ĐIỀU TRỊ CHẤN THƯƠNG NIỆU

10/4/2015

ĐIỀU TRỊ
CHẤN THƯƠNG NIỆU
PGS Phạm Văn Bùi

Urologic trauma

•Trauma: defined as the morbid condition of
the body produced by external violence.
•Renal trauma occurs in approximately 1%–
5% of all traumas

1


10/4/2015

Urologic trauma
Urgent but usually not emergent
• 1. Is the patient well enough to undergo an operation?
• 2. Will an operation improve the situation or is a minimally invasive
approach or patience a better course of action?
• 3. Have you considered possible concomitant pathology or injuries?
• 4. Should you involve a general surgeon, internist, or intensivist in the
patient’s care?
• 5. Would additional imaging be helpful?

Two rules govern the management of
urologic trauma.

• First: in the stable patient all efforts should be made to
evaluate and address genitourinary injuries at presentation.
• Second: in the unstable patient the urologic injuries must
be measured alongside other, often more life-threatening
injuries; urologic injuries can often be managed without
reconstruction or temporized with a drain

2


10/4/2015

RENAL TRAUMA
• Kidney:the most commonly injured genitourinary and abdominal organ,
with the male to female ratio being3:1
• Renal trauma: can be acutely life-threatening,
• Majority of renal blunt trauma can account for the largest percentage of
renal injuries(90%–95%)
• Blunt trauma is usually secondary to motor vehicle accidents, falls,vehicleassociated pedestrian accidents, contact sports,& assault.
• Renal lacerations & renal vascular injuries make up only 10%–15% of all
blunt renal injuries.
• Isolated renal artery injury following blunt abdominal trauma is extremely
rare & accounts for < 0.1% of all trauma patients

Diagnosis:
• Initial Emergency Assessment Initial assessment of the trauma patient
should include:
• Securing the airway,
• controlling external bleeding,
• resuscitation of shock as required.

• In many cases, physical examination is carried out simultaneous to
stabilization of the patient.
• When renal injury is suspected, further evaluation is required for a
prompt diagnosis.

3


10/4/2015

History and Physical Examination
History

• Conscious patients
• Possible indicators of major renal injury:
• rapid deceleration event (fall, high-speed motor vehicle accidents)
• direct blow to the flank.
• In assessing trauma patients after motor vehicle accidents:
• vehicle’s speed
• whether a passenger or pedestrian.
• Preexisting renal abnormality makes renal injury more likely following
trauma: solitary kidney, horseshoe kidneys, stone, hydronephrosis, cyst

History and Physical Examination
Physical examination

• Basis for the initial assessment of each trauma patient.:
• Hemodynamic stability: the primary criterion for the management of all renal
injuries.
• Shock: systolic blood pressure< 90mmHg

• Vital signs should be recorded throughout diagnostic evaluation.
• Penetrating trauma:
• stab wound:
• extent of the entrance wound not accurately reflecting the depth of
penetration.
• lower thoracic back, flanks and upper abdomen,
• bullet entry or exit
• Blunt trauma to the back, flank, lower thorax, upper abdomen may result in renal
injury.

4


10/4/2015

History and Physical Examination
Physical examination

• The following findings may
indicate possible renal
involvement:
• hematuria,
• flank pain
• flank ecchymosis and/or
abrasions,
• fractured ribs,
• Abdominal distension or
tenderness, and
• palpable mass.

Clinical presentation of renal vein
thrombosis depends on:
• balance achieved between the
rapidity & degree of venous
occlusion, as well as the
development of collateral veins.
• patients may be asymptomatic,
• no specific symptoms such as
nausea or vomiting,
• more specific symptoms such as
hematuria
• flank pain

Laboratory Evaluation

• Urinalysis, hematocrit and baseline creatinine values: most important tests for evaluating
renal trauma.
• Hematuria:
• hallmark sign of renal injury,
• neither sensitive nor specific enough for differentiating minor and major injuries.
• not necessarily correlate with the degree of injury
• urine dipstick: acceptably reliable and rapid test
• Serial hematocrit determination
Initial hematocrit in association with vital signs implies the need for emergency
resuscitation
• Creatinine measurement reflects renal function prior to the injury( As most trauma
patients are evaluated within 1 h after injury) → An increased creatinine usually reflects
preexisting renal pathology.

5

10/4/2015

Imaging: Criteria for Radiographic
Assessment in Adults

• Based on the clinical findings & the mechanism of injury
• With microscopic hematuria & no shock after blunt trauma
→ low likelihood of concealing significant renal injury
• Indications for radiographic evaluation:
• Gross hematuria,
• Microscopic hematuria and shock, or
• Presence of major associated injuries,
• Rapid deceleration injury

Imaging Ultrasonography

• Popular imaging modality in initial evaluation of abdominal trauma: quick,
noninvasive, low-cost means of detecting peritoneal fluid collections,
without exposure to radiation or contrast agents
• Color Doppler, power Doppler, or ultrasound with contrast: presence of
blood flow to the kidney.
• Limitations :
• Difficulty in obtaining good acoustic windows/trauma patient who has
sustained numerous associated injuries.
• Highly dependent on the operator.
• Can detect renal lacerations but cannot definitely assess their depth and
extent and do not provide functional information about renal excretion
or urine leakage.

• Cannot establish if renal function is present, and there is also difficulty
in some cases of differentiating a shattered kidney from a congenitally
absent kidney.

6


10/4/2015

Imaging Ultrasonography
• More sensitive & specific than
standard intravenous pyelography
(IVP) in minor renal trauma
• Serially evaluating stable renal
injuries for the resolution of
urinomas and retroperitoneal
hematomas
• Effective screening examination
• Suitable for routine follow-up of
renal parenchymal lesions or
hematoma in ICU

Imaging: Standard Intravenous Pyelography
• No longer the study of choice for evaluation of
renal trauma,
• Clearly define the renal parenchyma, & outline
collecting system.
• Non-visualization, contour deformity, or
extravasation of contrast implies a major renal
injury → further radiological evaluation with CT

or less commonly, angiography if available.
• One-shot IVP in the operating suite: 2 ml/ kg
radiographic contrast followed by a single plain
film taken after 10 min.

7


10/4/2015

Imaging: Computed Tomography(CT)
• Gold standard method for the radiographic assessment of stable
patients with renal trauma,
• More accurately defines the location of injuries, easily detects
contusions and devitalized segments, visualizes the entire
retroperitoneum & any associated hematomas, & simultaneously
provides a view of both the abdomen and pelvis.
• Superior anatomical detail, including:
• Depth & location of renal laceration,
• Presence of associated abdominal injuries,
• Presence and location of the contralateral kidney

Magnetic Resonance Imaging
• Accurate in finding:
• perirenal hematomas, assessing viability of renal fragments,& detecting
preexisting renal abnormalities,
• but failed to visualize urinary extravasation on initial examination.
• IV gadolinium-based contrast material → helpful in the assessment of urinary
extravasation
• Clearly revealed renal fracture with a non viable fragment & able to detect

focal renal laceration not detected on CT due to perirenal hematoma
• MRI not 1st choice in managing patient with trauma:
• Longer imaging time,
• Cost,
• Limits access to the patient in the magnet during the examination.

8


10/4/2015

9


10/4/2015

Angiography

• CT largely replacing angiography for staging
renal injuries, since angiography less specific,
more time-consuming, & more invasive.
• More specific for defining exact location &
degree of vascular injuries
• Preferable when: planning selective
embolization for management of persistent
or delayed hemorrhage from branching
renal vessels
• Define renal lacerations, extravasation, &
pedicle injury.
• Test of choice for evaluating renal venous

injuries
• Indicated in stable patients to assess pedicle
injury,

10


10/4/2015

Radionuclide Scans

Radionuclide scans:
• Helpful to document renal blood flow in the trauma
patient with severe allergy to iodinated contrast
material,
• Following up repair of reno-vascular trauma

Treatment
• Goal of management of patients with renal injuries: to minimize morbidity
& to preserve renal function.
• Renal exploration should be undertaken selectively.
• Condition of patient remains the absolute determinant in the decision for
initial observation vs surgical intervention.
• Management of renal injury usually influenced by decision to explore or
observe associated abdominal injuries
• Non operative therapy is supported widely for the majority of blunt and
penetrating injuries.
• Grade of renal injury, overall injury severity of patient, & requirement
for blood transfusions are the primary prognostic factors for
nephrectomy & overall outcome

11


10/4/2015

Treatment

Indications for Renal Exploration

• life-threatening hemodynamic instability due to renal hemorrhage is an
absolute indication for renal exploration, irrespective of the mode of
injury
• expanding or pulsatile perirenal hematoma identified at
exploratorylaparotomyperformedforassociatedinjuries(thisfindingheral
dsaGrade5vascularinjuryand is quite rare).
• Grade 5 vascular renal injuries are by definition regarded as an
absolute indication for exploration;
• Inconclusive renal imaging & a preexisting renal abnormality or an
incidentally diagnosed tumor may require surgery even after relatively
minor renal injury
• Persistent extravasation or urinoma are usually managed successfully
with endourological techniques.

Treatment
• Renorrhaphy: most common reconstructive technique.
• Partial nephrectomy required when nonviable tissue detected.
• Watertight closure of the collecting system if open desirable ( close the
parenchyma over the injured collecting system → good results)
• If renal capsule not preserved, an omental pedicle flap or perirenal fat bolster may

be used for coverage
• Drainage of the ipsilateral retroperitoneum recommended to provide an outlet for
any temporary urinary leak.
• Renal wrapping with absorbable mesh valuable in organ preservation in cases of
multiple lacerations
• All penetrating injuries are explored via a transabdominal approach for preserving
kidney if feasible, exploring contralateral kidney, and controlling other abdominal
injuries,

12


10/4/2015

Treatment: Non operative Management of
Renal Injuries
• Treatment of choice for the majority of renal injuries.
• In stable patients: supportive care with bed rest, hydration, & antibiotics is
preferred initial approach.
• Primary conservative management associated with lower rate of nephrectomy,
without any increase in immediate or long-term morbidity( failure rate of
conservative management #5%).
• All Grade1& 2 managed non operatively, whether they are due to blunt or
penetrating trauma.
• Therapy of Grade 3 injuries: controversial
• Majority of patients with Grade 4 and 5 renal injuries present with major
associated injuries, with resultant high exploration and nephrectomy rates

Postoperative Care and Follow-up

• Repeat imaging 2–4 days after trauma → minimizes risk of missed
complications, especially in Grade 3–5 blunt renal injuries
• CT scans always performed
• Fever,
• Unexplained decreasing hematocrit
• Significant flank pain.
• Nuclear renal scans useful for documenting and tracking functional
recovery following renal reconstruction before discharge
• F-U: physical examination, urinalysis, individualized radiological
investigation, serial BP measurement, and serum determination of
renal function

13


10/4/2015

Complications

• Early complications(within the 1st month after
injury): bleeding, arteriovenous fistulae, infection,
perinephric abscess, sepsis, urinary fistula, hypertension,
urinary extravasation, & urinoma.
• Delayed complications: bleeding, hydronephrosis,
calculus formation, chronic pyelonephritis, hypertension,
arteriovenous fistula, & pseudoaneurysms.

14

10/4/2015

Trauma of the Ureter: Clinical Diagnosis
•Most important step for successful
outcome: prompt diagnosis.
•Hematuria, absent in approximately 30%–
45% cases

15


10/4/2015

Trauma of the Ureter: Clinical Diagnosis
• External Trauma: very rare
• Iatrogenic/Intraoperative Trauma
Open surgery, laparoscopic surgery, and ureterorenoscopy.
• 1. Crushing from misapplication of a clamp
• 2. Ligation with suture
• 3. Transsection (partial and complete)
• 4. Angulation of the ureter with secondary obstruction
• 5. Ischemia from ureteral stripping or electrocoagulation
• 6. Resection of a ureteral segment
• 7. Any combination of the above

Radiographic Diagnosis
• CT scan:
• Most accurate radiographic modality to diagnose ureteral injuries:
delayed excretory images able to completely judge renal pelvis,
ureter,& bladder

• Extravasation of contrast confined predominantly to the medial
perirenal space: most consistent finding
• Intravenous urogram (IVU): standard tool for evaluation before
widespread use of CT scan.
• If IVU & scan inconclusive, → invasive diagnostic procedure with
cystoscopy & a retrograde ureterogram(impractical in acute trauma )

16


10/4/2015

17


10/4/2015

BladderTrauma
•Incidence of blunt trauma rising as a result of
modern transportation preferences & increasing
reliance on motor vehicles that travel at higher
speeds
•Bladder injury seldom represents an
immediate threat to life

18


10/4/2015

Etiology
• Bladder injury caused by either external (blunt or penetrating) or
iatrogenic trauma,
EXTERNAL TRAUMA: BLUNT TRAUMA
• Blunt trauma accounts for 67%–86% of traumatic bladder ruptures
• Most common cause (90%): motor vehicle accidents
• Direct blow to the lower abdomen during the event, usually when the
bladder is distended with urine.
• Empty bladder is usually well protected within the bony pelvis and
injured by a sharp bony spicule when fractures occur to the bony
pelvis

19


10/4/2015

Etiology

Iatrogenic Trauma
• Bladder: most frequently injured genitourinary organ
during lower abdominal operations
• Recent increase in laparoscopic procedures →
↑incidence of iatrogenic bladder injuries.

Classification

20

10/4/2015

Risk Factors
Blunt Trauma
• Distended bladder
• Alcohol
• Pelvic injurie → bladder & urethra
as the most commonly injured
organs.

Iatrogenic Trauma

• Adhesions & pelvic scarring from
previous surgery,
• Inflammation,
• Endometriosis,
• Exposure to radiation,
• Malignant disease,
• Pregnancy,
• Pelvic organ prolapse,
• Multiple cesarean sections,
• Congenital abnormalities,
• Hemorrhage,
• Failure to empty bladder before
operation

21


10/4/2015

Diagnosis
• Two most common signs and symptoms :
• Gross hematuria (82%)
• Abdominal tenderness (62%)
• Other findings:
• Inability to void, bruises over suprapubic region, abdominal
distention
• Extravasation of urine may → swelling in perineum,
scrotum,& thighs, as well as along anterior abdominal wall

Diagnosis : Cystography
• Retrograde cystography: standard
diagnostic procedure
• Adequate bladder filling & post void
images obtained → accuracy rate
85%–100%.
• Injected contrast medium identified
outside bladder

22


10/4/2015

Diagnosis : Cystography
• Retrograde cystography: standard
diagnostic procedure
• Adequate bladder filling & post void
images obtained → accuracy rate

85%–100%.
• Injected contrast medium identified
outside bladder

Diagnosis

• Excretory Urography (Intravenous Pyelography)” Inadequate for
evaluation of bladder & urethra after trauma because of dilution of
contrast material within the bladder, & resting intravesical pressure too
low to demonstrate a small tear
• Ultrasound: peritoneal fluid in the presence of normal viscera or
failure to visualize the bladder after transurethral introduction of saline
→ highly suggestive of bladder rupture
• MRI: little place in evaluation of acute bladder
• Cystoscopy:
• Extremely useful tool in the diagnosis of iatrogenic bladder
injuries
• Detection rate from 85% to 94.1% indifferent series

23


10/4/2015

Diagnosis: CT Scan
CT Scan
- not reliable in diagnosis of bladder
rupture
- intraperitoneal & extraperitoneal
fluid but cannot differentiate urine

from ascites.

Treatment
• First priority stabilization of patient & treatment of associated lifethreatening injuries.
Blunt Trauma: Extraperitoneal Rupture
• Managed safely by catheter drainage only, even in the presence of
extensive retroperitoneal or scrotal extravasation.
• All ruptures healed in 3 weeks
• Involvement of bladder neck presence of bone fragments in bladder wall, or
entrapment of the bladder wall → surgical intervention
• Presence of open pelvic fractures and/or rectal injuries precludes
conservative management due to the high risk of serious infectious
complications

24


10/4/2015

Treatment

Blunt Trauma: Intraperitoneal Rupture
• Always be managed by surgical exploration.
• Potential risk of peritonitis due to urine leakage, if left
untreated
• Abdominal organs should be inspected for possible
associated injuries,& urinoma must be drained.

Complications:

• Usually the result of failure to diagnose the injury & repair promptly.
• Urinoma formation,
• Urinary leakage into peritoneal cavity → ileus, peritonitis,
• Hematoma,
• Abscess formation,
• Fistula formation (rectal,vaginal,or cutaneous),
• Urinary tract infection.
• Prostatic capsule contains abundant activators of plasminogen & urine
contains high levels of urokinase(potent plasminogen activator) →
increase & prolong hemorrhage

25