外科学-泌尿系统损伤-课件

泌尿系统损伤

UrologicTrauma泌尿系统损伤

UrologicTraumaGeneralConsiderationsIatrogenicInjuryExternalTraumaGeneralConsiderationsIatrogenRenalTraumaAnatomyIatrogenicRenalInjuryExternalRenalInjuriesSpontaneousRetroperitonealHemorrhageRenalTraumaAnatomyReasonsBluntrenalinjuriesmostoftencomefrommotorvehicleaccidents,fallsfromheights,andassaults.

Penetratingrenalinjuriesmostoftencomefromgunshotandstabwounds.PercutaneousRenalProceduresReasonsBluntrenalinjuriesmodecelerationinjurydecelerationinjuryPresentationHematuriaisthebestindicatoroftraumaticurinarysysteminjury

However,thedegreeofhematuriaandtheseverityoftherenalinjurydonotcorrelateconsistently:inupto36%ofrenalvascularinjuriesfromblunttrauma,hematuriaisabsentPresentationHematuriaistheClassificationI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III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ClassificationI挫伤肉眼或镜下血尿

IndicationsforRenalImagingallblunttraumapatientswithgrosshematuriaandpatientswithmicroscopichematuriaandshock(systolicbloodpressure<90mmHganytimeduringevaluationandresuscitation)shouldundergorenalimaging,usuallyCTwithintravenouscontrast.

Patientswithmicroscopichematuriawithoutshockcanbeobservedclinicallywithoutimagingstudies.Penetratinginjurieswithanydegreeofhematuriashouldbeimaged.

Ultrasonographyisapopularimagingmodalityintheinitialevaluationofabdominaltrauma.IndicationsforRenalImaging外科学-泌尿系统损伤--课件NonoperativeManagementindeed,98%ofbluntrenalinjuriescanbemanagednonoperatively.GradeIVandVinjuriesmoreoftenrequiresurgicalexploration.Patientswithhigh-gradeinjuries(gradesIIItoV)selectedfornonoperativemanagementshouldbeobservedcloselyTheisolatedrenalinjury,withoutsignificantassociatedinjuries,occursmorecommonlyfromblunttraumaandinmostcircumstancescanbemanagednonoperatively.TheexceptionismajorgradeVvascularpedicleavulsioninjuries.Isolatedrenalinjurieswithparenchymallacerationsandevensegmentalarterialinjurycanhaveactivebleedingwellcontrolledbyangiographicembolization.NonoperativeManagementindeedOperativeManagementAbsoluteindicationsincludeevidenceofpersistentrenalbleeding,expandingperirenalhematoma,andpulsatileperirenalhematoma

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Relativeindicationsincludeurinaryextravasation,nonviabletissue,delayeddiagnosisofarterialinjury,segmentalarterialinjury,andincompletestaging.相对适应症包括：尿外渗、组织坏死、延迟诊断的动脉创伤、肾段动脉创伤及分级不明确OperativeManagementAbsoluteRenalExplorationRenalExplorationRenalReconstructionRenalReconstructionRenalReconstructionRenalReconstructionIndicationsforNephrectomyGradeVrenalinjury(77%)Theunstablepatient,withlowbodytemperatureandpoorcoagulation,cannotriskanattemptatrenalrepairifanormalcontralateralkidneyispresent(23%)IndicationsforNephrectomyGrComplicationsPersistenturinaryextravasationcanresultinurinoma,perinephricinfection,andrenalloss.Delayedrenalbleedingcanpotentiallyoccurseveralweeksafterinjurybutusuallyoccurswithin21days.Perinephricabscess-PercutaneousdrainageHypertension:1)renalvascularinjury,leadingtostenosisorocclusionofthemainrenalarteryoroneofitsbranches;2)compressionoftherenalparenchymawithextravasatedbloodorurine;3)post-traumaarteriovenousfistula.Intheseinstances,therenin-angiotensinaxisisstimulatedbypartialrenalischemia,resultinginhypertensionComplicationsPersistenturinaUreteralinjuriesIatrogenicUreteralInjuryExternalUreteralInjuryUreteralinjuriesIatrogenicUIatrogenicUreteralInjuryOpenSurgeryLaparoscopicSurgeryUreterorenoscopyRadioactiveinjuryIatrogenicUreteralInjuryOpenExternalUreteralInjuryUreteralinjuriesafterexternalviolencearerareOpeninjuryblunttraumapatientswithureteralinjuriesaresubjecttoextremeforceappliedovertheentirebody.Thegreatdegreeofenergyimpartedtothevictimisassociatedwithsuchuncommoninjuriesasfracturedlumbarprocesses

andthoracolumbarspinaldislocation

ExternalUreteralInjuryUreterDiagnosisIntraoperativeRecognition

ImagingStudies

ExcretoryUrographyComputedTomographyRetrogradeUreterographyAntegradeUreterographyDiagnosisIntraoperativeRecognTreatmentTreatmentTreatmentTreatmentBladderTraumaThemostcommonassociatedinjuryispelvicfracture,associatedwith83%to95%ofbladderinjuries

obstetricandgynecologiccomplicationsarethemostcommonetiologyofIatrogenicbladderinjuries

BladderTraumaThemostcommondiagnosis耻骨上区疼痛或触痛不能排尿或尿量减少尿中有血块CT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diagnosis耻骨上区疼痛或触痛RadiographicImagingRadiographicImagingTreatmentTheusualtreatmentofuncomplicatedextraperitonealbladderruptures,whenconditionsareideal,isconservativemanagementwithurethralcatheterdrainagealone

complicationssuchasfistula,abscess,andprolongedleak

TreatmentTheusualtreatmento外科学-泌尿系统损伤--课件INDICATIONSFORIMMEDIATEREPAIROFBLADDERINJURY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INDICATIONSFORIMMEDIATEREPAUrethralTraumaPosteriorUrethra

AnteriorUrethra

UrethralTraumaPosteriorUrethPosteriorUrethraStraddlefractures”involvingallfourpubicrami

openfractures,andfracturesresultinginbothverticalandrotationalpelvicinstabilityareassociatedwiththehighestriskofurologicinjury

PosteriorUrethraStraddlefracdiagnosisUrethraldisruptionisheraldedbythetriadofbloodatthemeatus,inabilitytourinate,andpalpablyfullbladder

urethralcathetercannotbeplaced;misplacedintopelvichematoma.impalpableprostateUrethrography

diagnosisUrethraldisruptioniTreatmentSuprapubicCystostomy

PrimaryRealignment

DelayedReconstruction:At3months,scartissueattheurethraldisruptionsiteisstableenoughtoallowposteriorurethroplastytobeundertakensafely,providedthatassociatedinjuriesarestabilizedandthepatientisambulatoryTreatmentSuprapubicCystostomyPrimaryRealignmentPrimaryRealignmentDelayedReconstructionDelayedReconstructionTransurethralcutting-to-the-lightprocedureTransurethralcutting-to-the-lAnteriorUrethraThemajorityoccurafterstraddleinjuryandinvolvethebulbarurethraIn20%ofthecasesofruptureofcorporacavernosa,theurethraisinvolvedAnteriorUrethraThemajorityo外科学-泌尿系统损伤--课件InjuriesofthegenitaliaPenis(Fracture,Gunsho