONS
• Middle ureter
– Boari Bladder Flap
 URETERAL INJURY
TREATMENT OPTIONS
• Distal Ureter
– Psoas Hitch
Ruptured bladder
DIAGNNOSIS OF BLADDER INJURY

• Cystogram or CT-Cystogram

• Requires retrograde filling of bladder with

at least 300 cc
• Standard cystogram requires X-Ray with
bladder full and after drainage
 Cystogram
• intraperitoneal • extraperitoneal
 BLADDER INJURY

EXTRA PERITONEAL INJURY

• Usually secondary to tear by bone fragments
• Majority of bladder injuries are associated
with pelvic fractures
• Foley catheter drainage
 BLADDER INJURY
Intra peritoneal injury
• Blunt force to distended bladder
• Penetrating trauma
• Requires operative intervention
 TREATMENT
Intraperitoneal Injury
• Two layer absorbable closure
• Identify ureteral orifices inspected through laceration
indigo carmine identify
• Identify uretaral orifisces ureteral orifices

Optional
• Perivesical drain
• Suprapubic drain Closed suction

Postoperative management
• Foley drainage 7 to 10 days
• Cystogram prior to Foley
removal
 Injuries of penis
• Fractured
• Urethral rupture
• Iatrogenic, circumcici
• Mechanism and type
 URETHRAL INJURIES
• Posterior Urethra
• Urethral disruption injuries typically occur in conjunction with
multisystem trauma from vehicular accidents, falls, or industrial
accidents.
• Pubic diastasis, localized pubic rami fractures, or more complex pelvic
fractures may be associated with urethral disruption. “Straddle
fractures” involving all four pubic rami ( Fig. 83-9 ), open fractures, and
fractures resulting in both vertical and rotational pelvic instability are
associated with the highest risk of urologic injury ( Mundy, 1996 ;
Koraitim, 1999 ; Brandes and Borelli, 2001 ).
• Urethral injury has been reported to occur in approximately 10% of
males and up to 6% of females sustaining pelvic fractures ( Koraitim et al,
1999 ).
• Girls younger than 17 years have a higher risk of urethral injury
compared with women, perhaps owing to greater compressibility of the
pelvic bones ( Hemal, 1999 ).
• Because the posterior urethra is fixed at both the
urogenital diaphragm and the puboprostatic
ligaments, the bulbomembranous junction is
more vulnerable to injury during pelvic fracture
• Urethral disruption is heralded by the triad of
blood at the meatus, inability to urinate, and
palpably full bladder.
• When blood at the urethral meatus is discovered
Immediate suprapubic tube placement remains
the standard of care.
• an immediate retrograde urethrogram should be
performed to rule out urethral injury
• Anterior Urethra
• In contrast to posterior urethral distraction, anterior
injuries are most often isolated ( Kiracofe et al, 1975 ).
The majority occur after straddle injury and involve
the bulbar urethra, which is susceptible to
compressive injury because of its fixed location
beneath the pubis. A smaller percentage are the
result of direct penetrating injury to the penis.
• The primary morbidity of straddle injury is urethral
stricture, which may become symptomatic up to 10
years later
• Initial suprapubic cystostomy is the treatment of
choice for major straddle injuries involving the
urethra ( Park and McAninch, 2004 ).
• Primary surgical repair is recommended for low-
velocity urethral gunshot injuries; catheter
alignment alone is associated with a far worse
stricture rate (Husmann et al, 1993 ).
• Anastomotic urethroplasty is the procedure of
choice in the totally obliterated bulbar urethra
after a straddle injury.
 Acute scrotum - Testicle
• Torsion
• Inflamations
• Hematocele
• Hernia
• Malignancy
References ?
Orientasi fasilitas
• Sarana penunjang / operasi
• Informed consent
• Alat-alat & material medis
• Obat-obatan
• Hantu ? ? ?