css urogenital & pelvic trauma nufus ina

8/18/2019 CSS Urogenital & Pelvic Trauma Nufus Ina

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A E IEN ESESSION

UROGENITAL & PELVICTRAUMA

Nurhayati Nufus

Ina Ratna

Preceptor :

dr. Liza Nursanty, SpB,M.Kes, FINaCS

SMF BedahRS !"Is!a# Bandun$

Pro$ra# P%& " Fa'u!tas

Kedo'teran(ni)ersitas Is!a#

Bandun$ *ahun +-


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KIDNEY ANATOMY


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Retroperitonea!

*--"L% / ri$ht *-+"L%0 /!eft *--"L+0

*he ri$ht 'idney is separated fro# the

!i)er 1y the hepatorena! recess *he !eft 'idney is re!ated to the

sto#ach, sp!een, pancreas, 2e2unu#,

and descendin$ co!on


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KIDNEY INJURY


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More than ha!f these in2uries in)o!)epatients under the a$e of % years and#en area a3ected four ti#es as

fre4uent!y as 5o#en 6 7 1!unt trau#a


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ClassifcationMinor rena! in2ury /687 of a!! cases0

su1capsu!!ar and super9cia! !aceration

Major renal injury /-7 of a!! cases0

retroperitonea! and perinephrichae#ato#ata,

Renal vascular injuries /-7 of a!!

cases0se$#enta! arteries or )eins topartia! or co#p!ete a)u!sion of the #ainrena! pedic!e.


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Inj!" G!a#in$

G!a#% Inj!" T"%'D%sc!ition

I ;ae#aturia


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T!%at(%nt Minor rena! in2uries are #ana$ed conser)ati)e!y

1y strict 1edrest, anti1iotics and #onitorin$ of)ita! si$ns, hae#atocrit and the in2ured 'idney

Mayor rena! in2ury Indications for sur$ica!inter)ention are:

si$ns of continued 1!ood !oss, such as fa!!in$hae#atocritD

increasin$ size of retroperitonea! or perinephrichae#ato#aD and

#ar'ed urine e=tra)asation or )ascu!ar in2ury


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URETERSANATOMY


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*he ureters are #uscu!ar ducts /+8"%c# !on$0

*hey run inferior!y fro# the ape= ofthe rena! pe!)es at the hi!a of the'idneys, the pe!)ic 1ri# at the1ifurcation of the co##on i!iac

arteries

!atera! 5a!! of the pe!)is

the urinary 1!adder


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- the 2unction ofpe!)is and ureter, asit crosses the

+ e=terna! i!iac)esse!s and pe!)ic

1ri#% as it penetrates

the 5a!! of theurinary 1!adder


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URETERS INJURY


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(reteric in2uries are unco##on

Most ureteric in2uries are iatro$enic,

5ith %n%t!atin$ t!a(a )%l*ics!$%!"+

the second #ost fre4uent cause

,lnt t!a(a


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In2ury to the ureter #ay 1e reco$nized att-% ti(% o. s!$%!" or #ay !%s%nt in

t-% osto%!ati*%pyre=ia, Ean' or !o5er 4uadrant pain,

para!ytic i!eus or 9stu!a. ;ae#aturia, $rossor #icroscopic, is present in 7 of cases.

Dia$nosis

intra)enous uro$raphy


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T!%at(%ntIf reco$nized i##ediate!y: repair 5ith

stentin$ /e.$. o)er &ou1!e"2G stent0

If !ate dia$nosis: atte#pt repair 1ut hi$hnephrecto#y rate /%70


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Mana$%(%ntH Minor defect: $ent!e e=pert urethra!catheterisation.

H Ma2or defect: SPC < de!ayed urethrop!asty


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ANATOMY o.

,LADDER &URET/RA


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*he 1!adder is a ho!!o5, #uscu!ar or$an

adapted for storin$ and e=pe!!in$ urine.hen it is e#pty, it !ies posterior to the

pu1ic sy#physis in the pe!)is and ise=traperitonea!.

*he do#e of the 1!adder is co)ered5ith peritoneu#, and 5hen the 1!adderis fu!!, it can rise into the a1do#en and

is pa!pa1!e on physica! e=a#ination. *he nor#a! 1!adder can store

appro=i#ate!y %8 to 8 #L.


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*he #uscu!aris propria, a!so referred to

as the 1!adder detrusor, for#s the#uscu!ar 5a!! of the 1!adder. C!ose to theurethra, the #usc!e 91ers 1eco#e

or$anized into three !ayers: an inner!on$itudina!, #idd!e"circu!ar, and outer"!on$itudina!.

*he arteria! 1!ood supp!y to the 1!adderco#es fro# the superior, #idd!e, andinferior )esica! arteries, 5hich are a!!1ranches of the interna! i!iac artery. *he)enous return fro# the 1!adder drains


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In #en, urinary continence is #aintained 1y

the interna! and e=terna! sphincters.

*he interna! sphincter, co#posed of s#ooth#usc!e, is for#ed 1y the #idd!e circu!ar !ayer

of the 1!adder 5a!! as it in)ests the prostate$!and. Contraction of this sphincter durin$e2acu!ation pre)ents retro$rade e2acu!ation 1ydirectin$ the se#en to5ard the urethra!#eatus.

*he e=terna! sphincter surrounds the urethra atthe !e)e! of the dista! prostate $!and and isco#posed of 1oth s#ooth and striated #usc!e

91ers.


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In 5o#en, continence is #aintained 1y theresistance pro)ided 1y the coaptation ofthe urethra! #ucosa and the e=terna!

striated sphincter surroundin$ the dista!t5o"thirds of the urethra.


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,LADDER INJURIES


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B!adder in2uries are dia$nosed 1y cysto$raphy

/a post)oid )ie5 enhances the accuracy ofcysto$raphy0, C*, or durin$ !aparoto#y.

B!unt ruptures of the intraperitonea! portion

are c!osed 5ith a runnin$ sin$!e"!ayer c!osureusin$ %" a1sor1a1!e #ono9!a#ent suture.B!unt e=traperitonea! rupture is treated 5ith aFo!ey catheterD direct operati)e repair is not

necessary. Cysto$ra#s can 1e used todeter#ine 5hen the Fo!ey catheter can 1ere#o)ed, usua!!y in - to - days.


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Penetratin$ 1!adder in2uries are treated inthe sa#e fashion, a!thou$h in2uries nearthe tri$one shou!d 1e repaired throu$h anincision in the do#e so that iatro$enicin2ury to the intra)esicu!ar ureter isa)oided 1y direct )isua!ization.


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URET/RA inj!i%s


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B!unt disruption of the posterior urethra is#ana$ed 1y 1rid$in$ the defect 5ith a Fo!eycatheter /throu$h the urethra! #eatus and

throu$h an incision in the 1!adder0.Penetratin$ in2uries are treated 1y direct

repair.


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Anato(" o. .%(al%!%!o#ction


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E0TERNAL GENITALIA

)VULVA+ *he )u!)a is 1ounded 1y the sy#physis pu1is

anterior!y, the ana! sphincter posterior!y, and theischia! tu1erosities !atera!!y.

*he labia majora for# the cutaneous 1oundariesof the !atera! )u!)a. *he !a1ia #a2ora are fattyfo!ds co)ered 1y hair"1earin$ s'in in the adu!t.

*hey fuse anterior!y 5ith the anterior

pro#inence of the symphysis pubis, the monsveneris. Posterior!y, the !a1ia #a2ora #eet in astructure that 1!ends 5ith the perinea! 1ody andis referred to as the posterior commissure.


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d2acent and #edia! to the !a1ia #a2ora are the

labia minora, s#a!!er fo!ds of connecti)e tissueco)ered !atera!!y 1y non"hair"1earin$ s'in and#edia!!y 1y )a$ina! #ucosa. *he anterior fusionof the !a1ia #inora for#s the prepuce of theclitoris; posterior!y, the !a1ia #inora fuse in the

fossa navicularis, or posterior fourchette. *he ter# vestibule refers to the area #edia! to

the !a1ia #inora 1ounded 1y the fossana)icu!aris and the c!itoris. Both the urethra

and the )a$ina open into the )esti1u!e. *he c!itoris !ies superior to the urethra! #eatus.


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MUSCULATURE O1 PELVIC

1LOOR *he levator ani #usc!es /Fi$. "+0 for# the#uscu!ar Eoor of the pe!)is. *hese #usc!esinc!ude, fro# anterior to posterior, 1i!atera!!y, the

pubococcygeus, puborectalis, iliococcygeus, and

coccygeus #usc!es. *he 9rst t5o of these#usc!es contri1ute 91ers to the 91ro#uscu!arperinea! 1ody.

*he urogenital hiatus is 1ounded !atera!!y 1y thepu1ococcy$eus #usc!es and anterior!y 1y thesymphysis pubis. It is throu$h this #uscu!ardefect that the urethra and )a$ina pass


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&ista! or caudad to the !e)ator ani #usc!es, orlevator

sling is the perineal membrane. *his structure is1ounded 1y the ischia! tu1erosities infero!atera!!y and1y the pu1ic arch superior!y.

Latera! to the perinea! #e#1rane are theischiocavernosus #usc!es. *hese structures para!!e!and are attached to the inferior ra#i of the sy#physispu1is and, !i'e the bulbocavernosus #usc!es, containerecti!e tissue that 1eco#es en$or$ed durin$ se=ua!

arousa!. *he 1u!1oca)ernosus #usc!es arise in theinferoposterior 1order of the symphysis pubis andaround the dista! )a$ina 1efore insertin$ into theperinea! 1ody.


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*he transverse perinei #usc!es arise fro# theinferior ra#i of the sy#physis 2ust anterior to thepu1ic tu1erosities and insert #edia!!y into theperinea! 1ody, !endin$ #usc!e 91ers to this structureas 5e!!.


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INTERNAL GENITALIA

*he centra! uterus and cer)i= are suspended1y the !atera! 91rous cardina!, orMackenrodt's, (uterosacral) ligaments, 5hich

insert into the paracer)ica! fascia #edia!!yand into the #uscu!ar side5a!!s of the pe!)is!atera!!y.

Posterior!y, the uterosacra! !i$a#ents pro)idesupport for the )a$ina and cer)i= as theycourse fro# the sacru# !atera! to the rectu#and insert into the paracer)ica! fascia.


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*he 1i!atera! fa!!opian tu1es arise fro# the upper

!atera! cornua of the uterus and coursepostero!atera!!y and anterior to the o)aries. Jach5idens in the dista! third, or ampulla.

*he o)aries are attached to the uterine cornu 1ythe proper ovarian ligaments. *hese structurese=it the pe!)is throu$h the interna! in$uina! rin$and course throu$h the in$uina! cana! /cana! ofNuc'0 and e=terna! in$uina! rin$ to thesu1cutaneous tissue of the #ons )eneris. *hey

insert into the connecti)e tissue of the !a1ia#a2ora. *he o)aries are see#in$!y suspendedfro# the !atera! pe!)is 1y their )ascu!ar pedic!es,the infundibulopelvic ligaments


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*he peritoneu# enfo!din$ the adnexa /tu1e,

round !i$a#ent, and o)ary0 is referred to as thebroad ligament .

*he peritonea! recesses in the pe!)is anteriorand posterior to the uterus are referred to as theanterior and posterior culdesacs. *he !atter isa!so ca!!ed the pouch or culdesac of !ouglas.

n trans)erse section, inc!ude the !atera!para)esica! and pararecta! spaces, and, fro#anterior to posterior, the retropu1ic or pre)esica!

space of Retzius and the )esico)a$ina!,recto)a$ina!, and retrorecta! or presacra! spaces.


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*he pe!)ic 1ri# de#arcates the o1stetric, or true,

fro# the fa!se pe!)is contained 5ithin the i!iaccrests.

*he #usc!es of the pe!)ic side5a!! inc!ude thei!iacus, the psoas, and the o1turatorD 5ith thee=ception of the #idd!e sacra! artery, 5hichori$inates at the aortic 1ifurcation, the 1!oodsupp!y arises fro# the interna! i!iac arteries. *heinterna! i!iac, or hypo$astric, arteries di)ide intoanterior and posterior 1ranches. *he !atter supp!y

!u#1ar and $!utea! 1ranches and $i)e rise to thepudenda! arteries. Fro# the anterior di)ision of thehypo$astric arteries arise the o1turator, uterine,superior, and #idd!e )esica! arteries.


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*he ner)e supp!y to the pe!)is is co#posed ofthe sciatic, o1turator, and fe#ora! ner)es.Sy#pathetic 91ers course a!on$ the #a2orarteries and parasy#pathetics for# thesuperior and inferior pe!)ic p!e=us.

*he ureters enter the pe!)is as they cross thedista! co##on i!iac arteries !atera!!y and thencourse inferior to the o)arian arteries and

)eins unti! they cross under the uterinearteries 2ust !atera! to the cer)i=. Coursedo5n5ard and #edia!!y o)er the anteriorsurface of the )a$ina 1efore enterin$ the 1ase

of the 1!adder.


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G"n%colo$icinj!i%s


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>yneco!o$ic in2uries are rare. ccasiona!!y

the )a$ina 5i!! 1e !acerated 1y a sharp 1onefra$#ent fro# a pe!)ic fracture. Penetratin$in2uries to the )a$ina, uterus, fa!!opian tu1es,and o)aries are a!so unco##on.

*he usua! he#ostatic techni4ues are used tocontro! 1!eedin$, and suture repair is used toc!ose defects that co##unicate 5ith a !u#en.

*ransection at the in2ury site 5ith pro=i#a!!i$ation and dista! sa!pin$ecto#y is a #ore

prudent approach.


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*rau#a in pre$nancy a!so is rare.

B!unt trau#a can cause uterine rupture,5hich a!#ost a!5ays resu!ts in feta!de#ise. *he outco#es of penetratin$

uterine in2uries are #ore )aria1!e andare dependent on penetration of theuterine ca)ity, da#a$e to the p!acenta,and feta! in2ury. Spontaneous a1ortion is

a fre4uent outco#e. If the fetus is )ia1!e1y dates or e=a#ination, an e#er$encycesarean section shou!d 1e considered.


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&ia$nosis : *he 1!eedin$ associated 5ith$enita! trau#a #ay 1e dia$nosedsecondary to a history of rape or $enita!

in2ury. In the presence of $enita! 1!eedin$secondary to trau#a, the !esion #ust 1ee)a!uated carefu!!y


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Anato(" %l*ic


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Pe!)is is the part of the trun' inferoposterior to the

a1do#en and is the area of transition 1et5een thetrun' and the !o5er !i#1s.

*he pe!)is :

a. >reater pe!)is *he $reater pe!)is is surrounded 1y the superior

pe!)ic $ird!e. *he $reater pe!)is is occupied 1y inferior a1do#ina!

)iscera, a3ordin$ the# protection si#i!ar to the 5aythe superior a1do#ina! )iscera are protected 1y theinferior thoracic ca$e.

1. Lesser pe!)is

*he !esser pe!)is is surrounded 1y the inferior pe!)ic$ird!e, 5hich pro)ides the s'e!eta! fra#e5or' for 1oththe pe!)ic ca)ity and the perineu#


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PJLAIC >IR&LJ

*he pe!)ic $ird!e is a 1asin"shaped rin$ of 1onesthat connects the )erte1ra! co!u#n to the t5ofe#urs

*he pe!)ic $ird!e is for#ed 1y three 1onesRi$ht and !eft hip 1ones /co=a! 1onesD pe!)ic

1ones0: !ar$e, irre$u!ar!y shaped 1ones, each of5hich de)e!ops fro# the fusion of three 1ones,

the i!iu#, ischiu#, and pu1is.Sacru#: for#ed 1y the fusion of 9)e, ori$ina!!y

separate, sacra! )erte1rae


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P%l*ic INJURIES


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&ia$nosis

-2 /isto!" Ta3in$42 P-"sical E5a(ination

" Di$ital %5a(ination 9ndin$ of $ross 1!ood onstron$!y su$$ests in2ury to these or$ans.

" P!octosco" o! s%cl( %5a(ination #ayre)ea! the in2ury

" (rethra! in2uries are suspected 1y the fn#in$s o.6loo# at the #eatus, scrota! or perinea!

he#ato#as, and a hi$h"ridin$ prostate 1y recta!e=a#.


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%. ;ae#ato!o$y Routine

. >ross 1!ood on urina!ysis !acerated1!adder

8. P!ain ="rays $ross a1nor#a!ities

. C* scans the pe!)ic for sta1i!ity.

. n$io$raphy is indicated if thro#1osis

of the arteria! syste# is suspected


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C!inica! #anifestation

Pe!)ic fractures can cause e=san$uinatin$retroperitonea! he#orrha$e 5ithout associated#a2or )ascu!ar in2ury /1ranches of the interna!

i!iac )esse!s and the !o5er !u#1ar arteries areoften responsi1!e,h e#orrha$e a!so co#es fro#s#a!! )eins and fro# the cance!!ous portion ofthe fractured 1ones.

Lar$e retroperitonea! he#ato#as can a!socause a he#operitoneu#, particu!ar!y ifo)er!yin$ peritoneu# ruptures


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M%t-o#s .o! /a%(o!!-a$% Cont!olAnt%!io! %5t%!nal f5ation is not intended to

pro)ide de9niti)e fracture sta1i!ization in #ostinstances. Its ad)ocates intend for the de)ice to

decrease pe!)ic )o!u#e, ta#ponade 1!eedin$, andto pre)ent secondary he#orrha$e 5hich #ayoccur if the fractured 1ones shift

Milita!" Anti S-oc3 T!os%!s )MAST+ canpro)ide so#e sta1i!ity for the fracture andpro1a1!y ta#ponade )enous he#orrha$e. *hedisad)anta$es are the !oss of access to thea1do#en and the ris' of !o5er e=tre#ityco#part#ent syndro#e.


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An$io$!a-" 7it- %(6oli8ation is

)ery e3ecti)e for contro!!in$ arteria!he#orrha$e, 1ut arteria! he#orrha$eoccurs in on!y - to +7 of patients 5ithacti)e he#orrha$e fro# pe!)ic fractures.

P%l*ic ac3in$ #ay contro! )enoushe#orrha$e. *he on!y reason to consider

its use is 5hen a pe!)ic he#ato#a isinad)ertent!y entered or if it has ruptured.


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Co(lication pe!)ic sepsis

osteo#ye!itis

In.%ction P!%*%nti*%

*he pe!)ic 5ound is #anua!!y d1rided and

then irri$ated dai!y 5ith a hi$h"pressure,pu!sati!e irri$ation syste# unti! $ranu!ationtissue co)ers the 5ound

*o reduce the ris' of infection, a si$#oid

co!osto#y is reco##ended.


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RE1ERENCES-. Brunicardi, F Char!es, ndersen, &, Bi!iar, *R, &unn,&L. Sch5artzs Princip!es of Sur$ery. Jd 6. Ne5 yor' :Mc>ra5";i!!D +.

+. Moore, Keith L, &a!!ey F, $ur, MR. C!inica!!yriented nato#y. Jd . Phi!!ade!phia: Lippincotti!!ia#s O i!'insD +-.

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