Bladder & Urethral Trauma. Bohyun Kim Professor of Radiology Mayo Clinic College of Medicine
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1 Bladder & Urethral Trauma Bohyun Kim Professor of Radiology Mayo Clinic College of Medicine
2 Disclosure None Acknowledgement Akira Kawashima, Mayo Clinic Scottsdale, AZ Eric Lantz, Mayo Clinic Rochester, MN Boyum James, Mayo Clinic Rochester, MN Ashish Khandelwal, Mayo Clinic Rochester, MN
3 Bladder Anatomy Peritoneal covering Children: more bladder is intraperitoneal (IP), so IP rupture is more common Space of Retzius: anterior & lateral to the UV fascia (between the peritoneum & transversalis fascia), surrounds the urachus, umbilical a., bladder
4 Fat Triangle Sign
5 Fat Triangle Sign
6 Bladder Injury Causes: MVA (seat belt compression, ejection injury), falls, crush injuries, blow injuries Pelvic Fx. in 60%-90% pts. w BL injury; BL injury in 10%-30% pts. w pelvic Fx. Severity of the pelvic Fx. correlates w likelihood of BL & urethral injury Degree of BL distention at the time of injury influences the incidence of rupture Concomitant urethral Injury: - 1/3 of BL rupture+pelvic Fx. pts. Urethral injury - 1/4 of Pelvic Fx. pts. BL+posterior urethral injury - EP rupture in 85%
7 Guideline EAU: Urologic trauma (2016), Urologic & pediatric trauma (2014, updated 2015), iatrogenic trauma (2012) AUA: Urological trauma (2014, amended 2017)
8 Imaging CT cystography (Sens 95%, Spec 100%) & conventional cystography (Accu %) - Adequate distention (> 350 cc of contrast), > 2 oblique views for conventional cystography - Only seen on postdrainage images in 10% RECOMMENDATION CT or Conventional Cystography for hemodynamically stable pts. w gross hematuria & pelvic Fx. (EAU, AUA) RECOMMENDATION Cystoscopy for IP BL injuries, surgical injury, or foreign body (EAU) RUG if blood in urethral meatus
9 CT Cystography Kim FJ, et al GU trauma (In) Moore EE, et al. Trauma Test of choice for bladder wall integrity Adequate distention: Minimum cc of diluted contrast Accuracy ~100% MPR & postvoid or postdrainage imaging
10 Routine CT vs. CT Cystography Routine CT CT Cystography Passive bladder distention on routine CT should not be relied on!
11 Bladder Injury Contusion: Incomplete non-perforating tears of the mucosa (self limited, no treatment needed) Rupture EP (50-85%): Disruption of ligament attachment or direct laceration by bony spicules, almost exclusively w pelvic Fx. IP (15-45%): Dome, w distended BL Combined (0-12%)
12 Bladder Injury Classification AAST Organ Injury Severity Scale (2001) 1 hematoma, partial thickness laceration 2 EP laceration < 2 cm 3 EP laceration >2 cm or IP laceration < 2 cm 4 IP laceration > 2 cm 5 IP or EP laceration extending into BL neck or ureteral orifice Consensus Panel of Societe Internationale D Urologie 1 Contusion 2 IP rupture 3 EP rupture 4 Combined Injury
13 IP Bladder Rupture 1/3 of bladder injuries Blow w a distended bladder Sudden rise in intravesical pressure Rupture into the weakest point, dome Contrast surrounding bowel loops, separating mesenteric leaves, layering in paracolic gutters
14 IP Bladder Rupture * CT Cystography
15 IP Bladder Rupture * RECOMMENDATION Surgical Repair (EAU, AUA) -Exception: iatrogenic injury wo ileus or peritonitis
16 EP Bladder Rupture 60% of bladder injuries Simple (confined to pelvic EP space) vs. complex EP rupture (contrast in ant. abdominal wall, penis, scrotum, perineum) Usually associated w pelvic Fx. Direct laceration by bony spicules or ligamentous injury (contrecoup mechanism)
17 EP Bladder Rupture Flame shaped Dissecting tissue planes Perivesical or prevesical space of Retzius (molar tooth appearance) Fat triangle sign Teardrop or pear-shaped bladder configuration RECOMMENDATION Uncomplicated EP BL injury: urethral catheter drainage (2-3 wks) & observation (EAU, AUA) - F/U cystography, if not healed in 4 wks, surgical repair
18 Complex EP BL Rupture Female Male
19 EP Bladder Rupture RECOMMENDATION EP BL injury can be repaired at the time of surgery for abdominal or orthopedic injuries (AUA)
20 Combined IP & EP BL Rupture OPERATIVE REPORT: - Two full-thickness holes in the dome of the bladder. - The space of Retzius had been predissected by urine (a portion of the bladder rupture had gone into the EP space and dissected out all the planes).
21 Bladder Neck Injury RECOMMENDATION Complicated EP BL ruptures (exposed bone within BL lumen or rectal or vaginal laceration): early surgical repair (EAU) BL neck injury: surgical repair
22 Bladder Hernia & Entrapment Two different patients xxxx Pubic symphysis diastasis, bladder trapped between the pelvic bones Prevention of bladder entrapment or injury during orthopedic surgery
23 Bladder or Urethral Injury Martinez LM, et al. Urology 2013; 81(4): e25-26
24 Urethral Injury Male (up to 25% of Pelvic Fx. Pts.) - Anterior Urethra Mostly straddle injury (bulbous urethra) - Posterior Urethra (Pelvic Fx. urethral injury) Blunt trauma Pelvic Fracture & multiple organ injury Disruption of bulbomemb. junction Female: rare (6% of pelvic Fx. Pts.; Higher risk in girls < 17yrs), associated w pelvic fx.
25 Urethral Injury Associated Pelvic Fractures (odds ratio) - Single ramus (0.64) - Ipsilateral rami (0.76) - Malgaigne s (3.40) - Straddle (3.85) Malgaigne Fx. Straddle Fx. - Straddle + SI (24.02) Koraitim MM, et al. Br J Urol 1996
26 Anterior Urethra Urethral Injury Posterior Urethra Straddle Injury Pelvic Fracture urethral injury (ant. arch Fx.) Blunt trauma: SP or urethral catheter placement & delayed treatment (AUA, EAU) Penetrating injury: Prompt open surgery (AUA, EAU) Stable: Prompt urinary drainage, optional endoscopic alignment w catheter placement (4-8 wks) (AUA, EAU) Unstable: SP catheter placement & delayed treatment Posterior urethral distraction defect: Deferred urethral repair (>3 m) & immediate repair only for penetrating injury (EAU)
27 Radiological Evaluation Retrograde Urethrography Kim FJ, et al GU trauma (In) Moore EE, et al. Trauma Rosenstein DI, et al. Urol Clin N Am 2006 Gold standard for male urethral injury 16F or 18F Foley catheter w balloon at fossa navicularis or Knutsson or Brodney clamp; cc of iodinated contrast; gentle injection to prevent spasm 45 degree oblique, stretched penis, cephalad meatus
28 RUG before catheterization! Imaging RECOMMENDATION RUG for pts w blood at the meatus, perineal or penile hematoma, unable to void or straddle injury (AUA) CT: Not directly show the urethral trauma - Obscuration of UG diaphragm (88% w urethral injury) - Hematoma in the ischiocavernosus (88%) & obturator internus m. (53%) - Obscuration of prostatic contour (59%) - Obscuration of bulbocavernosus m. (49%) CT-RUG: Presence or absence of urethral injury, limited info about the location
29 Urethral Injury Classification Goldman et al. J Urol 1997 Type I Type II Type III Type IVV Kawashima A. Radiographics 2004; 24: S195
30 Type I Urethral Injury Obscuration of UG diaphragm fat plane Distortion of prostate contour Distortion of bulbocavernosus
31 Type II Urethral Injury RUG CT CT Cysto
32 Penile Fracture Rupture of the corpus cavernosum & tunica albuginea of erect penis during coitus or manipulation RECOMMENDATION if diagnosis is uncertain, US followed by MRI can be performed (not the first line modality) (AUA) Integrity of the Tunica Albuginea most important in determining the necessity for surgery MR imaging: Best suitable for the evaluation of tunical integrity Choi MH et al. Radiographics 2000 Turkay R, et al. Ulus Travma Acil Cerrhi Derg 2016 Associated urethral injury (10-22%): RUG or urethroscopy in suspected cases
33 Urethral Injury Associated w Penile Fx. RUG Aubergine (Eggplant) Sign OPERATIVE FINDINGS: Complete urethral disruption Large defects of the Tunica Albuginea In the ventral shaft
34 Urethral Injury Associated w Penile Fx. H T2WI
35 MRI for Pelvic Fracture Urethral Injuries MR urethrography vs. conventional RUG w VCUG - Better stricture length measurement w significantly lower error Sung DJ, et al. Radiology 2006 Change in management according to MRI - Narumi Y, et al. Radiology 1993 Pelvic Bone Fx. (22) 26% - Koraitim, et al. J Urol 1999 Pelvic Bone Fx. (21) 10% - Oh MM, et al. J Urol 2010 Straddle injury (17) 47% Pelvic Bone Fx. (6) 25% - Pandian R, et al. Int Braz J Urol 2017 Pelvic Bone Fx. (20) 0%
36 Conventional Urethrography RUG AUG Ingram MD, et al. Radiographics 2008; 28:
37 Posterior Urethral Injury
38 Anterior Urethral Injury RUG Sagittal T2WI
39 Gunshot Urethral Injury CT-topogram CT-RUG
40 Conclusion Bladder Rupture: CT or conventional cystography - IP vs EP rupture - Adequate distention of the bladder, essential Urethral Injury: RUG; MRI for delayed treatment planning & evaluation of urethral defect - Anterior Urethra - Pelvic fracture urethral injury Penile Fracture: US or MRI for equivocal cases
41 Thank you! Gracias!
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