Download Imaging of trauma in urinary system

Imaging of trauma
in urinary system
Dr Wong See Yin
QEH 2
Mohamed Ali
Alabbar
Adrian D. Smith
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OUTLINE
• Introduction
• Indication
• Modalities
• Special situation
• Conclusion
INTRODUCTION
• 8-10% of trauma associated with renal injury.
• 80-90% of cases involve blunt injury.
• 75-80% of patient with renal injury has multiorgan
involvement.
• 98% of isolated renal injury is minor.
• 95% of renal trauma patients have hematuria (>5 RBC
phf)
• Most trauma is blunt trauma with motor
vehicle accident (MVA) being the most
common cause, others include direct blow to
the flank / abdomen..
In Sabah….
INDICATION
There is injury scoring for..
• Adrenal organ
• Ureter
• Bladder
• Urethral
• Uterus (non pregnant)
• Uterus (pregnant)
• Fallopian tube
• Ovary
• Vagina
• Vulva
• Testis
• Scrotum
• Penis
American Assciation for Surgery of Trauma (AAST)
MODALITIES
• Ultrasound
• CT
• Radiography
• Angiography
Ultrasound
• US is highly sensitive for the detection of free
intraperitoneal fluid but not sensitive for identification
of organ injuries. In hemodynamically stable patients,
the value of US is mainly limited by the large
percentage of organ injuries that are not associated
with free fluid.
Radiology, 2003, Apr;227 (1): 95-103. Epub 2003 Feb 28. Blunt abdominal trauma:
should US be used to detect both free fluid and organ injuries? Poletti et al
FAST
•
Some studies have reported sensitivity of detected renal lesions to be as
low as 22%.
•
In summary, role of FAST in blunt trauma:
– Hemodynamic instability in pts with possible result warrant surgery, if
indeterminate leads to complete US or CT
– Hemodynamic stable pts with positive or indeterminate result should
undergo CT
– Hemodynamic stable pt with negative result may be followed up by FAST/
complete US in 6 hrs to confirm absence of injury
• (no concensus on indication on US, intervals and no. of negative results before patients
can be safely discharged, thus CT may still be needed)
CT
• CT is the gold standard examination in renal
trauma and has completely replaced IVP.
• CT can assess:
– Parenchymal lacerations
– Vascular injuries
– Perinephric hematomas
– Extravasation of contrast enhanced urine
– Associated injury
CT protocol
• Administer 75-100mLs of LOCM 300mgI/ml
• Scan time: 45-60 secs (parenchymal laceration,
devascularised fragment, vessels injury)
• ROI: above diaphragm till pelvis
• Delayed 5 mins for assessment of pelvicalyceal
system injury
Courtesy of Radiographic journal
Courtesy of Radiographic journal
CT cystography
• Drain bladder via Foley’s catheter
• Make contrast solution (50 mls in NS)
• Instill contrast via Foley’s catheter till
• Flow stops with a bag 40 cm above patient
• 350-400 mls instilled
• Patient unable to tolerate
• Image pelvis
www.radiologyassistant.com
• Why we don’t inject contrast into urinary
bladder the same time as IV contrast?
• Is there a need to perform additional CT
cystogram?
• …whether contrast is due to urinary bladder
rupture or vascular extravasation?
• This patient is in need of urgent embolization
without delay.
Radiography
• Single shot IVU
• Retrograde urethrography/ Voiding
cystourethrography
Single shot IVU
• Injection of 1-2mls/kg LOCM (370mgI/ml) via
large bore cannula.
• Xray KUB 10 mins after intravenous injection
of contrast.
Single shot IVU
Retrograde urethrography/ Voiding
cystourethrography
Angiography
• Seldom used as diagnostic tool
• More used as therapeutic tool, to embolise
bleeding vessels, more so in this era where
conservative treatment is now widely accepted.
• Also in managing late complication, eg
hypertension or pre operative mapping.
Renal pedicle is avulsed with inhomogenous
enhancement of parenchyma.
Renal artery is coiled, in preparation for nephrectomy
SPECIAL SITUATION…OR RATHER
SPECIAL CASES
TESTES – physical examination, ultrasound
PENIS – physical examination, ultrasound, MRI.
What about female
lower urinary tract?
• Female urethral injury is rare because it is
short and hidden.
• In a series of 31380 trauma patients with
urethral injuries… 0.15% female…1.5% male
(10x more common in males)
CONCLUSION
•
Imaging plays a crucial role in the evaluation of the genitourinary tract in
a patient who has suffered either blunt or penetrating trauma because
multiorgan injury is common in such patients. Contrast-enhanced CT
is the primary imaging technique used to evaluate the upper
and lower urinary tract for trauma. Cystography and
urethrography remain useful techniques in the initial evaluation and
follow-up of trauma to the urinary bladder and urethra.
•
Read More: http://www.ajronline.org/doi/full/10.2214/AJR.09.2470