Page 1352 - TNFlipTest

U34 Urology
Trauma Toronto Notes 2019
Investigations
• U/A
■ hematuria: requires workup but degree does not correlate with the severity of injury
• imaging
■ CT (contrast, triphasic) if patient stable: look for renal laceration, extravasation of contrast,
retroperitoneal hematoma, and associated intra-abdominal organ injury
Staging (does not necessarily correlate well with clinical status)
• I: contusion/hematoma
• II:<1cmlacerationwithouturinaryextravasation
• III:>1cmlacerationwithouturinaryextravasation
• IV:lacerationcausingurinaryextravasationand/ormainarterialorveininjurywithcontained
hematoma
• V:shatteredkidneyoravulsionofpedicle
Treatment
• microscopichematuria+isolatedwell-stagedminorinjuries→nohospitalization
• grosshematuria+contusion/minorlacerations→hospitalize,bedrest,repeatCTifbleedingpersists • surgicalintervention/minimallyinvasiveangiographyandembolization(majoritynowmanaged
conservatively, non-operatively) ■ absolute indications
◆ hemorrhage and hemodynamic instability ■ relative indications
◆ non-viable tissue and major laceration ◆ urinary extravasation
◆ vascular injury
◆ expanding or pulsating peri-renal mass ◆ laparotomy for associated injury
• follow-upwithU/SorCTbeforedischarge,andat6wk
Complications
• HTNin5%ofrenaltrauma
Bladder Trauma
Classification
• contusions:nourinaryextravasation,damagetomucosaormuscularis
• intraperitonealruptures:ofteninvolvethebladderdome
• extraperitonealruptures:involveanteriororlateralbladderwallinfullbladder
Etiology
• blunt(MVC,falls,andcrushinjury)vs.penetratingtraumatolowerabdomen,pelvis,orperineum • blunttraumaisassociatedwithpelvicfracturein97%ofcases
Clinical Features
• abdominaltenderness,distention,peritonitis,andinabilitytovoid
• canbehemodynamicallyunstablesecondarytopelvicfracture,othersustainedinjuries:ABCs • suprapubicpain
Investigations
• U/A:grosshematuriain90%
• imaging(includingCTcystogramandpost-drainagefilmsforextravasation)
Treatment
• penetratingtrauma→surgicalexploration
• contusion→urethralcatheteruntilhematuriacompletelyresolves
• extraperitonealbladderperforations→typicallynon-operativewithfoleyinsertion,andfollowwith
cystograms
■ surgery if: infected urine, rectal/vaginal perforation, bony spike into bladder, laparotomy for
concurrent injury, bladder neck involvement, persistent urine leak and failed conservative
management
• intraperitonealruptureusuallyrequiressurgicalrepairandsuprapubiccatheterization
Complications
• complicationsofbladderinjuryitselfarerare
• mortalityisaround20%,andisusuallyduetoassociatedinjuriesratherthanbladderrupture