Trauma Pelvis dan

Traktus Urinarius

Dr. Adam Suyadi , SpB, MM

Bag Bedah FK UII Yogyakarta

Pendahuluan
Organ urogenitalia terletak di rongga
ekstraperitoneal, kecuali genitalia eksterna
Terlindung otot dan organ lain
Aman kecuali trauma hebat
Kemungkinan cedera organ sekitarnya

Trauma Urogenital

Trauma Ginjal
Trauma Ureter
Trauma Buli-buli
Trauma Uretra
Ruptura Uretra Anterior
Ruptura Uretra Posterior

Trauma Penis

TESTIS

ANATOMI

Pendarahan
Arteri
spermatika
Pleksus
pampiniformis
vena
spermatika
90% varikokel
terjadi pada
sisi kiri
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Anatomi Ginjal

Trauma Ginjal
Terjadi karena :1) langsung kena benturan
2) cedera deselerasi
10% trauma abdomen mengenai ginjal
Dapat karena trauma tumpul, trauma tajam
maupun luka tembak
Guncangan pada ginjal dapat
menyebabkan robeknya capsul ginjal
bahkan parenchym

Mekanisme Trauma Tumpul

Derajat trauma ginjal

Derajat I : Kontusio ginjal/hematom
Derajat II : Laserasi ginjal pada
cortex
Derajat III : Laserasi sampai medulla
Derajat IV: sampai mengenai calixes
Derajat V: avulsi pedikel ginjal
sampai terbelah

Derajat Trauma Ginjal

Derajat Trauma Ginjal

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Diagnosis

Ada riwayat trauma didaerah pinggang

Ada hematuria
Fractur costa VIII XII
Trauma tembus abdomen sampai pinggang
Jatuh dari ketinggian
Multiple trauma

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Penatalaksanaan
Konservatif
Operatif

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Trauma Ureter
Jarang Dijumpai
Kurang dari 1% kasus cedera urologi:
- trauma tumpul
- trauma tajam
- trauma tembus/tembak (2-3%)
- trauma iatrogenik (terbanyak)

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PENDAHULUAN
Cedera ureter jarang terjadi
Kurang dari 1% kasus cedera urologi:
- trauma tumpul
- trauma tajam
- trauma tembus/tembak (2-3%)
- trauma iatrogenik (terbanyak)

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Kunci keberhasilan penanganan:

- Identifikasi dini
- Kewaspadaan tinggi
- Pengetahuan luas penanganan cedera
Diagnosis yang terlambat:
- morbiditas
- kematian
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Anatomi
Ureter

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ANATOMI

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FISIOLOGI
Fungsi Ureter :
Mengalirkan urine
dari pelvis ginjal ke
kandung kemih

Peristaltik ritmik: lapisan otot longitudinal dan sirkuler

Tekanan intravesika
: Anti Refluks
Menyemprot
Per menit : 1-5 kali
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ETIOLOGI & MEKANISME

CEDERA
TRAUMA PEMBEDAHAN
Tersering pada operasi daerah pelvis
Histerektomi
: 67%
Operasi kolorektal : 9%
Kasus Urologi : 42% dari kasus iatrogenik
(Endoskopi 79% ; bedah terbuka 21%)
Mayoritas cedera ureter bagian distal : 87%
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DERAJAT CEDERA URETER

Grade I : hematoma tanpa devaskularisasi

Grade II : laserasi terpotong < 50%
Grade III : laserasi terpotong > 50%
Grade IV : laserasi terpotong komplet &
devaskularisasi 2 cm
Grade V : avulsi hilus renalis &
devaskularisasi ren atau > 2 cm
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Tipe Cedera Ureter

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Diagnosis Klinis
Diagnosis Preoperatif
Hematuria : 40-70% (+)
- bukan tanda pasti
- trauma tajam 23-45% (-)
- trauma tumpul 31-67% (-)
- trauma iatrogenik : hanya 10-15% (+)
Cek lab : analisa dan kultur urine, DL,
kreatinin serum dan produk drain
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Kecurigaan Cedera Iatrogenik

DURANTE OP
Lapangan operasi
banyak cairan
Hematuria
Anuria/Oliguria pada
cedera bilateral

PASCAOPERASI
Demam
Ileus
Nyeri pinggang
Luka operasi basah
Drain jernih dan banyak
Hematuria persisten
Urinoma
Fistula ureterokutan 23

Cedera yang tak teridentifikasi

Demam dan sepsis (10%)
Massa atau pegal di pinggang (36-90%)
Urinoma, ileus yang lama, gagal ginjal, infeksi
(10%)
Warning : 70-80% cedera iatrogenik terdiagnosis
pascaoperasi

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 Regions of the abdomen

3 distinct anatomical compartments: peritoneum,
retroperitoneum and pelvis
peritoneal cavity subdivided into:
intrathoracic segment
covered by bony thorax and includes diaphragm, liver, spleen,
stomach and transverse colon

abdominal segment

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 retroperitoneum
aorta, vena cava,
pancreas, kidneys,
ureters and portions of
duodenum and colon
injuries to this region
notoriously difficult to
diagnose because the
area is remote from
physical examination
and is not sampled by
peritoneal lavage
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 pelvic organs
rectum, bladder, iliac
vessels, internal genitalia
of women
injury also difficult to
diagnose early because
of anatomical location

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 Fractures of the hip joint include fractures

of the proximal femur and acetabular.
Pelvic fractures also can be included in
the category of hip fractures, because
pain attributed to the hip region (i.e.,
buttock, groin, high) can emanate from
an injury to the pelvic ring.

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 most pelvic fractures involve high-energy forces

such as those generated in a motor vehicle
accident, crush accident or fall.
Depending on the direction and degree of the force,
these injuries can be life-threatening

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 A broken pelvis is painful, often swollen and

bruised.
The individual may try to keep the hip or knee bent
in a specific position to avoid aggravating the pain.

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Pelvic injury
Associated with a mortality
of 13-23% and significant
morbidity. In majority of
patients massive
retroperitoneal
haemorrhage is direct
cause or a major
contributing factor to
mortality

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Mechanism of injury
Significant pelvic
fractures are due to
high energy blunt
trauma. Usually a
RTA, fall or crush
injury.

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Clinical features
suggested by pain on movement, structural
instability, gross haematuria, peripelvic
ecchymoses
rectal examination mandatory to identify rectal
injury and prostatic position
if patient has a stable pelvic fracture hypotension
is probably due to haemoperitoneum

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PELVIC RING FRACTURES

Fractures of the pelvis involve 1 or more bones of the

pelvic ring (i.e., the sacrum and the 2 innominate
bones) and may involve the ligamentous structures
between these bones

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classification systems for pelvic ring

disruptions
According to the frequently used system proposed
by Tile :
type A pelvic injuries are stable with insignificant
displacement,
type B fractures are rotationally unstable or
displaced in the axial plane but are vertically
stable,
type C injuries are vertically (coronally),
posteriorly, and rotationally unstable
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ACETABULAR FRACTURES
Acetabular fractures occur primarily in young
adults as a result of high-energy trauma. These
fractures, by definition, involve the hip joint and
may be displaced or nondisplaced. Displaced
intraarticular fractures that are allowed to heal in
an abnormal position may lead to posttraumatic
arthritis

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 Acetabular fractures by Judet and colleagues

1964
Fractures are divided into 5 simple and 5
associated fracture types. The simple types are
fractures of the posterior wall, posterior column,
anterior wall, anterior column, and transverse
fractures (Figure 4), whereas the associated types
are formed by a combination of the simple types

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Complications of comminuted fracture of

the pelvis
Acute:
major haemorrhage (leading cause of death);
shock, elevated intra-abdominal pressure
visceral and soft tissue injury: fractures may be
compound into the perineum or vagina, or be
associated with lacerations into the rectum or
bladder (esp. with lateral compression and
vertically unstable injuries).
urethral injuries common in males. Iinsertion of a
urethral urinary catheter contraindicated
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sacral plexus injury

ileus
pain
fat embolization
acute respiratory distress syndrome: in about 15%
: thoracic injuries, multiple blood transfusions,
shock, and fat embolization.
DVT because of stasis resulting from prolonged
bed rest, and prophylaxis is often contraindicated
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Late:
infection-second most common cause of death
disability/immobility/instability
incontinence
pain

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 Urinary tract and renal injury

more common after blunt than penetrating injury
identification and treatment of other major injuries
takes precedence
gross haematuria requires investigation (CT is
examination of choice if haemodynamically
stable), while microscopic haematuria does not
unless there is unexplained shock. Degree of
macroscopic haematuria not related to severity of
injury
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 majority of renal injuries can be treated

conservatively
bladder rupture commonly associated with pelvic
fractures
>95% have macroscopic haematuria
Retrograde cystography is investigation of choice
Intraperitoneal rupture requires operative repair while
extraperitoneal rupture can be treated conservatively

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Trauma Tractus Urinarius Inferior

Penanganannya masih kontroversial
Pada kasus multipel trauma, harus diperhatikan:
monitor urine output dengan DC
Pencegahan eksaserbasi trauma uretra

Disuspek Ruptur Uretra apabila terdapat:

Darah di Meatus Uretra Eksternus
Laserasi perineum
Prostat melayang pada RT

JANGAN DIPASANG DC
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Management
bleeding is usually bony or venous in origin
if patient is still haemodynamically unstable perform
early open DPL. If grossly positive laparotomy
should precede external fixation or angiography. If
positive by cell count only risk of major intraabdominal haemorrhage is low and control of pelvic
bleeding becomes main priority
early stabilization with external fixators helps to
minimize bleeding from veins and small arterioles
near # sites. Also reduces volume of an open pelvis
and thus improves tamponade
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Management
pelvic angiography with embolization often
successful in controlling arterial haemorrhage but
logistically difficult
large vessel bleeding requires surgical control
early operative stabilization of complex pelvic
fractures preferred in ICU: facilitates respiratory
care, pain control and early mobilization
compound fractures involving perineum, rectum or
vagina require aggressive surgery to avoid high
mortality
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Pemeriksaan Penunjang

IVP
RPG
Sistografi

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Treatment is suprapubic drainage and

delayed definitive repair

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TAMAT

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