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Dr.

Mizar Erianto, SpB


 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
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
Pemeriksaan Radiologi
 Foto polos abdomen
 IVP ( Intra Vena Pyelografi )
 USG ( Ultra Sonographi )
 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. 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.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