Approach to imaging in urological injuries secondary to trauma

Transcription

1 Approach to imaging in urological injuries secondary to trauma Poster No.: C-1470 Congress: ECR 2015 Type: Educational Exhibit Authors: M. Pérez Rubiralta, R. Mast Vilaseca, A. Pons, M. de Albert, R. Barranco Pons, A. Guma Martinez, D. Leon Guevara, L. Farras Roca, A. Fernandez; Barcelona/ES Keywords: Trauma, Hemorrhage, Acute, Diagnostic procedure, Cystography / Uretrography, Contrast agent-intravenous, Image manipulation / Reconstruction, CT, Catheter arteriography, Urinary Tract / Bladder, Emergency DOI: /ecr2015/C-1470 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 23

2 Learning objectives - To make a quick-overview of the polytrauma patient: management and radiologic first evaluation. - Pictorial review of the types of injuries in the urological tract, using examples based on the different classifications. - To evaluate the role of radiology as a diagnostic method in traumatic injuries of the urinary tract. - To consider its contribution to the therapeutic approach. Background This pictorial review introduces the abdominal trauma and particularly the urological tract trauma. It also illustrates the different injury patterns to the urologic organs and the urinary tract, reviewing further the main grading systems that are currently used, depending on the organ damaged. INTRODUCTION: THE POLYTRAUMA OVERVIEW - The accidents that lead to polytrauma patients are the third leading cause of global mortality, and the first leading cause under 40 years. - Abdominal injury represents approximately 10-20% of the traumatic death. - The global management depends on the condition of the patient: when inestable # patient laparotomy, FAST (focused assessment with sonography for trauma) or MDCT (multidetector computed tomography), when estable # MDCT. - The role of computed tomography in this scenario is as follows: is crucial in the initial evaluation of blunt and penetrating trauma, to rule out injury and also in the follow up of non-operative management. MDCT TECHNIQUE PROTOCOLS: Page 2 of 23

3 Non-enhanced CT (NECT): useful in detecting calcifications and aids to differenciate from arterial contrast leakage Arterial phase (15-40 sec): useful in detecting contrast blush, splenic delayed rupture, exact bleeding point, Hepatic or portal phase (70-80 sec): if active bleeding, visceral lesions Delayed phase (2-5 minutes "wash out or equilibrium phase"): when active bleeding or excretory injury Ultra-delayed phase (10 minutes): if bladder or ureteral lesion is suspected + Multiplanar Reconstruction (MPR) and 3D Postprocessing UROLOGIC TRAUMATIC LESIONS OVERVIEW: - Approximate incidence data are: adrenal glands 2% kidneys 8-10% bladder 1-4% (15% in pelvic fractures) urethral and genital (less frequent) - The most typical clinical features are: Hematuria, shock, abdominal distension, although many of them enrolled asymptomatic. - Despite to the severity of some injuries (p.e. bladder trauma), the management tends to be increasingly conservative, because of the increasing presence of interventional radiology rooms in tertiary hospitals. CLASSIFICATION: The urogenial lesions are mainly: Adrenal glands: hematoma with/without active bleeding Renal: I-V (like contusion, laceration, subcapsular hematoma, laceration extending through renal cortex, devascularized kidney...) Bladder: intra and extraperitoneal injury Page 3 of 23

4 Others: urethral, perineal, testicular, prostatic and /or penile lesions. Findings and procedure details ADRENAL GLAND INJURY This is uncommon, being aproximately # 2-3%. If there is bilateral adrenal gland injuries, it could result in life-threatening adrenal insufficiency. In the setting of trauma, the adrenal injury is an important indicator of the severity of the trauma and is associated with overall increased morbidity and mortality. There are mainly two types of injuries: Hematoma ( Fig. 1 on page 8 ) and active bleeding ( Fig. 2 on page 8 ). KIDNEY INJURIES They are caused by a blunt trauma (90%) and by a penetrating trauma (10%). The kidney is the third most common involved organ in the abdominal trauma in the adult patients (10% of the solid visceral injury) and the first organ damaged in children. Specifically in the urinary tract injuries, the kidney is the most commonly injured organ. The renal imaging is specially indicated if there is gross hematuria, penetrating trauma with gross or microscopic hematuria, or blunt trauma and shock with gross or microscopic hematuria. Although the kidney trauma is usually minor, serious renal injuries are frequently associated with injuries to other organs. It is important to do an accurate evaluation for: parenchymal, capsule (subcapsular vs perirenal space), vascular and collectory system lesions. Page 4 of 23

5 Radiologic Clasification of Renal Injuries: based at multiphasic abdominal CT (Grade) (I) Contusion or subcapsular non expansive hematoma, no laceration. ( Fig. 3 on page 9 ) (II) Perirenal non expansive hematoma, cortical laceration < 1 cm in depth, medular non afected, no urine leakage. ( Fig. 4 on page 9 ) (III) Cortical laceration > 1 cm in depth, medular afectation with non urine extravasation (collectory system preserved), and non expansive perirenal hematoma. ( Fig. 5 on page 10 and Fig. 6 on page 11 ) (IV) Laceration extending through the renal cortex, medulla and collecting system; or minor vascular injury: segmentary artery or venous lesion with contained hematoma. ( Fig. 7 on page 12 ) (V) Shattered kidney: devascularized kidney, hilar avulsion... ( Fig. 8 on page 13 ) BLADDER INJURIES Most of them are caused by a blunt trauma (seat-belt or steering wheel) with other associated lesions. They are associated with pelvic fractures in > 80%, so it must take into account this fact when a pelvic ring injury is observed. The risk of injury increases as the degree of distension of the bladder. One of the clinical features that helps is to observe gross hematuria. The lack of it does not exclude this lesion. The best diagnostic imaging method to exclude this injury is the CT cystography, which is the retrograde filling of the bladder with contrast material prior to routine abdominopelvic CT. Radiologic Clasification for Bladder Injury: based at findings at CT cystography Page 5 of 23

6 (Grade) (I) Bladder contusion: conventional CT (II) Intraperitoneal rupture*. ( Fig. 9 on page 14 ) (III) Interstitial injury: intramural or partial - thickness laceration with intact serosa (intramural contrast material with no-extravasation) (IV) Extraperitoneal rupture **(diagnosed by cystography) is the most frequent type. There are two subtypes: a) Simple. ( Fig. 10 on page 15 and Fig. 11 on page 16 ) b) Complex. ( Fig. 12 on page 17 ) (V) Combined rupture: simultaneous intraperitoneal and extreperitoneal injury. * The intraperitoneal rupture is a 10-20% of the major bladder injuries and is frequently caused by a direct blow to the already distended bladder. ** The extraperitoneal rupture represents the most common type (approximately 80-90% of the total). It is most frequent in penetrating trauma, being in blunt trauma usually secondary to direct laceration of the bladder by bone fragments from a pelvic fracture. URETHRAL INJURY Very rare (1%). Non-iatrogenic urethral injuries are seen in the setting of significant pelvic trauma. A prompt diagnosis is imperative to decrease the morbidity associated, p.e. with a bladder catheterism through an injured urethra (it may convert a partial injury into a complete). Goldman Clasification System for Urethral Injuries: based on findings at urethrography (Grade) Page 6 of 23

7 (I) Stretching of the prostatic urethra without urethral urothelial discontinuity: intact but stretched urehtra (II) Membranous urethral disruption above an intact urogenital diaphragm: contrast extravasation above urogenital diaphragm, no inferior contrast extravasation into perineum (III) Disruption of the membranous urehtra with injury of the urogenital diaphragm: contrast material extravasation into pelvic extraperitoneal space and perineum (IV) Bladder base (involvement of the internal sphincter). ( Fig. 14 on page 19 ) (V) Isolated anterior urethral injury The optimal technique for the imaging diagnostic is the retrograde contrast opacification of the urethra, which is performed by instillation of contrast material through a small urinary catheter. The balloon should be inflated in the fossa navicularis. SCROTAL AND PERINEAL INJURY. ( Fig. 15 on page 20 ) Uncommon (<1%). It appears mostly in sportmen and younger men (under 30 years). A blunt force to the scrotum may result in: contusion, hematoma, or fracture / rupture. The ultrasound (US) is the most frequent modality used to evaluate the injured scrotum. Magnetic Resonance Imaging (MRI) may be helpful to better define the pattern of injury. PENILE INJURY. ( Fig. 16 on page 20 ) Penile injury may result from penetrating or blunt trauma. Erect penises are at increased risk for fracture. Similary to the scrotum, the sonography is the initially and preferred technique for penile imaging (because is well tolerated and widely available). MRI may be performed because of its ability to directly depict discontinuity of the tunica albuginea. Page 7 of 23

8 There is usually concomitant injury to the penile urethra in 10% to 20% of the penile fractures (and it should be suspected if there is associated blood at the urethral meatus). Images for this section: Fig. 1: Adrenal hematoma (*) and its characteristics. Page 8 of 23

9 Fig. 2: Adrenal arterial active bleeding. There is an intraglandular contrast leak showed in the arterial phase and progressive acumulation in the delayed phases (red arrows). Some cases, as this one, needed interventional management. Fig. 3: Grade I kidney injury: a subcapsular non expansive hematoma (39 UH) well delimited by the renal capsule (red ellipse). They are eccentric, hyperdense without enhancement after the intravenous contrast. Page 9 of 23

10 Fig. 4: Grade II kidney injury. A cortical laceration < 1 cm in depth. The superficial cortical lacerations are linear and hypodense parenchymal defects, with no enhancement after contrast administration. Page 10 of 23

11 Fig. 5: Grade III kidney injury. The same as the grade II but with depth > 1 cm, respecting the collecting system. Page 11 of 23

12 Fig. 6: Grade III kidney injury. Collectory system preserved and no urine / contrast leakage. Page 12 of 23

13 Fig. 7: Grade IV kidney injury. Pictures above: Minor vascular injury of a segmentary artery (red arrows) with contrast extravasation and contained hematoma. Pictures below: Laceration extending through the renal cortex affecting medulla and collecting system with large perirenal hematoma. Page 13 of 23

14 Fig. 8: Grade V kidney injury. Devascularized kidney due to a injury of the renal artery (red arrow). Page 14 of 23

15 Fig. 9: Intraperitoneal bladder rupture. Page 15 of 23

16 Fig. 10: Simple extraperitoneal bladder rupture. Page 16 of 23

17 Fig. 11: Simple extraperitoneal badder rupture. Page 17 of 23

18 Fig. 12: Complex extraperitoneal bladder rupture Page 18 of 23

19 Fig. 13: Figure of the urethral anatomy and the key locations in the context of urethral injuries. Fig. 14: Type IV urethral injury. An urinary catheter inserted into the bladder with contrast material visible around the catheter-balloon as well as outside the bladder. It is also possible to see the exact point where the urethra is disrupted and the contrast material Page 19 of 23

20 escapes (red arrow). There was a disruption of the membranous urethra with injury of the urogenital diaphragm too. Fig. 15: Scrotal and perineal injury. a) Hiperdensity and tumefaction of the soft tissues with trabeculation of the prepubic fat (red arrows), due to a hematoma secondary to blunt contusion. b) Testes hiperdensity (red arrow) with growing hematoma in the scrotal fascia and the surrounding fatty tissues. c) Arterial phase and d) Venous phase shows how the hematoma extends beyond the perineum and the root of the penis. Page 20 of 23

21 Fig. 16: Penile injury. Hematoma in the root of the penis (red arrows). Page 21 of 23

22 Conclusion Some of the injuries of the inferior urinary tract may be misdiagnosed, so its knowledge is mandatory for every emergency radiologist. TAKE HOME MESSAGE: It is crucial to know evident, subtle and indirect signs secondary to the different lesional mechanisms. An accurate evaluation through the imaging techniques allows to define the optimal management in each patient, being the multiphasic CT the imaging election technique. Personal information For any questions or comments, please feel free to contact: Pérez Rubiralta, Marta References 1.- Imaging of Genitourinary Trauma.P. Ramchandani and P. M. Buckler. AJR :6, Adrenal Gland Hematomas in Trauma Patients. Atif I. Rana, MBBS et al. Radiology 2004; 230: CT manifestations of adrenal trauma: experience with 73 cases. Alex O. Sinelnikov & Hani H. Abujudeh & David Chan & Robert A. Novelline. Emerg Radiol (2007) 13: Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings. Kevin P. Daly et al. RadioGraphics 2008; 28: Imaging of Renal Trauma: A Comprehensive Review. A. Kawashima et al. RadioGraphics 2001; 21: Page 22 of 23

23 6.- MDCT Findings of Renal Trauma. Soo Jin Park, J. Kon Kim, K. Won Kim. AJR 2006; 187: Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. R. Cano Alonso et al. RadioGraphics 2009; 29: MDCT Findings of Renal Trauma. S. Jin Park et al. AJR 2006; 187: CT Cystography in the Evaluation of Major Bladder Trauma. J.P. Vaccaro, J.M. Brody. Radiographics 2000; 20: Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. Mark D. Ingram, Sarah G. Watson, Philippa L. Skippage, Uday Patel. RadioGraphics 2008; 28: Imaging of Male Pelvic Trauma. Laura L. Avery, Mda, Meir H. Scheinfeld. Radiol Clin N Am 50 (2012) Imaging of Penile and Scrotal Emergencies. Laura L. Aver y, MD Meir H. Scheinfeld, MD, PhD. RadioGraphics 2013, 33: Blunt Polytrauma: Evaluation with 64- Section Whole-Body CT Angiography. David Dreizin. Felipe Munera. RadioGraphics 2012; 32: Page 23 of 23