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CONGENITAL ANOMALIES

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Title: CONGENITAL ANOMALIES


1
CONGENITAL ANOMALIES TRAUMA OF THE
GENITOURINARY TRACT
  • DEPARTMENT OF UROLOGY IASI 2010

2
CONGENITAL KIDNEY
  • more frequently than in any other organ
  • many cause impairment of renal function
  • association with other renal and extrarenal
    congenital anomalies
  • AGENESIS
  • bilateral extremely rare children do not
    survive prenatal suspicion oligohydramnios
    (US)
  • unilateral no symptoms cystoscopy ureteral
    ridge absent, no orifice visualized definitive
    diagnosis isotope studies, US, CT
  • HYPOPLASIA
  • small kidney, smtm dysplastic the other maybe
    larger than normal
  • observed in infants with fetal alcohol syndrome
    or in utero cocaine exposure

3
CONGENITAL KIDNEY
  • differentiation acquired atrophy (atrophic
    pyelonephritis, VUR, stenosis of the renal
    artery)
  • associated with hypertension ? nephrectomy
  • ADULT POLYCYSTIC KIDNEY DISEASE
  • autosomal dominant hereditary condition almost
    always bilateral (95)
  • in infants autosomal recessive disease short
    life expectancy
  • cysts of the liver, spleen and pancreas
  • Etiology Pathogenesis
  • defects in the development of the collecting and
    uriniferous tubules and in the mechanism of their
    joining ? blind secretory tubules connected to
    functioning glomeruli ? cysts enlarge compress
    adjacent parenchyma ? destroy it by ischemia and
    occlude normal tubules ? progressive functional
    impairment

4
CONGENITAL KIDNEY
  • Symptoms
  • pain (drag on the vascular pedicles by theheavy
    kidneys, obstruction, infection,hemorrhage into
    a cyst)
  • gross or microscopic total hematuria
  • colic (blood clots or stones)
  • abdominal mass
  • infection (chills, fever, renal pain)
  • renal insufficiency (headache, nausea,vomiting,
    weakness, loss of weight)
  • Signs
  • palpable kidneys (nodular, tender if infected)
  • hypertension ( 60-70)
  • fever (pyelonephritis or infected cysts)

5
CONGENITAL KIDNEY
  • uremia (anemia, loss of weight)
  • Laboratory
  • anemia (chronic loss of blood or hematopoietic
    depression of uremia)
  • proteinuria and hematuria pyuria and bacteriuria
  • progressive ? creatinine clearance
  • US multiple transsonic images, large renal size
  • IVU
  • enlarged renal shadows on a plain film
  • bizarre (spider deformity) caliceal pattern
    (broadened, flattened, enlarged, curved)
  • CT extremely accurate (95) for diagnosis
    multiple thin-walled cysts filled with fluid,
    large renal size

6
CONGENITAL KIDNEY
  • Differential Diagnosis
  • bilateral hydronephrosis
  • bilateral renal tumor
  • von Hippel-Lindau disease (angiomatous cerebellar
    cyst, angiomatosis of the retina, tumors or cysts
    of the pancreas, multiple bilateral cysts or
    adenocarcinomas of both kidneys)
  • tuberous sclerosis (convulsive seizures, mental
    retardation, adenoma sebaceum, hamartomatous
    tumors of the skin, brain, retinas, bones, liver,
    heart, and kidneys)
  • simple cyst
  • Complications
  • pyelonephritis
  • infection of cysts
  • severe gross hematuria

7
CONGENITAL KIDNEY
  • Treatment
  • General Measures low-protein diet (0.5-0.75
    g/kg/d), fluids ( 3 L/d), reasonable physical
    activity, treatment of uremia (hemodialysis),
    control of hypertension
  • Surgery a large cyst compressing the upper
    ureter (obstruction and impairment of renal
    function) ? resected or aspirated renal
    insufficiency ? chronic dialysis or renal
    transplantation
  • Treatment of Complications pyelonephritis
    infection of cysts ? surgical or percutaneous
    drainage severe bleeding ? nephrectomy or
    selective embolization
  • Prognosis
  • children very poor
  • clinical signs and symptoms after age 35-40
    more favorable

8
CONGENITAL KIDNEY
  • SIMPLE (SOLITARY) CYST
  • usually unilateral and single, but may
    bemultiple and multilocular more
    rarely,bilateral
  • Etiology Pathogenesis
  • origin may be similar to that of
    polycystickidneys, but the lesion can be
    acquired(chronic dialysis)
  • as it grows ? compresses and maydestroy renal
    parenchyma may compressthe ureter ? progressive
    hydronephrosis
  • spontaneous regression of cysts has occasionally
    been noted
  • Pathology
  • 5 contain hemorrhagic fluid (1/2 have papillary
    cancers on their walls)

9
CONGENITAL KIDNEY
  • Clinical Findings
  • Symptoms pain in the flank or back, intermittent
    and dull severe pain (bleeding) mass in the
    abdomen pain in the flank, malaise, and fever
    (infected cyst)
  • Signs mass palpated or percussed tenderness in
    the flank (infected cyst)
  • Laboratory usually normal
  • US differentiates between a cyst and a solid
    mass percutaneous cyst aspiration
  • CT differentiates renal cyst and tumor
    (attenuation of cysts water, density of tumors
    parenchyma parenchyma more dense with contrast
    i.v., cyst unaffected)
  • Percutaneous Cyst Aspiration With Cystography
    differentiation between cyst and tumor

10
CONGENITAL KIDNEY
  • Differential Diagnosis
  • carcinoma of the kidney (walls of a simple cyst
    cancerous degeneration)
  • polycystic kidney disease, renal carbuncle,
    hydronephrosis
  • extrarenal tumor (adrenal, mixed retroperitoneal
    sarcoma)
  • echinococcal (hydatid) cyst of the kidney
  • Complications (rare) spontaneous infection,
    hemorrhage into the cyst, hydronephrosis (cyst of
    the lower pole)
  • Treatment
  • follow-up with US if no definitive diagnosis
    with US, CT or MRI ? perc. needle aspiration
    (clear fluid ? benign cyst), cytologic
    evaluation, cystography hemorrhagic fluid ?
    surgical exploration
  • complications infected cyst ? intensive
    antimicrobial therapy percutaneous or surgical
    drainage hydronephrosis ? percutaneous puncture,
    aspiration sclerotherapy

11
CONGENITAL KIDNEY
  • RENAL FUSION
  • 1, the most common horseshoe kidney
  • Etiology Pathogenesis
  • fusion of the 2 metanephroi occurs early in
    embryologic life ? seldom ascend to the normal
    position (may remain in the pelvis) may derive
    its blood supply from many vessels (aorta,
    iliacs)
  • Pathology
  • normal rotation cannot occur ? each pelvis lies
    on the anterior surface ? ureter must ride over
    the isthmus (horseshoe kidney) or traverse the
    anterior surface (fused kidney) ? ureteral
    compression ? hydronephrosis
  • horseshoe kidney isthmus joins the lower poles
    of each kidney each renal mass lies lower than
    normal axes of the masses are vertical or
    divergent upwards

12
CONGENITAL KIDNEY
  • Clinical findings
  • Symptoms no symptoms ureteral obstruction
    infection calculus
  • Signs usually negative abnormally placed renal
    mass (horseshoe kidney palpable mass over the
    lower lumbar spine isthmus, crossed ectopy
    mass in the flank or lower abdomen)
  • Laboratory normal
  • X-Ray horseshoe kidney axes of the kidneys
    parallel to the spine on a plain film, isthmus
    can be identified large soft-tissue mass in one
    flank w/o a renal shadow on the other side
  • IVU horseshoe kidney renal pelves lie on the
    anterior surfaces of the kidney masses, calyces
    in the lower pole that point medially and lie
    medial to the ureter crossed renal ectopy with
    fusion 2 pelves and 2 ureters (one ureter must
    cross the midline) cake or lump kidney (fused
    pelvis kidney) may compress the dome of the
    bladder

13
CONGENITAL KIDNEY
  • Clinical findings
  • CT outlines the renal mass
  • Retrograde urograms show the position of
    theureters and pelves (pelvic fused kidney)
  • Renal scanning delineates the renal mass and its
    contour
  • Differential Diagnosis - separate kidneys that
    fail to undergo normal rotation, other abdominal
    masses
  • Complications ureteral obstruction,
    hydronephrosis, stone, infection, dystocia due to
    a large fused kidney occupying the concavity of
    the sacrum
  • Treatment no treatment unless obstruction or
    infection drainage of a horseshoe kidney by
    dividing the isthmus surgical resection

14
CONGENITAL KIDNEY
  • ECTOPIC KIDNEY
  • Simple Ectopy
  • low kidney on the proper side that failed to
    ascend normally (may lie in the pelvis), blood
    supply from adjacent vessels, short ureter prone
    to ureteral obstruction and infection ? pain or
    fever
  • may be palpable - differential diagnosis (cancer
    of the bowel, appendiceal abscess)
  • IVU position of the kidney no redundancy of
    the ureter (as with nephroptosis or acquired
    ectopy displacement by large adrenal tumor)
  • treatment of obstruction and infection
  • Crossed Ectopy Without Fusion
  • the kidney lies on the opposite side US,
    angiography or CT for diagnosis

15
CONGENITAL KIDNEY
  • ABNORMAL ROTATION
  • IVU abnormal position
  • MEDULLARY SPONGE KIDNEY
  • congenital autosomal recessive defect cystic
    dilatation of the renal collecting tubules
    (usually bilateral, affecting all of the
    papillae)
  • urinary stasis in the tubules ? infection and
    calculi
  • symptoms from infection and stone formation
  • diagnosis (IVU or CT) pelvis and calyces are
    normal, but dilated (streaked) tubules (cystic
    dilatation) plain film small, round calculi in
    the pyramidal regions (just beyond the calyces)
  • differential diagnosis tuberculosis, healed
    papillary necrosis, nephrocalcinosis
  • terapy of the complications (pyelonephritis,
    renal calculi)

16
CONGENITAL URETER
  • are common, may cause severe obstruction or may
    be asymptomatic and of no clinical significance
  • URETERAL ATRESIA
  • ureter may be absent entirely or may end blindly
    after extending only part of the way to the flank
  • embryologically failure of the ureteral bud to
    form from the mesonephric duct or by an arrest in
    its development before it comes in contact with
    the metanephric blastema
  • atretic ureteral bud ? absent or multicystic,
    dysplastic kidney, (rarely associated with
    hypertension, infection or tumor) contralateral
    VUR is common (voiding cystourethrogram)
  • treatment observation

17
CONGENITAL URETER
  • DUPLICATION OF THE URETER
  • one of the most common congenital malformations
    of the urinary tract (0.9) autosomal dominant
    FgtM often bilateral
  • incomplete (Y) type caused by branching of the
    ureteral bud before it reaches the metanephric
    blastema disorders of peristalsis may occur near
    the point of union
  • complete type 2 ureteral buds ? 2 totally
    separate ureters and 2 separate renal pelves the
    ureter to the upper segment migrates farther,
    ending medial and inferior to the ureter draining
    the lower segment (Weigert-Meyer law) ? the
    ureter draining the upper segment may migrate too
    far caudally and become ectopic and obstructed
    the ureter draining the lower segment may end
    laterally and have a short intravesical tunnel ?
    VUR

18
CONGENITAL URETER
  • clinical findings asymptomatic persistent or
    recurrent infections F ureter to the upper
    pole may be ectopic, distal to the external
    sphincter or outside the urinary tract ? true
    incontinence normal pattern of voiding M
    ectopic ureter is always proximal to the external
    sphincter (w/o incontinence)
  • IVU duplication occasionally, one segment of
    the kidney is not visualized, but there is
    displacement of the visualized calyces or ureter
    or discrepancy between the amount of renal
    parenchyma and the relatively small number of
    visualized calyces
  • voiding cystourethrogram VUR or ureterocele
  • US hydronephrotic upper pole and dilated distal
    ureter evaluate parenchymal thickness and the
    presence of bladder anomalies

19
CONGENITAL URETER
  • renal scanning (99mTc-DMSA) estimating the
    degree of renal function in each renal segment
  • treatment
  • lower grades of reflux ? medically
  • higher grades of reflux ? surgically
  • very poor renal function in one segment ?
    heminephrectomy
  • to preserve renal parenchyma ? pyeloureterostomy,
    ureteroureterostomy or ureteral reimplantation
  • URETEROCELE
  • sacculation of the terminal portion of the
    ureter it may be intravesical or ectopic
    (bladder neck or urethra)
  • FM 71 10 are bilateral

20
CONGENITAL URETER
  • delayed or incomplete canalization of the
    ureteral bud ? early prenatal obstruction and
    expansion of the ureteral bud forms between the
    superficial and deep muscle layers of the trigone
  • clinical findings infection bladder outlet
    obstruction or incontinence calculi can develop
    in the distal ureter
  • IVU, US significant ureterohydronephrosis and a
    dysplastic segment of the upper pole of the
    kidney voiding cystourethrography reflux into
    the lower pole or contralateral ureter renal
    scanning estimating renal function
  • treatment transurethral incision
    heminephrectomy and ureterectomy, excision of the
    ureterocele, vesical reconstruction, ureteral
    reimplantation

21
CONGENITAL URETER
  • ECTOPIC URETERAL ORIFICE
  • most commonly in association with duplication of
    the ureter
  • caused by a delay or failure of separation of the
    ureteral bud from the mesonephric duct
  • clinical picture M urinary tract infection or
    epididymitis (ureter may drain directly into the
    vas deferens or seminal vesicle)F continual
    dribbling despite normal voiding pathognomonic
    (ureteral orifice in the urethra, vagina or
    perineum), infection (urgency and urge
    incontinence)
  • US, voiding cystourethrography, MRI, cystoscopy
    (hemitrigone, ectopic orifice may be visualized
    or demonstrated by retrograde catheterization) or
    laparoscopy
  • renal scanning estimates relative renal
    function

22
CONGENITAL URETER
  • OBSTRUCTION OF THE URETEROPELVIC JUNCTION (UPJ)
  • the most common congenital abnormality of the
    ureter MF 52 LR 52
  • bilateral obstruction 10-15, especially common
    in infants
  • cause of obstruction (intrinsic or extrinsic)
    ureteral polyps and valves (very rare),
    angulation and kink at the junction, true
    stenosis (rarely), thin-walled, hypoplastic
    proximal ureter (frequently), histologic and
    ultrastructural changes ? abnormal peristalsis
    through the UPJ and interference with pelvic
    emptying, high origin of the ureter from the
    renal pelvis, abnormal relationship of the UPJ to
    a lower-pole renal artery
  • clinical findings - most common symptoms pain
    and vomiting hematuria, urinary infection,
    calculi, trauma to the enlarged kidney or
    (rarely) hypertension

23
CONGENITAL URETER
  • US diagnosis prenatal US diagnosis in utero
    in equivocal cases, diuretic renography or
    antegrade urography with pressure-flow studies
    voiding cystourethrogram findings in VUR may be
    similar
  • Therapy symptomatic obstruction ? treated
    surgically early surgery kidneys with
    diminished function, massive hydronephrosis,
    infection or stones nonoperative surveillance
    with close follow-up
  • procedures dismembered pyeloureteroplasty
    (Anderson-Hynes), Foley Y-V plasty, pelvic flap
    procedures (Culp, Scardino)
  • endopyelotomy antegrade, via a nephrostomy
    tract, or retrograde, using either a ureteroscope
    (for direct vision) or an Acucise balloon
    catheter with fluoroscopic visualization
  • laparoscopic pyeloplasty

24
CONGENITAL URETHRA
  • URETHRAL STRICTURE
  • uncommon in infant boys (fossa navicularis and
    membranous urethra)
  • severe strictures may cause bladder damageand
    hydronephrosis
  • symptoms of obstruction or urinary infection
  • POSTERIOR URETHRAL VALVES
  • the most common obstructive urethral lesionsin
    male infants and newborns
  • treatment destruction of the valves
    transurethral fulguration of the valves

25
CONGENITAL URETHRA
  • HYPOSPADIAS
  • urethral meatus opens on the ventral side of
    thepenis proximal to the tip of the glans penis
  • repair with foreskin island flaps/buccal
    mucosagrafts and incised urethral plate
  • EPISPADIAS
  • urethra opens on the dorsal aspect of thepenis
    a distal groove extends from themeatus through
    the glans
  • surgery is required to correct theincontinence,
    remove the chordee tostraighten the penis, and
    extend the urethraout onto the glans penis

26
CONGENITAL TESTIS
  • CRYPTORCHIDISM
  • incidence 3.4-5.8 (at birth) 1.8 (1 year
    puberty) ? after the first year spontaneous
    descent is unlikely to occur
  • ectopic descend normally through the external
    inguinal ring, then misdirected to an
    extrascrotal position (superficial inguinal,
    perineal, prepenile, transverse scrotal, femoral
    or umbilical)
  • true cryptorchid arrested in their normal line
    of descent (intraabdominal, intracanalicular or
    suprascrotal)
  • 1/3 of cryptorchid cases are bilateral ?
    infertility
  • Histology and Endocrine Pathology
  • reduced number of germ cells (2nd year, persists
    thereafter)
  • impaired function of the hypothalamic-pituitary-go
    nadal axis ?? testosterone ? failure of
    testicular descent failure of proliferation and
    maturation of germ cells

27
CONGENITAL TESTIS
  • the higher the testis location ? the worse its
    histology
  • unilateral cryptorchidism is a bilateral disease
    ? contralateral descended testis is abnormal
    similar abnormalities, but to a lesser degree ?
    subfertility
  • Diagnosis
  • every general pediatric examination in boys
    examination of the testicular position!
  • US high false-negative rate! (testis present
    despite negative ultrasound)
  • CT (irradiation!) MRI
  • selective diagnostic laparoscopy ? orchidopexy or
    orchiectomy

28
CONGENITAL TESTIS
  • Treatment
  • early (8-12 months) ? ? risk of infertility,
    malignancy (10-46?) and testicular torsion
  • hormonal treatment ? induction of testicular
    descent and stimulation of germ cell maturation
    and proliferation
  • hCG
  • GnRH (Kryptokur) nasal spray 1.2 mg/d,28 d,
    followed by hCG 1,500 IU/wk, 3 wks
  • LHRH analog (Buserelin) nasal spray
  • early orchiopexy ( 1 year)
  • postpubertal orchiectomy

29
INJURIES TO THE G-U TRACT
  • EMERGENCY DIAGNOSIS MANAGEMENT
  • 10 of all injuries
  • initial assessment control of hemorrhage and
    shock, along with resuscitation (i.v. lines and
    urethral catheter blood at the urethral
    meatus?)
  • history detailed description of the accident (?
    gunshot wounds type and caliber)
  • examination of abdomen and genitalia
  • contusions or subcutaneous hematomas
  • fractures of the lower ribs and/or the bony
    pelvis
  • diffuse abdominal tenderness

30
INJURIES TO THE G-U TRACT
  • SPECIAL EXAMINATIONS
  • Catheterization and Assessment of Injury
    (Staging)
  • catheterization blood at the urethral meatus in
    men ? urethral injury ? catheterization should
    not be attempted, but retrograde urethrography
    no blood ? urethral catheter ? ? microscopic or
    gross hematuria
  • abdominal CT with contrast media
    retroperitoneal hematoma, renal lacerations,
    urinary extravasation, renal arterial and venous
    injuries, intra-abdominal injuries (liver,
    spleen, pancreas, bowel)
  • retrograde cystography ( 300 mL) ? bladder
    perforations
  • retrograde urethrography (12 F/3 mL) 20 mL

31
INJURIES TO THE G-U TRACT
  • Catheterization and Assessment of Injury
    (Staging)
  • arteriography renal parenchymal and vascular
    injuries, persistent bleeding from pelvic
    fractures ? embolization with Gelfoam or
    autologous clot
  • IVU detect renal and ureteral injury
  • Cystoscopy and Retrograde Uretero-Pyelography
  • seldom necessary
  • Abdominal Sonography
  • if CT not available

32
INJURIES TO THE KIDNEY
  • the most common injuries of the urinary system
  • pathologic kidneys (hydronephrosis, malignant
    tumors etc.) are more readily ruptured from mild
    trauma
  • Etiology
  • blunt trauma to the abdomen, flank or back (85)
  • rapid deceleration ? can cause major vascular
    injury
  • gunshot and knife wounds ? penetrating injuries
  • associated abdominal visceral injuries are
    common!
  • Pathology Classification
  • early pathologic findings grade
  • 1 renal contusion or bruising of the renal
    parenchyma ? microscopic hematuria

33
INJURIES TO THE KIDNEY
  • 2 renal parenchymal laceration into the cortex
    ? small perirenal hematoma
  • 3 renal parenchymal laceration extending
    through the cortex and into the medulla ?
    significant bleeding, large retroperitoneal
    hematoma
  • 4 renal parenchymal laceration extending into
    the collecting system main renal artery
    thrombosis from blunt trauma, segmental renal
    vein or both artery injury with contained
    bleeding
  • 5 multiple grade 4 parenchymal lacerations,
    renal pedicle avulsion or both main renal vein
    or artery injury from penetrating trauma
  • late pathologic findings urinoma,
    hydronephrosis, arteriovenous fistula, renal
    vascular hypertension

34
INJURIES TO THE KIDNEY
  • late pathologic findings urinoma,
    hydronephrosis, arteriovenous fistula, renal
    vascular hypertension
  • Clinical Findings Indications for Studies
  • some cases of renal vascular injury
    (deceleration) are not associated with hematuria
    ? imaging studies
  • the degree of renal injury does not correspond to
    the degree of hematuria
  • gross hematuria or microscopic hematuria with
    shock (systolic BP lt 90 mm Hg) ? imaging studies
  • symptoms pain (flank or over the abdomen),
    hematuria, abdominal distention, ileus, nausea
    and vomiting (retroperitoneal bleeding )

35
INJURIES TO THE KIDNEY
  • signs shock or signs of a large loss of blood
    (heavy retroperitoneal bleeding), ecchymosis in
    the flank or upper quadrants of the abdomen,
    lower rib fractures, diffuse abdominal tenderness
  • "acute abdomen" free blood in the peritoneal
    cavity
  • palpable mass large retroperitoneal hematoma or
    urinary extravasation (torn retroperitoneum ?
    free blood in the peritoneal cavity, but no
    palpable mass)
  • laboratory microscopic or gross hematuria,
    anemia (acute or chronic)
  • staging ? systematic approach
  • abdominal CT scan ? parenchymal lacerations,
    urinary extravasation, extent of the
    retroperitoneal hematoma, nonviable tissue,
    injuries to surrounding organs
  • arteriography major arterial and parenchymal
    injuries

36
INJURIES TO THE KIDNEY
  • Complications
  • early hemorrhage (persistent retroperitoneal
    bleeding or heavy gross hematuria), urinary
    extravasation (urinoma) ? abscess formation
    sepsis
  • late hypertension, hydronephrosis,
    arteriovenous fistula, calculus formation,
    pyelonephritis, heavy late bleeding !
  • Treatment
  • emergency measures prompt treatment of shock
    and hemorrhage, complete resuscitation and
    evaluation of associated injuries
  • surgical measures
  • blunt trauma (lt 5) persistent retroperitoneal
    bleeding, urinary extravasation, nonviable renal
    parenchyma and renal pedicle injuries
  • penetrating injuries surgically explored
    (associated organ injury)

37
INJURIES TO THE KIDNEY
  • complications
  • retroperitoneal urinoma or perinephric abscess ?
    surgical drainage
  • malignant hypertension ? vascular repair or
    nephrectomy
  • hydronephrosis ? surgical correction or
    nephrectomy

38
INJURIES TO THE URETER
  • rare, during difficult pelvic surgical
    procedures, gunshot wounds, rapid deceleration
    accidents (avulsion of the ureter from the renal
    pelvis), endoscopic procedures (ureteroscopies,
    basket manipulation of ureteral calculi)
  • flank abdominal pain, nausea, vomiting, ileus
    vaginal or cutaneous fistula
  • imaging IVU, CT scan
  • Treatment prompt repair (if stenting not
    feasible)
  • immediate ureteroureterostomy,
    transureteroureterostomy, reimplantation into the
    bladder, autotransplantation of the kidney, bowel
    replacement of the ureter stenting
  • late percutaneous nephrostomy, then repair

39
INJURIES TO THE BLADDER
  • occur most often from external force and are
    often associated with pelvic fractures
  • iatrogenic injury gynecologic and surgical
    extensive pelvic procedures and transurethral
    operations
  • Pathogenesis Pathology
  • extraperitoneal pelvic fractures ?
    extraperitoneal rupture ? urine extravasation ?
    deep pelvic abscess
  • intraperitoneal ? acute abdomen (peritonitis)
  • Clinical findings
  • KUB pelvic fractures
  • CT scan
  • retrograde cystography

40
INJURIES TO THE BLADDER
  • Treatment
  • shock hemorrhage treatment
  • extraperitoneal urethral catheter drainage (10
    d) cystoraphy
  • intraperitoneal transperitoneal approach,
    cystoraphy, bladder peritoneal drainage

41
INJURIES TO THE URETHRA
  • INJURIES TO THE POSTERIOR URETHRA
  • pelvic fractures from blunt trauma ? the
    membranous urethra is sheared from the prostatic
    apex ? acute retention of urine
  • retrograde urethrogram
  • treatment suprapubic cystostomy, delayed
    urethral reconstruction
  • INJURIES TO THE ANTERIOR URETHRA
  • straddle injury, self- or iatrogenic
    instrumentation
  • urethral bleeding retention of urine
    retrograde urethrogram
  • urethral contusion ? no instrumentation or
    urethral catheter
  • urethral laceration ? suprapubic cystostomy,
    delayed retrograde urethrography, no further
    instrumentation or urethral catheter or
    urethroplasty
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