Block 15.

UNTAD PALU 2014

dr. HM. Untung Tranggono, MS, SpB, SpU, PA(K))

Division of Urology Department of Surgery Faculty of Medicine

Universitas Gadjah Mada / Sardjito Hospital
Yogyakarta, Indonesia
 UNTAD PALU MEI 2014
BLUNT AND PENETRATING TRAUMA

GENITOURINARY INJURIES MANAGEMENT

dr. Untung Tranggono, MS, SpB, SpU, PA(K)

Sub Bagian Urologi Bagian Ilmu Bedah FK UGM

/ SMF Urologi RS Sardjito
Yogyakarta
CURRICULUM VITAE

NAMA : UNTUNG TRANGGONO, DR, MS, SPB, SPU, PA (K)

TEMPAT/ TANGGAL LAHIR : KEBUMEN, 11-07-1960
PEKERJAAN/JABATAN : KETUA TPK CR / SEKRETAIS BAGIAN ILMU BEDAH FKUGM
KASUBBAG / SMF UROLOGI FKUGM / RS SARDJITO YOGYAKARTA
RIWAYAT PENDIDIKAN FORMAL :
DOKTER : FAKULTAS KEDOKTERAN UGM
MAGISTER SAINS : FAKULTAS PASCA SARJANA UGM
SPESIALIS ILMU BEDAH : FAKULTAS KEDOKTERAN UGM,
SPESIALIS UROLOGI : FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
PAKAR ANATOMI KONSULTAN : PAAI

RIWAYAT PENDIDIKAN TAMBAHAN:

INTERNSHIP NUTRITIONAL ASSESSMENT
PHOTOMICROSCOPY
EDUCATIONAL WORKSHOPS & COURSES (INTERNATIONAL / NATIONAL)
LAPAROSCOPIC SURGERY
PCNL, URETHROPLASTY, DLL
RIWAYAT ORGANISASI:
IDI, PAAI, IKABI, IAUI, PBEI
KIDNEY TRAUMA . . .
WILL BE OPERATED ?
RUPTURED KIDNEY
 CONSERVATIVE ?
KINDS OF INJURY
Blunt
Penetrating
Gunshot
Stab
UROLOGIC INJURIES
Urologic Injuries
 Occur in less than 5% of trauma pts

 80% of these are renal injuries

 Mechanism is predominantly blunt

 Majority of these injuries do not require

operative intervention
 Regions: costovertebra angle (CVA),
flank, costal fracture
 Grading (American Asscociation for the
Surgery of Trauma)
 Grade 1, grade 2, grade 3, grade 4, grade
5
ORGAN INVOLVED
 Kidney
 Ureter

 Bladder

 Urethra

 Penis

 Scrotum

 Testis

 Vulva

 Vagina
PAIN, BLOOD, VULNUS,
TUMOR, FEBRIS, SHOCK ?
 UROLOGIC PAIN
 Important symptom
 The most common reason to visit doctor

 Accompany with
 Hematuria
 Pyuria
 Cloudy urine
 Vomite, cold sweating, hypotension

 Strong analgesics
PATHOPHYSIOLOGY
 Distention of UT
 Increase of intraluminar pressure
 Intra PCS: 0 – 10 cmH2O
 When obstructed: 50 cmH2O
 Distention velocity > obstrution degree
 Acute: RBF > (prostaglandin)
 ≥ 2 hours: RBF < (tromboxane, RAA)
 CVA: distended renal capsule, ischemia
PAIN LOCATION
Partof UT Region
Pyelum CVA
Upper ureter Flank
Mid ureter Mid-inferior
inguinal
Lower ureter Suprapubic
CAUSES OF UT DISTENTION
 InternalDistal obstruction
Stones
Clott
Tumor
Stenosis / stricture / fibrosis
 External compression
Tumor
Retroperitoneal hematome
DIRECTION, VELOCITY, MECHANISM
OF TRAUMA ?
PROTECTED LOCATION
Have you listen to the cell ?
AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA
ORGAN INJURY SEVERITY SCALE FOR THE KIDNEY [*]
GRADE[†] TYPE DESCRIPTION

 I. Contusion Microscopic or gross hematuria, urologic studies normal

Hematoma Subcapsular, nonexpanding without parenchymal laceration
 II. Hematoma Nonexpanding perirenal hematoma confined to renal
retroperitoneum Laceration <1 cm parenchymal depth of renal cortex without
urinary extravasation
 III. Laceration >1 cm parenchymal depth of renal cortex without collecting
system rupture or urinary extravasation
 IV. Laceration Parenchymal laceration extending through renal cortex, medulla,
and collecting system Vascular Main renal artery or vein injury with contained
hemorrhage
 V. Laceration Completely shattered kidney Vascular Avulsion of renal hilum,
devascularizing the kidney *

 Data drawn from Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: Spleen, liver, and kidney. J
Trauma 1989;29:1664-1666. † Advance one grade for bilateral injuries up to grade III.
AAST GRADING SYSTEM

Grade I
 Contusion:
hematuria without
X-Ray
Abnormalities
 Subcapsular
hematoma: No
parenchymal
laceration
AAST GRADING SYSTEM

Grade II
 Perinephric
hematoma
confined to
retroperitoneum
 Laceration < 1 cm
in depth of renal
cortex
AAST GRADING SYSTEM

Grade III
 Laceration > 1 cm
in depth

Grade IV
 Laceration through
collecting system
AAST GRADING SYSTEM

Grade IV
 Vascularinjury with
contained
hemorrhage

Grade V
 Vascular avulsion
 Shattered Kidney
FIGURE 39-1  CLASSIFICATION OF RENAL INJURIES BY GRADE (BASED ON THE
ORGAN INJURY SCALE OF THE AMERICAN ASSOCIATION FOR THE SURGERY OF
TRAUMA [BASED ON MOORE ET AL, 1989
 I. Contusion
Microscopic or gross
hematuria, urologic
studies normal
Hematoma
Subcapsular,
nonexpanding
without
parenchymal
laceration
 II.
Hematoma
Nonexpanding
perirenal hematoma
confined to renal
retroperitoneum
Laceration <1 cm
parenchymal depth of
renal cortex without
urinary extravasation
III.Laceration >1
cm parenchymal
depth of renal
cortex without
collecting system
rupture or
urinary
extravasation
IV. Laceration
Parenchymal
laceration extending
through renal
cortex, medulla, and
collecting system
Vascular Main renal
artery or vein injury
with contained
hemorrhage
 V.Laceration
Completely
shattered kidney
Vascular Avulsion
of renal hilum,
devascularizing
the kidney
PENEGAKAN DIAGNOSIS -1
Trauma pada daerah kostovertebra
Nyeri dan jejas
Massa retroperitoneal,
bulging, flattening pada flank
Hematoma, urinoma
Peritoneal sign
PENEGAKAN DIAGNOSIS - 2
 Syok
 Awal tindakan  eksplorasi
 Single shot IVU waktu resusitasi
 Hematuria  IVU
 Trauma tumpul + mikrohematuri + syok
 Trauma tajam + gross/mikro-hematuri
 Penunjang
 IVU
 CT scan
 Arteriografi
 TAMPILAN PADA IVU

 Ekskresi kontras kurang

dibanding kontralateral
 Psoas line atau renal contour
menghilang
 Scoliosis ke arah kontralateral
 Ekstravasasi kontras
ADVANTAGES OF CT SCAN
Laserasi ginjal
Kerusakan arteri
Ekstravasasi
Hematoma retroperitoneal
Jaringan ginjal non-vital
Trauma penyerta
TAMPILAN PADA
ARTERIOGRAFI
Ekstravasasi
Bagian ginjal yang avaskuler
Oklusi total arteri renalis
INDIKASI OPERASI
Syok yang tidak teratasi, syok
berulang
Hematoma yang extensif dan
pulsatif
Pada IVU
Ekstravasasi kontras
Ada bagian ginjal yang tak
tervisualisasi
TEKNIK OPERASI

Approach transperitoneal
Mengatasi trauma abdominal lain
Isolasi vasa renalis
Prosedur Mc Aninch
Rekontruksi
Observasi / post-operative care
RETROPERITONEUM  3 ZONA
(BLAISDELL DAN TRUNKEY, 1982)
ISOLASI VASA RENALIS - 1
ISOLOASI VASA RENALIS -2
ISOLASI VASA RENALIS - 3
UTAMAKAN KESELAMATAN
PASIEN
CT-SCAN
Football player
15 yo male
Left kidney
Ruptured
parenchyme
Urinoma
SUBCAPSULAR HEMATOME ?
RUPTURED PCS ?
MULTILACERATIONS OF
PARENCHYME
EXPOSURE
 Medial rotation of
intestinal structures
 Vascular control
either by isolating
the hilar vessels
first or by medially
rotating the kidney
TREATMENT
Grade
I
Observation
TREATMENT
Grade II & III
 Observe in stable
blunt injury pts
 Renorrhaphy with
capsular
approximation
 Pledgeted sutures
or mesh wrap
TREATMENT
Grade IV & V
 Closure of calices
during repair or
partial nephrectomy
 Absorbable
interrupted suture
 Prevents urinoma

 Perinephric drain
TREATMENT

Grade IV & V
Stable patient
Repair
Partial
nephrectomy
Nephrectomy
TREATMENT

Grade IV & V
Unstable patient
Nephrectomy
ureterectomy
 ASSESSMENT OF CONTRALATERAL
KIDNEY
Presence
Size
Injury
IVP
Methylene Blue
FAST
URETERAL INJURY

Exposure
Locate ureter at
the level of the
iliac bifurcation
then trace
proximally and
distally
REIMPLANTATION
 Bench to repair
 Preservation of vascular pedicle and ureter

 Four hour warm ischemic time limit to allow meaningful

function
URETERAL INJURY
Treatment
 Repair with interrupted suture over double J stent

 Drain adjacent to repair

 IVP prior to removal of stent

URETERAL INJURY
Complete transection
 Debride to viable
tissue
 Primary repair with
spatulation over
stent
 Interrupted
absorbable suture
TREATMENT OF URETERAL INJURY
URETERAL INJURY
TREATMENT OPTIONS

Proximalureter
Transureteroureterostomy
Put the uninjured kidney at

risk
Not recommended
 URETERAL INJURY TREATMENT OPTIONS

 Middleureter
 Boari Bladder Flap
 URETERAL INJURY
TREATMENT OPTIONS

 Distal
Ureter
Psoas Hitch
RUPTURED
BLADDER
DIAGNNOSIS OF BLADDER INJURY

 Cystogram or CT-Cystogram

 Requires retrograde filling of bladder with at least 300 cc

 Standard cystogram requires X-Ray with bladder full and
after drainage
CYSTOGRAM
 intraperitoneal  extraperitoneal
BLADDER INJURY

EXTRA PERITONEAL INJURY

 Usually secondary to tear by bone fragments
 Majority of bladder injuries are associated with
pelvic fractures
 Foley catheter drainage
BLADDER INJURY

Intra peritoneal injury

 Blunt force to distended
bladder
 Penetrating trauma
 Requires operative
intervention
 TREATMENT
Intraperitoneal Injury
 Two layer absorbable closure

 Identify ureteral orifices inspected through laceration

indigo carmine identify
 Identify uretaral orifisces ureteral orifices

Optional
 Perivesical drain

 Suprapubic drain Closed suction

Postoperative management
 Foley drainage 7 to 10 days

 Cystogram prior to Foley

removal
INJURIES OF PENIS
Fractured
Urethral rupture
Iatrogenic, circumcici
Mechanism and type
ACUTE SCROTUM - TESTICLE

Torsion
Inflamations
Hematocele
Hernia
Malignancy
REFERENCES ?
ORIENTASI FASILITAS
 Sarana penunjang
 Informed consent

 Alat & material medis

 Obat-obatan

 Hantu ? ? ?
MATUR NUWUN . . .