泌尿系统损伤

泌尿系统损伤UrinarysystemUppertractKidneyUreterLowertractBladderUrethraexternalgenitaliaclinicalmanifestation

bleeding(出血)urinaryextravasation（尿外渗）Secondarysymptoms(继发的症状)

shock(休克)

hematoma(血肿)

infection(感染)Characteristic（特点）

associatedinjurywithotherorgans(合并伤)TheContentofStudyKidneyTrauma

肾损伤UreterTrauma

输尿管损伤BladderTrauma膀胱损伤UrethralTrauma

尿道损伤Injuriesoftheexternalgenitalia外生殖器损伤

Anatomiccharacteristicofthekidney（特点）position(encolsedbyrib,lumbarvertebrae,backbone,diaphragma,abdominalwall,andorgans肋骨、腰椎、脊柱、膈肌、腹壁及腹腔脏器)

fattyrenalcapsule脂肪囊

mobility活动度othersfragile质地脆，包膜薄easytoinjury肋骨、锐器刺伤RenalInjuryRenalinjuriesconstitute45%ofallUrinarytractinjuries;Mostrenalinjuries(80%)areminoranddonotrequiresurgicalintervention;Renaltraumacanhappeninbothbluntorpenetratingtrauma;1.openinjury

开放性损伤Bullet,blade,etal.Accompaniedbyotherorgansinjury常伴有胸腹部损伤Complicatedandserious复杂而严重etiology(病因):2．

Closedinjury

闭合性损伤（最多见）directviolence直接暴力：

撞击、跌打、挤压、肋骨骨折indirectviolence间接暴力：

对冲伤、突然暴力扭转等etiology(病因):Others：Renaldiseases：

肾积水、肿瘤、结核、囊性变-“自发性”破裂Iatrogenicinjury医源性损伤：

Renalbiopsy,otheroperations（肾穿刺活检）等etiology(病因):肾损伤的病理类型肾实质损伤renalparenchyma 肾脏挫伤

Contusion

部分裂伤IncompletedLaceration全层裂伤CompletedLaceration肾脏碎裂ShatteredKidney肾盂裂伤

PelvicLaceration肾蒂伤

PedicleInjuryRenalInjuryScale

1.Kidneycontusion肾挫伤

Partialrenalparenchyma限于部分肾实质：瘀斑/包膜下血肿Mildhematuria轻度血尿Self-healing症状轻微，可自愈2.partiallacerationofkidney

肾部分裂伤Renalcapsulerupture包膜破裂Perirenalhematoma肾周血肿Hematuria血尿Majoritycanbecuredwithoutsurgery多数不需手术3.Renallaceration

肾全层裂伤extensivehematoma,Urinaryextravasationandhematuria广泛血肿、尿外渗和血尿NeedtobeoperatedfollowingseriousSymptom症状严重，手术治疗4.Injuryofrenalpedicle

肾蒂损伤（少见）Seriousbleeding—shock,death大出血，休克，死亡突然加速或减速：急剧移位肾血管牵拉内膜断裂，形成血栓hematuria血尿pain疼痛mass腰腹部包块shock休克fever发热RelatedtotheextentofinjuryClinicalpresentation临床表现

一、Historyandbodyexamination病史及体检associatedinjurywithotherorgans(合并伤)Injurycondition≠sysptom肾损伤的严重程度与症状不成正比Nomisdiagnosis避免误诊diagnosis

诊断二．Laboratoryexamination化验Urine尿液检查：红细胞Blood血液检查：活动性出血感染三、Radiographicinspection影像学检查1．B超

easyandfaststudyrenalcondition

detectsotherabdominalinjuries2．CT:computerizedtomography检查：Moresensitiveandspecificforstaging精确检测：Studyofchoiceifstableforrenalinjury肾实质伤情,尿外渗、肾周血肿Detectsotherabdominalinjuries其他脏器（肝脾等）有无合并伤CTStagingforRenalInjuryRightrenalstabwound(GradeIV)Leftrenallaceration3.IVP（excretoryurography,intravenouspyelographyIVP/IVU）：静脉尿路造影（排泄性尿路造影)Usedtobeintialexamofchoice.VerypoorsensitivityforpenetratinginjuryLimitationinstagingrenalinjuriesNot1stchoiceanymore.Onlyifptunstable.4.肾动脉造影(renalarteriography)：Studyarterialandrenalparenchymaldamage

了解动脉和肾实质损伤情况Invasiveexamination

有创伤检查，己较少应用Relatedtotheinjureddegree与损伤程度直接相关Conservativetreatment保守治疗

Contusion轻微肾挫伤:短期休息可以康复

minimallaceration多数肾裂伤可保守治疗，少数需手术治疗Management

治疗Stayonthebedfor2-4weeks绝对卧床休息2-4周Withoutphysicallaborin2-3months

恢复后2～3月内不应从事重体力劳动、剧烈活动Watching密切观察:是否继续出血？Conservativetreatment保守治疗SurgeryManagement手术治疗

AbsoluteindicationforSurgery适应症:Uncontrollablerenalhemorrage：严重出血Multiplylacerated,shatteredkidney：肾破裂Mainrenalvesselsavulsed：肾血管撕裂Penetratinginjuriesusually：Why?贯通伤Howtomanagefollowingseriousdamage

operation立即手术：Renalrepair吻合或缝合必要时：

Nephrectomy切肾，止血，挽救生命Urinoma,perinephricabscess----Incisionanddrainage尿性囊肿、肾周脓肿----切开引流Ureteralstricture输尿管狭窄、UPJO----Ureteralangioplasty成形术Arteriovenousfistula,aneurysm动静脉瘘、动脉瘤----Embolization介入栓塞managethelatecomplication并发症的处理Renaltrauma:肾脏损伤：Associatedinjuries大多数合并伤Clinicalpresentation:bleedingandUrinaryextravasationinducedpain,mass,orinfection出血、尿外渗---疼痛、肿块、感染ExaminiationCT：1stchoice(首选检查)Management:definethepostionoftrauma,operation,etal.紧急纠正休克，检查明确损伤，必要时手术---修补、切肾等Conclusion小结

UreteralTrauma输尿管损伤

Retroperitonealorgan腹膜后器官NotsocommoncomparedtorenalinjuryIatrogenicinjury多为医源性损伤Easilytobeoverlooked易被忽视Characteristic（特点）

Opensurgery开放手术

Gynecologicalsurgery妇科手术Colonsurgery直肠手术etiology(病因):endoscopicequipmentdamage腔内器械损伤:输尿管镜检、扩张、取石Radiationinjury放射性损伤

(宫颈癌、前列腺癌)组织水肿、缺血坏死、纤维化Exogenousinjury外源性损伤：锐器、枪弹、交通事故等

etiology(病因):

Causedbythedamage不同的损伤程度引起结果不一样Theinjuryinducedsymptom损伤相关：bleeding,pain出血、疼痛urinaryextravasation尿外渗：感染、尿性腹膜炎、尿性囊肿、脓肿Secondaryinjury损伤继发：输尿管狭窄，梗阻--肾积水、肾功能受损pathology病理:1.hematuria血尿:notsocommon,不常见Note:Completerupture完全断裂者，不一定血尿

Why?2.Infectionandfever:感染、发热Clinicalpresentation临床表现

Urinaryextravasation尿外渗：损伤时或数日后，腰痛，腹胀：尿性腹膜炎，刺激症状Obstruction梗阻：

Narroworcompletelysuture狭窄或完全缝扎--Anuria,oliguria无尿、少尿

--painandfever腰痛、发热Urinaryfistula尿瘘：尿液与阴道、腹壁、肠管等相通相通Clinicalpresentation临床表现

history,病史，手术史Symptoms症状Imagingstudies影像学检查diagnosis

诊断RetrogradepyelographyorUreteroscopy逆行插管造影或输尿管镜检术Intravenousdyeblue静脉注射美兰

Why?diagnosis

诊断Drainage引流：

Torestoretheintegrityoftheureter恢复输尿管的完整性ureteralstent支架管

removethesutures拆除缝线

opensurgery:端端吻合吻合、再植肠代、膀胱瓣肾造瘘、自体肾移植Treatment治疗

InjuryofBladder膀胱损伤

解剖：BladderAnatomy腹膜间位器官：Lieswithinpelviswhenempty,canreachumbilicuswhenfull三层组织：Consistsof3musclelayers多合并其它严重的组织器官损伤：Bladdertraumausuallyassociatedwithsevereinjuries,mortality22-44%病因一、openinjury:开放性损伤：枪弹、锐器:合并其他脏器损伤：直肠、阴道、腹腔;二、closedinjury:膀胱充盈时，下腹部受到撞击骨盆骨折：碎片刺破膀胱生产时，胎头压迫，膀胱壁缺血坏死三、Iatrogenicinjury:医源性损伤

见于膀胱镜检查或治疗经尿道电切术盆腔手术疝修补术阴道手术等。病理生理PathophysiologyExtraperitonealruptureusuallyfrompelvicfracturewithlacerationofbladder,butmayoccurwithblunttrauma腹膜外型：多损伤膀胱前壁；外渗到膀胱周围组织及耻骨后间隙，沿着骨盆筋膜到盆底，或沿输尿管周围蔓延到肾区；(２)Intraperitonealruptureusuallyfromblunttraumainpatientswithafullbladder；

腹膜内型：

膀胱壁破裂伴腹膜破裂，尿液流入腹腔---腹膜炎

BladderInjuryBladderinjuriesclassifiedintocontusions,extraperitonealandintraperitonealruptures;Intraperitoneal(20%)Extraperitoneal(80%)RuptureAfullbladderismorelikelytobecomeinjuredthananemptyone.ClinicalPresentation98%:Grosshematuria肉眼血尿2%:Microscopichematuria镜下血尿85%pain痛;Inabilitytourine:排尿困难：Shock:休克RadiologyRetrogradecystogramisdiagnosticprocedureofchoice逆行膀胱造影3、X线检查腹部平片(KUB)可发现骨盆骨折或其他骨折，膀胱造影可发现有无膀胱破裂。

CTSCANCTrevealsintraperitonealbladderrupturewithcontrastmaterialsurroundingbowelloops腹膜内膀胱破裂后造影剂分布在肠管周围Treatment没有尿外渗：保守治疗IfnoextravasationtreatwithorwithoutFoleydrainage腹膜外破裂：尿管引流ExtraperitonealrupturestreatedwithFoleydrainagefor7to15dayswith20Fr.orgreatersizedcatheter手术修复：膀胱颈或近端尿道Surgicalrepairifruptureinvolvesbladderneckorproximalurethra腹膜内破裂：手术IntraperitonealrupturesalwaysrequiresurgicalrepairSurgicalMangementofBladderRupture

UrethralTrauma尿道损伤UrethraInjury多见于男性：AlmostexclusivelyinmaleMostcommoninstraddleinjure骑跨伤并发症：SignificantmorbidityStrictureIncontinenceImpotence导尿：Foleycatheterimplication后尿道posteriorurethra前列腺部膜部前尿道anteriorurethr