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Genitourinary trauma

  2. Location of GU trauma Kidney- 67% Ureter- 1% Bladder-22% Urethra-3% External genitalia-7%
  3. Renal trauma • 90% - Blunt, 10%-Penetrating • 10% of pts with significant abdominal trauma. • When severe, associated with injuries to other organs in upto 80%. • When kidney is the only organ damaged, injury is minor in 98%.
  4. Mechanism of renal trauma • Blunt trauma: direct blow to the kidney. • Penetrating trauma: stab or gunshot injury, renal biopsy. • High-velocity deceleration: pedicle injury (avulsion of renal vessels).
  5. Predisposing factors • Pre existing renal abnormalities -Vulnerable position: transplant kidnyes horse shoe kidneys crossed fused ectopia -Increased bulk: Tumours(angiomyolipoma,RCC), Cysts,Hydronephrosis) • Paediatric kidneys.
  6. Indications for renal imaging • Penetrating • Gross hematuria • Microhematuria with shock( Systolic BP<90 mmHg) • Microhematuria with - Flank impact(contusion, haematoma over frank) • Fracture of lower ribs, transverse processes or thoracolumbar spine • Deceleration injury • Paediatric
  7. Federle Classification • Category I- MINOR -Contusion -Cortical laceration not extending into a calyx. • Category II- MAJOR -Cortical laceration extending into the collecting system(renal fracture) • CategoryIII- CATASTROPHIC -Renal pedicle injuries -Shattered kidney • Category IV -PUJ Injuries.
  8. AAST (American Association for the Surgery of Trauma) Classification • Grade 1 – Contusions – Nonexpanding subcapsular hematomas • Grade 2 – Superficial cortical lacerations less than 1 cm in depth without collecting system injury • Grade 3 – – Renal lacerations greater than 1 cm in depth that do not involve the collecting system • Grade 4 – Renal lacerations extending to the corticomedullary junction or into the collecting system – Injuries involving the main renal artery or vein with contained hemorrhage • Grade 5 – Shattered kidney – Renal pedicle avulsion
  9. AAST
  10. Imaging modalities • CT Scan • IVU • Anterograde / Retrograde pyelography • Cystography • Urethrography • USG • Renal angiography • MRI
  11. IVU • Historical interest, largely replaced by cross sectional imaging. • Quality of IVU in the setting of trauma is likely to be poor; hypotensive patient minimal or no secretion from both kidneys. • Single shot IVU(full length film 15 mins after contrast inj.)in hemodynamically unstable patients destined for ER laparotomy. • Provides information regarding: -presence of functioning contralateral kidney. -some gross information about the injured kidney. • Intra-operative IVU in severely injured patients.
  12. IVU • Absence of unilateral excretion:major vascular injury (usually RA avulsion) • Soft tissue swelling with loss of psoas outline: retroperitoneal, perinephric and subcapsular hematomas. • Disruption of PCS:extravasation of opacified urine (70% sensitivity for urine leak)
  13. 15 min single shot IVU in a pt with stab injury to back. IVU-normal kidneys and ureter bilaterally.
  14. USG • Advantages: easily available, non invasive, high negative predictive value(96-98%) • Disadvantages: -poor resolution (compared to CT) -does not provide information about renal function. -significant trauma may be missed(upto 80%of parenchymal lesions may be overlooked)
  15. Findings in USG • Acute parenchymal, subcapsular and perinephric hematomas - echo poor areas. • More heterogenous and echogenic with time. • Disruption of renal parenchyma with capsular tears and urinomas can be identified • Doppler-pedicle injuries.
  16. Ultrasound gray-scale image shows normal right kidney.Doppler study shows absent colour uptake in intrarenal arteries s/o grade 5 injury.
  17. Grade 4 renal injury. Sonogram in an 8-year-old child with posttraumatic renal infarction shows both kidneys with an avascular area in the lower half of the affected kidney
  18. CT Scan • Modality of choice, most accurate technique. • Allows assessment of entire abdomen, including liver and spleen. • Arteriovenous phase • Delayed scan at 10-20 min
  19. • Technique: - the abdomen and pelvis should be scanned from the diaphragmatic dome to pubic symphysis with contrast. -Protocol: • commence scanning 30 sec after the start of an injection of 50-100ml of 300 strength contrast at 2-3 ml/sec, collimation 7 mm, pitch 1.3, reconstruction interval of 7 mm.
  20. CT Findings:Grade I Injuries • Contusions and/or non expanding subcapsular hematomas. -accounts for 80% of renal injuries. • Contusions: -ill-defined or sometimes sharply marginated areas of reduced enhancement and excretion. • Sucapsular hematoma: -crescentic low density area following the convexity of the outer aspect of the renal cortex
  21. Grade 1 renal injury, contusion-shows ill-defined area of hypoenhancement in the medial right kidney.
  22. Grade 1 renal injury, subcapsular hematoma-Image shows crescentic high- density fluid collection around the left kidney with well-defined outer margin
  23. Grade 1 renal injury, subcapsular hematoma
  24. Grade 2&3 Injuries • Grade2: non expanding perinephric hematomas contained by the retroperitoneum and superficial cortical lacerations less than 1 cm in depth not extending into a calyx. • Grade3: cortical lacerations greater than 1 cm in depth not extending into a calyx. • Perinephric hematoma : -ill-defined, hyperattenuating fluid collection located between the Gerota fascia and the renal parenchyma • Renal lacerations : -jagged or linear parenchymal disruptions that can contain fresh or clotted blood . • Both grade 2 and grade 3 renal lacerations :No evidence of urinary contrast extravasation on delayed CT.
  25. Grade 2 renal trauma-an ill-defined fluid collection in the left perinephric space andsubcapsular hematoma with deformity of the renal parenchyma.
  26. Grade 2 renal injury-superficial (less than 1 cm deep) renal parenchymal defect with a large perinephric hematoma
  27. Grade 3 renal laceration, CT-renal parenchymal defect with extension greater than 1 cm deep to near the renal pelvis
  28. Grade 3 renal laceration
  29. Grade 4 Injuries • A) renal lacerations that extend into the collecting system, B) injuries to the main renal artery or vein with contained hemorrhage, and C)segmental infarctions without associated lacerations. • Renal lacerations with collecting system involvement : - frequently produce extravasation of urine or contrast agent. -delayed images allow adequate views of any urinary extravasation • Renal segmental infarctions: well-delineated, linear or wedge-shaped, often multifocal and nonenhancing areas that extend through the parenchyma in a radial or segmental orientation .
  30. Grade 4 renal injury segmental infarction. Shows a segmental area of nonenhancement in the upper medial left kidney without associated renal laceration.
  31. Grade 4-5 renal injury shows deep lacerations extending into the collecting system of the right kidney . Extension into the collecting system is confirmed by urinary contrast extravasation on the delayed image through the kidney in excretory phase.
  32. Grade 5 Injuries • Shattered or devascularized kidney, UPJ avulsions, and complete laceration or thrombosis of the main renal artery or vein. • Shattered kidney: multiple renal fragments. • Renal artery disruption/avulsion: commonest vascular injury. -non perfusion of the kidney. -some preservation of peripheral perfusion due to early take off of the capsular artery. -traumatic renal artery dissection may be identified on CT. • Traumatic renal vein thrombosis. -persistent nephrogram, -thrombus may be directly demonstrated in the renal vein. • UPJ avulsion-contrast extravasation -total disruption-ureter fails to opacify. -partial disruption-contrast appears in the ureter.
  33. Grade 5 renal injury. Shattered left kidney
  34. Grade 5 renal injury -delayed image shows urinary contrast extravasation.
  35. Grade 5 renal injury. Shattered kidney with renal vein thrombosis (incomplete). CT scan shows shattered right kidney and renal vein thrombus extending slightly into the inferior vena cava.
  36. Grade 5 renal injury, devascularization. CECT shows dissection of the origin of the left renal artery, with no perfusion of the left kidney.
  37. MRI • MRI provides excellent detail of the renal anatomy but offers no clear advantage over CT, and is less able to detect extravasation. • A rare indication for MRI in the renal trauma setting may be severe contrast allergy.
  38. Management(EAU 2003 guidelines) • Blunt : Grade 1-4 conservative MX • Penetrating :Grade 1-3 conservative Mx • Absolute indications for SX
  39. Complications • Urinoma • Perinephric Abscess • Pseudoaneurysm • HTN • Renal insufficiency • Urinary fistula • Pyelonephritis
  40. Ureteric trauma • <1% of urinary tract trauma • Mechanism of injury: a) External: Penetrating injuries Deceleration injuries: -PUJ avulsion, -less often upper 1/3rd of ureter -more frequent in children(sufficient flexibilty to produce hyperflexion injuries) b) Iatrogenic: gynaecologic Surgery for malignancy.
  41. Grading-AAST
  42. • Haematuria may be absent in one third of cases. Features include: • Contrast extravasation • Formation of urinoma • Ureteric discontinuity
  43. Imaging findings • IVU: -mild to moderate fullness of the PCS and extravasation at the site of tear. - complete tear-ureter fails to opacify below the tear. -fistulations to other structures. • Retrograde pyelogram: -findings as above. -limited use in acute setting.
  44. Bladder trauma • Causes:Trauma Spontaneous • Trauma:Blunt Penetrating
  45. • Blunt trauma: - most common in patients with multi injury trauma - predisposed by full bladder at the time of trauma. - pelvic fractures(especially anterior ring) commonly asscociated -7 % symphysis pubis diastasis associated with bladder trauma. • Spontaneous: • pre-existing bladder wall abormalities &/or excessive straining -bladder tumour,cystitis,perivesical inflammation, BOO,neurogenic bladder,previous radiotherapy.
  46. • Iatrogenic trauma Surgery particularly caessarean section and transurethral bladder resection( usually for tumour)
  47. Classification 1 Contusion (incomplete or partial tear of the bladder mucosa,imaging findings usually normal) 2 Intraperitoneal rupture (contrast material seen around bowel loops and in the major peritoneal spaces) 3 Interstitial bladder injury(rare, contrast material dissects into bladder wall but not outside the bladder) 4 Extraperitoneal rupture (contrast seen within the perivesical space and a variable number of adjacent extraperitoneal spaces, depending upon the severity of injury) 5 Combined intraperitoneal and extraperitoneal rupture.
  48. Imaging modalities • Conventional cystography • CT Cystography
  49. Conventional Cystography • Advantages: -nearly 100% sensitive for detecting rupture, provided that adequate distention is accomplished and that post voiding images are obtained. • Disadvantages: -time consuming, -require extra radiography in addition to necessary trauma evaluation. -not useful in evaluating trauma to other viscera.
  50. CT cystography • Advantages of CT Cystography -less time consuming. -concomitant injury to other viscera(most importantly the kidneys) • The absence of free fluid in the abdomen during the CT is a strong negative predictor of bladder injury.
  51. Imaging findings • Extraperitoneal rupture: -commonest bladder injury(90% of cases) -associated anterior pelvic ring fracture in 90% of cases. -extravasation of contrast into the perivesical space- - in florid extravasation,contrast may extend anterosuperiorly along the anterior pelvic and abdominal wall upto umbilicus,or posteriorly around the rectum in presacral space. -associated tear of urogenital diaphragm allowing the contrast to appear within the perinerum,thigh and scrotum. • The extravasated contrast stays close to the bladder and has a sharp irregular margins.
  52. CT cystogram of victim of motor vehicle collision (A) shows streaky extravasated contrast material around urinary bladder consistent with extraperitoneal bladder injury. (B) Coronal reformatted image better demonstrates the site of injury at the left bladder base
  53. • Intraperitoneal rupture -contrast extravasates into the peritoneal cavity and has a more cloudy nebulous appearance. -usually tear is along the dome of bladder which is the weakest part. -associated pelvic fractures seen in 75%
  54. Conventional cystogram demonstrating an intraperitoneal bladder rupture.
  55. Urethral trauma • Almost entirely restricted to males unless there is major pelvic trauma in females. • Should be suspected- – Pelvic trauma with hematuria or retention – Blood at the urethral meatus. Imaging: Retrograde urethrogram
  56. Male posterior urethral injuries Type Membranous urethra Bulbar Urethra Contrast Extravasation Perineu m Retropu bic space I Contusion or partial tear Normal or stretced No No II Rupture above UGD Normal or stretched No Yes III Rupture below UGD Ruptured Yes No
  57. • Type II injuries-most common,rupture at the prostatic apex (prostatomembranous junction) immediately above the UGD with sparing of the UGD itself. • Type III injuries-membranous urethra ruptures at the membranobulbar junction below the UGD,which itself is disrupted.
  58. Retrograde urethrogram reveals a type I urethral injury with minimal stretching and slight luminal irregularity of the posterior urethra. No extravasation of contrast material is present
  59. Retrograde urethrogram - type II urethral disruption. Extravasation of contrast material (solid arrow) from the posterior urethra is seen superior to an intact urogenital diaphragm (dashed arrow).
  60. Retrograde urethrogram - type III urethral injury. Extravasation is located in both the extraperitoneal pelvis and in the perineum (above and below the urogenital diaphragm).
  61. Anterior urethral trauma • Mechanisms: -iatrogenic (attempted catheterisation, instrumentation) -blunt perineal trauma(straddle injury):bulbar urethra and corpus spongiosum are compressed against the inferior aspect of anterior pelvic ring.
  62. Straddle injury. Retrograde urethrogram shows a type 5 urethral injury with extravasation of contrast material from the distal bulbous urethra.
  63. Findings • Rupture -partial:contrast extravasation with some filling of proximal urethra. -complete:failure of filling of proximal urethra
  64. Complications • Stricture • Impotence(up to 10%) • Incontinence (2%)
  65. SCROTAL TRAUMA • Injury to the testis may occur from penetrating wounds, direct impact of high- velocity objects against the testis or compression of the testis against the pubic arch and impacting object. • Ultrasound is the imaging technique of choice in acute scrotal trauma.
  66. • Intratesticular haematomas are common after trauma. • The ultrasound appearance depends on the time between occurrence of trauma and ultrasound evaluation. • Acute haematomas are typically isoechoic to the normal testicular parenchyma and can be difficult to identify.
  67. • Testicular rupture implies tearing of the tunica albuginea with extrusion of testicular parenchyma into the scrotal sac. • The margins of the testis are poorly defined and the echogenicity of the testis is heterogeneous.
  68. • The use of colour Doppler is essential as rupture of the tunica albuginea will almost always be associated with a loss of vascularity to a portion of or the entire testis.
  69. • Trauma to the testis can also result in dislocation or torsion. • Dislocation most commonly results from impact of the scrotum against the fuel tank in motorcycle accidents. • Testicular dislocation, typically into the inguinal canal, may be detected by CT or ultrasound. • Testicular torsion is preceded by trauma in 5–8% of cases.
  70. References • Textbook of radiology and imaging David Sutton 7th edition • Grainger and Allison’s Diagnostic Radiology 6th edition • Fundamentals of Diagnostic Radiology Bryant & Helms 4th edition • Radiopedia

Hinweis der Redaktion

  1. Major renal injury(grade 4 and 5): - up to 25% of blunt, and in up to 70% of penetrating renal trauma cases.
  2. (more ant location and proximity to rigid spine or iliac crest)
  3. ? omit if normal kidneys with no perinephric, retroperitoneal or pelvic fluid.
  4. addition of 400-600 ml of oral contrast (4% diatriazoate) immediately before scan helps in delineating associated bowel injuries (stomach,duodenum and proximal jejunum).