Injuries to urinary tract

1
Injuries to urinary tract
2
Renal injury
3
Classification (Moore 1989)

• I Contusion
• II Perirenal hematoma
• III Laceration lt1cm
• IV Laceration gt1cm Laceration into collecting
  system
• V Shattered kidney Vascular injury

4
Investigations

• San Francisco trauma group (Nicolaisen 1985) 359
  patients
• Renal imaging needed
• Penetrating injury
• Blunt injury with gross hematuria
• Blunt injury with microscopic hematuria plus
  shock
• Renal imaging not needed
• Blunt injury with microscopic hematuria without
  shock
• Children with blunt trauma and hematuria
• Imaging regardless of BP or degree of hematuria

5
Treatment

• Blunt, operation indicated if
• Persistent retroperitoneal bleeding
• Urine extravasation
• Nonviable renal parenchyma
• Renal pedicle injuries
• Penetrating
• Exploration

6
Complication

• Urinoma
• Hydronephrosis
• AVF
• Renal vascular hypertension

7
Ureteric injury
8
Classification

• Mechanism blunt or penetrating
• Level upper, middle or lower
• Recognition immediate or delayed
• Associated injuries

9
Treatment

• Stenting
• PCN
• Deligation
• Primary ureterio-ureterostomy
• Reimplantation
• Reimplantation with psoas hitch
• Boari-Ockerblad flap
• Trans-uretero-ureterostomy
• Enteric interposition
• Renal mobilization
• Inferior translocation of right renal vein

10
Treatment

• Renal autotransplantation into pelvis
• Cutaneous ureterostomy
• Uretero-enteric diversion
• Nephrectomy
• Purposeful ligation of injured ureter

11
Bladder injury
12
Pathology

• Extraperitoneal more common
• Intraperitoneal more severe
• 89-100 extraperitoneal rupture have pelvic
  fracture
• 5-10 pelvic fracture have bladder rupture

13
Treatment

• Extraperitoneal
• Bladder drainage
• Surgical repair and bladder drainage if
• Severe hematuria
• Infection of pelvic hematoma
• Persistent leakage
• Intraperitoneal
• Surgical repair and bladder drainage
• Penetrating
• Surgical

14
Posterior urethral injury
15
Pathology

• Pelvic fractures
• Stable butterfly fracture
• Unstable fracture
• Usually at prostatomembranous junction
• Prostate displaced superiorly except intact
  puboprostatic ligament or partial disruption
• Extravasation in extraperitoneal space (similar
  to extraperitoneal bladder rupture)
• Pie-in-the-sky appearance on cystogram (contrary
  to tear-drop appearance of extraperitoneal
  bladder rupture)

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Treatment

• Rupture
• Suprapubic, delayed repair of stricture at 3
  months
• Problems of primary repair
• Hemodynamically unstable
• Bleeding hinders exposure
• Infection introduced
• High rates of stricture, incontinence and
  impotence
• Primary repair if
• Severe prostatomembranous dislocation
• Major bladder neck laceration
• Concomitant pelvic vascular injury
• Concomitant rectal injury

17
Anterior urethral injury
18
Pathology

• Straddle injury
• Extravasation
• Confined by Bucks fascia
• Through Bucks fascia confined by Colles fascia

19
Treatment

• Immediate vs delayed repair

20
Complications

• Bleeding from corpus spongiosum, immediate
  operation if uncontrolled
• Extravasation infected
• Stricture

21
Urine extravasation
22
Urine extravasation

• Intraperitoneal
• Intraperitoneal ruptrue of bladder
• Extraperitoneal
• Extraperitoneal rupture of bladder (tear-drop
  appearance on cystogram)
• Rupture of posterior urethra (pie-in-the-sky
  appearance on cystogram)
• Suprapubic puncture
• Rupture of ureter
• TURP
• Confined by Bucks fascia or through Bucks
  fascia confined by Colles fascia (latter with
  extravasation into scrotum, perineum, penis and
  lower anterior abdominal wall but excluded from
  thigh because of attachment of Colles fascia
  with fascia lata which is deep fascia of thigh)
• Rupture of anterior urethra
• Rupture of periurethral abscess