TRAUMA UROGENITAL

Anatomi

Ginjal
Ureter
Buli buli
Uretra

TRAUMA UROGENITAL
Anatomi

Ginjal
Ureter
Buli buli
Uretra

Ginjal
Sepasang organ seperti kacang
Terletak retroperitonel diregio lumbal
superior
Dilapisi oleh 3 lapis jaringan penunjang:
kapsul ginjal
kapsul adipose dan
fasia renalis

Ureter
Tubulus muscular yang
menghubungkan ginjal ke buli buli
Terletak di belakang rongga
peritoneum (retroperitoneal)
Panjang 25 30 cm

TRAUMA GINJAL
Trauma 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 trauma
Keterlibatan trauma organ lain
Fasilitas penanggulangan trauma

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

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

Mekanisme Trauma
Trauma tumpul -> penyebab trauma
Langsung, tidak langsung
Trauma tumpul langsung
KLL
Olah raga
Kecelakaan kerja
Perkelahian

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 iatrogenik

Pemasangan kateter di atas ureter
Pengambilan biopsi ginjal
Infeksi 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 Mayor
Laserasi korteks, medula tanpa
ekstravasasi
Laserasi korteks, medula dengan
ekstravasasi
Cedera Vaskuler
Avulsi
Trombosis

Berdasarkan AAST ( American for The Surgery of

Trauma )

Berdasarkan AAST
( American for The Surgery of Trauma )
Dibagi 5 derajat
Derajat 1
Kontusio ginjal /subkapsularhematom
Tidak meluas
Hematuria dengan normal imaging

Derajat 2
Hematom perineal
Tdk meluas ke retroperitonium
Laserasi superficial ( < 1cm )
Tdk melibatkan collecting systim
Derajat 3
Renal laserasi ( > 2cm )
Sub capsular hematom
Perinephric hematom
Tdk melibatkan collecting systim

Derajat 4
Laserasi yang meluas ke collecting
systim
Extravasasi
Trauma vasculer segmental
infark

Derajat 5
Shattered kidney
Devaskularisasi / oklusi / trombosis
arteri / vena utama
Laserasi komplit
Extravasasi
UPJ avulsi

 Foto polos abdomen

IVP ( Intra Vena Pyelografi )
USG ( Ultra Sonographi )
Pemeriksaan
Radiologi
CT Scan abdomen / Whole
abdomen
uretrocistografi

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 Scan
Pemeriksaan yang sensitif dan spesifik
Menentukan derajat trauma
Tidak invasif
Dpt mengevaluasi organ lain
( hepar , lien , aorta )
kontras non kontras
Angiografi
Invasif
Delayed 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

Derajat II dan III

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

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 (<1
cm deep) renal parenchymal defect with a large perinephric hematoma

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 IV

Gambar13 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 V

Gambar 17. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrastenhanced 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. Contrastenhanced 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. Contrastenhanced 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.Arteriografy

Gambar 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 Ureter
Ureter jalur transportasi dari ginjal ke buli-buli
Trauma ureter mengganggu fungsi ginjal
Trauma mengenai pinggang, punggung
resiko mengenai ureter
ok * Lokasi terlindungi
* Ukuran kecil
* Mobilitas / fleksibel
trauma ureter jarang

Etiologi
Trauma Luar
a. Tajam
b. Tumpul
Iatrogenik
a. Ginekologis
b. Pembedahan rektum
c. 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
- Iatrogenik
Didaerah pelvis / abdomen bawah/
perineum
60-85 % trauma tumpul
15-40 % trauma tajam

Ruptur vesika urinaria : ke

Ekstra peritoneum
Intra peritoneum
Keduanya
Kontusio Vesika Urinaria
Sobekan sebagian mkosa vesika urinaria
Dinding memar hematom
Pemeriksaan :
Sistografi
CT scan abdomen - pelvis

Kontusio Vesika Urinaria

Normal
Tear Drop
Mudah sembuh
Ruptur Vesika Urinaria
Terlihat ekstravasasi kontras
- ekstra peritonial
- intra peritonial
Dengan CT Scan dpt juga mengevaluasi organ
lain

Pear shaped appearance

TRAUMA URETRA
Uretra laki-laki lebih panjang dari wanita
Dihubungkan dgn trauma daerah pelvis yg
cukup berat

Etiologi
Trauma tumpul
Trauma tembus
Iatrogenik

Anatomi
Uretra posterior
* uretra prostatika
* uretra membranosa
Uretra anterior
3 segmen : * pars bulosa
* pars pendulans
* pars glanularis
sampai ke meatus uretra externa

Diagnosa
Berdasarkan gejala klinik
Pemeriksaan penunjang radiologi
RUG ( Retrograde Uretrografi )
Klasifikasi trauma uretra Hasil RUG
Klasifikasi Gold Man yaitu :
Berdasarkan Kerusakan Anatomi

Ada 5 tipe

Tipe 1
. Ruptur ligamentum puboprostatika
. Prostate bergeser ke posterior
. Uretra tetap intak
. Tdk ada extra vasasi zat kontras

Tipe 2
Trauma uretra posterior & diafragma
urogenital
Terlihat extravasasi kontras dlm
pelvis extra peritoneal
Zat kontras tdk ada dalam perineum

Tipe 3
Tipe yang sering
Kerusakan meluas
Terlihat extravasasi kontras pada
rongga pelvis extra peritoneal dan
perineum

Tipe 4
Terjadi dekat buli-buli meluas ke
uretra proximal
Extravasasi kontras pada pelvis extra
peritoneal & sekitar proximal uretra
Dapat merusak sfingter uretra
interna

Tipe 5
Terjadi di uretra anterior
Terlihat extravasasi kontras
bagian inferior diafragma
urogenital