医学精品课件：14.Genitourinary Trauma-13级7年制20170525.ppt

1、Free photoshow template from 1Genitourinary Trauma Liu chuan Department of Urology,Second Affiliated Hospital Free photoshow template from 2Free photoshow template from 3 Approximately 10%of injuries involve the genitourinary system（泌尿生殖系统）（泌尿生殖系统）.Free photoshow template from 4 Doctors should suspe

2、ct multiple-organ injuries（多器官损伤）（多器官损伤）with Genitourinary Trauma patients.The abdomen（腹部）（腹部）and genitalia（外（外生殖器）生殖器）should be examined for evidence of contusions（挫伤）（挫伤）or subcutaneous hematomas（皮下血肿）（皮下血肿）,which might indicate deeper injuries to the retroperitoneum（腹膜后）（腹膜后）and pelvic（骨（骨盆）盆）str

3、uctures.Free photoshow template from 5Free photoshow template from 6 Fractures of the lower ribs（肋骨）（肋骨）are often associated with renal injuries,and pelvic fractures（骨盆骨折）（骨盆骨折）often accompany bladder and urethral injuries.A wound to the upper abdomen or lower chest should alert the physician to ren

4、al injury.Free photoshow template from 7Kidney Trauma Kidney Trauma are the most common injuries of the urinary system.The kidney is well protected by heavy lumbar muscles（腰部肌肉）（腰部肌肉）,vertebral bodies,ribs,and the viscera anteriorly.Free photoshow template from 8 Fractured ribs and transverse verteb

5、ral（横断的（横断的脊椎骨）脊椎骨）processes may penetrate（贯穿）（贯穿）the renal parenchyma（实质）（实质）or vasculature（脉管系统）（脉管系统）.Most injuries occur from automobile accidents or sporting mishaps,chiefly in men and boys.Free photoshow template from 9 Kidneys with existing pathologic conditions such as hydronephrosis（肾积水）（肾积

6、水）or malignant tumors are more readily ruptured（破裂）（破裂）from mild trauma.Free photoshow template from 10 Etiology Blunt trauma（钝性损伤）（钝性损伤）directly to the abdomen,flank,or back is the most common mechanism,accounting for 8085%of all renal injuries.Trauma may result from motor vehicle accidents（机动车事故）（

7、机动车事故）,fights,falls,and contact sports.Free photoshow template from 11 Vehicle collisions（碰撞）（碰撞）at high speed may result in major renal trauma from rapid deceleration（减速）（减速）and cause major vascular injury（血管损（血管损伤）伤）.Free photoshow template from 12 Etiology Gunshot（枪弹伤）（枪弹伤）and knife wounds cause

8、most penetrating injuries to the kidney，any such wound in the flank（侧腹）（侧腹）area should be regarded as a cause of renal injury until proved otherwise.Free photoshow template from 13 Etiology In the case of polytrauma（多发伤）（多发伤）,the abdomen,chest,and back must be examined:fractures of the lower ribs an

9、d upper lumbar（腰部）（腰部）and lower thoracic vertebrae（胸椎）（胸椎）are associated with renal injuries.Free photoshow template from 14Pathology and Classification*A1.Renal contusion（挫伤）（挫伤）or subcapsular hematoma（包膜下血肿）（包膜下血肿），without parenchymal（实质）（实质）laceration（裂伤）（裂伤）.Free photoshow template from 15B2.Par

10、tial parenchymal laceration:Parenchymal depth of renal cortex（肾皮质）（肾皮质）without collecting system（收集系统）（收集系统）rupture（破裂）（破裂）or urinary extravasation（尿外渗）（尿外渗）.CPathology and Classification*Free photoshow template from 163.Full-thickness parenchymal laceration：Parenchymal laceration extending through

11、renal cortex,medulla（髓质）（髓质）,and collecting system.Urinary extravasation be present.DEPathology and Classification*Free photoshow template from 17FGHF.Avulsion of the main renal artery or vein or both.G.Thrombosis of a segmental renal artery without a parenchymal laceration.Note the corresponding pa

12、renchymal ischemia(缺血缺血).H.Thrombosis of the main renal artery.4.Vascular injury:Main renal artery or vein injury.Or Avulsion of renal hilum,devascu-larizing the kidney.Pathology and Classification*Free photoshow template from 18Pathology and Classification*In injuries from rapid deceleration（减速）（减速

13、）,the kidney moves upward or downward,causing sudden stretch on the renal pedicle and sometimes complete or partial avulsion.Acute thrombosis of the renal artery may be caused by an intimal tear from rapid dece-leration injuries owing to the sudden stretch.Free photoshow template from 19Late Patholo

14、gic Findings 1.Urinoma（尿囊肿）（尿囊肿）Deep lacerations that are not repaired may result in persistent urinary extra-vasation and late complications of a large perinephric renal mass and,eventually,hydro-nephrosis and abscess formation.Free photoshow template from 20Late Pathologic Findings2.Hydronephrosis

15、（肾积水）（肾积水）Large hematomas in the retroperitoneum and associated urinary extravasation may result in perinephric fibrosis（肾周纤维化）（肾周纤维化）engulfing the ureteropelvic junction,causing hydronephrosis.Free photoshow template from 21Late Pathologic Findings3.Arteriovenous fistula（动静脉瘘）（动静脉瘘）Arteriovenous fi

16、stulas may occur after penetrating injuries but are not common.Free photoshow template from 22Late Pathologic Findings4.Renal vascular hypertension（肾血管性高血（肾血管性高血压）压）The blood flow in tissue rendered non-viable by injury is compromised，this results in renal vascular hypertension.Fibrosis from surroun

17、ding trauma has also been reported to constrict the renal artery and cause renal hyper-tension.Free photoshow template from 23Clinical Presentation 1.Hematuria（血尿）：（血尿）：Hematuria is the best indicator of traumatic urinary system injury.The presence of microscopic hematuria or gross hematuria is char

18、acteristic.Free photoshow template from 24However,the degree of renal injury does not correspond to the degree of hematuria,since gross hematuria may occur in minor renal trauma and only mild hematuria in major trauma.Some cases of renal vascular injury are not associated with hematuria.Free photosh

19、ow template from 25Clinical Presentation 2.Shock：Initially,shock or signs of a large loss of blood from heavy retroperitoneal bleeding may be noted.Free photoshow template from 26Clinical Presentation 2.Pain:Pain may be localized to one flank area or over the abdomen.3.Palpable mass:A palpable mass

20、may represent a large retroperitoneal hematoma or perhaps urinary extravasation.Free photoshow template from 27Diagnosis1.The history should include a detailed description of the accident.In cases involving gunshot wounds,the type and caliber（尺寸）（尺寸）of the weapon should be determined.Free photoshow

21、template from 28Diagnosis 2.Urinalysis（尿液分析）（尿液分析）is one of the most important and useful urologic tests.The presence of even a few erythrocytes in the urine(hematuria)is abnormal and requires further investigation.The presence of Leukocytes（白细胞）（白细胞）may be a indication of infection.Free photoshow t

22、emplate from 29Diagnosis 3.Hemogram：The drop of hematocrit（红（红细胞压积）细胞压积）may represents persistent retroperitoneal bleeding and development of a large retroperitoneal hematoma.HemoglobinFree photoshow template from 30Diagnosis3.Imaging Studies(1)Abdominal Sonography（经腹部超声）（经腹部超声）Sonography is being u

23、sed with greater fre-quency in the immediate evaluation of injuries.It confirms the presence of two kidneys and can easily define any Retro-peritoneal hematoma.Free photoshow template from 31 But it can not clearly delineate parenchymal lacerations and vascular or collecting system injuries and can

24、not accurately detect urinary extravasation in acute injuries.Free photoshow template from 32Diagnosis(2)Computed tomography(CT)Abdominal computed tomography with contrast media(增强增强CT)is the best imaging study to detect renal injuries.It can define the size and extent of the retroperitoneal hematom

25、a,renal lacerations,urinary extravasation,and renal arterial and venous injuries;additionally,it can detect intraabdominal injuries(liver,spleen,pancreas,bowel)Free photoshow template from 33Free photoshow template from 34Free photoshow template from 35Free photoshow template from 36Free photoshow t

26、emplate from 37Free photoshow template from 38Free photoshow template from 39Free photoshow template from 40Free photoshow template from 41Free photoshow template from 42Free photoshow template from 43Free photoshow template from 44Free photoshow template from 45Free photoshow template from 46Free p

27、hotoshow template from 47Free photoshow template from 48Free photoshow template from 49Free photoshow template from 50Free photoshow template from 51Computed tomography shows left renal infarction cauesed by thrombosis of the main renal artery.Free photoshow template from 52Diagnosis(3)Intravenous u

28、rography（静脉肾盂造影）（静脉肾盂造影）Intravenous urography can be used to detect renal and ureteral injury.This is best done with high-dose bolus injection of contrast media followed by appropriate films.But it has largely been replaced by CT.Free photoshow template from 53Diagnosis(4)Arteriography（动脉造影）（动脉造影）Ar

29、teriography defines major arterial and parenchymal injuries when previous studies have not fully done so.Arterial thrombosis and avulsion of the renal pedicle are best diagnosed by arteriography.Free photoshow template from 54Treatment 1.Emergency treatment：The objectives of early management are pro

30、mpt treatment of shock and hemorrhage,and evaluation of associated injuries.observe vital sign carefully,blood transfusion,etc.Free photoshow template from 55Treatment 2.Nonoperative management（1）absolute bed rest is required.（2）observe vital sign closely.（3）transfusion or blood transfusion.（4）anti-

31、infective therapy.（5）symptomatic treatment：relieve pain，etc.Free photoshow template from 56Treatment 3Operative Management（1）Penetrating injuries：Penetrating injuries should be surgically explored(手术探查手术探查).Free photoshow template from 57Treatment（2）Blunt injuries：Cases in which operation is indicat

32、ed include those associated with persistent retroperitoneal bleeding（持续性腹膜后出（持续性腹膜后出血）：血）：vital sign could not improved after shock treatment actively.Free photoshow template from 58Hematuria become more serious or heamoglobin and haematocrit decrease persistently.Mass in flank area or abdomen augme

33、nt gradually.Suspection of abdominal organ trauma.Free photoshow template from 59Treatment Surgical exploration of the acutely injured kidney is best done via a intraabdominal approach,which allows complete inspection of intraabdominal organs and bowel.The renal vessels are isolated before explorati

34、on to provide the immediate capability to occlude them if massive bleeding should ensue once Gerotas fascia is opened.Free photoshow template from 60 Renal Reconstruction Vascular repair Nephrectomy Free photoshow template from 61Treatment 4.Treatment of complications Retroperitoneal urinoma or peri

35、nephric abscess demands prompt surgical drainage（引流）（引流）.Malignant hypertension requires vascular repair or nephrectomy.Hydronephrosis may require surgical correction or nephrectomy.Free photoshow template from 62Bladder Trauma Bladder Trauma occur most often from external force and are often associ

36、ated with pelvic fractures（骨盆骨折）（骨盆骨折）.Accordingly,when bladder injury is present,other severe injuries are usually associated.Free photoshow template from 63Etiology 1.Bladder injuries after blunt trauma are overwhelmingly associated with pelvic fracture.Most patients with bladder injuries(83%to 10

37、0%)have an associated pelvic fracture.Free photoshow template from 64Etiology 2.Penetrating bladder injuries are commonly associated with major abdominal injuries,and these patients are often in shock.3.Iatrogenic injury（医源性损伤）（医源性损伤）may result from gynecologic and other extensive pelvic procedures

38、as well as from hernia repairs（疝修补）（疝修补）and transurethral operations（经尿道手术）（经尿道手术）.Free photoshow template from 65Pathology The bony pelvis protects the urinary bladder very well.When the pelvis is fractured by blunt trauma,fragments from the fracture site may perforate the bladder.These perforation

39、s usually result in extraperitoneal rupture.Free photoshow template from 66Pathology When the bladder is filled to near capacity,a direct blow to the lower abdomen may result in bladder disruption.This type of disruption ordinarily is intraperitoneal.Free photoshow template from 67Pathology Since th

40、e reflection of the pelvic peri-toneum covers the dome（顶部）（顶部）of the bladder,a linear laceration will allow urine to flow into the abdominal cavity.If the urine is infected,immediate peritonitis and acute abdomen will develop.Free photoshow template from 68Clinical Presentation Patients ordinarily a

41、re unable to urinate,but when spontaneous voiding occurs,gross hematuria is usually present.Most patients complain of pelvic or lower abdominal pain.Heavy bleeding associated with pelvic fracture may result in hemorrhagic shock.Free photoshow template from 69Diagnosis 1.There is usually a history of

42、 lower abdominal trauma.When catheterization is done,gross or,less commonly,microscopic hematuria is usually present.Free photoshow template from 70Diagnosis 2.X-Ray Findings:A plain abdominal film（腹部平片）（腹部平片）generally demonstrates pelvic fractures.Bladder disruption is shown on cystography（膀胱造影）（膀胱

43、造影）.Free photoshow template from 71Extraperitoneal bladder rupture on cystography Intraperitoneal bladder rupture on cystography Free photoshow template from 72Treatment Emergency Measures:Shock and hemo-rrhage should be treated.Surgical Measures:The bladder should be opened and carefully inspected.

44、After repair,a suprapubic cystostomy tube（耻骨上膀胱造（耻骨上膀胱造瘘管）瘘管）is usually left in place to ensure complete urinary drainage and control of bleeding.Free photoshow template from 73Urethral Injuries Urethral injuries are uncommon and occur most often in men,usually associated with pelvic fractures or st

45、raddletype falls（骑跨（骑跨伤）伤）.They are rare in women.Various parts of the urethra may be lacerated（破裂）（破裂）,transected（横断）（横断）,or contused（挫伤）（挫伤）.Free photoshow template from 74ProstaticMembranousBulbousPendulousposterior urethraanterior urethra The urethra can be separated into 2 broad anatomic divisi

46、ons:the posterior urethra,consisting of the prostatic and membranous portions,and the anterior urethra,consisting of the bulbous（球部）（球部）and pendulous portions（悬垂部）（悬垂部）.Free photoshow template from 75 Injuries To The Anterior Urethera Straddle injury may cause laceration or contusion of the urethra.

47、Iatrogenic instrumentation may cause partial disruption.Free photoshow template from 76Pathology 1.Contusion:Contusion of the urethra is a sign of crush injury without urethral disruption.Perineal hematoma（会阴血肿）（会阴血肿）usually resolves without complications.Free photoshow template from 77Pathology2.La

48、ceration:A severe straddle injury may result in laceration of part of the urethral wall,allowing extravasation of urine.Free photoshow template from 78PathologyExtravasation of blood and urine enclosed within Collesfascia If the extravasation is unrecognized,it may extend into the scrotum（阴囊）（阴囊）,al

49、ong the penile shaft（阴（阴茎）茎）,and up to the abdominal wall.It is limited only by Colles fascia and often results in infection,sepsis（败血症）（败血症）,and serious morbidity.Free photoshow template from 79Clinical Presentation Bleeding from the urethra.There is local pain into the perineum（会阴）（会阴）and sometime

50、s massive perineal hematoma.If voiding has occurred and extravasation is noted,sudden swelling（肿胀）（肿胀）in the area will be present.Free photoshow template from 80Diagnosis1.Symptoms and Signs:There is usually a history of a fall,perineal hematoma,urinary extravasation.2.Incomplete urethral tears are