Bài giảng Điều trị chấn thương niệu - Phạm Văn Bùi

pertension, urinary extravasation, & urinoma.•Delayed complications: bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension, arteriovenous fistula, & pseudoaneurysms.
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Trauma of the Ureter: Clinical Diagnosis
•Most important step for successful outcome: prompt diagnosis. •Hematuria, absent in approximately 30%–45% cases 
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Trauma of the Ureter: Clinical Diagnosis
• External Trauma: very rare• Iatrogenic/Intraoperative TraumaOpen 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 ) 
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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
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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
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Etiology
Iatrogenic Trauma• Bladder: most frequently injured genitourinary organ during lower abdominal operations• Recent increase in laparoscopic procedures → ↑incidence of iatrogenic bladder injuries.
Classification
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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
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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
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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 
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Diagnosis: CT Scan
CT Scan - not reliable in diagnosis of bladder rupture - intraperitoneal & extraperitonealfluid but cannot differentiate urine from ascites.
Treatment
• First priority stabilization of patient & treatment of associated life-threatening 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 
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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 
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UrethralTrauma
Posterior Urethral Injuries• Posterior urethra Injuries occuringwith pelvic fractures (road traffic accidents, crush injuries, or falls from height.
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Urethral Trauma
Stable Pelvic Fracture Unstable Pelvic Fractures 
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UrethralTraumaAnterior Urethral Injuries 
Blunt Trauma• Caused by vehicular accidents, falls, or blows• Against the perineum,• Relatively immobile bulbar urethra is trapped & compressed by a direct force on it against the inferior surface of the symphysis pubis.
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UrethralTraumaAnterior Urethral Injuries 
Intercourse-Related Trauma • With ruptures of the corpora cavernosa, which usually occur with an erect penis, often during intercourse• Intraluminal stimulation of the urethra with foreign objects • Most short & incomplete & occur in distal penile urethra. • Masturbation• Break Usually only corpora cavernosa injured 
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Clinical Assessment
• Blood at meatus(preclude any attempts at urethral instrumentation, until entire urethra adequately imaged)• Blood at vaginal introitus
• Hematuria: first voided specimen→urethral injury
• Pain on urination/ inability to void• Hematoma/swelling
• High-riding prostate
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Radiographic Examination
• Retrograde urethrography: gold standard for evaluating urethral injury.• If posterior urethral injury suspected→suprapubic catheter inserted → simultaneous cystogram& ascending urethrogram (within1week)→ assess site, severity, & length of urethral injury.
Management: Anterior Urethral Injuries 
Blunt Injuries
• Partial tears: suprapubic catheter or urethral • Cystostomy tube catheterization(maintained for approximately 4 weeks to allow urethral healing.)• Voiding cystourethrography then performed & if normal voiding & no contrast extravasation nor subsequent stricture → tube safely removed.• Complications: strictures & infections.• Acute or early urethroplasty is not indicated & best management is simply suprapubic diversion
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Management: Posterior Urethral InjuriesDistinction: between posterior urethral stricture ≠ subprostatic pelvic fracture urethral distraction defect
Management: Posterior Urethral Injuries
Partial Urethral Rupture • Suprapubic or urethral catheter and repeat retrograde urethrography at 2-week intervals until healing has occurred• Residual/ subsequent stricture• Urethral dilation or optical urethrotomy,(if short & flimsy)• Anastomotic urethroplasty (if denser)
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Management: Posterior Urethral Injuries
Complete Urethral Rupture• Primary Realignment: either transpubically (open realignment) or with endoscopic techniques (endoscopic realignment).• Primary Open Realignment: associated with concomitant bladder neck or rectal injuries → immediate open exploration, repair & urethral realignment advisable• Primary Endoscopic Realignment: • Patient’s overall condition & extent of associated injuries → decision to proceed with primary endoscopic realignment.• Endoscopic urethral realignment may be considered during the first 2 weeks after trauma
Management: Posterior Urethral Injuries
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Management: Posterior Urethral Injuries
Immediate Open Urethroplasty (<48 h After Injury: not indicated • Poor visualization & inability to assess accurately the degree of urethral disruption during the acute phase, • Extensive swelling & ecchymosis.• Difficulty in identifying structures & planes hamper adequate mobilization and subsequent surgical apposition• Incontinence & impotence rates high
Delayed Primary Urethroplasty (2–14 Days After Injury) • Now more active orthopedic management of pelvic fractures with immediate external & internal fixation → option for early repairs of urethral injuries • Placement of a suprapubic tube at time of initial injury, with repair undertaken when the patient stable, usually within 10–14 days. 
Management: Posterior Urethral Injuries
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Fig. 15.9.19. Management of anterior urethral injuries in men
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Management: Posterior Urethral Injuries
•Erectile dysfunction (20%–60%): severity of initial injury (most important determining factor), age, defect length, type of fracture; bilateral pubic rami fractures(bilateral damage of cavernous nerves )
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