Trauma genitourinario by cirugiasanjuan

Trauma Genitourinario

Dr. Chris2an Haussmann 2015

n o s e n i l e Guid

l a c i g o l Uro a m u Tra

F.E.

. Kitrey, D . N , c i . Djakov N , ) harma r S i . a h M . C ( D merton tinidis, e m f a u r S e . S J . . D umen, E L . N , s Kuehha

Trauma Genitourinario •  Trauma à principal causa de muerte en menores 40 años •  Traumas abdominales: 10-‐15% asociado a trauma GU •  Ambos sexos, más común en hombres •  En todos los grupos etáreos •  Riñón es el más comúnmente afectado •  Principal problema es el diagnósFco à politrauma, múlFples lesiones, pasa desapercibido •  Clasif.: Alto (Riñón y uréter) y bajo (vejiga, uretra y genitales)

Trauma Genitourinario •  Requiere un alto índice de sospecha –  Trauma Contuso: caídas, atropello, acc. AutomovilísFco, a c e l e r a c i ó n / d e s a c e l e r a c i ó n , a c c . i n d u s t r i a l , politraumaFzado, deporte de contacto. –  Trauma Penetrante: arma de fuego, puñalada.

Trauma Genitourinario •  Hallazgos clínicos sugieren Trauma GU: Fx. costales bajas, hematoma torácico inferior/lumbar, herida penetrante, Fx. de pelvis, globo vesical, trauma perineal, próstata ascendida. •  Signos capitales: –  Micro o macrohematuria** –  Uretrorragia –  Globo vesical –  Incapacidad miccional –  Próstata ascendida o no palpable al TR –  Escape vaginal de orina

TRAUMA RENAL

Anatomía 8

SECTION I ● Anatomy 4 SECTION I ● Anatomy

Figure 1–1. A, The retroperitoneum dissected. The anterior perirenal (Gerota) fascia has been removed. B, 1, Diaphragm. 2, Inferior vena cava. 3, Right adrenal gland. 4, Upper abdominal wall musculature, deep dissection. pointer, celiac artery; lower pointer, celiac autonomic nervous plexus. 5, Right kidney. 6, Right renal Figure vein. 7, 1–5. GerotaPosterior fascia. 8, Pararenal retroperitoneal fat. 9, Perinephric fat. 10, The lumbodorsal fascia and costovertebral ligament are visualize arising from the processes the lumbar relation of the kidney and pleura is also shown. Upper pointer, right gonadal vein; lower pointer, right gonadal artery. 11, Lumbar lymph nodes. 12, Retroperitoneal fat.transverse 13, Right common iliacof artery. 14, Rightvertebrae. ureter. 15, The Sigmoid colon (cut). 16, Esophagus (cut). 17, Right crus of diaphragm. 18, Left inferior phrenic artery. 19, Upper pointer, left adrenal gland; lower pointer, left adrenal vein. 20, Upper pointer, superior mesenteric artery; lower pointer, left renal artery. 21, Left kidney. 22, Upper pointer, left renal vein; lower pointer, left gonadal vein. 23, Aorta. 24, Perinephric fat. 25, Aortic

Trauma renal •  •  •  •  •  •  •

1-‐5% de todos los traumas, 10% de los traumas abdominales Trauma más común de la vía urinaria Razón hombre/mujer de 3/1 Mayoría por trauma cerrado de alta energía Trauma penetrante se asocia a lesiones otros órganos Hematuria a menudo presente Alteraciones renales preexistentes aumentan riesgo de lesión renal por trauma cerrado (quistes, tumores)

•  En lesiones severas las complicaciones tardías incluyen: hematoma, hematuria, urinoma, infección, dolor HTA-‐RV

Clasiﬁcación

CHAPTER 42 ● Upper Urinary Tra

Grade I

CHAPTER 42 ● Upper Urinary Tract Trauma

Grade I

Grade II

Grade III

1171

Grade III

Grade IV

Grade V

Evaluación Diagnós2ca •  Politrauma: Estabilización/resucitación (ABCDE) •  Historia y examen ]sico sugerentes •  Lab: –  Hematuria macro o micro (uro-‐análisis) –  Hematocrito seriado –  Crea2nina basal •  Imágenes: –  Indicaciones: Penetrante, contuso con hematuria o hipotensión, mec des/aceleración rápida, lesión de otros órganos –  GS: TAC Trifásico con fase de eliminación tardía (10-‐15 min) –  Otros: ECO, PIV, PIV-‐IO

Manejo •  ABC del Trauma •  Grado I TTO conservador* •  Grado II •  Grado III TTO conservador en ausencia de lesiones Grado IV intraperitoneales**

•  Grado V à Exploración renal * Reposo absoluto, JJ en caso de sangrado, control imagen ** 20% sangrado tardío, mayoría TTO con embolización

Manejo •

•

Exploración renal 1.  Hemorragia renal con riesgo vital / Hemodinamia inestable 2.  Exploración por lesiones asociadas 3.  Hematoma retroperitoneal expansivo o pulsáFl 4.  Lesión Grado V En caso de cirugía de urgencia, priorizar manejo conservador renal si hemodinamia lo permite.

•

Exploración renal 1.  Hemodinamia inestable 2.  Exploración por lesiones asociadas 3.  Hematoma peri-‐renal expansivo o pulsáFl (laparotomía) 4.  Lesión vascular G 5 En caso de cirugía de urgencia, priorizar manejo conservador renal si hemodinamia lo permite.

CHAPTER 42 â&#x2014;? Upper Urinary Tract Trauma

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Inferior mesenteric vein Inferior mesenteric vein Right renal vein

Gonadal vein

Left renal vein

Left renal artery Right renal artery

Aorta

Figure 42â&#x20AC;&#x201C;6. The surgical approach to the renal vessels and kidney. A, Retroperitoneal incision over the aorta medial to the inferior mesenteric vein. B, Anatomic relationships of the renal vessels. C, Retroperitoneal incision lateral to the colon, exposing the kidney.

In some reported series of penetrating injuries, associated organ injury has been noted to be as high as 94% (McAninch et al, 1993). Injuries to the great vessels, liver, spleen, pancreas, and bowel can be identified and stabilized if necessary before renal exploration. The surgical approach to renal exploration is shown in Figure

vascular control before opening Gerota fascia can decrease renal loss: in a comparative series, the total nephrectomy rate was reduced from 56% to 18% (McAninch and Carroll, 1982). Carroll and coauthors (1989), evaluating the use of early vascular control, reported the need to occlude the vessels in 12% of renal explorations. In a series of 133 renal units in which early

1176

SECTION IX ● Upper Urinary Tract Obstruction and Trauma

B Partial polar nephrectomy

C Collecting system closure

D Omental pedicle flap

Figure 42–7. Technique for partial nephrectomy: A, total renal exposure; B, sharp removal of nonviable tissue; C, hemostasis obtained and collecting system closed; D, defect covered.

A Deep midrenal laceration into pelvis

B Closure of pelvis Ligation of vessels

C Defect closure

D Absorbable gelatin sponge (Gelfoam) bolster

Figure 42–8. Technique for renorrhaphy: A, typical injury in midportion of kidney; B, debridement, hemostasis, and collecting system closure; C, approximation of parenchymal margins; D, sutures tied over gelatin sponge bolster.

lymphatic supply, omentum promotes wound healing and

nephrectomy is advocated. In rare instances where repair is pos-

TRAUMA URETERAL

Trauma ureteral •  Raras, mayoría iatrogénica y penetrantes •  Desapercibidas durante cirugía •  > uréter inferior, secuelas graves potenciales •  FR: Alteración anatomía (neo avanzado, Cx, RT)

ANATOMÍA URÉTERES

re 1–1. A, The retroperitoneum dissected. The anterior perirenal (Gerota) fascia has been removed. B, 1, Diaphragm. 2, Inferior vena cava. 3, Right adrenal gland. 4, Upper nter, celiac artery; lower pointer, celiac autonomic nervous plexus. 5, Right kidney. 6, Right renal vein. 7, Gerota fascia. 8, Pararenal retroperitoneal fat. 9, Perinephric fat. 10,

Evaluación Diagnós2ca •  Mayoría diagnosFcada tarde •  Requiere alto índice de sospecha: Tipo de cirugía, uroperitoneo con elevación de creaFnina, cólico renal, drenajes con alto débito. •  Imágenes: Ø TAC muestra extravasación de cte en caso de lesión penetrante Ø Hidronefrosis

function impairment. ¯ Haematuria is an unreliable indicator. ¯ Extravasation of contrast material in CT is the hallmark sign of ureteral trauma, and in unclear cases, a retrograde or antegrade urography is required for confirmation.

Management

Manejo

¯ Partial injury can be managed with ureteral stenting or urinary diversion by a nephrostomy. ¯ In complete injuries, ureteral reconstruction following •  Depende e Fpo isyrequired. lugar de lesión. Se aconseja la reparación inmediata temporary urinary d diversion ¯ The type of repair procedure depends on the site of the •  Ligadura, lesión parcial: JJ o derivación urinaria con nefrostomía injury (Table 2), and it should follow the principles outlined in 3. •  Table Lesión completa: ¯ Proximal- and mid-ureteral injuries can often be managed –  IO reparación primaria o reimplante según altura. CHAPTER 42 ● Upper Urinary Tract Trauma 1183 by primary uretero-ureterostomy, while a distal injury is –  Derivación urinaria en caso de segmento importante con reparación diferida often treated with ureteral reimplantation. published data to assess its accuracy to date (Kenney et al, 1987; Townsend and DeFalco, 1995). Reports of the utility of CT in ureteral trauma are still limited to small numbers of cases. Ureteral injuries can be difficult to diagnose on CT. If the urinary extravasation from the ureteral injury is contained by Gerota fascia, the extent of medial leakage can be small, obscuring the diagnosis (Kenney et al, 1987). It is also known that ureteral injuries often manifest with absence of contrast in the ureter on delayed images. This underscores the absolute necessity of tracing both ureters throughout their entire course on CT scans obtained to evaluate urogenital injuries (Townsend and DeFalco, 1995). In addition, because modern helical CT scanners can obtain images before intravenous contrast dye is excreted in the urine, delayed images must be obtained (5 to 20 minutes after contrast injection) to allow contrast material to extravasate from the injured collecting system, renal pelvis, or ureter (Brown et al, 1998; Mulligan et al, 1998; Kawashima et al, 2001). Because ureteral injuries are often detected late, periureteral urinoma seen on delayed CT scans may be diagnostic (Gayer et al, 2002). In reported series, all patients with significant ureteropelvic laceration, for instance, had either medial extravasation of contrast material or nonopacification of the ipsilateral ureter on CT (Kenney et al, 1987; Kawashima et al, 2001). Such findings should always raise suspicion for ureteral injury. Retrograde Ureterography. Retrograde ureterograms, the most sensitive radiographic test for ureteral injury, are used in some centers as a primary diagnostic technique to detect acute ureteral injuries (Campbell et al, 1992); however, the authors tend to use

Table 2: Ureteral reconstruction options by site of injury Site of injury Reconstruction options Upper ureter Uretero-ureterostomy Transuretero-ureterostomy Uretero-calycostomy Mid ureter Uretero-ureterostomy Transuretero-ureterostomy Ureteral reimplantation and a Boari flap Lower ureter Ureteral reimplantation Ureteral reimplantation with a psoas hitch Complete Ileal interposition graft Autotransplantation

UPPER Direct ureteroureterostomy Transureteroureterostomy

MIDDLE Direct ureteroureterostomy Transureteroureterostomy LOWER Reimplantation Psoas hitch

Figure 42–15. Suggested management options for ureteral injuries at different levels.

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SECTION IX ● Upper Urinary Tract Obstruction and Trauma

A Table 3: Principles of surgical repair of ureteral injury Debridement of necrotic tissue Spatulation of ureteral ends Watertight mucosa-to-mucosa anastomosis with absorbable sutures Internal stenting External drain Isolation of injury with peritoneum or omentum

Bladder Trauma

Bladder injuries can be due to external (blunt or penetrating) or iatrogenic trauma. Iatrogenic trauma is caused by external laceration or internal perforation (mainly during TURB). Blunt bladder injuries are strongly associated with pelvic fractures. Bladder injuries are classified as extraperitoneal, intraperitoneal or combined.

Diagnostic evaluation Clinical signs and symptoms

D E

Figure 42–16. Technique of ureteroureterostomy after traumatic disruption: A, injury site definition by ureteral mobilization; B, debridement of margins and spatulation; C, stent placement; D, approximation with 5-0 absorbable suture; E, final result.

External trauma ¯ Cardinal sign: visible haematuria. rate (83% [Toporoff et al, 1992] to 88% [Lang, 1984]). Other ¯ Others: abdominal tenderness, inability to void, bruises authors have recommended stenting for a longer period, up to 8

Upper Ureteral Injuries Ureteroureterostomy. Ureteral avulsion from th

TRAUMA VESICAL

Trauma vesical •  Penetrante vs Contuso –  Contuso: con vejiga llena

•  TraumáFco vs Iatrogénico •  Clasiﬁcación: –  Extra-‐peritoneales –  Intra-‐peritoneales –  Combinadas.

Anatomía

Evaluación Diagnós2ca •  Traumá2co: –  Hematuria macros, dolor abdom, diﬁcultad miccional, contusión suprapúbica, distensión (asciFs urinaria) –  Penetrante: heridas de entrada y salida •  Iatrogénico: –  Extravasación orina, visión directa, aparición Foley, sangre/aire en la bolsa de Foley. –  Sx post-‐op: hematuria , dolor, distensión, íleo, peritoniFs, sepsis , orina por la herida , disminución gasto urinario y aumento creaFnina, débitos altos por drenaje •  Imágenes: –  Cistogra]a convencional/TAC (Cistoscopía)

intravesically with absorbable suture. The

surgically repair the extraperitoneal rupture at the same tomaand should not be disturbed. When int setting. The anterior bladder wall is entered, the tear is closed fractures is performed, concomitant bl intravesically with absorbable suture. The perivesical pelvic hemamendedfixation because urine leakage from the i toma should not be disturbed. When internal of pelvic fractures is performed, concomitant bladder repairfixative is recomorthopedic hardware is prevente mended because urine leakage from therisk injured bladder onto the of hardware infection. Drainage of t orthopedic fixative hardware is prevented, thereby reducing the be safely accomplished with a large-bore F risk of hardware infection. Drainage of the repaired bladder can be safely accomplished with a large-borecystography Foley catheter performed alone, and 1 week after repa healing. cystography performed 1 week after repair should verify bladder healing. All penetrating or intraperitone All penetrating or intraperitoneal injuries resulting from external trauma should be ma from external trauma should be managed by immediate operative repair. These injuries are ofte operative repair. These injuries are often larger than suggested on cystography and are unlikely to heal s on cystography and are unlikely to heal spontaneously, and continued leak of urine causes a chemical per tinued leak of urine causes a chemical peritonitis. Although most injuries are may repaired with open surgery, sele injuries are repaired with open surgery, select patients undergo laparoscopic repair (Kim et al, 2008)—primarily those whose laparoscopic repair (Kim et al, 2008)— bladder may have been injured during bladder laparoscopic maysurgical have probeen injured during la cedures. When bladder injuries are explored after penetrating cedures. When bladder injuries are exp trauma without preliminary imaging, the ureteral orifices should trauma without preliminary imaging, the be inspected for clear efflux; ureteral integrity may also be ensured Figure 88–10. CT cystogram demonstrates contrast material be carmine inspected clear efflux; ureteral integ by intravenous administration of indigo or for methylene surrounding loops of bowel consistent with intraperitoneal Figure 88–10. CT cystogram demonstrates contrast material by intravenous administration of indigo blue or retrograde passage of a ureteral catheter. Any penetrating bladder rupture. surrounding loops of bowel consistent with intraperitoneal

weeks but will resolve with continuation of urethral catheter

blue or retrograde passage of a ureteral ca

bladder rupture.

Figure 88–11. A, Dense flame-shaped pattern of contrast extravasation in pelvis due to extraperitoneal bladder rupture. B, Repeated cystogram in same patient after 2 weeks of catheter drainage shows completely healed bladder.

Manejo •  Intraperitoneales •  Reparación quirúrgica (vesicorraﬁa) en 2 planos + S. Foley: –  Compromiso cuello, fragmentos óseos, lesión rectal concomitante, atrapamiento pared vesical. •  Extraperitoneales –  Conservador: S. Foley 3 lúmenes con irrigación vesical conFnua

TRAUMA URETRAL

Anatomía

Trauma ureteral •  Espectro: –  Contusión o esFramiento –  Desgarro parcial –  Desgarro/Transección completa

•  Diferenciar entre UA y UP

Trauma ureteral anterior •

Uretra anterior/distal (UA): anterior a porción membranosa –  Primera causa Iatrogénica (Sonda), < frec. Fx pene, trauma penetrante

•

Diagnós2co UA: –  Historia sondeo frustro, uretrorragia post coital –  Sangre en MUE lo mas común à CanFdad = severidad –  Otros: hematoma genital, dolor, fractura de pene

•

Imágenes: –  Uretrogra]a retrogradaà GS para evaluar lesión a TODOS –  En lesión UA SÍ se podría poner S. Foley

•

Manejo: –  Derivación urinaria SP o CU + reparación diferida –  Reparación inmediata: Fx pene, penetrante, proyecFles

Trauma ureteral posterior •

Uretra posterior (UP): uretra membranosa a vejiga –  Por Fx pelvis en AAM (4-‐19% UP masculina y 0-‐6% uretra femenina).

•

Diagnós2co UP: –  Historia de Fx pelvis, uretrorragia –  Imposibilidad de orinar, globo vesical, TR próstata ascendida

•

Imágenes: –  Uretrogra]a retrogradaà GS para evaluar lesión a TODOS –  Evitar Sonda uretral, hasta obtener imagen uretral **(paciente inestable) Manejo: –  Derivación urinaria SP o CU* + reparación diferido +/-‐ uretroplaska –  Reparación inmediata: Con lesión rectal o cuello vesical asociado

•

TRAUMA GENITAL

Trauma genital •  Traumas GUà 33-‐66% genitales externos •  Mucho más frecuente en hombres, 15-‐40 años (anatomía, AAM, deportes, guerra, violencia) •  Causado –  80% trauma contuso –  20% trauma penetrante

TRAUMA GENITAL MASCULINO

Anatomía genital masculina

Fractura de pene •  Desgarro de la túnica albugínea del cuerpo cavernoso •  Usualmente durante coito al salir de vagina y golpear contra sínﬁsis del pubis o periné femenino, masturbación. •  Lesión uretral en 10-‐20% a nivel •  Riesgo: disfunción erécFl y enfermedad de Peyronie

Diagnos2co

Imágenes

•  ECO (negaFva no descarta) o RNM podrían ser úFles –  Considerar uretrogra]a retrograda (Si uretrorragia

–  Sonido de crujido/estallido, dolor y detumescencia inmediata –  Luego hematoma cuerpo pene (“eggplant deformity / berenjena”), incluso hasta pared abdominal, periné y escroto (si lesión en fascia de Buck) –  Rotura de túnica puede ser palpable

Manejo •  EMERGENCIA!!! à intervención quirúrgica inmediata –  Incisión, denudación inspección de CC y CE, idenFﬁcación de lesión y reparación de T. Albugínea con sutura absorbible (vicril 2-‐0) –  Sutura lesión uretral –  Hematoma sin rotura de albugínea cavernosa: •  AINEs + Hielo –  No se recomienda tratamiento conservador

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SECTION XV â&#x2014;? Benign and Malignant Bladder Disorders

Figure 88â&#x20AC;&#x201C;2. A, Large arrow indicates pronounced ecchymosis and swelling in this patient with a penile fracture sustained during intercourse. Small arrow indicates blood at urethral meatus. B, During surgical exploration and repair, urethral laceration with exposed Foley catheter is noted (large arrow). Small arrow indicates laceration of corpus cavernosum.

suspected penile fracture because it is time consuming and unfamiliar to most urologists and radiologists (Morey

fashion over a catheter. Therapy with broad-spectrum antibiotics and 1 month of sexual abstinence are recommended. In uncircum-

TRAUMA ESCROTAL/TESTICULAR

Anatomía

Hematoma 1.  Escrotales cutáneos (Extra-‐escrotal): piel del escroto por trauma directo, trauma uretral o desplazamiento sangre subcutánea 2.  Hematocele (Intra-‐escrotal): espacio entre túnica albugínea y túnica vaginal por trama, cirugía escrotal o sangre desde cavidad peritoneal.

-‐  Diagnós2co: Historia, Ex. ]sico, ECO (Doppler)

Manejo •  Tratar la causa asociada: lesión uretral, rotura tesFcular, lesión intra-‐abdominal •  Hematoma Escrotales cutáneos: –  Conservador: suspensión/elevación escrotal + Ice packs •  Hematoceles: –  Mayoría según criterio clínico, laboratorio y evolución –  Hematocele traumáFco (> por Rotura tes2cular): cirugía precoz

Rotura/Fractura Tes2cular –  Desgarro de la túnica albugínea más extrusión de Tub. Seminiferos y hematocele –  En 50% de los traumas contuso, con fuerza de al menos 50kg –  DiagnósFco principalmente clínico: dolor, nauseas, vómitos, sincope, historia sugerente. –  Imágenes: ECO: ecotextura heterogénea con visión de la fractura en un 20% y posible visualización de extrusión de TS. –  EMERGENCIA!!! à Reparación quirúrgica precoz

ROTURA/FRACTURA TESTICULAR

Rotura/Fractura Tes2cular •  Reconstrucción primaria tes2cular y escroto 1.  2.  3.  4.  1.  2.  3.  4.

Abordaje escrotal Evacuar de Hematocele y coágulos Debridar túbulos seminíferos y tejido necróFco Cerrar túnica albugínea con sutura conFnua reabsorbible 4-‐0 ** Colgajo libre túnica vaginal para cierre de teste Reparar lesiones de epidídimo Drenaje Penrose peritesFcular por incisión separada 36 hr ATB amplio espectro x 7 días, vacuna anFtetánica Cierre primario de piel o diferido con injerto

exploration (40%), and orchiectomy (15%) (Cass and Luxenberg, 1988). Significant hematoceles should also be explored, regardless of imaging studies, because up to 80% are caused by testicular rupture (Vaccaro et al, 1986). Penetrating scrotal injuries should be surgically explored to inspect for vascular and vasal injury; as in blunt trauma the same principles of salvage, hemostasis, and reconstruction apply. The vas deferens is injured in 7% to 9% of scrotal gunshot wounds (Gomez et al, 1993; Brandes et al, 1995). The injured vas should be ligated with nonabsorbable suture and delayed reconstruction performed if necessary. Approximately

Rotura/Fractura Tes2cular Figure 88–4. Ultrasound examination demonstrates hypoechoic intratesticular areas (arrow) consistent with testicular rupture sustained by blunt trauma. Scrotal exploration revealed large hematocele and exposed seminiferous tubules.

Figure 88–5. A, Testicular rupture after blunt trauma. B, Reconstructed testis after debridement and closure. Arrow indicates placement of tunica vaginalis graft.

Dislocación tes2cular •  Desplazamiento del teskculo a posiciones extra-‐escrotales •  Accidentes en moto a alta velocidad, infrecuente. •  Uni o bilateral •  Puede dislocarse a abdomen, pubis, canal inguinal, canal femoral, pene o periné •  Puede acompañarse de torsión o rotura tesFcular •  Diagnos2co: dolor y bolsa escrotal vacía. Si no puede ser encontrado, ECO/ECO Doppler o TAC son de ayuda •  Manejo: exploración quirúrgica precoz y orquidopexia con incisión inguinal para mejor manejo de cordón.

Dislocación tes2cular •  Dislocación Tes2cular

Trauma penetrante tes2cular •  Exploración quirúrgica y reconstrucción tesFcular •  Lesiones penetrantes escrotales son bilaterales en 30% (vs 1 % contusa) •  Herida penetrante de tescculo –  Manejo similar a Rotura TesFcular

•  No logra reconstrucción/ tejido mínimo viable –  Orquidectomía

•  Sangrado de vasos del cordón espermá2co –  Ligadura

•  Lesiones por explosivos: –  Reconstrucciones complejas

•  Disrupción completa Cordón –  Orquidectomía

FIN