Renal Trauma: Management Options

Transcription

1 Renal Trauma: Management Options Immediate surgical repair Nephrectomy Conservative management Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29: Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192: Renal Trauma Management Absolute indications for surgery are: Life threatening bleeding with instability Expanding, pulsatile, or uncontained retroperitoneal hematoma Vascular pedicle avulsion Complete ureteropelvic junction or ureteral transection Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:

2 Renal Trauma Management Conservative management is standard Avoids unnecessary nephrectomy Poor functional renal outcome of surgical repair Surgicalintervention intervention is performedin only 5% 10% of renal injuries Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29: Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192: Bladder Trauma Not uncommon Blunt 60 85% 60 90% have pelvic fractures 10 30% of patients with pelvic fractures have bladder injury Cass AS. Diagnostic studies in bladder rupture: indications and techniques. Urol Clin North Am 1989; 16: Vaccaro JP et al. CT Cystography in the Evaluation of Major Bladder Trauma. RadioGraphics 2000; 20:

3 Bladder Trauma Sandler CM, Hall JT, Rodriguez MB, Corriere JN. Bladder injury in blunt pelvic trauma. Radiology 1986; 158: Bladder Trauma Intra vs Extra Peritoneal Rupture? Sandler CM, Hall JT, Rodriguez MB, Corriere JN. Bladder injury in blunt pelvic trauma. Radiology 1986; 158:

4 Bladder Trauma Location of laceration determines type of injury Sandler CM, Hall JT, Rodriguez MB, Corriere JN. Bladder injury in blunt pelvic trauma. Radiology 1986; 158: Bladder Trauma Type of injury determines treatment Sandler CM, Hall JT, Rodriguez MB, Corriere JN. Bladder injury in blunt pelvic trauma. Radiology 1986; 158:

5 Bladder Trauma Intra Peritoneal Rupture = Surgery! Sandler CM, Hall JT, Rodriguez MB, Corriere JN. Bladder injury in blunt pelvic trauma. Radiology 1986; 158: Extra vs Intra Peritoneal Rupture Extraperitoneal = 50 71% Intraperitoneal = 25 43% Combined = 7 14%

6 Predictors of Bladder Injury? Pelvic fractures Particularly midline fractures Bladder distention Hematuria Diagnosis of Bladder Injury? Passive filling of bladder is insufficient Conventional vs CT cystogram? Similar sensitivity and specificity of conventional vs CT cystography Sens and spec >95% Quagliano PV, et al. Diagnosis of Blunt Bladder Injury: A ProspectiveComparative Study of Computed Tomography Cystography and Conventional Retrograde Cystography/ J Trauma. 2006;61: Chan DNP et al. CT Cystography with Multiplanar Reformation for Suspected Bladder Rupture: Experience in 234 Cases. AJR 2006; 187:

7 Diagnosis of Bladder Injury? CT cystogram: Fast, easy Can be integrated as a part of CT evaluation CT cystography accurary routinely >95% Quagliano PV, et al. Diagnosis of Blunt Bladder Injury: A ProspectiveComparative Study of Computed Tomography Cystography and Conventional Retrograde Cystography/ J Trauma. 2006;61: Chan DNP et al. CT Cystography with Multiplanar Reformation for Suspected Bladder Rupture: Experience in 234 Cases. AJR 2006; 187: CT Cystogram Technique Bladder catheterization Only after surgeon determines no urethral injury based on clinical exam or retrograde urethrogram

8 MDCT CT Cystogram Technique Precontrast CT pelvis (3mm) Calcifications Pre existing contrast leakage? Document catheter placement CT pelvis with maximum bladder distention Minimum of cc dilute water soluble (4%) 3mm axial, sagittal and coronal CT pelvis post void

9 Simple extraperitoneal bladder rupture Simple extra peritoneal bladder rupture

10 Complex Extra Peritoneal Bladder Rupture

11 Intra Peritoneal Bladder Rupture

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13 Intra Peritoneal Bladder Rupture Urethral Injuries Common complication of pelvic trauma Up to 24% of adults with pelvic fractures Not life threatening, significant morbidity Strictures Incontinence Impotence Early diagnosis and treatment Koraitim MM. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol 1996;156: Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28:

14 High Risk for Urethral Injury Gross hematuria High clinical suspicion! Blood at the meatus Inability to void Swelling or hematoma of the perineum High riding prostate on DRE Significant lower abdominal or perineal trauma without a fracture Koraitim MM. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol 1996;156: Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28: Never blindly insert a bladder catheter URETHROGRAM!

15 Male >> female Urethral Injuries Female urethral injuries i <6% of pelvic fractures Shorter Internal location Increased elasticity Less rigid attachment to pubic bones Severe pelvic trauma Associated with vaginal (75%) or rectal trauma (33%) Patil U, Nesbitt R, Meyer R. Genitourinary tract injuries due to fracture of the pelvis in females: sequelae and their management. Br J Urol 1982;54: Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28: Kommu SS, Illahi I, Mumtaz F. Patterns of urethral injury and immediate management. Curr Opin Urol 2007;17: Urethral Injuries CT is neither sensitive nor specific for the diagnosis or exclusion of urethral injuries High quality urethrography necessary Koraitim MM. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol 1996;156: Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28:

16 Urethral Injuries Posterior > anterior urethral injuries 2/3 posterior 1/3 anterior Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28:

17 Posterior Urethral Injuries Approximately 2/3 of urethral injuries Membranous urethra most common 3% 25% of patients with pelvic fractures May disrupt active continence mechanism Up to 20% may have bladder laceration Directinjury injury from fractures Shearing and rupturing of the puboprostatic ligaments Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28: Patel U. Lower urinary tract trauma. In: Patel U, Rickards D, eds. Imaging and urodynamics of the lower urinary tract. London, England: Taylor & Francis, 2005; Anterior Urethral Injuries Approximately 1/3 of urethral injuries Straddling mechanism Compression of the urethra against the pubis Bulbar urethra > penile urethra Coexisting pelvic fractures are less common Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28: Patel U. Lower urinary tract trauma. In: Patel U, Rickards D, eds. Imaging and urodynamics of the lower urinary tract. London, England: Taylor & Francis, 2005;

18 Urethral Injury Classification Moore EE, Cogbill TH, Malagoni MA, et al. Organ injury scaling. Surg Clin North Am 1995;75: Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28: Urethral Injury Classification Goldman SM, et al. Blunt urethral trauma: a unified, anatomical mechanical classification. J Urol 1997;157: Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28:

19 Urethrogram Technique Ascending (retrograde) urethrogram Sterile technique 6 8F catheter with 3 5cc balloon Inflate balloon in fossa navicularis Oblique imaging (fluoroscopy vs film) 10 30cc 30ccwater soluble contrast (slowly!) until flow into bladder Multiple images if possible Goldman Type I Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28:

20 Goldman Type II Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28: Goldman Type II Ramchandani and Buckler. Imaging of GenitourinaryTrauma. AJR 2009; 192:

21 Goldman Type III

22 Goldman Type III

23 Goldman Type IV Ingram MD, et al. Urethral Injuries after Pelvic Trauma: evaluation with Urethrography. RadioGraphics 2008; 28: Goldman Type V

24 Goldman Type V Ramchandani and Buckler. Imaging of GenitourinaryTrauma. AJR 2009; 192: Genitourinary Tract Trauma: Conclusions Genitourinary tract trauma is common Renal parenchymal injuries managed conservatively Intervention if: Active bleeding Ureteral transection Intra peritoneal bladder rupture Urethral transecion

25 References Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29: Cass AS. Diagnostic studies in bladder rupture: indications and techniques. Urol Clin North Am 1989; 16: Chan DNP et al. CT Cystography with Multiplanar Reformation for Suspected Bladder Rupture: Experience in 234 Cases. AJR 2006; 187: Goldman SM, et al. Blunt urethral trauma: a unified, anatomical mechanical classification. J Urol 1997;157: Ingram MD, et al. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics 2008; 28: Kawashima A, et al. Imaging of renal trauma: a comprehensive review. Radiographics 2001;21(3): Knudson MM and Maull KI. Nonoperative management of solid organ injuries: past, present and future. Surg Clin North Am 1999; 79: Kommu SS, et al. Patterns of urethral injury and immediate management. Curr Opin Urol 2007;17: Koraitim MM. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol 1996;156: Moore EE, et al. Organ injury scaling. Surg Clin North Am 1995;75: Patil U, et al. Genitourinary tract injuries due to fracture of the pelvis in females: sequelae and their management. Br J Urol 1982;54: Patel U. Lower urinary tract trauma. In: Patel U, Rickards D, eds. Imaging and urodynamics of the lower urinary tract. London, England: Taylor & Francis, 2005; Quagliano PV, et al. Diagnosis of Blunt Bladder Injury: A ProspectiveComparative Study of Computed Tomography Cystography and Conventional Retrograde Cystography. J Trauma. 2006;61: Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192: Sandler CM, et al. Bladder injury in blunt pelvic trauma. Radiology 1986; 158: Vaccaro JP et al. CT Cystography in the Evaluation of Major Bladder Trauma. RadioGraphics 2000; 20: