TRAUMA

Renal
Kidneys commonest site for trauma
80% blunt, most of which is MCA. More common in abnormal kidneys
A subset is deceleration injuries - renal art thrombosis, PUJ disruption (esp children)
30% major parenchymal injury assoc splenic injury
20% penetrating, of which most is gunshot

Classification
Class I - minor trauma, contusions & minor lacerations that spare the collecting system
Class II - major - deeper lacerations involving the collecting system, often get extravasation of urine
Class III - shattered kidney with renal vascular injury
Class IV - PUJ avulsion & lacerations of renal pelvis

Clinical - macro haematuria - absence does not exclude renal injury. Lack of correlation bw extent of
haematuria & severity of injury. Pathol kidney will bleed with rel minor trauma .: IVP all micro
Hturia
- local signs - tenderness, bruising, mass
- N&V, ileus with abdo distention
- hypovolaemic shock possible
Ix - AXR - loss of psoas shadow, displacement of bowel gas, # tvp/ribs, scoliosis away from injury
- IVP - need high dose of contrast
- normal if contused; extravasation if lacerated; absent if vascular injury
- important as it demonstrates function of other kidney
- CT - can replace IVP. Best 1st line Ix. + Rpt at 3-4/7
- angiography - s'times for planning reconstruction
Complications - early - continued bleeding - can be fatal - 20 haem at 8-9/7
- enlarging flank mass, falling Hb
- grumbling resolution of haematoma - inc morbidity
- infection in a haematoma - uncommon, assoc urine leak
- late - ureteral obstruction with hydronephrosis - IVP at 6w & 1yr
- atrophy, HT - 1-5%
Mx - blunt trauma - 90-95% conservative :. Gerotas fascia tamponades
- most heal with conservative Rx. Bed rest till haematuria stops. Class I & some II
- laparotomy for persistent bleeding, (? + for abscess, urinoma)
- laparotomy for devitalized kidney/pole (Class III)
- penetrating trauma - explore & repair. Drain
- high velocity injury - need to explore & drain urine (nephrostomy or stent)
Tear into the collecting system can continue bleeding as there is no tamponade. Get clot retention etc.
Angiography & embolization is Rx of choice

Indications for exploration

Absolute
- haemodynamic instability from renal bleeding
- expanding RP mass
- renal artery thrombosis in solitary or bilat injury
Relative indications
- non-viable tissue with major laceration (increases complications)
- urinary extravasation
- RA thrombosis
- laparotomy for associated injuries
Operative approach
Control pedicle prior to opening Gerotas fascia (midline incision)
Control bleeding, debride, drain collections. Cover amputated part with Dexon mesh / omentum

Ureteric
 Mostly iatrogenic
Ligation can be asymptomatic unless bilateral
Division leads to - peritonitis, local pain & tenderness, ileus
- drainage through wound or vaginal (after hysterectomy)
Ix - analysis of drain fluid for Urea & creatinine
- IVP - for level of occlusion/extravasation
- US - hydroureter, fluid mass
Mx 1. prevention - placement of stent preop with difficult pelvic Sx
2. recognized at Sx - division - spatulate ends then repair over stent, leave 6/52. IVP at 3-4/12. Mid ureter
good bs, access, distal more diff access, poorer bs, implant more reliable
- distal/mid ureter: mobilize bladder to inc length or reimplant, new submucosal tunnel
4/0CCG, stent, + psoas hitch to dec tension
- high injuries or dec length: nephrostomy Can use 16-18F Foley through post inf calyx,
leave ureter end. Drain the area of repair
- resection - repair/reimplant without tension eg Boari flap - base:length 3:1, can get to
lower pole. Take wide strip, reimplant onto post aspect of tube, or provide an
interposition graft (intestine) In extreme cases,consider autotransplantation.
3. recognized post-op - early reoperation, with any of above techniques.
If advanced obstruction/infection - initial nephrostomy, subsequent repair when stable

Bladder
Causes - blow over a full bladder. Almost always drunk males
- # pelvis
- pelvic Sx, cystoscopic Sx
Clinically - Associated injuries common
- Haematuria, suprapubic pain
- tenderness & guarding
- inability to void
Intraperitoneal - peritonitis, minimal signs initially, inc creat + urea at 24hrs, creamy urine in IDC
Extraperitoneal - pelvic mass
Ix - Pelvic XR - ?#
- cystography - "distention cystogram", requires up to 400ml
- look for extravasation on post-drainage film
In intraperitoneal, get diffuse leak of contrast, may see a pyelogram
In extraperitoneal, get contrast bilaterally low-down
- CT may provide Dx
DDx - renal injury for haematuria
 - membranous urethral rupture - similar signs to extraperitoneal bladder rupture
Mx - extraperitoneal - large - drain, decompress bladder, antibiotics
- small - IDC adequate
- intraperitoneal - laparotomy, closure, IDC

Urethra
Laceration occurs with - "butterfly" # of pelvis - membranous urethra, uncommon with simple #
- fall astride injury - bulbar urethra, usually not complete
- intercourse - pendulous urethra (associated with # corpus)
Clinically - blood at meatus
- +/- perineal haematoma, high-riding prostate
Ix - retrograde urethrogram (Foley + urograffin). If some contrast enters bladder - partial
Mx - partial tear - one attempt gentle catheterization 16F or
supra-pubic, wait 2-3/7, cystoscopy & attempt to traverse tear with guide-wire
Leave IDC in for 6/52
- complete - if possible - do laparotomy, open bladder, rail-road catheter for 6/52
- if not possible - suprapubic - higher incidence of severe stricture
Complications - impotence, incontinence, stricture

Testicular
US ? Tunica ruptured explore, evacuate haematoma, caution repairing tunica :. Swelling ++
? Orchidectomy.
May get ABs