外科學(xué)-泌尿系統(tǒng)損傷-課件

泌尿系統(tǒng)損傷

UrologicTrauma泌尿系統(tǒng)損傷

UrologicTraumaGeneralConsiderationsIatrogenicInjuryExternalTraumaGeneralConsiderationsIatrogenRenalTraumaAnatomyIatrogenicRenalInjuryExternalRenalInjuriesSpontaneousRetroperitonealHemorrhageRenalTraumaAnatomyReasonsBluntrenalinjuriesmostoftencomefrommotorvehicleaccidents,fallsfromheights,andassaults.

Penetratingrenalinjuriesmostoftencomefromgunshotandstabwounds.PercutaneousRenalProceduresReasonsBluntrenalinjuriesmodecelerationinjurydecelerationinjuryPresentationHematuriaisthebestindicatoroftraumaticurinarysysteminjury

However,thedegreeofhematuriaandtheseverityoftherenalinjurydonotcorrelateconsistently:inupto36%ofrenalvascularinjuriesfromblunttrauma,hematuriaisabsentPresentationHematuriaistheClassificationI挫傷肉眼或鏡下血尿其他泌尿系檢查正常血腫包膜下血腫II血腫腹膜后腎周血腫撕裂傷<1cm的腎皮質(zhì)裂傷，無(wú)尿外滲III撕裂傷>1cm的腎皮質(zhì)裂傷，無(wú)尿外滲及集合系統(tǒng)損傷IV撕裂傷腎皮質(zhì)、髓質(zhì)和集合系統(tǒng)全層裂傷血管腎動(dòng)脈或靜脈主干損傷伴出血V撕裂傷腎碎裂血管腎蒂撕脫傷，腎無(wú)血供ClassificationI挫傷肉眼或鏡下血尿

IndicationsforRenalImagingallblunttraumapatientswithgrosshematuriaandpatientswithmicroscopichematuriaandshock(systolicbloodpressure<90mmHganytimeduringevaluationandresuscitation)shouldundergorenalimaging,usuallyCTwithintravenouscontrast.

Patientswithmicroscopichematuriawithoutshockcanbeobservedclinicallywithoutimagingstudies.Penetratinginjurieswithanydegreeofhematuriashouldbeimaged.

Ultrasonographyisapopularimagingmodalityintheinitialevaluationofabdominaltrauma.IndicationsforRenalImaging外科學(xué)-泌尿系統(tǒng)損傷--課件NonoperativeManagementindeed,98%ofbluntrenalinjuriescanbemanagednonoperatively.GradeIVandVinjuriesmoreoftenrequiresurgicalexploration.Patientswithhigh-gradeinjuries(gradesIIItoV)selectedfornonoperativemanagementshouldbeobservedcloselyTheisolatedrenalinjury,withoutsignificantassociatedinjuries,occursmorecommonlyfromblunttraumaandinmostcircumstancescanbemanagednonoperatively.TheexceptionismajorgradeVvascularpedicleavulsioninjuries.Isolatedrenalinjurieswithparenchymallacerationsandevensegmentalarterialinjurycanhaveactivebleedingwellcontrolledbyangiographicembolization.NonoperativeManagementindeedOperativeManagementAbsoluteindicationsincludeevidenceofpersistentrenalbleeding,expandingperirenalhematoma,andpulsatileperirenalhematoma

絕對(duì)適應(yīng)癥包括：持續(xù)性腎臟出血、腎周血腫擴(kuò)大及腎周搏動(dòng)性血腫Relativeindicationsincludeurinaryextravasation,nonviabletissue,delayeddiagnosisofarterialinjury,segmentalarterialinjury,andincompletestaging.相對(duì)適應(yīng)癥包括：尿外滲、組織壞死、延遲診斷的動(dòng)脈創(chuàng)傷、腎段動(dòng)脈創(chuàng)傷及分級(jí)不明確OperativeManagementAbsoluteRenalExplorationRenalExplorationRenalReconstructionRenalReconstructionRenalReconstructionRenalReconstructionIndicationsforNephrectomyGradeVrenalinjury(77%)Theunstablepatient,withlowbodytemperatureandpoorcoagulation,cannotriskanattemptatrenalrepairifanormalcontralateralkidneyispresent(23%)IndicationsforNephrectomyGrComplicationsPersistenturinaryextravasationcanresultinurinoma,perinephricinfection,andrenalloss.Delayedrenalbleedingcanpotentiallyoccurseveralweeksafterinjurybutusuallyoccurswithin21days.Perinephricabscess-PercutaneousdrainageHypertension:1)renalvascularinjury,leadingtostenosisorocclusionofthemainrenalarteryoroneofitsbranches;2)compressionoftherenalparenchymawithextravasatedbloodorurine;3)post-traumaarteriovenousfistula.Intheseinstances,therenin-angiotensinaxisisstimulatedbypartialrenalischemia,resultinginhypertensionComplicationsPersistenturinaUreteralinjuriesIatrogenicUreteralInjuryExternalUreteralInjuryUreteralinjuriesIatrogenicUIatrogenicUreteralInjuryOpenSurgeryLaparoscopicSurgeryUreterorenoscopyRadioactiveinjuryIatrogenicUreteralInjuryOpenExternalUreteralInjuryUreteralinjuriesafterexternalviolencearerareOpeninjuryblunttraumapatientswithureteralinjuriesaresubjecttoextremeforceappliedovertheentirebody.Thegreatdegreeofenergyimpartedtothevictimisassociatedwithsuchuncommoninjuriesasfracturedlumbarprocesses

andthoracolumbarspinaldislocation

ExternalUreteralInjuryUreterDiagnosisIntraoperativeRecognition

ImagingStudies

ExcretoryUrographyComputedTomographyRetrogradeUreterographyAntegradeUreterographyDiagnosisIntraoperativeRecognTreatmentTreatmentTreatmentTreatmentBladderTraumaThemostcommonassociatedinjuryispelvicfracture,associatedwith83%to95%ofbladderinjuries

obstetricandgynecologiccomplicationsarethemostcommonetiologyofIatrogenicbladderinjuries

BladderTraumaThemostcommondiagnosis恥骨上區(qū)疼痛或觸痛不能排尿或尿量減少尿中有血塊CT或超聲提示腹腔內(nèi)游離液體會(huì)陰或生殖器外傷體征無(wú)反應(yīng)、醉酒或感知異常腹部膨脹或腸梗阻diagnosis恥骨上區(qū)疼痛或觸痛RadiographicImagingRadiographicImagingTreatmentTheusualtreatmentofuncomplicatedextraperitonealbladderruptures,whenconditionsareideal,isconservativemanagementwithurethralcatheterdrainagealone

complicationssuchasfistula,abscess,andprolongedleak

TreatmentTheusualtreatmento外科學(xué)-泌尿系統(tǒng)損傷--課件INDICATIONSFORIMMEDIATEREPAIROFBLADDERINJURY外傷導(dǎo)致的腹腔內(nèi)損傷穿刺傷或醫(yī)源性非泌尿外科損傷膀胱引流不暢或尿中有血塊膀胱頸損傷直腸或子宮損傷開(kāi)放性骨盆骨折骨盆骨折需要復(fù)位和內(nèi)固定由于其他原因行剖腹探查的穩(wěn)定患者骨碎片插入膀胱內(nèi)INDICATIONSFORIMMEDIATEREPAUrethralTraumaPosteriorUrethra

AnteriorUrethra

UrethralTraumaPosteriorUrethPosteriorUrethraStraddlefractures”involvingallfourpubicrami

openfractures,andfracturesresultinginbothverticalandrotationalpelvicinstabilityareassociatedwiththehighestriskofurologicinjury

PosteriorUrethraStraddlefracdiagnosisUrethraldisruptionisheraldedbythetriadofbloodatthemeatus,inabilitytourinate,andpalpablyfullbladder

urethralcathetercannotbeplaced;misplacedintopelvichematoma.impalpableprostateUrethrography

diagnosisUrethraldisruptioniTreatmentSuprapubicCystostomy

PrimaryRealignment

DelayedReconstruction:At3months,scartissueattheurethraldisruptionsiteisstableenoughtoallowposteriorurethroplastytobeundertakensafely,providedthatassociatedinjuriesarestabilizedandthepatientisambulatoryTreatmentSuprapubicCystostomyPrimaryRealignmentPrimaryRealignmentDelayedReconstructionDelayedReconstructionTransurethralcutting-to-the-lightprocedureTransurethralcutting-to-the-lAnteriorUrethraThemajorityoccurafterstraddleinjuryandinvolvethebulbarurethraIn20%ofthecasesofruptureofcorporacavernosa,theurethraisinvolvedAnteriorUrethraThemajorityo外科學(xué)-泌尿系統(tǒng)損傷--課件InjuriesofthegenitaliaPenis(Fracture,Gunsho