pediatric nephrology urology genitourinary tract trauma

1. BY : DR INAYAT ULLAH
PGY-1 PEDIATRICS.
Genitourinary Trauma
February12th , 2015

2. Introduction
 10-20% of all injure patients
 Kidney : The most Common
 Life-threatening injuries first
A : airway with cervical spine protection
B : breathing
C : circulation and control of external bleeding
D : disability or neurological status
E : exposure (undress) and environment
(temperature control)

3. Content
 Upper Urinary tract trauma
 Renal injuries
 Ureteral injuries
 Lower Urinary tract trauma
 Bladder injuries
 Urethral injuries
 External Genitalia injuries

4. Upper
Urinary tract trauma

5. RENAL INJURIES : Etiology
 The most common of all injuries to the GU system
 Blunt trauma 80-85%
 Motor vehicle accidents, fights, falls, contact sports
 Vehicle collision at high speed : rapid deceleration , major vascular injury
 Penetrating : Associated abdominal visceral injuries 80%
- Gunshot wounds
- Stab wounds

6. Mechanism of Renal Injuries

7. Clinical findings
 Pain : localized to one flank area or over the
abdomen
 Gross or microscopic hematuria
 Ecchymosis in the flank or upper quadrants of
the abdomen
 Lower ribs or transverse process fracture
 Palpable mass : large retroperitoneal hematoma
or urinary extravasation
 Generalized peritonitis

8. Staging:Renal Trauma.

11. Indications for Renal Imaging
 Blunt trauma with gross hematuria
 Blunt trauma with microscopic hematuria and
shock (SBP < 90 mmHg anytime)
 Penetrating injuries with any degree of hematuria
 Pediatric patients (< 16 years)
 suspected any possible renal injury (e.g. patients
sustaining blunt trauma from rapid deceleration )

12. Imaging studies
 Contrast-enhanced CT -- preferred
 Single-shot intraoperative excretory urography
 Arteriography
 Sonography

13. Imaging Studies : Contrast-Enhanced CT
The preferred imaging study;
 Parenchymal lacerations
 Extravasation of contrast-enhanced urine
 Associated injuries
 Degree of retroperitoneal bleeding
 Lack of uptake of contrast material in the
parenchyma suggests arterial injury

15. Findings on CT that suggest
Major injury
(1) medial hematoma : suggesting vascular injury
(2) medial urinary extravasation : suggesting renal
pelvis or ureteropelvic junction avulsion injury
(3) lack of contrast enhancement of the parenchyma
: suggesting arterial injury

16. Single-shot intraoperative IVP
 Only a single film is taken 10 minutes after
intravenous injection (IV push) of 2 mL/kg of
contrast material
 If findings are not normal or near normal, the kidney
should be explored to complete the staging of the
injury and reconstruct any abnormality found

17. Arteriography
 To define arterial injuries suspected on CT
 To localize arterial bleeding that can be controlled by
embolization

18. Sonography
 Immediate evaluation of injuries
 Confirms the presence of two kidneys
 Can easily define any retroperitoneal hematoma
 Cannot clearly delineate parenchymal lacerations
and vascular or collecting system injuries
 Cannot accurately detect urinary extravasation in
acute injuries

20. MANAGEMENT.
Management

21. Nonoperative Management :
Isolated Renal Injuries
 Approximately 80% to 90% of renal injuries have
major associated organ injury
 Blunt trauma can be managed nonoperatively
 Patients with grade IV parenchymal lacerations can be
observed expectantly • Complete bed rest
• IV fluid replacement
• Antibiotics prophylaxis
• Analgesic and Sedation
•TT prophylaxis

22. Operative Management
 Absolute indications
 Evidence of persistent renal bleeding
 Expanding perirenal hematoma
 Pulsatile perirenal hematoma
 Relative indications
 Urinary extravasation
 Nonviable tissue
 Delayed diagnosis of arterial injury
 Segmental arterial injury
 Incomplete staging

23. Renal Exploration
Surgical exploration of the
acutely injured kidney is best done by
Transabdominal approach
allows complete inspection of
intra-abdominal organs and bowel
ส

24. Surgical Approach to
the renal vessels and kidney

25. Renal Reconstruction

26. Technique for Renorrhaphy

27. Renovascular Injuries

29. Indications for Nephrectomy
 Unstable patient, with low body temperature and
poor coagulation
 Extensive renal injuries when the patient’s life
would be threatened by attempted renal repair

30. Complications
 Urinoma – internal ureteral stent
 Perinephric abscess – percutaneous draingage,
surgical drainage
 Delayed renal bleeding
 Usually occurs within 21 days
 Angiography and embolization
 Hypertension

31. Arterial Hypertension
 Renal vascular injury, leading to stenosis or
occlusion of the main renal artery or one of its
branches
 Compression of the renal parenchyma with
extravasated blood or urine
 Post-trauma arteriovenous fistula

33. Ureteral Injuries

34. URETERAL INJURIES : Etiology
 External Trauma (20%)
- After external violence are rare (<1%)
- 10 - 28% have associated renal injuries
-5% have associated bladder injuries
 Surgical Injury (80%)
 Pelvic surgical procedure (M/C: Hysterectomy)
 Endoscopic manipulation, etc.

35. Clinical findings
 Post operative fever
 Flank and lower quadrant pain
 Paralytic ileus with nausea and vomitting
 Peritonitis
 Uretervaginal fistula
 Ureterocutaneous fistula
 Hematuria

36. American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Ureter

37. Imaging Studies
 Excretory Urography : intraoperative one-shot
pyelography
 Computed Tomography - IVP
 Retrograde Ureterography
 Antegrade Ureterography : If retrograde stent
placement is not possible

38. Imaging findings
 Excretory
urography
 Delayed function
 Hydronephrosis
 Extravasation
 Retrograde
ureterography
 Demonstrates the exact
site of obstruction or
extravasation

39. Treatment
 Repair when injury occurs
 Before 7 days  immediate Reexploration and
repair
 Delayed diagnosis  nephrostomy + repair after
3 months
Goals of ureteral repair
 Complete debridement, tension-free spatulated
anastomosis, watertight closure, ureteral
stenting, retroperitoneal drainage

44. Treat penile hair-tourniquet with an ice bag to ease the
pain and shrink the swelling.
Application of soapy water to the hairs facilitates
removal.
Wrap any size of penile amputation in saline gauze, put it
in a plastic bag, and place it on ice, with pressure and
sterile dressings applied to the remaining shaft.
Immediate reanastomosis surgery may be successful
External Genital Trauma

45.  . gently attempt to remove penile skin caught in a
zipper.
 If unsuccessful, inject 1% lidocaine (without
epinephrine) over foreskin. Then, the zipper can be
closed, releasing the entrapped skin.
 Amputation or avulsion of scrotal: treat skin with
sterile saline-soaked towels and consult a urologist
.
 Urethral foreign body: arrange for cystoscopy and
transurethral extraction after percutaneous
placement of a suprapubic catheter by a urologist.
Obtain a sonogram for suspected traumatic
testicular torsion or testicular rupture.