the management of injuries to the kidneys.

Grading of renal injuries:

Grade I: ‫ عدد انواعهن واشرح‬/‫س‬
‫واحد منهن‬

Contusion with microscopic or gross haematuria, urological

studies normal; nonexpanding subcapsular haematoma
without parenchymal laceration.
Grade II: ‫تجمع دموي‬

Nonexpanding prerenal haematoma confined to renal

retroperitoneum; laceration < 1 cm parenchymal depth of
renal cortex without urinary extravasation.
Grade III:
Laceration > 1 cm parenchymal depth of renal cortex without
collecting system rupture or urinary extravasation.
Grade IV:
Parenchymal laceration extending through renal cortex,
medulla, and collecting system; injury to main renal artery
or vein with contained hemorrhage.
Grade V: ‫مهشم‬، ‫محطم‬

Completely shattered kidney; avulsion of renal hilum that

devascularizes kidney.
Treatment of renal injuries according to grading:
Grade I or II: ‫ شنو العالج‬/‫س‬

Keep patient on bed rest until urine is grossly clear. ‫بده يتحرك‬
Remove Foley catheter when patient is ambulatory.
Watch for delayed bleeding. If this‫بالشريان‬
occurs, consider renal
‫نخلي مثل الخثرة‬
angiography and selective embolisation. ‫يوكف النزف‬
Treat persistent urinary extravasation with internalized
ureteral stent.
Grade III or nonvascular grade IV:
Determine whether there are other intraperitoneal injuries
that necessitate laparotomy.
‫لالطالع‬

Laparotomy is unnecessary: Treat as for grade I or II .

grade IV or grade V: Treat as for "laparotomy is necessary",
 management of injuries to the ureters
Grading of ureteral
‫انضرب‬
injuries:
Grade I: Contusion or haematoma
‫قطع‬
without devascularization
Grade II: < 50% transection
Grade III: ≥ 50% transection
Grade IV: Complete transection with < 2 cm devascularization
Grade V: Avulsion with > 2 cm devascularization ‫هنا ينراد زرع حالب‬
Treatment of ureteral injuries: Intra venous urogram
If the patient is stable: Perform IVU or CT
o If findings are normal: Observe patient.
‫مراقبة‬

o If findings are abnormal: Perform laparotomy.

Explore ureter, exposing entire ureter and renal pelvis.
Determine location and type of injury. Repair injuries
surgically over indwelling stent.
 ‫لالطالع‬
Remove retroperitoneal drains when output is low.
Remove Foley and suprapubic catheters after 7-10 days.
Remove double J stent after 4-6 weeks.
Perform follow-up IVU after 8 weeks.
If recognition of injury is delayed or if abscess or
urinoma occurs postoperatively, consider percutaneous
nephrostomy and abscess drainage. Stent ureter if
possible.
If the patient is unstable: Perform laparotomy. Perform
on-table IVU with one film at 10 min.
 management of injuries to the urinary bladder.
Grading of urinary bladder injuries:‫تجمع دموي‬
Grade I: Contusion, intramural haematoma; partial thickness
laceration. ‫تمزق‬
‫خارج الحاجز البيرتوني‬
Grade II: Extraperitoneal bladder wall laceration < 2 cm
Grade III: Extraperitoneal bladder wall laceration > 2 cm or
intraperitoneal bladder wall laceration < 2 cm
Grade IV: Intraperitoneal bladder wall laceration > 2 cm
Grade V: Intraperitoneal or Extraperitoneal bladder wall
laceration extending into bladder neck or ureteral orifice
(trigon)
gallbladder ‫ ب‬ureter ‫منطقة دخول‬
Treatment of urinary bladder injuries: ‫ﻟﻼطﻼع‬

Perform retrograde plain-film cystography or CT cystography

with adequate bladder filling.
If the patient has intraperitoneal rupture or penetrating injury:
o Explore bladder via intraperitoneal or extraperitoneal
approach.
Repair injuries from inside bladder. Close bladder in two layers.
Provide adequate urinary drainage.
o Remove perivesical drain when output is low. Obtain follow-
up cystogram at 7 – 10 days.
Remove catheters when there is no extravasation.
 If the patient has extra peritoneal rupture from blunt
trauma: Q/What is ‫عالج تحفظي‬
Assess for contraindications to conservative management
Uriary trak infection
/‫(ج‬UTI, bony fragments in the bladder, bladder neck injury,

female genital lacerations from pelvic fracture and

requirement for laparotomy for associated injuries):

No contraindications to conservative management are

present:
Manage with large-bore catheter drainage for 10 days.
Remove perivesical drain when output is low.
Obtain follow-up cystogram at 7 – 10 days.
Remove catheters when there is no extravasation.
 ‫ﻣﮭﻢ‬
the predisposing causes, clinical features and treatment of
torsion of the testis.
Predisposing causes :
testis ‫اﻟﺘﻮاء‬
Torsion
‫ ﻣﺠﻠﺒﺔ‬، ‫ﻻطﺸﺔ‬، ‫ﻻزﻣﺔ‬
of the testis is uncommon because the normal testis is
anchored and can not rotate.
For torsion to occur one of several abnormalities must be
present: ‫ﻣﻘﻠﻮب‬ torsion ‫ﻋﻮﻣﺎل ﻣﺴﺎﻋﺪة ﺣﺘﻰ ﺗﺼﯿﺮ ﻋﻨﺪه‬
Inversion of the testis is the most common predisposing
cause; ‫ﻣﺎ ﺛﺎﺑﺘﮫ زﯾﻦ‬
High investment of the tunica ‫ﺿﻐﻂ‬
vaginalis "bell-clapper";
Separation of the epididymis from the body of the testis.
Straining at stool, lifting a heavy weight and coitus are all
‫ﺿﻐﻂ‬

possible precipitating factors, but torsion may occur

spontaneously during sleep.
Clinical features ‫ﯾﺠﻲ ﺳﺆال ﺷﻠﻮن‬ ‫ﺑﺈﺧﺘﺼﺎر ﻓﮭﻢ‬

Testicular torsion is most common between 10 and 25 years of

age.
There is sudden agonising pain in the groin and the lower
abdomen.
Nausea and vomiting.
On examination: The testis seems high with tender twisted cord
‫ارﺗﻔﺎع درﺟﺔ اﻟﺤﺮارة‬
can be palpated above it. Redness of the skin and mild pyrexia.
Doppler ultrasound scan can confirm the absence of the blood
supply to the affected testis.
If there is any doubt about the diagnosis, the scrotum should be
explored without delay.
An empty edematous hemiscrotum suggests that a tender lump at
the external inguinal ring is a rotated testis rather than a
strangulated hernia.
Treatment
‫ﯾﺠﻲ ﺳﺆال ﺷﻠﻮن‬ ‫ﺑﺈﺧﺘﺼﺎر ﻓﮭﻢ‬

In the 1st hour it may be possible to untwist the testis by gentle

manipulation.
Exploration for torsion can be performed through a scrotal
incision.
If the testis is viable it should be prevented from twisting again by
fixation with non-absorbable suture between the tunica vaginalis
and the tunica albuginea.
The other testis should also be fixed because the anatomical
abnormality is bilateral.
An infracted testis should be removed and the patient should be
counselled and consented for orchiectomy before operation.
‫ﻻزم ﺗﺎﺧﺬ ﻣﻮاﻓﻘﺔ ﻣﻦ اھﻞ اﻟﻤﺮﯾﺾ اذا ﻣﺎ‬
‫اﺳﺘﺄﺻﻠﺘﮭﺔ راح ﯾﺼﯿﺮ ﮔﺮﮔﺮﯾﻦ وﯾﻤﻮت‬
‫لالطالع‬