泌尿系统损伤

泌尿系损伤第1页大纲要求

掌握尿道损伤病理、诊断和急诊处理标准。熟悉肾、膀胱损伤症状、诊断、鉴别诊断和治疗标准。理解泌尿系各部位损伤病因和有关病理解剖第2页第3页概述

解部生理特点决定于损伤特点损伤分类：

创伤（闭合性和开放性）

医源性损伤

自发性（病理性）损伤第4页概述：肾

解部位置深→相对少见、复合伤多脂肪囊→青少年较成年多见医源性创伤→微创外科并发症症状上→血、尿→急第5页第6页

20%OFCARDIACOUTPUT(APPROX.1200ml/min)STRAIGHTGOESTOTHEKIDNEYS第7页概述：输尿管

位置深、蠕动→创伤少见行程长→易医源性损伤症状→尿漏、梗阻、尿瘘等第8页概述：膀胱

充盈时易损伤、空虚时少见腹膜内外破裂→尿外渗范围不一样第9页概述：尿道

浅表→男性球部骑跨伤、女性少见损伤部位不一样→尿外渗范围不一样第10页概述发生频率：男性尿道>肾和膀胱>输尿管联合伤多见，闭合性损伤为主症状特点：血、尿、梗阻等必须注意医源性损伤泌尿外科手术针对腹腔和腹膜后其他脏器手术提醒：一侧肾行手术，必须先理解对侧肾情况第11页概述病理泌尿系统损伤出血血肿尿外渗短时间内大量出血压迫梗阻继发感染休克脓肿脓毒症尿瘘尿道狭窄输尿管梗阻第12页肾损伤RenalInjury第13页肾损伤病因和病理病因开放性损伤闭合性损伤直接暴力损伤间接暴力损伤自发性肾破裂医源性损伤第14页挫伤Contusion:Microscopicorgrosshematuria,urologicstudiesnormal肾损伤分类：Ⅰ度（小挫伤）

第15页血肿Hematoma:Subcapsular,nonexpandingwithoutparenchymallacerationHematoma:Nonexpandingperirenalhematomaconfinedtorenalretroperitoneum

Ⅱ度（血肿）

第16页Ⅲ度（小裂伤）

裂伤Laceration:<1-cmparenchymaldepthofrenalcortexwithouturinaryextravasation第17页Ⅳ度（深裂伤）

Laceration:>1-cmparenchymaldepthofrenalcortexwithoutcollectingsystemruptureorurinaryextravasationLaceration:Parenchymallacerationextendingthroughtherenalcortex,medulla,andcollectingsystem第18页Vascular:MainrenalarteryorveininjurywithcontainedhemorrhageLaceration：CompletelyshatteredkidneyVascular:Avulsionofrenalhilum,devascularizingthekidney

Ⅴ度（碎裂、肾蒂损伤

第19页肾损伤临床体现和诊断临床体现开放性损伤创口休克血尿思考：什么情况下肾损伤不发生血尿？疼痛腰腹肿块及瘀斑、擦伤感染症状合并伤第20页肾损伤诊断病史（致伤原因）→非常主要临床体现试验室检查影像学检查第21页血尿HematuriaIsthebestindicatoroftraumaticurinarysysteminjury.However,thedegreeofhematuriaandtheseverityoftherenalinjurydonotcorrelateconsistently.第22页其他症状Othersymptoms出血性休克Hemorrhagicshock恶心Nausea呕吐Vomiting腹部肿块Abdominaldistention第23页试验室检查LaboratoryfindingsTrauma-----MicroscopicorgrosshematuriaThepresenceofmicroscopichematuria(morethanfiveredbloodcellsperhigh-powerfield[RBC/HPF]orpositivedipstickfinding)orgrosshematuriaischaracteristic.Hematocrit:normalinitially,dropwhenpresistentbleeding第24页影像学检查：增加CT首选HelpfulinassessingtheextentofrenalinjuryThepreferredimagingstudyforrenaltraumaiscontrast-enhancedCT.

♫highlysensitive

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highlyspecificextensiveurinaryextravasationandlargeretroperitonealhematoma第25页第26页其他影像学检查Imagingsstudies平片PlainfilmObliterationofthepsoasshadow----retroperitonealhematomaorurinaryextravasationBowelgasTransversevertebralprocessfracturesorribfracture静脉尿路造影Excretoryurograms(IVU)NormalwhenmildlycontusedExtravasationwhenlaceratedNofunctionwhenvascularpedicleinjuried第27页超声SonographySonographyisbeingusedwithgreaterfrequencyintheimmediateevaluationofinjuries.Itconfirmsthepresenceoftwokidneysandcaneasilydefineanyretroperitonealhematoma.第28页肾损伤并发症近期并发症腹膜后尿性囊肿感染、脓肿远期并发症肾性高血压肾积水肾萎缩肾周假性囊肿肾盂肾炎肾结石第29页肾损伤治疗紧急治疗：着重于休克防治非手术治疗绝对卧床病例讨论：肾损伤后卧床一周，血尿消失患者，返家后再次出血，终致肾切除，为何？维持血容量抗感染密切观测手术治疗开放性损伤几乎所有需要手术闭合性损伤处理流程第30页肾损伤闭合损伤处理流程闭合性肾损伤镜下血尿稳定不稳定肉眼血尿稳定不稳定大剂量静脉尿路造影纠正休克肾挫伤或轻型肾裂伤重型肾裂伤肾粉碎伤肾盂破裂肾不显影（肾蒂伤？）非手术治疗手术治疗非手术治疗手术探查肾动脉造影非手术治疗稳定不稳定继续非手术治疗手术治疗手术探查血压、血尿、血常规检查、局部肿块等情况是否好转伤后有没有休克、昏迷、恶心、呕吐等有没有休克第31页远期并发症处理肾周脓肿必须引流Perinephricabscessshouldbedrained肾性高血压:血管重建vascularreconstructionor肾切nephrectomy第32页输尿管损伤UretericTrauma第33页特点

创伤少见Ureterictraumaisuncommon医源性多见Iatrogenicinjuriescontinuetooccur妇科手术Pelvicsurgery

输尿管镜UreteroscopicInjury

放疗Radiationtherapy第34页诊断病史→非常主要临床体现试验室检查影像学检查第35页临床体现侧腹和下腹疼Flankandlowerabdominalpain肾盂肾炎pyelonephritis急性肾功能衰竭Acuterenalfailureor肾积水hydronephrosis尿漏Urineleakfromthewound腹膜炎peritonealsigns输尿管膀胱瘘uretero-vaginalfistula第36页影像学检查ImagingsstudiesExcretoryurograms(IVU)AlargeareaofincreaseddensityinthepelvisorinanareaofretroperitoneumHydronephrosis—delayedexcretionContrastextracasationfromtheinjury第37页超声SonographyHydronephrosisHydroureterFluidmassduetourineextravasation肾动态显像RadionuclidescanningDelayedexcretionAccumulationofcountsinthepelvisandrenalparanchyma----ureterobstructionUrinaryextravasation第38页鉴别诊断Differentdiagnosis腹膜炎Mimicperitonitis膀胱阴道瘘Vesicovaginaland输尿管阴道瘘ureterovaginalfistulas---MethylenebluestainCystoscopy第39页并发症Complications尿瘘Urinaryfistula输尿管梗阻Ureteralobstruction肾积水Hydronephrosis感染Renalinfection腹膜炎Peritonitis尿毒症Uremia第40页治疗TreatmentUreteraldivision置管Stent输尿管端端吻合Ureteroureterostomy输尿管再植Neoureterocystostomy输尿管与对侧输尿管吻合TransureteroureterostomyUreteralresection修复Repair自体肾移植Autotransplantofkidney第41页术中早期发觉处理Earlyreoperation膀胱瓣PsoashitchorBoariflap回肠代Intestinalureter经皮肾引流Percutaneousnephrostomy修补Definitiverepair

肾切除Nephrectomy第42页膀胱损伤BladderTrauma第43页原因CauseofBladderInjury直接暴力Mostbladderinjuries--bluntforcetoafullbladder骨盆骨折15%inpelvicfracture盆腔手术Pelvicsurgery膀胱镜Cystoscopicmaneuvers尿道扩张UrethralDilation第44页病理Pathology挫伤Contusion破裂BladderRupture

腹膜外Extraperitoneal

腹膜内Intraperitoneal第45页临床体现Symptomandsigns挫伤无症状Nosymptom---Contusion不能排尿Unabletourine肉眼血尿Grosshematuria耻骨上痛Suprapublicpain出血性休克Hemorrhagicshock腹膜炎Peritonealsigns盆腔尿性囊肿Pelvicurinoma第46页试验室检查Laboratoryfindings血色素下降Falllinghematocrit连续出血Continuedbleeding血尿Hematuria第47页

导尿试验CatheterizationTestPutCatheterNoUrineInject200MlNSLessthanormorethan200MLindicate---bladderrupture(WHY?)第48页影像学Imagings膀胱造影Acystogramisappropriate.Plainfilm----fractureofpelvisThebladderfillingphaseofanintravenouspyelogramorCTwillnotshowabladderinjurysincedistensionisnecessaryforleakagetooccur.第49页治疗Treatment处理休克、出血和其他损伤Treatshock,hemorrhageandotherinjury挫伤—尿管2-3周Contusion---Catheterizationonly(2-3wks)胸膜外损伤只有在腹膜炎体现时才需开放手术修补Extraperitonealbladderinjuriesrequireopenrepaironlyifthereisperitonealextravasationofurine.穿透伤需要探查Penetratinginjuriesalwaysneedopensurgicalrepair.第50页尿道损伤UrethralTrauma第51页解剖Anatomy尿生殖隔Urogenitaldiaphragm前尿道Anteriorurethra---bulbousandpendulous后尿道Posteriorurethra---membranousandprostate第52页解剖Anatomy第53页球部损伤Bulbousurethralinjury骑跨伤最常见Mostcommoncause:straddleinjury器械损伤Instrumentinjury尿外渗范围Urinaryextravasationlocation第54页第55页解剖Anatomy第56页第57页第58页第59页第60页A,normalanatomy;B,rupturebelowtheprostaticapex;C,ruptureatthemembranous/bulbarurethraljunction.第61页球部尿道损伤临床体现下腹痛Lowerabdominalpain不能排尿Inabilitytourinate血尿Hematuria耻骨上肿块Suprapublicmass尿外渗Urinaryextravasation第62页球部损伤尿外渗范围第63页球部尿道损伤诊断试导尿，不超出1次Catheterizationshouldnotbeattempted(only1time)尿道造影Urethrography:extravasationX光检查X-ray:fracturedpelvis第64页第65页治疗Treatment急诊处理EmergencyTreatment导尿成功者停留尿管1周Catherization1wk---nospecialtreatment失败者，尿道修补Catherizationfailure---urethralrepair---keepcatheter2-3wks膀胱造瘘3-6月后二期修复Suprapubiccystostomy3-6ms—urethrarepair尿道扩张Urethraldilation内镜Endourology第66页SurgicalReconstruction

D,approxima