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URETHRAL TRAUMA
(Brown & Martindale, Jou of Trauma, 2008)
SUB BAGIAN UROLOGIBAGIAN / SMF BEDAHFK UNS/RSUD Dr. MOEWARDI
POSTERIOR URETHRAL INJURY
Is not common associated with pelvic fracture Most patients best treated by SPC for 3 month, then end to
end anastomotic urethroplasty
Mechanism of injury : Fracture pelvic 90 %, 5 – 10 % associated urethral injury 60 % posterior urethral injury are complete rupture, 40 %
incomplete Impotence occurs 10 – 20 % of pelvic fracture injury, and
about half with urethral rupture
Diagnosis and imaging : Blood at the external urethral meatus Imaging : urethrography
MANAGEMENT
Immediate management in pelvic fracture and injuries to the posterior urethra is controversy
◦ Primary realignment, primary repair ◦ Delayed primary repair a few days later◦ Delayed primary realignment a few days later◦ Suprapubic catheterization, repair 3 month or so
later
Early surgery for ruptured posterior urethra :Traditional treatment “railroading” (open
surgical procedure, endoscopically) Stricture rate 70 %Open railroading complication :
Impotence, incontinence, infection, bleedingPrimary repair by end to end anastomosis
Delayed primary repair and realignment for rupture posterior :
Indication for the distracted “pie-in-the-sky” bladder
Evacuation of the haematoma Open or endoscopic realignment
Delayed surgery for rupture posterior urethra :Suprapubic catheterization for 3 month
is the GOLD STANDARD of treatment follow by end to end anastomosis
Suprapubic catheterization and delayed uretheoplasty cause the least harm
10 - year stricture-free survival 90 %
Complication
Impotence2.6 to 75 % after pelvic fracture42 % with urethral injury, 5 % withouth urethral
injury22.5 % after suprapubic inwelling catheterization 42 % after railroading procedureCause damage the neurovascular bundle (80-85
% vascular)
IncontinenceMechanism : destroyed or non function of the
urethral sphincter
ANTERIOR URETHRAL INJURY
The incidence is relatively low compare to the posterior urethra
Mechanism of injury :Due to instrumentation iatrogenic, self-
inflected, contusionBlunt trauma : straddle- type injuryGunshout, stab wounds
Mechanism and Imaging
History presence urethral injuryPresent the blood at the meatus (OUE)Inability to voidDysuria HematuriaButterfly hematoma
Butterfly
hematoma
(Sullivan & Morgan, 2004)
Retrograde Urethrography :
Normal urethrography diagnosis contusion
Contrast extravasation and some contrast reaching the bladder partial disruption
Contrast extravasation without contrast reaching the bladder complete disruption
Management
Catheterization the protocol in severely injury patient by the trauma team during primary resuscitation
Not catheterization partial tear covert to complete
Initial management :1. Adequate drainage of urin 2. Minimize potential complication (stricture, fistula,
infection)
Stable patient retrograde urethrogram
Unstable patient pass catheter can be made, suprapubic catheterization stable retrograde study
Partial tear suprapubic or urethral catheterization, 2 weekly interval urethrogram
Stricture manage direct visual uretrotomy
Blunt trauma complete disruption suprapubic catheterization urethroplasty 3-6 months
SCROTAL EMERGENCY
(Zomorrodi et al, Int. Med J Vol. 6, 2007)
Etiology Acute Scrotal
(Sullivan & Morgan, 2004)
Torsion of the testicle is a urological emergency the risk testiculer loss
Can occur at any age, most common during adolescent (12 – 18; peak 14 – 16 years old)
In adult the torsion is intravaginal, in neonates is extravaginal
Left testes more frequently than the right ( 6 : 4 ), bilateral < 1 %
Common in cold weather due to cremasteric contraction
When torsion occurs venous blood supply obstruction secondary edema and hemorrhage subsequent arterial obstruction testicular necrosis
Degree and duration of torsion affect the severity ischemic damage
Extravaginal Torsion
First describe by Tailor (1897) , can occur pre-postnatally 75 % prenatally and 25 % postnatally within 30 days of birth
Present hard scrotal mass at time delivery
Some infants have oedematous, erythematous scrotum, inflammatory reaction surrounding area
The diagnosis depend on physical examination
Rarely neonates with normal postnatal examination then found swollen tender testes in 1 month of life
Management
The management is controversial
Some surgeons no exploration
Exploration and fix the contralateral testes
Methode of on fixation of the contralateral testes debatable
The three – points fixation using monofilamentous non-absorbable has been recomended
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