49) Injuries & Instrumental examination of the Kidney & Ureter скачать в хорошем качестве

49) Injuries & Instrumental examination of the Kidney & Ureter

ENDOSCOPY:- Endoscopy has revolutionized investigating method of lower urinary tract . Cystoscopy - previously rigid cystoscopes were used though recently fibre optic cystoscopes have made the procedure more comfortable. Cystoscope is mainly used to visualize inside of the bladder, through ureteric catheters may be introduced through the ureteric orifices retrogradely to perform retrograde urography. The ureteric openings are usually situated at 4 o clock and 8 o clock positions indicated by a knob on the handle cystoscopes can be used in 3 types (a) Visualizing cystoscope. (b) Operating cystoscope e.g excision of small polyp or tumour cauterization of tumour and for taking biopsies from tumour. (c) Catheterising cystoscope - Ureteric catheterisation - the ureteric catheters are long narrow, graduated gum elastic tubes with stellats the catheters are passed through the cystoscope in to the ureteric orifices ureteric catheterisation is performed for - (i) To collect specimen of urine from individual kidney (ii) To perform retrograde pyelography (iii) To locate the level of obstruction within the ureter (iv) The catheter may be pushed above the impacted stone for dranage as well as to instil lubricants so that the stone may be passed out through the bladder. (v) To relieve ureteric obstruction in case of calculus anuria. Urethroscopy - there are two types of urethroscopy - (a) Anterior urethroscopy, which means inspection of penil urethra and (b) Posterior urethroscopy, which means inspection of membranous and prostaic urethra. (a) Anterior urethroscopy (b) Posterour urethroscopy - verumontanum, INJURIES TO THE KIDNEY - Renal injuries are the most common injuries of the urinary system. the kidney is well protected by ribs. vertebral bodies lumber muscles and the viscera blows of the loin and crushing road traffic accidents are the usual causes of injury to the kidney. Aetiology _ (i) Blunt trauma to the abdomen flank or back is the most common mechanism of renal injuries. (ii) Gun - shot and knife wounds may cause penetrating injuries to the kidney (iii) Sudden brake in high speed vehicle may result in major vascular injury of the kidney. Pathology and classification - (a) MINOR RENAL INJURY.- Renal contusion or bruising of the parenchyma is the most common lesion. (b) MAJOR RENAL INJURY. - This means deep cortico-medullary lacerations which extend into the pelvis to cause extravasation of urine in the peri-renal space. (C) VASCULAR INJURY - (i) Stretch on the main renal artery without avulsion may cause renal artery thrombosis (II) The segmental branch of the renal artery. (iii) Total avulsion of the renal artery or vein Clinical features - 1) Pain 2) Haematuria - 3) General abdominal distension 4) present with a swelling in the loin after injury B) PHYSICAL SIGNS - General examination hypo-volaemic shock or signs of high blood loss may be noted. Abdominal examination may reveal tenderness in the loin or there may be diffuse tenderness. TREATMENT - A) Emergency measures- The objectives of this are to treat shock and hemorrhage the measures consist of - (i) The patient must be hospitalized and lie flat in bed movement is disallowed. (ii) A sedative is immediately (iii) An appropriate antibiotic is started at the same time to prevent infection of the haematoma. (iv) Intravenous infusion is started which should be followed by blood transfusion hourly pulse and blood pressure charts should be maintained (v) Once the central venous pressure ( CVP) has been normal excretory urography ( IVP) should be done urgently to know that other kidney is normally functioning. B) LOCAL Management - 1) BLUNT INJURIES - (a) as mentioned earlier MINOR INJURIES constitute 85% of cases these usually do not require any operation bleeding stops spontaneousely with emergency measures . B) In case of majour renal injuries there is persistent retropritoneal bleeding urinary extra vasation and evidence of non viable renal parenchyma for which operation is justified. When the kidney is found to be ruptured in several places or the kidney pedicle is damaged, nephrectomy should be performed. 2) PENETRATING INJURIES - these injuries require more often surgical interventions as other organs are often injured. INJURIES TO THE URETER - Ureteral injury is rare it may occure in stabbing and gun - shot injures but in majority of cases ureter is injuerd by the surgeons ( idtrogenic ) Ureter may be injured in operations e.g. emergency cesarean section or for ruptured ectopic pregnancy . Extensive lymph node dissection may also injure ureter.