Trauma genitourinario

1. Trauma
Genitourinario
Dr.
Chris2an
Haussmann
2015

2. Guidelines on
Urological
Trauma
D.J. Summerton (Chair), N. Djakovic, N.D. Kitrey,
F.E. Kuehhas, N. Lumen, E. Serafetinidis, D.M. Sharma

3. Trauma
Genitourinario
• Trauma
à
principal
causa
de
muerte
en
menores
40
años
• Traumas
abdominales:
10-­‐15%
asociado
a
trauma
GU
• Ambos
sexos,
más
común
en
hombres
• En
todos
los
grupos
etáreos
• Riñón
es
el
más
comúnmente
afectado
• Principal
problema
es
el
diagnósFco
à
politrauma,
múlFples
lesiones,
pasa
desapercibido
• Clasif.:
Alto
(Riñón
y
uréter)
y
bajo
(vejiga,
uretra
y
genitales)

4. Trauma
Genitourinario
• Requiere
un
alto
índice
de
sospecha
– Trauma
Contuso:
caídas,
atropello,
acc.
AutomovilísFco,
aceleración/desaceleración,
acc.
industrial,
politraumaFzado,
deporte
de
contacto.
– Trauma
Penetrante:
arma
de
fuego,
puñalada.

5. Trauma
Genitourinario
• Hallazgos
clínicos
sugieren
Trauma
GU:
Fx.
costales
bajas,
hematoma
torácico
inferior/lumbar,
herida
penetrante,
Fx.
de
pelvis,
globo
vesical,
trauma
perineal,
próstata
ascendida.
• Signos
capitales:
– Micro
o
macrohematuria**
– Uretrorragia
– Globo
vesical
– Incapacidad
miccional
– Próstata
ascendida
o
no
palpable
al
TR
– Escape
vaginal
de
orina

6. TRAUMA
RENAL

7. Anatomía
8 SECTION I G Anatomy
Figure 1–5. Posterior abdominal wall musculature, deep dissection. The lumbodorsal fascia and costovertebral ligament are visualize
arising from the transverse processes of the lumbar vertebrae. The relation of the kidney and pleura is also shown.
4SECTIONIGAnatomy
B
A
Figure 1–1. A, The retroperitoneum dissected. The anterior perirenal (Gerota) fascia has been removed. B, 1, Diaphragm. 2, Inferior vena cava. 3, Right adrenal gland. 4, Upper
pointer, celiac artery; lower pointer, celiac autonomic nervous plexus. 5, Right kidney. 6, Right renal vein. 7, Gerota fascia. 8, Pararenal retroperitoneal fat. 9, Perinephric fat. 10,
Upper pointer, right gonadal vein; lower pointer, right gonadal artery. 11, Lumbar lymph nodes. 12, Retroperitoneal fat. 13, Right common iliac artery. 14, Right ureter. 15, Sigmoid
colon (cut). 16, Esophagus (cut). 17, Right crus of diaphragm. 18, Left inferior phrenic artery. 19, Upper pointer, left adrenal gland; lower pointer, left adrenal vein. 20, Upper pointer,
superior mesenteric artery; lower pointer, left renal artery. 21, Left kidney. 22, Upper pointer, left renal vein; lower pointer, left gonadal vein. 23, Aorta. 24, Perinephric fat. 25, Aortic

8. Trauma
renal
• 1-­‐5%
de
todos
los
traumas,
10%
de
los
traumas
abdominales
• Trauma
más
común
de
la
vía
urinaria
• Razón
hombre/mujer
de
3/1
• Mayoría
por
trauma
cerrado
de
alta
energía
• Trauma
penetrante
se
asocia
a
lesiones
otros
órganos
• Hematuria
a
menudo
presente
• Alteraciones
renales
preexistentes
aumentan
riesgo
de
lesión
renal
por
trauma
cerrado
(quistes,
tumores)
• En
lesiones
severas
las
complicaciones
tardías
incluyen:
hematoma,
hematuria,
urinoma,
infección,
dolor
HTA-­‐RV

9. CHAPTER 42 G Upper Urinary Tract Trauma 1171
Grade I Grade II Grade III
CHAPTER 42 G Upper Urinary Tra
Grade I Grade II Grade III
Grade IV Grade V
Clasificación

10. Evaluación
Diagnós2ca
• Politrauma:
Estabilización/resucitación
(ABCDE)
• Historia
y
examen
]sico
sugerentes
• Lab:
– Hematuria
macro
o
micro
(uro-­‐análisis)
– Hematocrito
seriado
– Crea2nina
basal
• Imágenes:
– Indicaciones:
Penetrante,
contuso
con
hematuria
o
hipotensión,
mec
des/aceleración
rápida,
lesión
de
otros
órganos
– GS:
TAC
Trifásico
con
fase
de
eliminación
tardía
(10-­‐15
min)
– Otros:
ECO,
PIV,
PIV-­‐IO

11. Manejo
• ABC
del
Trauma
• Grado
I
TTO
conservador*
• Grado
II
• Grado
III
TTO
conservador
en
ausencia
de
lesiones
Grado
IV
intraperitoneales**
• Grado
V
à
Exploración
renal
*
Reposo
absoluto,
JJ
en
caso
de
sangrado,
control
imagen
**
20%
sangrado
tardío,
mayoría
TTO
con
embolización

12. Manejo
• Exploración
renal
1. Hemorragia
renal
con
riesgo
vital
/
Hemodinamia
inestable
2. Exploración
por
lesiones
asociadas
3. Hematoma
retroperitoneal
expansivo
o
pulsáFl
4. Lesión
Grado
V
• En
caso
de
cirugía
de
urgencia,
priorizar
manejo
conservador
renal
si
hemodinamia
lo
permite.
• Exploración
renal
1. Hemodinamia
inestable
2. Exploración
por
lesiones
asociadas
3. Hematoma
peri-­‐renal
expansivo
o
pulsáFl
(laparotomía)
4. Lesión
vascular
G
5
• En
caso
de
cirugía
de
urgencia,
priorizar
manejo
conservador
renal
si
hemodinamia
lo
permite.

13. CHAPTER 42 G Upper Urinary Tract Trauma 1175
vascular control before opening Gerota fascia can
decrease renal loss: in a comparative series, the total nephrec-
tomy rate was reduced from 56% to 18% (McAninch and Carroll,
1982). Carroll and coauthors (1989), evaluating the use of early
vascular control, reported the need to occlude the vessels in 12%
of renal explorations. In a series of 133 renal units in which early
In some reported series of penetrating injuries, associated organ
injury has been noted to be as high as 94% (McAninch et al,
1993). Injuries to the great vessels, liver, spleen, pancreas, and
bowel can be identified and stabilized if necessary before renal
exploration.
The surgical approach to renal exploration is shown in Figure
Figure 42–6. The surgical approach to the renal vessels and kidney. A, Retroperitoneal incision over the aorta medial to the inferior
mesenteric vein. B, Anatomic relationships of the renal vessels. C, Retroperitoneal incision lateral to the colon, exposing the kidney.
Aorta
Inferior
mesenteric vein
Inferior
mesenteric vein
Left renal
vein
Right renal
vein
Left renal
artery
Right renal
artery
Gonadal
vein
A B C

14. 1176 SECTION IX G Upper Urinary Tract Obstruction and Trauma
Figure 42–7. Technique for partial nephrectomy: A, total renal exposure; B, sharp removal of nonviable tissue; C, hemostasis obtained and
collecting system closed; D, defect covered.
B Partial polar
nephrectomy
A C Collecting system
closure
D Omental pedicle
flap
Figure 42–8. Technique for renorrhaphy: A, typical injury in midportion of kidney; B, debridement, hemostasis, and collecting system
closure; C, approximation of parenchymal margins; D, sutures tied over gelatin sponge bolster.
A Deep midrenal laceration into
pelvis
B Closure of pelvis
Ligation of vessels
C Defect closure D Absorbable gelatin
sponge (Gelfoam) bolster
lymphatic supply, omentum promotes wound healing and nephrectomy is advocated. In rare instances where repair is pos-

15. TRAUMA
URETERAL

16. Trauma
ureteral
• Raras,
mayoría
iatrogénica
y
penetrantes
• Desapercibidas
durante
cirugía
• >
uréter
inferior,
secuelas
graves
potenciales
• FR:
Alteración
anatomía
(neo
avanzado,
Cx,
RT)

17. ANATOMÍA
URÉTERES
B
re 1–1. A, The retroperitoneum dissected. The anterior perirenal (Gerota) fascia has been removed. B, 1, Diaphragm. 2, Inferior vena cava. 3, Right adrenal gland. 4, Upper
nter, celiac artery; lower pointer, celiac autonomic nervous plexus. 5, Right kidney. 6, Right renal vein. 7, Gerota fascia. 8, Pararenal retroperitoneal fat. 9, Perinephric fat. 10,

18. Evaluación
Diagnós2ca
• Mayoría
diagnosFcada
tarde
• Requiere
alto
índice
de
sospecha:
Tipo
de
cirugía,
uroperitoneo
con
elevación
de
creaFnina,
cólico
renal,
drenajes
con
alto
débito.
• Imágenes:
Ø TAC
muestra
extravasación
de
cte
en
caso
de
lesión
penetrante
Ø Hidronefrosis

19. Manejo
• Depende
de
Fpo
y
lugar
de
lesión.
Se
aconseja
la
reparación
inmediata
• Ligadura,
lesión
parcial:
JJ
o
derivación
urinaria
con
nefrostomía
• Lesión
completa:
– IO
reparación
primaria
o
reimplante
según
altura.
– Derivación
urinaria
en
caso
de
segmento
importante
con
reparación
diferida
CHAPTER 42 G Upper Urinary Tract Trauma 1183
published data to assess its accuracy to date (Kenney et al, 1987;
Townsend and DeFalco, 1995). Reports of the utility of CT in
ureteral trauma are still limited to small numbers of cases.
Ureteral injuries can be difficult to diagnose on CT. If the
urinary extravasation from the ureteral injury is contained by
Gerota fascia, the extent of medial leakage can be small, obscuring
the diagnosis (Kenney et al, 1987). It is also known that ureteral
injuries often manifest with absence of contrast in the ureter on
delayed images. This underscores the absolute necessity of tracing
both ureters throughout their entire course on CT scans obtained
to evaluate urogenital injuries (Townsend and DeFalco, 1995). In
addition, because modern helical CT scanners can obtain images
before intravenous contrast dye is excreted in the urine, delayed
images must be obtained (5 to 20 minutes after contrast injection)
to allow contrast material to extravasate from the injured collect-
ing system, renal pelvis, or ureter (Brown et al, 1998; Mulligan
et al, 1998; Kawashima et al, 2001). Because ureteral injuries are
often detected late, periureteral urinoma seen on delayed CT scans
may be diagnostic (Gayer et al, 2002).
In reported series, all patients with significant ureteropelvic
laceration, for instance, had either medial extravasation of con-
trast material or nonopacification of the ipsilateral ureter on CT
(Kenney et al, 1987; Kawashima et al, 2001). Such findings should
always raise suspicion for ureteral injury.
Retrograde Ureterography. Retrograde ureterograms, the most
sensitive radiographic test for ureteral injury, are used in some
centers as a primary diagnostic technique to detect acute ureteral
injuries (Campbell et al, 1992); however, the authors tend to use
Figure 42–15. Suggested management options for ureteral
injuries at different levels.
UPPER
Direct ureteroureterostomy
Transureteroureterostomy
MIDDLE
Direct ureteroureterostomy
Transureteroureterostomy
LOWER
Reimplantation
Psoas hitch
function impairment.
Haematuria is an unreliable indicator.
Extravasation of contrast material in CT is the hallmark
sign of ureteral trauma, and in unclear cases, a retrograde
or antegrade urography is required for confirmation.
Management
Partial injury can be managed with ureteral stenting or
urinary diversion by a nephrostomy.
In complete injuries, ureteral reconstruction following
temporary urinary diversion is required.
The type of repair procedure depends on the site of the
injury (Table 2), and it should follow the principles outlined
in Table 3.
Proximal- and mid-ureteral injuries can often be managed
by primary uretero-ureterostomy, while a distal injury is
often treated with ureteral reimplantation.
Table 2: Ureteral reconstruction options by site of injury
Site of injury Reconstruction options
Upper ureter Uretero-ureterostomy
Transuretero-ureterostomy
Uretero-calycostomy
Mid ureter Uretero-ureterostomy
Transuretero-ureterostomy
Ureteral reimplantation and a Boari flap
Lower ureter Ureteral reimplantation
Ureteral reimplantation with a psoas hitch
Complete Ileal interposition graft
Autotransplantation

20. 1184 SECTION IX G Upper Urinary Tract Obstruction and Trauma
Upper Ureteral Injuries
Ureteroureterostomy. Ureteral avulsion from th
rate (83% [Toporoff et al, 1992] to 88% [Lang, 1984]). Other
authors have recommended stenting for a longer period, up to 8
Figure 42–16. Technique of ureteroureterostomy after traumatic disruption: A, injury site definition by ureteral mobilization;
B, debridement of margins and spatulation; C, stent placement; D, approximation with 5-0 absorbable suture; E, final result.
A
B
E
D
C
Table 3: Principles of surgical repair of ureteral injury
Debridement of necrotic tissue
Spatulation of ureteral ends
Watertight mucosa-to-mucosa anastomosis with absorbable
sutures
Internal stenting
External drain
Isolation of injury with peritoneum or omentum
Bladder Trauma
Bladder injuries can be due to external (blunt or penetrating)
or iatrogenic trauma. Iatrogenic trauma is caused by external
laceration or internal perforation (mainly during TURB). Blunt
bladder injuries are strongly associated with pelvic fractures.
Bladder injuries are classified as extraperitoneal, intraperito-
neal or combined.
Diagnostic evaluation
Clinical signs and symptoms
External trauma
Cardinal sign: visible haematuria.
Others: abdominal tenderness, inability to void, bruises

21. TRAUMA
VESICAL

22. Trauma
vesical
• Penetrante
vs
Contuso
– Contuso:
con
vejiga
llena
• TraumáFco
vs
Iatrogénico
• Clasificación:
– Extra-­‐peritoneales
– Intra-­‐peritoneales
– Combinadas.

23. Anatomía

25. Evaluación
Diagnós2ca
• Traumá2co:
– Hematuria
macros,
dolor
abdom,
dificultad
miccional,
contusión
suprapúbica,
distensión
(asciFs
urinaria)
– Penetrante:
heridas
de
entrada
y
salida
• Iatrogénico:
– Extravasación
orina,
visión
directa,
aparición
Foley,
sangre/aire
en
la
bolsa
de
Foley.
– Sx
post-­‐op:
hematuria
,
dolor,
distensión,
íleo,
peritoniFs,
sepsis
,
orina
por
la
herida
,
disminución
gasto
urinario
y
aumento
creaFnina,
débitos
altos
por
drenaje
• Imágenes:
– Cistogra]a
convencional/TAC
(Cistoscopía)

26. intravesically with absorbable suture. The
toma should not be disturbed. When int
fractures is performed, concomitant bl
mended because urine leakage from the i
orthopedic fixative hardware is prevente
risk of hardware infection. Drainage of t
be safely accomplished with a large-bore F
cystography performed 1 week after repa
healing.
All penetrating or intraperitone
from external trauma should be ma
operative repair. These injuries are ofte
on cystography and are unlikely to heal s
tinued leak of urine causes a chemical per
injuries are repaired with open surgery, sele
laparoscopic repair (Kim et al, 2008)—
bladder may have been injured during la
cedures. When bladder injuries are exp
trauma without preliminary imaging, the
be inspected for clear efflux; ureteral integ
by intravenous administration of indigo
blue or retrograde passage of a ureteral ca
Figure 88–10. CT cystogram demonstrates contrast material
surrounding loops of bowel consistent with intraperitoneal
bladder rupture.
surgically repair the extraperitoneal rupture at the same
setting. The anterior bladder wall is entered, and the tear is closed
intravesically with absorbable suture. The perivesical pelvic hema-
toma should not be disturbed. When internal fixation of pelvic
fractures is performed, concomitant bladder repair is recom-
mended because urine leakage from the injured bladder onto the
orthopedic fixative hardware is prevented, thereby reducing the
risk of hardware infection. Drainage of the repaired bladder can
be safely accomplished with a large-bore Foley catheter alone, and
cystography performed 1 week after repair should verify bladder
healing.
All penetrating or intraperitoneal injuries resulting
from external trauma should be managed by immediate
operative repair. These injuries are often larger than suggested
on cystography and are unlikely to heal spontaneously, and con-
tinued leak of urine causes a chemical peritonitis. Although most
injuries are repaired with open surgery, select patients may undergo
laparoscopic repair (Kim et al, 2008)—primarily those whose
bladder may have been injured during laparoscopic surgical pro-
cedures. When bladder injuries are explored after penetrating
trauma without preliminary imaging, the ureteral orifices should
be inspected for clear efflux; ureteral integrity may also be ensured
by intravenous administration of indigo carmine or methylene
blue or retrograde passage of a ureteral catheter. Any penetrating
Figure 88–10. CT cystogram demonstrates contrast material
surrounding loops of bowel consistent with intraperitoneal
bladder rupture.
Figure 88–11. A, Dense flame-shaped pattern of contrast extravasation in pelvis due to extraperitoneal bladder rupture. B, Repeated
cystogram in same patient after 2 weeks of catheter drainage shows completely healed bladder.
A B
weeks but will resolve with continuation of urethral catheter

27. Manejo
• Intraperitoneales
• Reparación
quirúrgica
(vesicorrafia)
en
2
planos
+
S.
Foley:
– Compromiso
cuello,
fragmentos
óseos,
lesión
rectal
concomitante,
atrapamiento
pared
vesical.
• Extraperitoneales
– Conservador:
S.
Foley
3
lúmenes
con
irrigación
vesical
conFnua

28. TRAUMA
URETRAL

29. Anatomía

30. Trauma
ureteral
• Espectro:
– Contusión
o
esFramiento
– Desgarro
parcial
– Desgarro/Transección
completa
•
Diferenciar
entre
UA
y
UP

31. Trauma
ureteral
anterior
• Uretra
anterior/distal
(UA):
anterior
a
porción
membranosa
– Primera
causa
Iatrogénica
(Sonda),
<
frec.
Fx
pene,
trauma
penetrante
• Diagnós2co
UA:
– Historia
sondeo
frustro,
uretrorragia
post
coital
– Sangre
en
MUE
lo
mas
común
à
CanFdad
=
severidad
– Otros:
hematoma
genital,
dolor,
fractura
de
pene
• Imágenes:
– Uretrogra]a
retrogradaà
GS
para
evaluar
lesión
a
TODOS
– En
lesión
UA
SÍ
se
podría
poner
S.
Foley
• Manejo:
– Derivación
urinaria
SP
o
CU
+
reparación
diferida
– Reparación
inmediata:
Fx
pene,
penetrante,
proyecFles

32. Trauma
ureteral
posterior
• Uretra
posterior
(UP):
uretra
membranosa
a
vejiga
– Por
Fx
pelvis
en
AAM
(4-­‐19%
UP
masculina
y
0-­‐6%
uretra
femenina).
• Diagnós2co
UP:
– Historia
de
Fx
pelvis,
uretrorragia
– Imposibilidad
de
orinar,
globo
vesical,
TR
próstata
ascendida
• Imágenes:
– Uretrogra]a
retrogradaà
GS
para
evaluar
lesión
a
TODOS
– Evitar
Sonda
uretral,
hasta
obtener
imagen
uretral
**(paciente
inestable)
• Manejo:
– Derivación
urinaria
SP
o
CU*
+
reparación
diferido
+/-­‐
uretroplaska
– Reparación
inmediata:
Con
lesión
rectal
o
cuello
vesical
asociado

33. TRAUMA
GENITAL

34. Trauma
genital
• Traumas
GUà
33-­‐66%
genitales
externos
• Mucho
más
frecuente
en
hombres,
15-­‐40
años
(anatomía,
AAM,
deportes,
guerra,
violencia)
• Causado
– 80%
trauma
contuso
– 20%
trauma
penetrante

35. TRAUMA
GENITAL
MASCULINO

36. Anatomía
genital
masculina

37. Fractura
de
pene
• Desgarro
de
la
túnica
albugínea
del
cuerpo
cavernoso
• Usualmente
durante
coito
al
salir
de
vagina
y
golpear
contra
sínfisis
del
pubis
o
periné
femenino,
masturbación.
• Lesión
uretral
en
10-­‐20%
a
nivel
• Riesgo:
disfunción
erécFl
y
enfermedad
de
Peyronie

38. Diagnos2co
– Sonido
de
crujido/estallido,
dolor
y
detumescencia
inmediata
– Luego
hematoma
cuerpo
pene
(“eggplant
deformity
/
berenjena”),
incluso
hasta
pared
abdominal,
periné
y
escroto
(si
lesión
en
fascia
de
Buck)
– Rotura
de
túnica
puede
ser
palpable
Imágenes
•
ECO
(negaFva
no
descarta)
o
RNM
podrían
ser
úFles
– Considerar
uretrogra]a
retrograda
(Si
uretrorragia

39. Manejo
• EMERGENCIA!!!
à
intervención
quirúrgica
inmediata
– Incisión,
denudación
inspección
de
CC
y
CE,
idenFficación
de
lesión
y
reparación
de
T.
Albugínea
con
sutura
absorbible
(vicril
2-­‐0)
– Sutura
lesión
uretral
– Hematoma
sin
rotura
de
albugínea
cavernosa:
• AINEs
+
Hielo
– No
se
recomienda
tratamiento
conservador

40. 2508 SECTION XV G Benign and Malignant Bladder Disorders
fashion over a catheter. Therapy with broad-spectrum antibiotics
and 1 month of sexual abstinence are recommended. In uncircum-
suspected penile fracture because it is time consuming
and unfamiliar to most urologists and radiologists (Morey
Figure 88–2. A, Large arrow indicates pronounced ecchymosis and swelling in this patient with a penile fracture sustained during
intercourse. Small arrow indicates blood at urethral meatus. B, During surgical exploration and repair, urethral laceration with exposed
Foley catheter is noted (large arrow). Small arrow indicates laceration of corpus cavernosum.
A B

41. TRAUMA
ESCROTAL/TESTICULAR

42. Anatomía

43. Hematoma
1. Escrotales
cutáneos
(Extra-­‐escrotal):
piel
del
escroto
por
trauma
directo,
trauma
uretral
o
desplazamiento
sangre
subcutánea
2. Hematocele
(Intra-­‐escrotal):
espacio
entre
túnica
albugínea
y
túnica
vaginal
por
trama,
cirugía
escrotal
o
sangre
desde
cavidad
peritoneal.
-­‐ Diagnós2co:
Historia,
Ex.
]sico,
ECO
(Doppler)

44. Manejo
• Tratar
la
causa
asociada:
lesión
uretral,
rotura
tesFcular,
lesión
intra-­‐abdominal
• Hematoma
Escrotales
cutáneos:
– Conservador:
suspensión/elevación
escrotal
+
Ice
packs
• Hematoceles:
– Mayoría
según
criterio
clínico,
laboratorio
y
evolución
– Hematocele
traumáFco
(>
por
Rotura
tes2cular):
cirugía
precoz

45. Rotura/Fractura
Tes2cular
– Desgarro
de
la
túnica
albugínea
más
extrusión
de
Tub.
Seminiferos
y
hematocele
– En
50%
de
los
traumas
contuso,
con
fuerza
de
al
menos
50kg
– DiagnósFco
principalmente
clínico:
dolor,
nauseas,
vómitos,
sincope,
historia
sugerente.
– Imágenes:
ECO:
ecotextura
heterogénea
con
visión
de
la
fractura
en
un
20%
y
posible
visualización
de
extrusión
de
TS.
– EMERGENCIA!!!
à
Reparación
quirúrgica
precoz

46. ROTURA/FRACTURA
TESTICULAR

47. Rotura/Fractura
Tes2cular
• Reconstrucción
primaria
tes2cular
y
escroto
1. Abordaje
escrotal
2. Evacuar
de
Hematocele
y
coágulos
3. Debridar
túbulos
seminíferos
y
tejido
necróFco
4. Cerrar
túnica
albugínea
con
sutura
conFnua
reabsorbible
4-­‐0
**
Colgajo
libre
túnica
vaginal
para
cierre
de
teste
1. Reparar
lesiones
de
epidídimo
2. Drenaje
Penrose
peritesFcular
por
incisión
separada
36
hr
3. ATB
amplio
espectro
x
7
días,
vacuna
anFtetánica
4. Cierre
primario
de
piel
o
diferido
con
injerto

48. exploration (40%), and orchiectomy (15%) (Cass and Luxenberg,
1988). Significant hematoceles should also be explored, regardless
of imaging studies, because up to 80% are caused by testicular
rupture (Vaccaro et al, 1986).
Penetrating scrotal injuries should be surgically
explored to inspect for vascular and vasal injury; as in
blunt trauma the same principles of salvage, hemostasis, and
reconstruction apply. The vas deferens is injured in 7% to 9% of
scrotal gunshot wounds (Gomez et al, 1993; Brandes et al, 1995).
The injured vas should be ligated with nonabsorbable suture and
delayed reconstruction performed if necessary. Approximately
Figure 88–4. Ultrasound examination demonstrates hypoechoic
intratesticular areas (arrow) consistent with testicular rupture
sustained by blunt trauma. Scrotal exploration revealed large
hematocele and exposed seminiferous tubules.
Figure 88–5. A, Testicular rupture after blunt trauma. B, Reconstructed testis after debridement and closure. Arrow indicates placement of
tunica vaginalis graft.
A B
Rotura/Fractura
Tes2cular

49. Dislocación
tes2cular
• Desplazamiento
del
teskculo
a
posiciones
extra-­‐escrotales
• Accidentes
en
moto
a
alta
velocidad,
infrecuente.
• Uni
o
bilateral
• Puede
dislocarse
a
abdomen,
pubis,
canal
inguinal,
canal
femoral,
pene
o
periné
• Puede
acompañarse
de
torsión
o
rotura
tesFcular
• Diagnos2co:
dolor
y
bolsa
escrotal
vacía.
Si
no
puede
ser
encontrado,
ECO/ECO
Doppler
o
TAC
son
de
ayuda
• Manejo:
exploración
quirúrgica
precoz
y
orquidopexia
con
incisión
inguinal
para
mejor
manejo
de
cordón.

50. Dislocación
tes2cular
• Dislocación
Tes2cular

52. Trauma
penetrante
tes2cular
• Exploración
quirúrgica
y
reconstrucción
tesFcular
• Lesiones
penetrantes
escrotales
son
bilaterales
en
30%
(vs
1
%
contusa)
• Herida
penetrante
de
tescculo
– Manejo
similar
a
Rotura
TesFcular
• Sangrado
de
vasos
del
cordón
espermá2co
– Ligadura
• Disrupción
completa
Cordón
– Orquidectomía
• No
logra
reconstrucción/
tejido
mínimo
viable
– Orquidectomía
• Lesiones
por
explosivos:
– Reconstrucciones
complejas

53.
FIN