1、Urologic TraumaGeneral ConsiderationsIatrogenic InjuryExternal TraumaRenal TraumaAnatomyIatrogenic Renal InjuryExternal Renal InjuriesSpontaneous Retroperitoneal HemorrhageReasonsBlunt renal injuries most often come from motor vehicle accidents,falls from heights,and assaults.Penetrating renal injur
2、ies most often come from gunshot and stab wounds.Percutaneous Renal Procedures deceleration injury Presentation Hematuria is the best indicator of traumatic urinary system injury However,the degree of hematuria and the severity of the renal injury do not correlate consistently:in up to 36%of renal v
3、ascular injuries from blunt trauma,hematuria is absent Classification I 挫伤 肉眼或镜下血尿 其他泌尿系检查正常 血肿 包膜下血肿II 血肿 腹膜后肾周血肿 撕裂伤 1cm的肾皮质裂伤，无尿外渗及集合系统损伤IV 撕裂伤 肾皮质、髓质和集合系统全层裂伤 血管 肾动脉或静脉主干损伤伴出血V 撕裂伤 肾碎裂 血管 肾蒂撕脱伤，肾无血供 Indications for Renal Imaging all blunt trauma patients with gross hematuria and patients with mi
4、croscopic hematuria and shock(systolic blood pressure 90 mm Hg any time during evaluation and resuscitation)should undergo renal imaging,usually CT with intravenous contrast.Patients with microscopic hematuria without shock can be observed clinically without imaging studies.Penetrating injuries with
5、 any degree of hematuria should be imaged.Ultrasonography is a popular imaging modality in the initial evaluation of abdominal trauma.Nonoperative Management indeed,98%of blunt renal injuries can be managed nonoperatively.Grade IV and V injuries more often require surgical exploration.Patients with
6、high-grade injuries(grades III to V)selected for nonoperative management should be observed closely The isolated renal injury,without significant associated injuries,occurs more commonly from blunt trauma and in most circumstances can be managed nonoperatively.The exception is major grade V vascular
7、 pedicle avulsion injuries.Isolated renal injuries with parenchymal lacerations and even segmental arterial injury can have active bleeding well controlled by angiographic embolization.Operative Management Absolute indications include evidence of persistent renal bleeding,expanding perirenal hematom
8、a,and pulsatile perirenal hematoma 绝对适应症包括：持续性肾脏出血、肾周血肿扩绝对适应症包括：持续性肾脏出血、肾周血肿扩大及肾周搏动性血肿大及肾周搏动性血肿Relative indications include urinary extravasation,nonviable tissue,delayed diagnosis of arterial injury,segmental arterial injury,and incomplete staging.相对适应症包括：尿外渗、组织坏死、延迟诊断相对适应症包括：尿外渗、组织坏死、延迟诊断的动脉创伤、肾段动
9、脉创伤及分级不明确的动脉创伤、肾段动脉创伤及分级不明确Renal Exploration Renal Reconstruction Renal ReconstructionIndications for Nephrectomy Grade V renal injury(77%)The unstable patient,with low body temperature and poor coagulation,cannot risk an attempt at renal repair if a normal contralateral kidney is present(23%)Compli
10、cations Persistent urinary extravasation can result in urinoma,perinephric infection,and renal loss.Delayed renal bleeding can potentially occur several weeks after injury but usually occurs within 21 days.Perinephric abscess-Percutaneous drainage Hypertension:1)renal vascular injury,leading to sten
11、osis or occlusion of the main renal artery or one of its branches;2)compression of the renal parenchyma with extravasated blood or urine;3)post-trauma arteriovenous fistula.In these instances,the renin-angiotensin axis is stimulated by partial renal ischemia,resulting in hypertension Ureteral injuri
12、es Iatrogenic Ureteral InjuryExternal Ureteral InjuryIatrogenic Ureteral InjuryOpen SurgeryLaparoscopic SurgeryUreterorenoscopyRadioactive injuryExternal Ureteral InjuryUreteral injuries after external violence are rare Open injuryblunt trauma patients with ureteral injuries are subject to extreme f
13、orce applied over the entire body.The great degree of energy imparted to the victim is associated with such uncommon injuries as fractured lumbar processes and thoracolumbar spinal dislocation DiagnosisIntraoperative Recognition Imaging Studies lExcretory Urography lComputed TomographylRetrograde Ur
14、eterography lAntegrade Ureterography TreatmentTreatmentBladder TraumaThe most common associated injury is pelvic fracture,associated with 83%to 95%of bladder injuries obstetric and gynecologic complications are the most common etiology of Iatrogenic bladder injuries diagnosis耻骨上区疼痛或触痛不能排尿或尿量减少尿中有血块C
15、T或超声提示腹腔内游离液体会阴或生殖器外伤体征无反应、醉酒或感知异常腹部膨胀或肠梗阻Radiographic Imaging TreatmentThe usual treatment of uncomplicated extraperitoneal bladder ruptures,when conditions are ideal,is conservative management with urethral catheter drainage alone complications such as fistula,abscess,and prolonged leak INDICATION
16、S FOR IMMEDIATE REPAIR OF BLADDER INJURY 外伤导致的腹腔内损伤穿刺伤或医源性非泌尿外科损伤膀胱引流不畅或尿中有血块膀胱颈损伤直肠或子宫损伤开放性骨盆骨折骨盆骨折需要复位和内固定由于其他原因行剖腹探查的稳定患者骨碎片插入膀胱内Urethral TraumaPosterior Urethra Anterior Urethra Posterior UrethraStraddle fractures”involving all four pubic rami open fractures,and fractures resulting in both verti
17、cal and rotational pelvic instability are associated with the highest risk of urologic injury diagnosisUrethral disruption is heralded by the triad of blood at the meatus,inability to urinate,and palpably full bladder urethral catheter cannot be placed;misplaced into pelvic hematoma.impalpable prost
18、ate Urethrography TreatmentSuprapubic Cystostomy Primary Realignment Delayed Reconstruction:At 3 months,scar tissue at the urethral disruption site is stable enough to allow posterior urethroplasty to be undertaken safely,provided that associated injuries are stabilized and the patient is ambulatory
19、 Primary RealignmentDelayed ReconstructionTransurethral cutting-to-the-light procedureAnterior UrethraThe majority occur after straddle injury and involve the bulbar urethra In 20%of the cases of rupture of corpora cavernosa,the urethra is involvedInjuries of the genitalia Penis(Fracture,Gunshots an
20、d Penetrating Injuries,Animal and Human Bites,Amputation )TestisGenital Skin Loss KeyPointsThe diagnosis of penile fracture is often straightforward and can be made reliably by history and physical examination alone Early exploration and repair of testis injury is associated with increased testis sa
21、lvage,reduced convalescence and disability,faster return to normal activities,and preservation of fertility and hormonal function Testis salvage rates exceed 90%with exploration and repair within 3 days of injury,versus orchiectomy rates threefold to eightfold higher with conservative management and delayed surgery Treatment of AmputationThanks
