Pediatric urological emergencies - PowerPoint Presentation

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Pediatric urological emergencies

Traumatic

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Rapid assessment and management of urological emergencies are essential to preservation of urological health

Children with acute abdominal pain sholud be evaluated immediately

Failure

to recognize true urologic emergencies may result in renal failure, organ damage, or loss of sexual

function

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Classification

Traumatic

Renal trauma

Ureteral injury

Bladder traumaUrethral injuryPenile traumaTesticular trauma

Non traumatic

Congenital malformation

Hematuria

R

enal colic

Urinary retention

Obstructive pyelonephritis

Acute scrotum

Paraphimosis

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Renal trauma

Accounts for greater than 60% of the pediatric genitourinary injuries

80-85% blunt trauma

Penetrating trauma – associated abdominal visceral injuries

Mechanism of trauma : motor vehicle collision, fall from height, direct blow to the torso, sport injury,...

Pediatric kidney is more susceptive to trauma (more pliable thoracic cage, weaker abdominal musculature, less perineal fat, sits in a lower position)Rarely occurs in isolation (often associated with liver, spleen, closed head, orhopedic injuries)

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Renal injury – clinical manifestation :

Pain localized to one flank area or over the abdomen

Gross or microscopic hematuria

!

Renal injury

can be present even without hematuria. The

degree

of hematuria does not correlate with degree of

injury

!

Ecchymosis in the flank or upper quadrants of the abdomen

Palpable mass (retroperitoneal hematoma or urinary extravasation)

Abdominal tenderness

Fractured ribs

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Grading (The American Association for the Surgery of Trauma grading

system

)

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GRADE I

 – Contusion or non-expanding sub capsular hematoma

GRADE II

 – Non-expanding perinephric hematoma < 1cm deep

GRADE III

 – Hematoma >1cm in depth. No urine extravasation.GRADE IV – Laceration involving collecting system. Segmental vein/artery injury. Renal pelvis laceration or complete ureteric pelvic disruption. “Shattered kidney“

GRADE V

 – Main renal vein/artery laceration or avulsion of main artery or thrombosis of renal vein.

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Renal injury - Imaging options

CT

with IV contrast

Gold standart method

Detects all grades of injuries and associated injuriesIdeally a “Four-phase” CT with IV contrast that images the arterial,

nephrographic

, and

pyelographic

phases

Functional details

CT findings alone 

do NOT determine

managemen

t

Ultrasound 

-

U/S

with Doppler

 can be used for those with 

very mild trauma and lower suspicion

 for significant

injury.

- non invasive low cost way of detecting peritoneal fluid

- can detect renal laceration (NOT depth and extent)

-

U/S

cannot distinguish

extravasated

urine from blood.

-

U/S

cannot image the vascular pedicle well

.

 

- better for the follow up and checking resolution of hematomas

Angiography

or intraoperative IV Urography are also tools to image in certain cases

.

MRI – not used routinely, longer imaging time

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Renal contusion

Superficial laceration

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Subcapsular hematoma

Complete renal laceration

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Management

Overall, renal trauma in children is 

managed conservatively

, even with higher grade

injuries

These higher grade injuries require a careful, tailored approach to each individualSurgery is recommended for

h

emodynamically

 

unstable patient and

with

severe intra-abdominal 

PENETRATING

 injuries

.

Surgery or interventional radiology may be required

for

: m

assive

urinary

extravasation

,

e

xtensive

(>20%) nonviable

tissue

,

Arterial injury

,

Incomplete

staging

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Complications

Urine

extravasation

-

Most common complication of Stage IV injuriesUrinomaMay be acute, or present weeks-months later.Pain, fever, ileus, and palpable mass may be signs

Perinephric

abscess

-

Rare

complication

Secondary hemorrhage

Delayed bleeding occurs in 13-25% of Grade III-V injuries

Usually seen in first 2-3 weeks after trauma

AV fistula formation

Rare and exclusively from stab wounds

Pseudoaneurysm

Impaired renal function

Hypertension

-

Still

controversial

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Ureteral injury

External trauma (20%) – associated with renal and bladder injuries, penetrating, blunt trauma (deceleration injury)

Surgical injury (80%) – iatrogenic, pelvic surgical procedure, endoscopic manipulation

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Ureteral injury – clinical features

peritonitis, pain, fever, paralytic ileus

Hematuria – poor sensitivity

hydronephrosis

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Ureteral injury - Investigation

IVP, CT

Ureteral dilatation, deviation

Delayed or no visualisation of renal unit

Urinary/contrast extravasation

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Ureteral injury - reconstruction

Reimplantation of proximal end of ureter on bladder

Primary uretero ureterostomy

Transureteroureterostomy

Ileal interposition flap

Permanent cutaneous flap

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Bladder trauma

Causes : road traffic accidents, blow, kick or fall, stabs, gunshot injuries, diathermy, iatrogenic injuries

Classic triad : suprapubic pain, difficulty passage of urne, hematuria

Classification : intraperitoneal/extraperitoneal

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Intraperitoneal rupture

Occcurs due to blow, kick or fall

Blunt trauma more likely to result in intraperitoneal rupture in children than adults (pediatric bladder is more intraperitoneal)

Bladder needs to to be fully distended

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Intraperitoneal rupture - clinical features

Sudden pain in suprapubic region

Shock and syncope

Diffuse abdominal pain

Abdominal distension

Lately : peritonitis, guarding rigidity, rebound tenderness

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Extraperitoneal bladder rupture

The most common type

It occurs commolnly in a non distended bladder

Occurs secondary to adjent pelvic fracture

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Extraperitoneal injury – clinical features

Blood and urine in the extraperitoneal space

Suprapubic tendernees and pain

Scrotal swelling

Inability to micturate

Associated with other injuries

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Investigation

Plain x-ray (ground glass appearance, fractured pelvis)

Peritoneal tap (conformed presence of urine)

Cystography (leak from the bladder)

U/S

CT scan

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Treatment

Emergency laparotomy

Catheter drainage

Bladder is needed to be sutured in two layers

Peritoneal and estraperitoneal wash, prevesical scape and peritoneal cavity are drained

Adequate specific antibiotics (to prevent sepsis)

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Complications of bladder injury

UTI (cystitis, pyelonephritis)

Peritonitis, pelvic abscess

Vesicovaginal or retrovesical fistula

Paralytic ileus

Haemorrhage

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Urethral injury

Rare (short and mobile urethra, protected by the pubic bone)

Urtethral injury account for 3,4% of the children with traumatic injuries

Mainly occur with pelvic fractures

Straddle injuries (blow to the perineum)

In males the urethra is divided into the anterior and posterior part (urogenital diaphragm)The posterior urethra consists of the membranous and the prostatic urethraThe anterior part is formed by the bulbar and penile urethra

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Classification of urethral injury

Anterior /Posterior

Depending on circumference of the urethral wall : Complete/incomplete

Depending on the thickness of the urethra : total/partial

Goldman classification – based on the results of retrograde urethrography

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Goldman classification

type I:

 stretching of the posterior urethra due to disruption of puboprostatic ligaments, though the urethra is intact

type II:

 posterior urethral injury above urogenital diaphragm

type III: injury to the membranous urethra, extending into the proximal bulbous urethra (i.e. with laceration of the urogenital diaphragm)type IV: bladder base injury involving bladder neck extending into the proximal urethrainternal sphincter is injured, hence the potential for incontinence

type IVa:

 bladder base injury, not involving bladder neck (cannot be differentiated from type IV radiologically)

type V:

 anterior urethral injury (isolated)

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Goldman classification

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Anterior urethral injuries

blunt trauma, straddle-type injuries,

predominantly in boys, mostly the bulbous urethra is compressed between the object and symphysis

Clinical features :

1.blood in external meatus

2.perineal, scrotal and labial haematoma3.retention of urine

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Therapy

Patient should be told not to try to micture (extravasation of urine!)

Gentle attempt of urethral catheterization. If able to pass, it is left in place

If catheter fails to pass, suprapubic cystostomy is done

antibiotics

reconstruction - bulbous urethra is exposed throught perineal midline incisionPerineal urethrostomy – if is not possible to suture the tear

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Posterior urethral injuries

linked with pelvis fractures (road traffic accidents, falls from height), during instrumentation (catheterisation)

boys have predisposition for complete posterior urethral rupture (intraabdominal location of the bladder, more cranially placed prostate)

Clinical features : blood in external meatus

failure in passing urine extravasation of urine

„floating prostate“

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Therapy

The extent and depth of the traumatic posterior urethral distraction defect, with or without involvement of the external sphincter complex, is frequently difficult to predict before surgical

intervention

Transpubic urethroplasty

Bulboprostatic anastomosis from perineal approach

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Diagnosis

Clinical assesment : presence of pelvic fracture, straddle injuries, penetrating trauma close to urethra, blood on meatus, hematuria, hematoma – typical butterfly configurationof the hematoma on perineum, scrotal enlargement or labial swelling

CT – complex analysis of the entire involved bone structure and soft tissue organs

MRI -

evaluating posterior urethral injuries and estimating the length of the urethral obliteration as well as the degree of fibrosis of the external sphincter

complexRetrograde uretrography - gold standard method, able to reveal foreign bodies

Anterograde cystourethrogram - in posterior urethral ijnuries

USG - with insufflation of saline solution distending the lumen

Cystoscopy – therapeutic transurethral splinting

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Retrograde urethrogram with extravasation of contrast agent

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The management of the urethral trauma remains controversial largely because of the limited expertise of most pediatric

urologists.

The

aim of therapy should be to minimize remote damages such as

urethrocutaneous

fistula, periurethral diverticula, urethral stricture, incontinence and impotence.

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Penile injuries

Penile injuries in children can be due to several causes: traffic accidents, iatrogenic trauma, animal bite, electrocution, zipper injuries and hair

strangulation

trivial or more severe

Functional and psychosocial consequences

Fracture of penis – disruption of the tunica albuginea with ruptute of corpus cavernosus

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Testicular injury

Mechanism : direct blow, straddle injury, penetrating injury

Haematocele

Haematoma

Testicular rupture, laceration

Traumatis epididymitisTesticular dislocation/torsionClinical features : pain, bruising, swelling, haematuria

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Hematoma

Usually focal, may be multiple

US : Difficult to identify, may appear isoechois or may have a diffusely heterogenous echotexture

Color Dopler imaging helps differentiate hematomas from tumors

Large testicular hematoma may need drainage

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Hematocele

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Hematocele

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Hematocele

Blood within tunica vaginalis – collection that separate the visceral and parietal layers

Most common finding in the scrotum after blunt injury

May represent severe testicular injury

Acute onset of a large hematocele may result in reduced blood flow to the testes (extrinsic pressure on the vessels)

Investigation : USG (blood is more echogenis than fluid)Treatment : surgical exploration, drain, repair of rupture

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Testicular rupture

More than 80% of ruptured testes can be salvaged, if surgical repair is performed within 72 hours of injury

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Thank you!