Ruptur Traktus Urinarius

Yan Josua Sinaga

160100207
Departemen Radiologi
 Renal Trauma
3 penyebab utama dari trauma ginjal :
• Trauma tumpul : - langsung (KLL)
- tidak langsung (jatuh)
• Trauma tajam seperti tembakan pada abdomen dan
tikaman di abdomen bagian atas atau pinggang.
• Trauma iatrogenik disebabkan oleh tindakan operasi,
biopsi ginjal juga dapat menyebabkan trauma ginjal.
• Pada anak (<1 tahun) bisa terjadi dikarenakan ukurang
ginjal yang relatif besar, sedikit lemak perirenal dan fasia
gerota yang belum berkembang
Renal Trauma dalam beberapa derajat :
Grade 1 • Hematuria dengan pemeriksaan radiologi
yang normal
• Kontusio
• Hematoma subkapsular non-ekspandin

Grade 2 • Hematoma perinefrik non-ekspanding

yang terbatas pada retroperitoneum
• Laserasi kortikal superficial dengan
kedalaman < 1 cm tanpa adanya trauma
pada sistem lain

Grade 3 • Laserasi ginjal yang kedalamannya > dari 1

cm tidak melibatkan sistem lainnya.

Grade 4 • Laserasi ginjal yang memanjang mencapai

ginjal dan sistem lainnya
• Melibatkan arteri renalis utama atau vena
dengan adanya hemoragik
• Infark segmental tanpa disertai laserasi
• Hematoma pada subkapsuler yang
menekan ginjal
Grade 5 • Devaskularisasi ginjal
• Avulse ureteropelvis
• Laserasi lengkap atau thrombus pada
arteri atau vena utama
 Manifestasi Klinis Renal Trauma
• Pada trauma tumpul =jejas di daerah lumbal
• Pada trauma tajam = tampak luka
• Pada palpasi = nyeri tekan daerah lumbal, ketegangan
otot pinggang sedangkan massa jarang teraba.
• Nyeri abdomen ditemukan di daerah pinggang atau perut
bagian atas dengan intensitas nyeri yang bervariasi.
• Bila disertai cidera hepar atau limpa ditemukan adanya
tanda perdarahan dalam perut.
• Hematuria makroskopik merupaan tanda utama cidera
saluran kemih
 Ureteric Injury
• Penyebab :
– Trauma tajam (tersering)
– Trauma tumpul (fraktur pelvic)
– Surgical trauma

• Gejala : • Tanda :
• Demam dan nyeri • Acute hydronephrosis,
di bagian lower tanda dan gejala dari
quadrant jika acute peritonitis bisa
bilateral -> anuria dijumpai
 Klasifikasi Ureteric Injury :
Grade Type of injury Description of injury

Grade 1 • Hematoma • Kontusio atau hematoma without

devascularization

Grade 2 • Laceration • Transection <50%

Grade 3 • Laceration • Transection > 50%

Grade 4 • Laceration • Complete transection with <2cm

devascularization

Grade 5 • Laceration • Avulsion with >2cm of

devascularization
 Bladder Rupture
Cedera kandung kemih dapat terjadi akibat
trauma tumpul, tembus, atau iatrogenik.
Kemungkinan cedera kandung kemih bervariasi
sesuai dengan derajat distensi kandung kemih,
kandung kemih penuh lebih rentan terhadap
cedera daripada kandung kemih kosong.
 Bladder Rupture
• Mekanisme

Intraperitoneal Extraperitoneal
Bladder Rupture Bladder Rupture

Gejala dan tanda

• hematuria, nyeri suprapubik, nyeri tekan
• Sulit untuk berkemih
 Urethral Injury
According to location
Prostatic
• Anterior urethra:
Membranous
– bulbous & pendulous
Bulbous
• Posterior urethra:
– Membrano & prostatic

Pendulous
 Posterior Urethral Injury
• Cause : pelvic fracture
• Triad :
– blood at the meatus
– Inability to urinate
– Full bladder

Symptoms and sign :

• Blood at meatus
• Gross hematuria
• Scrotal or penile hematoma
• Distended bladder
• Non palpable prostate
 Anterior Urethral Injury
• Caused by direct injury to the penis & urethra
• More common than posterior
• If Buck’s fascia intact  blood & urine remain
within the penis  ‘sleeve hematoma’
• If Buck’s fascia disrupted  blood & urine can
spread to the scrotum, abdominal wall,
perineum and thigh
• Extravasation into the perineum  ‘butterfly
sign”
• Sleeve Hematoma
• Butterfly Hematoma
 Anterior Urethral Injury
• Symptoms & sign :
• History of direct perineal trauma / strddle
injury
• Blood at meatus (the most important predictor)
• Perineal and/or scrotal swelling
• Penile hematoma
Trauma Renal

Gambaran Radiologi:
• Trauma Renal

Non-enhanced series shows an obstructive calculus at the

right ureterovesicular junction with free fluid in the perirenal
space and the right paracolic gutter extending inferiorly to
the pelvis.
Delayed phase series shows contrast extravasation from the
the right renal collecting system, indicative of rupture of the
collecting system. The rupture is probably located at the
right ureteropelvic junction or proximal ureter.
Incidentally noted are two adrenal adenomas lipid rich
(measured <10 HU in the precontrast study) and multiple
 Traumatic Renal Laceration
Note : Laceration of the left
kidney appearing as linear or
wedge-shaped opacifacation
defects, with perirenal hematoma

Case dicussion : traumatic renal laceration

(grade II-III of AAST) apperaring as linear or
wedg-shaped opacification defects that are
particularly evident in the nephrographic
phase, may have a depth < 1 cm (grade II)
or > 1 cm (grade III) without involvement
CT axial renal parenchymal phase
of the collectiong system; in most cases
there is associated perirenal hematoma, a
hyperattenuating fluid in the perinephric
fat.
 Ureteric Injury
Gambaran Radiologis :
• Ureteric Injury

Abdominal fat stranding. Collection overlying

the left psoas with air bubbles. Contrast
extravasation from the collecting system
compatible with rupture of the ureter.
 Ureteric Injury Post Cesarean Section
Presentation : Post emergency cesarean section
with high output intraperitoneal tube drainage.
The C-section is preceded by 5 trials of vacuum
delivery

xray

Fluoroscopy
Note : Contrast leakage and
spillage is seen in the left side of
pelvis in the region of lower third
left uretere denoting a left
ureteric injury
 Ureteric Injury Post Total
Abdominal Hysterectomy
Saggital
renal
Presentation : recent total abdominal excretory
hysterectomy. Urine-like fluid
draining from drain tube in pre-sacral
space.

Note : leak of contrast from the distaal

right ureter is a well recognized
complication of hysterectomy. It is
important in this case that the ureter
beyond the leak is intact albeit kinked so Axial
there is a chance that a urologist will be renal
able to pass a wire and ureteric stent excretory
though to the renal pelvis thus avoiding
the need dor open intervention at least in
the short term although there is always of
the risk of developing a structure at the
site of the ureteric injury.
 Bladder Rupture
Gambar Radiologi :
• Extraperitoneal Rupture

Postvoid film shows a flame-shaped density adjacent to lateral

walls of bladder representing extra-peritoneal contrast from a
bladder rupture.
 Bladder Rupture (Extraperitoneal)

Note : Note :
USG Xray
The kidney have a normal apperance. The Urinary catheter in situ. Left
bladder is thicked-walled with a poorly defined superior and inferior pubic rami
anterior wall. There is a large volume of free fluid fractures and widening of the
in the hepatorenal and splenorenal spaces left sacroiliac joint
 Bladder Rupture (Extraperitoneal)
Note :
Axial non-contrast
CT confirms fractures of the left superior and
inferior rami pubic. There are also fractures
involving the left iliac extending into the
sacroiliac joint with widening of the left SI joint.
There is free fluid and gas particularly anterior to
the catheretized urinary bladder. Some gas is also
present in the urinary bladder
Note :
Axial c+arterial phase
A moderate amount of free fluid
throughtout the abdominal cavity, and in
particular arteriorly within the pelvis.
No sign of another musculoskeletal injury,
nor of any other solid organ, pulmonary or
vascular injury. Moderate sized left pleural
effusion with bibasal atelectasis
Bladder Rupture
Gambaran Radiologis:
• Intraperitoneal Rupture
 Urethral Rupture
Gambaran Radiologi :
• Urethral Rupture

Retrograde urethrogram
 demonstrates urethral
 Bladder Rupture (Intraperitoneal)
Note :
CT axial C+ portal venous phase
Portal venous phase CT ahows low density
free intraperiotenal fluid (mean densiity
around 5 HU) in the right para-colic gutter
and supramesocolic space (peri-hepatic
and peri-splenic). Renal excretory phase
reveals extravasation if intra-venous
administered contrast-stained fluid is seen
in the right para-colic gutter and in
between small bowel loops, confirming its
intraperitoneal location. Kidneys and
ureters are unremarkable. No pelvic
fracture were seen.

A small traumatic hematoma with active

bleeding (contrast blush) in the segment
Iva of the liver is also worth mentioning
 Traumatic Urethral Injury
Presentation :
trauma with
displaced pelvic
fractures
Note : retrograde urethrogram in a
patient with pelvic fractures
demonstrates contained contrast
leakage at the posterior urethra
(membranous portion). Contrast does
ascend into the bladder and therefore
the urethral injury is incomplete.
Contrast in the right ureter was due to
previous renal excreted contrast from a
CT study rather than reflux
Retrograde urethrogram
Fluoroscopy
TERIMAKASIH