TRAUMA UROGENITALAnatomi GinjalUreterBuli buliUretra

TRAUMA UROGENITALAnatomi GinjalUreterBuli buliUretra

GinjalSepasang organ seperti kacang Terletak retroperitonel diregio lumbal superiorDilapisi oleh 3 lapis jaringan penunjang: kapsul ginjal kapsul adipose dan fasia renalis

UreterTubulus muscular yang menghubungkan ginjal ke buli buliTerletak di belakang rongga peritoneum (retroperitoneal)Panjang 25 30 cm

TRAUMA GINJALTrauma Ginjal Sering 8-10% trauma tumpul / tajam abdomen Separuh dari kejadian trauma urogenital Di proteksi :* Otot-otot lumbal* Iga* Vertebrae

Angka kesakitan / kematian ok trauma ginjal tergantung :

Derajat traumaKeterlibatan trauma organ lainFasilitas penanggulangan trauma

Buli-buliBuli buli normal dapat menampung 350 450 mL urineDrainase kendung kemih bermuara ke vena iliaca interna

UretraTabung yang menyalurkan urine ke luar dari buli-buli Secara anatomis uretra dibagi menjadi 2 bagian : Uretra posterior dan Uretra anterior

Mekanisme TraumaTrauma tumpul -> penyebab trauma Langsung, tidak langsung

Trauma tumpul langsung KLLOlah ragaKecelakaan kerjaPerkelahian

Trauma tumpul tidak langsung

* Jatuh dari ketinggian* KLL menyebabkan pergerakan ginjal tiba-tiba dlm rongga retro peritonium Avulsi pedikel ginjal Robekan tunika intima

Bisa juga oleh trauma iatrogenikPemasangan kateter di atas ureterPengambilan biopsi ginjalInfeksi tidak langsung

Klasifikasi* Ada beberapa macam* Ditentukan oleh luas dan penatalaksanaan

Cedera Ginjal* Minor* Mayor* Vaskuler

Cedera Minor 90% trauma ginjal Kontusio ginjal Laserasi parenkim superficial

Cedera MayorLaserasi korteks, medula tanpa ekstravasasiLaserasi korteks, medula dengan ekstravasasi

Cedera VaskulerAvulsiTrombosis

Berdasarkan AAST ( American for The Surgery of Trauma )

Berdasarkan AAST( American for The Surgery of Trauma )Dibagi 5 derajatDerajat 1 Kontusio ginjal /subkapsularhematomTidak meluasHematuria dengan normal imaging

Derajat 2 Hematom perinealTdk meluas ke retroperitoniumLaserasi superficial ( < 1cm )Tdk melibatkan collecting systim Derajat 3Renal laserasi ( > 2cm )Sub capsular hematomPerinephric hematomTdk melibatkan collecting systim

Derajat 4Laserasi yang meluas ke collecting systimExtravasasiTrauma vasculer segmental infark

Derajat 5Shattered kidneyDevaskularisasi / oklusi / trombosis arteri / vena utamaLaserasi komplitExtravasasiUPJ avulsi

Pemeriksaan Radiologi

Foto polos abdomenIVP ( Intra Vena Pyelografi )USG ( Ultra Sonographi )CT Scan abdomen / Whole abdomenuretrocistografi

IVP* Melihat ekstravasasi urin / kontras* Tidak bisa mendeteksi trauma ginjal derajat I, II* Fungsi ginjal kontra lateral

USG* Melihat hemoperitoneum* Tdk dianjurkan utk evaluasi trauma ginjal* Dengan color doppler melihat vaskuler

CT ScanPemeriksaan yang sensitif dan spesifikMenentukan derajat traumaTidak invasifDpt mengevaluasi organ lain ( hepar , lien , aorta ) kontras non kontras

AngiografiInvasifDelayed renal bleeding-pseudo-aneurisma

IVP normal

USG ginjal normal

CT scan ginjal normal

Gambar 1. Kidney trauma. Absent nephrogram. Abdominal radiograph after intravenous contrast administration in a patient with hypotension after a motor vehicle collision shows absent right nephrogram

Gambar 2. Kidney trauma. Grade 3 renal laceration on abdominal radiograph. Abdominal radiograph after intravenous contrast administration shows very diminished left nephrogram and no urinary contrast extravasation

Gambar 3. Kidney trauma. Grade 5 renal injury. Shattered kidney with renal vein thrombosis (incomplete). Abdominal radiograph after intravenous contrast administration shows absent right nephrogram

Gambar 4 Kidney trauma. Grade 1 renal injury, contusion. Image from a contrast-enhanced CT scan of the abdomen in a patient with hematuria after a motor vehicle collision shows ill-defined area of hypoenhancement in the medial right kidney.

Gambar. 5. Kidney trauma. Grade 1 renal injury, subcapsular hematoma. CT scan of the abdomen with intravenous contrast in a patient after a motor vehicle collision shows crescentic high-density fluid collection around the left kidney. Note the well-defined outer margin

Gambar 6. Kidney trauma. Grade 1 renal injury, subcapsular hematoma. CT scan of the abdomen with intravenous contrast in a patient after a motor vehicle collision; shows crescentic high-density fluid collection around the left kidney. Note the well-defined outer margin and the mild deformity of the renal parenchyma

Gambar 6. Kidney trauma. Grade 2 renal injury, subcapsular and perinephric hematomas. Contrast-enhanced CT scan of the abdomen on a patient with hematuria after a motor vehicle collision shows an ill-defined fluid collection in the left perinephric space. There is also a subcapsular hematoma with deformity of the renal parenchyma Derajat II dan III

Gambar 7 Kidney trauma. Grade 2 renal injury, perinephric hematoma. Contrast-enhanced CT scan of the abdomen on a patient with hematuria after a motor vehicle collision shows an ill-defined fluid collection in the left perinephric space

Gambar 8. Kidney trauma. Grade 3 renal laceration with normal one-shot intravenous pyelogram. CT scan through the kidneys after intravenous contrast on the same patient as in Image 1 shows renal laceration and perinephric hematoma.

Gambar 9 Kidney trauma. Grade 2 renal laceration. Contrast-enhanced CT scan of the abdomen after a motor vehicle collision shows a superficial (less than 1 cm deep) renal parenchymal defect with a large perinephric hematoma

Gambar 10. Kidney trauma. Grade 2 renal laceration. Delayed image shows no urinary contrast extravasation. Contrast-enhanced CT scan of the abdomen after a motor vehicle collision shows a superficial (

Gambar 11. Kidney trauma. Grade 3 renal laceration. CT scan of the abdomen after intravenous contrast administration shows irregular nonenhancing renal parenchymal defect with extension greater than 1 cm deep to near the renal pelvis. no urinary contrast extravasation

Gambar 12. Kidney trauma. Grade 3 renal laceration. CT scan of the abdomen after intravenous contrast administration shows irregular nonenhancing renal parenchymal defect with extension greater than 1 cm deep to near the renal pelvis. This delayed image showed no urinary contrast extravasation.

Derajat IVGambar13 Kidney trauma. Grade 4-5 renal injury. Lacerations extending to the collecting system. Contrast-enhanced CT scan of the abdomen in a patient with hematuria after a motor vehicle collision shows deep lacerations extending into the collecting system of the right kidney. Extension into the collecting system is confirmed by urinary contrast extravasation on delayed image through the kidney in excretory phase

Gamba14. Kidney trauma. Grade 4-5 renal injury. Lacerations extending to the collecting system. Contrast-enhanced CT scan of the abdomen in a patient with hematuria after a motor vehicle collision shows deep lacerations extending into the collecting system of the right kidney (Image 22). Extension into the collecting system is confirmed by urinary contrast extravasation on this delayed image through the kidney in excretory phase

Gambar 15. Kidney trauma. Grade 4 renal injury segmental infarction. Contrast-enhanced CT scan of the upper abdomen shows a segmental area of nonenhancement in the upper medial left kidney without associated renal laceration

Gambar 16. Kidney trauma. Grade 4 renal injury segmental infarction. Contrast-enhanced CT scan of the upper abdomen in another patient after a motor vehicle collision shows a segmental area of nonenhancement in the upper medial left kidney without associated renal laceration

Derajat VGambar 17. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-enhanced CT scan of the abdomen in a patient with hematuria and hypotension after a motor vehicle collision shows transection of the right kidney with a large hematoma around and between the 2 halves of the kidney. The 2 halves are both perfused because there were 2 renal arteries Delayed images show urinary contrast extravasation

Gambar 18. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-enhanced CT scan of the abdomen in a patient with hematuria and hypotension after a motor vehicle collision shows transection of the right kidney with a large hematoma around and between the 2 halves of the kidney. The 2 halves are both perfused because there were 2 renal arteries. Delayed images show urinary contrast extravasation

Gambar 19 Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-enhanced CT scan of the abdomen in a patient with hematuria and hypotension after a motor vehicle collision shows transection of the right kidney with a large hematoma around and between the 2 halves of the kidney. The 2 halves are both perfused because there were 2 renal arteries Delayed images show urinary contrast extravasation

Gambar 20. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-enhanced CT scan of the abdomen in a patient with hematuria and hypotension after a motor vehicle collision shows transection of the right kidney with a large hematoma around and between the 2 halves of the kidney. The 2 halves are both perfused because there were 2 renal arteries. Delayed images show urinary contrast extravasation

Gambar 21. Kidney trauma. Grade 5 renal injury. Shattered kidney with renal vein thrombosis (incomplete). CT scan of the abdomen with intravenous contrast administration shattered right kidney and renal vein thrombus extending slightly into the inferior vena cava

Gambar 22. Kidney trauma. Normal ultrasound with grade 5 renal injury. Ultrasound gray-scale image of a patient involved in a motor vehicle collision shows what appears to be a normal right kidney

Gambar 23 Kidney trauma. Grade 5 renal injury. Color Doppler ultrasound of same motor vehicle collision patient as in Image 4 shows no blood flow within the right kidney.

4.ArteriografyGambar 24. Kidney trauma. Active vascular contrast extravasation. Catheter angiography during arterial phase on the same patient as in Image 40 shows a small pseudoaneurysm at the lower pole

gambar 25. Kidney trauma. Active vascular contrast extravasation. Catheter angiography during nephrographic phase in the same patient as in Image 41 shows a small pseudoaneurysm at the lower pole

gambar 26. Kidney trauma. Active vascular contrast extravasation. Pseudoaneurysm at the lower pole in the same patient as in Image 42 was embolized by using a coil.

Trauma UreterUreter jalur transportasi dari ginjal ke buli-buliTrauma ureter mengganggu fungsi ginjal

Trauma mengenai pinggang, punggung resiko mengenai ureterok * Lokasi terlindungi * Ukuran kecil * Mobilitas / fleksibel trauma ureter jarang

Etiologi

Trauma Luar a. Tajamb. TumpulIatrogenik a. Ginekologisb. Pembedahan rektumc. Endoskopi

Pemeriksaan Radiologi

IVP ( Intra Vena Pyelografi )RPG ( Retro Grade Pyelografi )USG ( Ultra Sono Grafi )CT Scan Abdomen

Trauma Vesika Urinaria

Disebabkan : Trauma- Tumpul- Tajam- IatrogenikDidaerah pelvis / abdomen bawah/ perineum 60-85 % trauma tumpul 15-40 % trauma tajam

Ruptur vesika urinaria : keEkstra peritoneumIntra peritoneumKeduanya

Kontusio Vesika UrinariaSobekan sebagian mkosa vesika urinariaDinding memar hematom

Pemeriksaan :SistografiCT scan abdomen - pelvis

Kontusio Vesika UrinariaNormalTear DropMudah sembuh

Ruptur Vesika UrinariaTerlihat ekstravasasi kontras- ekstra peritonial- intra peritonialDengan CT Scan dpt juga mengevaluasi organ lain

Pear shaped appearance

TRAUMA URETRA

Uretra laki-laki lebih panjang dari wanitaDihubungkan dgn trauma daerah pelvis yg cukup berat

EtiologiTrauma tumpulTrauma tembusIatrogenik

AnatomiUretra posterior * uretra prostatika* uretra membranosaUretra anterior 3 segmen : * pars bulosa * pars pendulans * pars glanularis sampai ke meatus uretra externa

Diagnosa

Berdasarkan gejala klinikPemeriksaan penunjang radiologiRUG ( Retrograde Uretrografi )

Klasifikasi trauma uretra Hasil RUGKlasifikasi Gold Man yaitu :Berdasarkan Kerusakan Anatomi

Ada 5 tipeTipe 1

. Ruptur ligamentum puboprostatika. Prostate bergeser ke posterior. Uretra tetap intak. Tdk ada extra vasasi zat kontras

Tipe 2

Trauma uretra posterior & diafragma urogenitalTerlihat extravasasi kontras dlm pelvis extra peritonealZat kontras tdk ada dalam perineum

Tipe 3

Tipe yang sering Kerusakan meluasTerlihat extravasasi kontras pada rongga pelvis extra peritoneal dan perineum

Tipe 4

Terjadi dekat buli-buli meluas ke uretra proximalExtravasasi kontras pada pelvis extra peritoneal & sekitar proximal uretraDapat merusak sfingter uretra interna

Tipe 5

Terjadi di uretra anteriorTerlihat extravasasi kontras bagian inferior diafragma urogenital

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