外科學(xué)課件：泌尿生殖創(chuàng)傷（英文版）

1GenitourinaryTrauma

2Approximately10%ofinjuriesinvolvethegenitourinarytract.

3Doctorsshouldsuspectmultiple-organinjurieswithGenitourinaryTraumapatients.Theabdomenandgenitaliashouldbeexaminedforevidenceofcontusionsorsubcutaneoushematomas,whichmightindicatedeeperinjuriestotheretroperitoneumandpelvicstructures.

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Fracturesofthelowerribsareoftenassociatedwithrenalinjuries,andpelvicfracturesoftenaccompanybladderandurethralinjuries.Awoundtotheupperabdomenorlowerchestshouldalertthephysiciantorenalinjury.5KidneyTraumaKidneyTraumaarethemostcommoninjuriesoftheurinarysystem.Thekidneyiswellprotectedbyheavylumbarmuscles,vertebralbodies,ribs,andthevisceraanteriorly.

6Fracturedribsandtransversevertebralprocessesmaypenetratetherenalparen-chymaorvasculature.Mostinjuriesoccurfromautomobileaccidentsorsportingmishaps,chieflyinmenandboys.Kidneyswithexistingpathologicconditionssuchashydronephrosisormalignanttumorsaremorereadilyrupturedfrommildtrauma.7Blunttraumadirectlytotheabdomen,flank,orbackisthemostcommonmecha-nism,accountingfor80–85%ofallrenalinjuries.Traumamayresultfrommotorvehicleaccidents,fights,falls,andcontactsports.Vehiclecollisionsathighspeedmayresultinmajorrenaltraumafromrapiddecelerationandcausemajorvascularinjury.

Etiology

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Gunshotandknifewoundscausemostpenetratinginjuriestothekidney，anysuchwoundintheflankareashouldberegardedasacauseofrenalinjuryuntilprovedotherwise.Etiology

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Inthecaseofpolytrauma,theabdomen,chest,andbackmustbeexamined:fracturesofthelowerribsandupperlumbarandlowerthoracicvertebraeareassociatedwithrenalinjuries.Etiology

10PathologyandClassification

***A1.Renalcontusionorsubcapsularhema-toma，withoutparenchymallaceration.

11B2.Partialparenchymallaceration:Parenchymaldepthofrenalcortexwithoutcollectingsystemruptureorurinaryextravasation.CPathologyandClassification

***123.Full-thicknessparenchymallaceration：Parenchymallacerationextendingthroughrenalcortex,medulla,andcollectingsystem.Urinaryextravasationbepresent.DEPathologyandClassification

***13F.avulsionofthemainrenalarteryorveinorboth.G.thrombosisofasegmentalrenalarterywithoutaparenchymallaceration.Notethecorrespondingparenchymalischemia.H.thrombosisofthemainrenalartery.

4.Vascularinjury:Mainrenalarteryorveininjury.OrAvulsionofrenalhilum,devascu-larizingthekidney.PathologyandClassification

***14Ininjuriesfromrapiddeceleration,thekidneymovesupwardordownward,causingsuddenstretchontherenalpedicleandsometimescompleteorpartialavulsion.Acutethrombosisoftherenalarterymaybecausedbyanintimaltearfromrapiddecelerationinjuriesowingtothesuddenstretch.PathologyandClassification

***151.Urinoma—Deeplacerationsthatarenotrepairedmayresultinpersistenturinaryextravasationandlatecomplicationsofalargeperinephricrenalmassand,eventually,hydronephrosisandabscessformation.

LatePathologicFindings162.Hydronephrosis—Largehematomasintheretroperitoneumandassociatedurinaryextravasationmayresultinperinephricfibrosisengulfingtheureteropelvicjunction,causinghydronephrosis.LatePathologicFindings173.Arteriovenousfistula—Arteriovenousfistulasmayoccurafterpenetratinginjuriesbutarenotcommon.LatePathologicFindings184.Renalvascularhypertension—Thebloodflowintissuerenderednon-viablebyinjuryiscompromised，thisresultsinrenalvascularhypertension.Fibrosisfromsurroundingtraumahasalsobeenreportedtoconstricttherenalarteryandcauserenalhyper-tension.

LatePathologicFindings191.Hematuria：Hematuriaisthebestindicatoroftraumaticurinarysysteminjury.Thepresenceofmicroscopichematuriaorgrosshematuriaischaracteristic.

ClinicalPresentation

20However,thedegreeofrenalinjurydoesnotcorrespondtothedegreeofhematuria,sincegrosshematuriamayoccurinminorrenaltraumaandonlymildhematuriainmajortrauma.Somecasesofrenalvascularinjuryarenotassociatedwithhematuria.212.Shock：Initially,shockorsignsofalargelossofbloodfromheavyretroperitonealbleedingmaybenoted.

ClinicalPresentation

22Pain:Painmaybelocalizedtooneflankareaorovertheabdomen.palpablemass:Apalpablemassmayrepresentalargeretro-peritonealhematomaorperhapsurinaryextravasation.ClinicalPresentation

231.Thehistoryshouldincludeadetaileddescriptionoftheaccident.Incasesinvolvinggunshotwounds,thetypeandcaliberoftheweaponshouldbedetermined.Diagnosis242.Urinalysisisoneofthemostimportantandusefulurologictests.Thepresenceofevenafewerythrocytesintheurine(hematuria)isabnormalandrequiresfurtherinvestigation.ThepresenceofLeukocytesmaybeaindicationofinfection.Diagnosis25Thedropofhematocritmayrepresentspersistentretroperitonealbleedinganddevelopmentofalargeretroperitonealhematoma.Diagnosis263.ImagingStudies(1)AbdominalSonographySonographyisbeingusedwithgreaterfrequencyintheimmediateevaluationofinjuries.Itconfirmsthepresenceoftwokidneysandcaneasilydefineanyretro-peritonealhematoma.Butitcannotclearlydelineateparenchymallacerationsandvascularorcollec-tingsysteminjuriesandcannotaccuratelydetecturinaryextra-vasationinacuteinjuries.Diagnosis27(2)Computedtomography(CT)Abdominalcomputedtomographywithcontrastmediaisthebestimagingstudytodetectrenalinjuries.Itcandefinethesizeandextentoftheretroperitonealhema-toma,renallacerations,urinaryextra-vasation,andrenalarterialandvenousinjuries;additionally,itcandetectintra-abdominalinjuries(liver,spleen,pancreas,bowel)Diagnosis28(3)IntravenousurographyIntravenousurographycanbeusedtodetectrenalandureteralinjury.Thisisbestdonewithhigh-dosebolusinjectionofcontrastmediafollowedbyappropriatefilms.ButithaslargelybeenreplacedbyCT.Diagnosis29(4)ArteriographyArteriographydefinesmajorarterialandparenchymalinjurieswhenpreviousstudieshavenotfullydoneso.Arterialthrombosisandavulsionoftherenalpediclearebestdiagnosedbyarteriography.

Diagnosis30

1.Emergencytreatment：Theobjectivesofearlymanagementareprompttreatmentofshockandhemorrhage,andevaluationofassociatedinjuries.observevitalsigncarefully,bloodtransfusion,etc.Treatment312.nonoperativemanagement（1）absolutebedrestisrequired（2）observevitalsignclosely（3）transfusionorbloodtransfusion（4）anti-infectivetherapy（5）symptomatictreatment：relievepain，etcTreatment323．OperativeManagement（1）Penetratinginjuries：Penetratinginjuriesshouldbesurgicallyexplored.

Treatment33（2）Bluntinjuries：Casesinwhichoperationisindicatedincludethoseassociatedwithpersistentretroperitonealbleeding：vitalsigncouldnotimprovedaftershocktreatmentactively.hematuriabecomemoreseriousorheamoglobin

andhaematocritdecreasepersistently.Massinflankareaorabdomenaugmentgradually.Suspectionofabdominalorgantrauma.

Treatment34

Surgicalexplorationoftheacutelyinjuredkidneyisbestdoneviaaintraabdominalapproach,whichallowscompleteinspectionofintraabdominalorgansandbowel.TherenalvesselsareisolatedbeforeexplorationtoprovidetheimmediatecapabilitytooccludethemifmassivebleedingshouldensueonceGerota’sfasciaisopened.

RenalReconstructionVascularrepairNephrectomyTreatment354.TreatmentofcomplicationsRetroperitonealurinomaorperinephricabscessdemandspromptsurgicaldrainage.Malignanthypertensionrequiresvascularrepairornephrectomy.Hydronephrosismayrequiresurgicalcorrectionornephrectomy.Treatment36BladderTraumaBladderTraumaoccurmostoftenfromexternalforceandareoftenassociatedwithpelvicfractures.Accordingly,whenbladderinjuryispresent,othersevereinjuriesareusuallyassociated.371.Bladderinjuriesafterblunttraumaareoverwhelminglyassociatedwithpelvicfracture.Mostpatientswithbladderinjuries(83%to100%)haveanassociatedpelvicfracture.Etiology382.Penetratingbladderinjuriesarecommonlyassociatedwithmajorabdominalinjuries,andthesepatientsareofteninshock.3.Iatrogenicinjurymayresultfromgynecologicandotherextensivepelvicproceduresaswellasfromherniarepairsandtransurethraloperations.

Etiology39Thebonypelvisprotectstheurinarybladderverywell.Whenthepelvisisfracturedbyblunttrauma,fragmentsfromthefracturesitemayperforatethebladder.Theseperforationsusuallyresultinextra-peritonealrupture.

Pathology

40Whenthebladderisfilledtonearcapacity,adirectblowtothelowerabdomenmayresultinbladderdisrup-tion.Thistypeofdisruptionordinarilyisintraperitoneal.

Pathology

41Sincethereflectionofthepelvicperitoneumcoversthedomeofthebladder,alinearlacerationwillallowurinetoflowintotheabdominalca-vity.Iftheurineisinfected,imme-diateperitonitisandacuteabdomenwilldevelop.Pathology

42ClinicalPresentationPatientsordinarilyareunabletourinate,butwhenspontaneousvoidingoccurs,grosshematuriaisusuallypresent.Mostpatientscomplainofpelvicorlowerabdominalpain.Heavybleedingassociatedwithpelvicfracturemayresultinhemorrhagicshock.

431.Thereisusuallyahistoryoflowerabdominaltrauma.Whencatheteri-zationisdone,grossor,lesscommon-ly,microscopichematuriaisusuallypresent.

Diagnosis442.X-RayFindings:Aplainabdominalfilmgenerallydemonstratespelvicfractures.Bladderdisruptionisshownoncystography.Diagnosis45ExtraperitonealbladderruptureoncystographyIntraperitonealbladderruptureoncystography46EmergencyMeasures:Shockandhemorrhageshouldbetreated.SurgicalMeasures:Thebladdershouldbeopenedandcarefullyinspected.Afterrepair,asuprapubiccystostomytubeisusuallyleftinplacetoensurecompleteurinarydrainageandcontrolofbleeding.Treatment47UrethralInjuries

Urethralinjuriesareuncommonandoccurmostofteninmen,usuallyassociatedwithpelvicfracturesorstraddletypefalls.Theyarerareinwomen.Variouspartsoftheurethramaybelacerated,transected,orcontused.48Theurethracanbeseparatedinto2broadanatomicdivisions:theposteriorurethra,consistingoftheprostaticandmembranousportions,andtheanteriorurethra,consistingofthebulbousandpendulousportions.

ProstaticMembranousBulbousPendulousposteriorurethraanteriorurethra49

Straddleinjurymaycauselace-rationorcontusionoftheurethra.Iatrogenicinstrumentationmaycausepartialdisruption.InjuriesToTheAnteriorUrethera501.Contusion:Contusionoftheurethraisasignofcrushinjurywithouturethraldisruption.Perinealhema-tomausuallyresolveswithoutcomplications.Pathology512.Laceration:Aseverestraddleinjurymayresultinlacerationofpartoftheurethralwall,allowingextravasationofurine.Iftheextravasationisunrecognized,itmayextendintothescrotum,alongthepenileshaft,anduptotheabdominalwall.ItislimitedonlybyColles’fasciaandoftenresultsininfection,sepsis,andseriousmorbidity.Pathology52PathologyExtravasationofbloodandurineenclosedwithinColles’fascia53Bleedingfromtheurethra.Thereislocalpainintotheperineumandsometimesmassiveperinealhematoma.Ifvoidinghasoccurredandextravasationisnoted,suddenswellingintheareawillbepresent.ClinicalPresentation541.SymptomsandSigns:Thereisusuallyahistoryofafall.Perinealhematoma,urinaryextravasation.2.Incompleteurethraltearsarebesttreatedbystentingwithaurethralcatheterfor1week.Operationshouldbegently.Diagnosis553.X-RayFindings:Aurethrogramdemonstratesextravasationandthelocationofinjury.Acontusedurethrashowsnoevidenceofextravasation.DiagnosisRupturedbulbar(anterior)urethrafollowingstraddleinjury.Extravasation(atarrow)onurethrogram.561.EmergencyMeasures:Ifheavybleedingdoesoccur,localpressureforcontrolisrequired.2.Urethralcontusion:Thepatientwithurethralcontusionshowsnoevidenceofextravasation,andtheurethraremainsintact.Ifbleedingpersists,urethralcatheterdrainagecanbedone.

Treatment573.Urethrallaceration:Incompleteurethrallacerationarebesttreatedbystentingwithaurethralcatheterfor1week. Treatment58Themembranousurethrapassesthroughthepelvicfloorandvoluntaryurinarysphincterandistheportionoftheposteriorurethramostlikelytobeinjured.Whenpelvicfracturesoccurfromblunttrauma,themembranousurethraisshearedfromtheprostaticapexattheprostatomembranousjunction.InjuriesToThePosteriorUrethera59Injurytotheposteriorurethra.Theprostatehasbeenavulsedfromthemembranousurethrasecondarytofractureofthepelvis.Extravasationoccursabovethetriangularligamentandisperiprostaticandperivesical601.Shock：becauseofbloodfromheavypelvicbleeding.2.Patientsusuallycomplainoflowerabdominalpainandinabilitytourinate.3.Bloodattheurethralmeatusisthesinglemostimportantsignofurethralinjury.butsomepatientsdidn’thavethissign.ClinicalPresentation611.SymptomsandSigns:Ahistoryofcrushinginjurytothepelvisisusuallyobtained.Bloodattheurethralmeatus.Rectalexaminationmayrevealalargepelvichematomawiththeprostatedisplacedsuperiorly.Diagnosis622.X-RayFindings：Fracturesofthebonypelvisareusuallypresent.