医学精品课件：14.Genitourinary Trauma-13级7年制0525

Freephotoshowtemplatefrom1GenitourinaryTrauma

LiuchuanDepartmentofUrology,SecondAffiliatedHospitalFreephotoshowtemplatefrom2Freephotoshowtemplatefrom3

Approximately10%ofinjuriesinvolvethegenitourinarysystem（泌尿生殖系统）.Freephotoshowtemplatefrom4

Doctorsshouldsuspectmultiple-organinjuries（多器官损伤）withGenitourinaryTraumapatients.Theabdomen（腹部）andgenitalia（外生殖器）shouldbeexaminedforevidenceofcontusions（挫伤）orsubcutaneoushematomas（皮下血肿）,whichmightindicatedeeperinjuriestotheretroperitoneum（腹膜后）andpelvic（骨盆）structures.

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Fracturesofthelowerribs（肋骨）areoftenassociatedwithrenalinjuries,andpelvicfractures（骨盆骨折）oftenaccompanybladderandurethralinjuries.Awoundtotheupperabdomenorlowerchestshouldalertthephysiciantorenalinjury.Freephotoshowtemplatefrom7KidneyTrauma

KidneyTraumaarethemostcommoninjuriesoftheurinarysystem.Thekidneyiswellprotectedbyheavylumbarmuscles（腰部肌肉）,vertebralbodies,ribs,andthevisceraanteriorly.

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Fracturedribsandtransversevertebral（横断的脊椎骨）processesmaypenetrate（贯穿）therenalparenchyma（实质）orvasculature（脉管系统）.Mostinjuriesoccurfromautomobileaccidentsorsportingmishaps,chieflyinmenandboys.

Freephotoshowtemplatefrom9Kidneyswithexistingpathologicconditionssuchashydronephrosis（肾积水）ormalignanttumorsaremorereadilyruptured（破裂）frommildtrauma.Freephotoshowtemplatefrom10

Etiology

Blunttrauma（钝性损伤）directlytotheabdomen,flank,orbackisthemostcommonmechanism,accountingfor80–85%ofallrenalinjuries.Traumamayresultfrommotorvehicleaccidents（机动车事故）,fights,falls,andcontactsports.Freephotoshowtemplatefrom11

Vehiclecollisions（碰撞）athighspeedmayresultinmajorrenaltraumafromrapiddeceleration（减速）andcausemajorvascularinjury（血管损伤）.Freephotoshowtemplatefrom12

Etiology

Gunshot（枪弹伤）andknifewoundscausemostpenetratinginjuriestothekidney，anysuchwoundintheflank（侧腹）areashouldberegardedasacauseofrenalinjuryuntilprovedotherwise.Freephotoshowtemplatefrom13

Etiology

Inthecaseofpolytrauma（多发伤）,theabdomen,chest,andbackmustbeexamined:fracturesofthelowerribsandupperlumbar（腰部）andlowerthoracicvertebrae（胸椎）areassociatedwithrenalinjuries.Freephotoshowtemplatefrom14PathologyandClassification

***A1.Renalcontusion（挫伤）orsubcapsularhematoma（包膜下血肿），withoutparenchymal（实质）laceration（裂伤）.

Freephotoshowtemplatefrom15B2.Partialparenchymallaceration:Parenchymaldepthofrenalcortex（肾皮质）withoutcollectingsystem（收集系统）rupture（破裂）orurinaryextravasation（尿外渗）.CPathologyandClassification

***Freephotoshowtemplatefrom163.Full-thicknessparenchymallaceration：Parenchymallacerationextendingthroughrenalcortex,medulla（髓质）,andcollectingsystem.Urinaryextravasationbepresent.DEPathologyandClassification

***Freephotoshowtemplatefrom17FGHF.Avulsionofthemainrenalarteryorveinorboth.G.Thrombosisofasegmentalrenalarterywithoutaparenchymallaceration.Notethecorrespondingparenchymalischemia(缺血).H.Thrombosisofthemainrenalartery.

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

***Freephotoshowtemplatefrom18PathologyandClassification

***Ininjuriesfromrapiddeceleration（减速）,thekidneymovesupwardordownward,causingsuddenstretchontherenalpedicleandsometimescompleteorpartialavulsion.Acutethrombosisoftherenalarterymaybecausedbyanintimaltearfromrapiddece-lerationinjuriesowingtothesuddenstretch.Freephotoshowtemplatefrom19LatePathologicFindings

1.Urinoma（尿囊肿）—Deeplacerationsthatarenotrepairedmayresultinpersistenturinaryextra-vasationandlatecomplicationsofalargeperinephricrenalmassand,eventually,hydro-nephrosisandabscessformation.

Freephotoshowtemplatefrom20LatePathologicFindings2.Hydronephrosis（肾积水）—Largehematomasintheretroperitoneumandassociatedurinaryextravasationmayresultinperinephricfibrosis（肾周纤维化）engulfingtheureteropelvicjunction,causinghydronephrosis.Freephotoshowtemplatefrom21LatePathologicFindings3.Arteriovenousfistula（动静脉瘘）—Arteriovenousfistulasmayoccurafterpenetratinginjuriesbutarenotcommon.Freephotoshowtemplatefrom22LatePathologicFindings4.Renalvascularhypertension（肾血管性高血压）—Thebloodflowintissuerenderednon-viablebyinjuryiscompromised，thisresultsinrenalvascularhypertension.Fibrosisfromsurroundingtraumahasalsobeenreportedtoconstricttherenalarteryandcauserenalhyper-tension.

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1.Hematuria（血尿）：Hematuriaisthebestindicatoroftraumaticurinarysysteminjury.Thepresenceofmicroscopichematuriaorgrosshematuriaischaracteristic.Freephotoshowtemplatefrom24However,thedegreeofrenalinjurydoesnotcorrespondtothedegreeofhematuria,sincegrosshematuriamayoccurinminorrenaltraumaandonlymildhematuriainmajortrauma.Somecasesofrenalvascularinjuryarenotassociatedwithhematuria.Freephotoshowtemplatefrom25ClinicalPresentation

2.Shock：Initially,shockorsignsofalargelossofbloodfromheavyretroperitonealbleedingmaybenoted.Freephotoshowtemplatefrom26ClinicalPresentation

2.Pain:Painmaybelocalizedtooneflankareaorovertheabdomen.3.Palpablemass:Apalpablemassmayrepresentalargeretroperitonealhematomaorperhapsurinaryextravasation.Freephotoshowtemplatefrom27Diagnosis1.Thehistoryshouldincludeadetaileddescriptionoftheaccident.Incasesinvolvinggunshotwounds,thetypeandcaliber（尺寸）oftheweaponshouldbedetermined.Freephotoshowtemplatefrom28Diagnosis

2.Urinalysis（尿液分析）isoneofthemostimportantandusefulurologictests.Thepresenceofevenafewerythrocytesintheurine(hematuria)isabnormalandrequiresfurtherinvestigation.ThepresenceofLeukocytes（白细胞）maybeaindicationofinfection.Freephotoshowtemplatefrom29Diagnosis

3.Hemogram：Thedropofhematocrit（红细胞压积）mayrepresentspersistentretroperitonealbleedinganddevelopmentofalargeretroperitonealhematoma.HemoglobinFreephotoshowtemplatefrom30Diagnosis3.ImagingStudies(1)AbdominalSonography（经腹部超声）Sonographyisbeingusedwithgreaterfre-quencyintheimmediateevaluationofinjuries.ItconfirmsthepresenceoftwokidneysandcaneasilydefineanyRetro-peritonealhematoma.Freephotoshowtemplatefrom31Butitcannotclearlydelineateparenchymallacerationsandvascularorcollectingsysteminjuriesandcannotaccuratelydetecturinaryextravasationinacuteinjuries.Freephotoshowtemplatefrom32Diagnosis(2)Computedtomography(CT)Abdominalcomputedtomographywithcontrastmedia(增强CT)isthebestimagingstudytodetectrenalinjuries.Itcandefinethesizeandextentoftheretroperitonealhematoma,renallacerations,urinaryextravasation,andrenalarterialandvenousinjuries;additionally,itcandetectintraabdominalinjuries(liver,spleen,pancreas,bowel)Freephotoshowtemplatefrom33Freephotoshowtemplatefrom34Freephotoshowtemplatefrom35Freephotoshowtemplatefrom36Freephotoshowtemplatefrom37Freephotoshowtemplatefrom38Freephotoshowtemplatefrom39Freephotoshowtemplatefrom40Freephotoshowtemplatefrom41Freephotoshowtemplatefrom42Freephotoshowtemplatefrom43Freephotoshowtemplatefrom44Freephotoshowtemplatefrom45Freephotoshowtemplatefrom46Freephotoshowtemplatefrom47Freephotoshowtemplatefrom48Freephotoshowtemplatefrom49Freephotoshowtemplatefrom50Freephotoshowtemplatefrom51 Computedtomographyshowsleftrenalinfarctioncauesedbythrombosisofthemainrenalartery.Freephotoshowtemplatefrom52Diagnosis(3)Intravenousurography（静脉肾盂造影）Intravenousurographycanbeusedtodetectrenalandureteralinjury.Thisisbestdonewithhigh-dosebolusinjectionofcontrastmediafollowedbyappropriatefilms.ButithaslargelybeenreplacedbyCT.Freephotoshowtemplatefrom53Diagnosis(4)Arteriography（动脉造影）Arteriographydefinesmajorarterialandparenchymalinjurieswhenpreviousstudieshavenotfullydoneso.Arterialthrombosisandavulsionoftherenalpediclearebestdiagnosedbyarteriography.

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1.Emergencytreatment：Theobjectivesofearlymanagementareprompttreatmentofshockandhemorrhage,andevaluationofassociatedinjuries.observevitalsigncarefully,bloodtransfusion,etc.Freephotoshowtemplatefrom55Treatment2.Nonoperativemanagement（1）absolutebedrestisrequired.（2）observevitalsignclosely.（3）transfusionorbloodtransfusion.（4）anti-infectivetherapy.（5）symptomatictreatment：relievepain，etc.Freephotoshowtemplatefrom56Treatment3．OperativeManagement（1）Penetratinginjuries：Penetratinginjuriesshouldbesurgicallyexplored(手术探查).

Freephotoshowtemplatefrom57Treatment（2）Bluntinjuries：Casesinwhichoperationisindicatedincludethoseassociatedwithpersistentretroperitonealbleeding（持续性腹膜后出血）：①

vitalsigncouldnotimprovedaftershocktreatmentactively.Freephotoshowtemplatefrom58②Hematuriabecomemoreseriousorheamoglobin

andhaematocritdecreasepersistently.③Massinflankareaorabdomenaugmentgradually.④Suspectionofabdominalorgantrauma.

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Surgicalexplorationoftheacutelyinjuredkidneyisbestdoneviaaintraabdominalapproach,whichallowscompleteinspectionofintraabdominalorgansandbowel.TherenalvesselsareisolatedbeforeexplorationtoprovidetheimmediatecapabilitytooccludethemifmassivebleedingshouldensueonceGerota’sfasciaisopened.Freephotoshowtemplatefrom60

RenalReconstructionVascularrepairNephrectomy

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4.TreatmentofcomplicationsRetroperitonealurinomaorperinephricabscessdemandspromptsurgicaldrainage（引流）.Malignanthypertensionrequiresvascularrepairornephrectomy.Hydronephrosismayrequiresurgicalcorrectionornephrectomy.Freephotoshowtemplatefrom62BladderTraumaBladderTraumaoccurmostoftenfromexternalforceandareoftenassociatedwithpelvicfractures（骨盆骨折）.

Accordingly,whenbladderinjuryispresent,othersevereinjuriesareusuallyassociated.Freephotoshowtemplatefrom63Etiology1.Bladderinjuriesafterblunttraumaareoverwhelminglyassociatedwithpelvicfracture.Mostpatientswithbladderinjuries(83%to100%)haveanassociatedpelvicfracture.Freephotoshowtemplatefrom64Etiology2.Penetratingbladderinjuriesarecommonlyassociatedwithmajorabdominalinjuries,andthesepatientsareofteninshock.3.Iatrogenicinjury（医源性损伤）mayresultfromgynecologicandotherextensivepelvicproceduresaswellasfromherniarepairs（疝修补）andtransurethraloperations（经尿道手术）.Freephotoshowtemplatefrom65Pathology

Thebonypelvisprotectstheurinarybladderverywell.Whenthepelvisisfracturedbyblunttrauma,fragmentsfromthefracturesitemayperforatethebladder.Theseperforationsusuallyresultinextraperitonealrupture.

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Whenthebladderisfilledtonearcapacity,adirectblowtothelowerabdomenmayresultinbladderdisruption.Thistypeofdisruptionordinarilyisintraperitoneal.

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Sincethereflectionofthepelvicperi-toneumcoversthedome（顶部）ofthebladder,alinearlacerationwillallowurinetoflowintotheabdominalcavity.Iftheurineisinfected,immediateperitonitisandacuteabdomenwilldevelop.Freephotoshowtemplatefrom68ClinicalPresentation

Patientsordinarilyareunabletourinate,butwhenspontaneousvoidingoccurs,grosshematuriaisusuallypresent.Mostpatientscomplainofpelvicorlowerabdominalpain.Heavybleedingassociatedwithpelvicfracturemayresultinhemorrhagicshock.

Freephotoshowtemplatefrom69Diagnosis1.Thereisusuallyahistoryoflowerabdominaltrauma.Whencatheterizationisdone,grossor,lesscommonly,microscopichematuriaisusuallypresent.Freephotoshowtemplatefrom70Diagnosis2.X-RayFindings:Aplainabdominalfilm（腹部平片）generallydemonstratespelvicfractures.Bladderdisruptionisshownoncystography（膀胱造影）.Freephotoshowtemplatefrom71ExtraperitonealbladderruptureoncystographyIntraperitonealbladderruptureoncystographyFreephotoshowtemplatefrom72TreatmentEmergencyMeasures:Shockandhemo-rrhageshouldbetreated.SurgicalMeasures:Thebladdershouldbeopenedandcarefullyinspected.Afterrepair,asuprapubiccystostomytube（耻骨上膀胱造瘘管）isusuallyleftinplacetoensurecompleteurinarydrainageandcontrolofbleeding.Freephotoshowtemplatefrom73UrethralInjuriesUrethralinjuriesareuncommonandoccurmostofteninmen,usuallyassociatedwithpelvicfracturesorstraddletypefalls（骑跨伤）.Theyarerareinwomen.Variouspartsoftheurethramaybelacerated（破裂）,transected（横断）,orcontused（挫伤）.Freephotoshowtemplatefrom74ProstaticMembranousBulbousPendulousposteriorurethraanteriorurethraTheurethracanbeseparatedinto2broadanatomicdivisions:theposteriorurethra,consistingoftheprostaticandmembranousportions,andtheanteriorurethra,consistingofthebulbous（球部）andpendulousportions（悬垂部）.

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InjuriesToTheAnteriorUretheraStraddleinjurymaycauselacerationorcontusionoftheurethra.Iatrogenicinstrumentationmaycausepartialdisruption.Freephotoshowtemplatefrom76Pathology

1.Contusion:Contusionoftheurethraisasignofcrushinjurywithouturethraldisruption.Perinealhematoma（会阴血肿）usuallyresolveswithoutcomplications.

Freephotoshowtemplatefrom77Pathology2.Laceration:Aseverestraddleinjurymayresultinlacerationofpartoftheurethralwall,allowingextravasationofurine.Freephotoshowtemplatefrom78PathologyExtravasationofbloodandurineenclosedwithinColles’fascia

Iftheextravasationisunrecognized,itmayextendintothescrotum（阴囊）,alongthepenileshaft（阴茎）,anduptotheabdominalwall.ItislimitedonlybyColles’fasciaandoftenresultsininfection,sepsis（败血症）,andseriousmorbidity.Freephotoshowtemplatefrom79ClinicalPresentationBleedingfromtheurethra.Thereislocalpainintotheperineum（会阴）andsometimesmassiveperinealhematoma.Ifvoidinghasoccurredandextravasationisnoted,suddenswelling（肿胀）intheareawillbepresent.Freephotoshowtemplatefrom80Diagnosis1.SymptomsandSigns:Thereisusuallyahistoryofafall,perinealhematoma,urinaryextravasation.2.Incompleteurethraltearsarebesttreatedbystentingwithaurethralcatheter（导尿）for1week.Operationshouldbegently.Freephotoshowtemplatefrom81DiagnosisRupturedbulbar(anterior)urethrafollowingstraddleinjury.Extravasation(atarrow)onurethrogram.3.X-RayFindings:Aurethrogram（尿道造影）demon-stratesextravasationandthelocationofinjury.Acontusedurethrashowsnoevidenceofextravasation.Freephotoshowtemplatefrom82Treatment1.EmergencyMeasures:Ifheavybleedingdoesoccur,localpressure（局部压迫）forcontrolisrequired.2.Urethralcontusion:Thepatientwithurethralcontusionshowsnoevidenceofextravasation,andtheurethraremainsintact.Ifbleedingpersists,urethralcatheterdrainagecanbedone.

Freephotoshowtemplatefrom83Treatment3.Urethrallaceration:Incompleteurethrallacerationarebesttreatedbystentingwithaurethralcatheterfor1week.Freephotoshowtemplatefrom84Treatment4.Urethrallacerationwithextensiveurinaryextravasation：

Drainageoftheseareasisindicated.Suprapubiccystostomyforurinarydiversionisrequired.Infectionandabscess（脓肿）formationarecommonandrequireantibiotictherapy.Freephotoshowtemplatefrom855.Immediaterepair：

Immediaterepairofurethrallacerationscanbeperformed.Freephotoshowtemplatefrom866.Treatmentofcomplications:Stricturesatthesiteofinjurymaybeextensiveandrequiredelayedreconstruction.Freephotoshowtemplatefrom87InjuriesToThePosteriorUretheraThemembranousurethrapassesthroughthepelvicfloorandvoluntaryurinarysphincter（括约肌）andistheportionoftheposteriorurethramostlikelytobeinjured.Whenpelvicfracturesoccurfromblunttrauma,themembranousurethraisshearedfromtheprostaticapex（尖）attheprostatomembranousjunction.Freephotoshowtemplatefrom88Injurytotheposteriorurethra.Theprostatehasbeenavulsedfromthemembranousurethrasecondarytofractureofthepelvis.Extravasationoccursabovethetriangularligament（三角韧带）andisperiprostaticandperivesicalFreephotoshowtemplatefrom89ClinicalPresentation1.Shock：becauseofbloodfromheav