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C HA P TE 10 R

Trauma to the urinary tract

Renal trauma: classification and grading
Classifi cation

90% of renal injuries from blunt trauma.95% of blunt injuries can be managed conservatively. • Penetrating renal injuries, roughly 50% of stab injuries and 75% of gunshot wounds require surgicalexploration. Blunt injures

• •

A direct blow associated with renal laceration.

Rapid-deceleration injuries renal vascular injuries (tears or thrombosis) or UPJ disruption may occur. Penetrating injuries

1.

anterior to the anterior axillary line are more likely to injure the renal vessels and renal pelvis than are injuries 2. posterior to this line, where less serious parenchymal injuries are more likely.

Mechanism

1.5–3% of trauma patients have renal injuries. Associated injuries are therefore common (e.g., spleen, liver, mesentery of bowel).

and degree of hematuria and the severity of renal injury is neither predictable nor reliable. • • • Indications for renal imaging 99. in young adults and children. respiratory rate. blood pressure is maintained until a there has been substantial blood loss. location of entry and exit wounds. flank bruising. Remember.8% correct 1) 2) gross hematuria Microscopic (>5 RBCs per high-powered field [hpf]) or dipstick hematuria in a hypotensive patient (systolic blood pressure of <90 mmHg recorded at any time since the injury1) 3) History of rapid deceleration with evidence of multisystemtrauma 4) Penetrating chest and abdominal wounds (knives. Examination the trauma (blunt. Pulse rate.166 C HA P TE 10 R Trauma to the urinary tract Renal trauma: clinical and radiological assessment History includes mechanism of penetrating). hypotension is a late manifest tion of hypovolemia. . thus making shock a less reliable indicator. systolic blood pressure. and rib fractures need to be assessed. bullets) with any degree of hematuria or suspicion of renal injury based on wound location 5) Any child with urinalysis showing ≥ 50 RBC/hpf after blunt trauma Degree of hematuria the relationship between the presence. absence.

Higher injury severity scales are associated with poorer outcomes...1) Parenchymallaceration of cortex >1 cm deep. no extravasation of urine (i. systolic BP (mmHg) Microhematuria. Grade I Grade II Grade III Grade IV Grade V Contusion or subcapsular hematoma with no parenchymal laceration Parenchymallaceration of cortex <1 cm deep.*SBP >90 Gross hematuria. renal injuries are staged according to the American Association for the Surgery of Trauma (AAST) Organ Injury Severity Scale. no extravasation of urine (i. SBP >90 Gross or microhematuria.1 Renal injury as indicated by hematuria and S B P Degree of hematuria.1 Staging of the renal injury Using CT. collecting system intact) Parenchymallaceration involvingcortex. medulla. collecting system intact) (Fig.e.2% 10% 10% .10.SB P <90 * Dipstick hematuria or microscopic Significant renal injury 0. and collectingsystem OR segmental renal artery or renal vein injury with contained hemorrhage Completely shattered kidney OR avulsionof renal hilum Table 10.R E N AL T R A U M A C L IN IC A AND R A D IOLO G IC A : L L ASSESSMENT 167 Box 10.e.

In this situation. .168 C HA P TE 10 R Trauma to the urinary tract The hemodynamically unstable patient Such patients may need to be taken to the operating room immediately to control bleeding. an intraoperative on-table IV P (see Table 10.1) is indicated if 1) A retroperitoneal hematoma is found and/or 2) A renal injury is found that is likely to require nephrectomy.

R E N AL T R A U M A C L IN IC A AND R A D IOLO G IC A : L L ASSESSMENT 169 Figure 10.1 Renal CT with IV contrast in blunt trauma patent shows a superficial (grade 2) laceration amenable to nonoperative management. .

Renal exploration is needed for a persistent leak. or pulsatile perirenal hematoma is present (suggests a renal pedicle avulsion. Repeat CT im aging if the patient develops a prolonged ileus or a fever. The hemoglobin decreases(there are no strict definitions of what represents a significant fall in hemoglobin). which can be drained percutaneously. hematuria is absent in 20%).admit for bed rest. (1) antibiotics. grade IV and. I f there is substantial contrast extravasation. Surgical exploration (see Box 10. 3. In these situations. large. Outpatient follow-up of microhematuria should be considered. (2) serial labs. 4. There is urinary extravasation and associated bowel or pancreatic injury. However. Urinary extravasation This is not an absolute indication for exploration. especially. im aging and admission is not required. 2. the renal repair should be well drained and omentum interposed between the kidney and bowel or pancreas.170 C HA P TE 10 R Trauma to the urinary tract Renal trauma: treatment Conservative (nonoperative) management Most blunt (95% )and many penetrating renal injuries(50% of stab injuriesand 25% of gunshot wounds) can be managed nonoperatively. since these signs may indicate development of a urinoma. The threshold for operative repair is lower with associated bowel or pancreatic injury—bowel contents mixing with urine is a recipe for sepsis. Expanding. consider placing a J J stent and a Foley catheter. Gross hem aturia: a hemodynamically stable patient whose injury has In been staged with CT.2) This is indicated (whether blunt or penetrating injury) if 1. The patient develops shock that does not respond to resuscitation with fluids and/or blood transfusion. and (3) observation until the hematuria resolves (cross-match in case blood pressure drops). Almost 80–90% of these injuries will heal spontaneously. grade V injuries may require prompt nephrectomy to control bleeding (grade V injuries function poorly if repaired). . D ipstick or m icroscopic hematuria:If systolic B P since injury has always been >90 mmHg and there is no history of deceleration. High-grade injuriescan be managed nonoperatively if they are cardiovascularly stable.

If urinary extravasation is also present.R E N AL T R A U M A C L IN IC A AND R A D IOLO G IC A : L L ASSESSMENT 171 Devitalized segments Exploration is usually not requiredfor patients with devitalized segments of kidney (F ig. these patients may be at higher risk for septic complications. . 10.2).

and tie them over the bolster. Finding a nonexpanding. Control bleeding vessels within the kidney with 4-0 absorb. Preoperative or imaging Action intraoperative . look for the inferior mesenteric vein and make your incision medial to this. Here. trace it upward toward the crossing of the left renal vein.2 Technique of renal exploration Midlineincision allows following: the • Exposure of renal pedicle. renal exploration may release retroperitoneal tamponade. This will stop them from cutting through the friable renal parenchyma. nonpulsatile retroperitoneal hematoma found at laparotomy. Close any defects in the collectingsystem similarly. I f your sutures cut out. A large perirenal hematoma may obscure the correct site for this incision. Controversy surrounds management of the nonexpanding. above the inferior mesenteric artery. thus increasingrisk of bleeding that can be controlled only by nephrectomy. for early control of renal artery and vein • Inspection for injury to other organs L ift the small bowel upward to allow access to the retroperitoneum. I f the patient is stable. In inexperienced hands. If this is the case. Once on the aorta. place perirenal fat or a strip of gelatin or collagen over the site of bleeding. Bleeding may be reduced by applying pressure to vessels via a Rummel tourniquet. Incise the peritoneum over the aorta. most can be left alone or treated with percutaneous angiographic embolization if needed postoperatively. place your sutures through the renal capsule on either side of this. Expose kidney by reflecting the colon up off of the retroperitoneum. both renal arteries may be accessed and vessel loops passed around these vessels.R EN AL TRAUMA: TREATMENT 171 Box 10. Nephrectomy may be required to stop lifethreateninghemorrhage.able sutures. nonpulsatile retroperitoneal hematoma at laparotomy An expanding or pulsatile retroperitoneal hematoma found at laparotomy in an unstable patient often indicates renal pedicle avulsionor laceration.

Explore and repair kidn ey if major injury is suspected (especiallyfor penetrating injury).172 Normal P TE 10 C HA R Abnormal Trauma to the urinary tract Leave the hematoma alone. Consider 1-shot IV P on table. None .Leave hematoma alone unless pulsatile and/or patient is unstable (especiallyblunt injuries). Explore and repair renal injury if hematoma is pulsatile and patient is unstable.

3 Contrast CT after abdominalstab wound shows deep central renal laceration and large perirenal hematoma with intravascularcontrast extravasation. Figure 10. Notice the normal contralateral kidney on this scan.R EN AL TRAUMA: TREATMENT 173 Figure 10. . This patient remained unstable after 3 units of blood were transfused and thus underwent nephrectomy.2 Left renal artery thrombosis after blunt trauma resulting in devitalizedparenchyma successfullytreated nonoperatively.

3).bore nephrostomy tube. While this may control bleeding in some cases. This is the surgicalequivalent of a stab wound and serious hemorrhage results in ~1% of cases. The exact inci. 10. Traditionally. Iatrogenic renal injury: renal hemorrhage after percutaneous nephrolithotomy Significantrenal injuries can occur during percutaneous nephrolithotomy (PCNL) for kidney stones. Eur U rol37:136–139. Bleeding during or after PCNL can occur from vessels in the nephrostomy track itself. prompt nephrectomy is warranted.persistent bleedingthrough the nephrostomy tube is managed by clampingthe nephrostomy tube and waiting for the clot to tamponade the bleeding. These are usually unstable patients who persist in shock despite multiple transfusionsand have deep renal lacerations near the hilum (Fig. and arteriography with embolization can also be used to stop the bleeding in these cases.4 and 10. Track bleeding will usually tamponade around a large. This can lead to hypertension months or years after renal injury.dence of post-traumatic hypertension is uncertain but felt to be rare. Failure to stop the bleeding by this technique is an indicationfor renal exploration. Severe bleeding after nephrolithotomy: results of hyperselective embolization. Hypertension and renal injury Excess renin excretion occurs followingrenal ischemia from renal artery injury or thrombosis or renal compression by hematoma or fibrosis.10. However. rather than as acute hemorrhage causingshock. from an arteriovenous fistula. . in others a rising or persistently elevated pulse rate (with later hypotension) indicates the possibility of persistent bleeding and is an indication for renal arteriography and embolization of the arteriovenous fistula or pseudoaneurysm (Figs.174 C HA P TE 10 R Trauma to the urinary tract Nephrectomy For severe renal injuries producing life-threatening bleeding. the bleeding usually occurs over a longer time course (days or even weeks). or from a pseudoaneurysm that has ruptured. Arteriovenous fistulae can sometimes occur following open renal surgery for stones or tumors. 1 Martin X (2000).5).

. An arteriovenous fistula was found and embolized.R EN AL TRAUMA: TREATMENT 175 Figure 10. Note the embolization coils in the lower pole.4 Renal arteriography after PCNL where severe bleeding was encountered.5 Post-embolization of arteriovenous fistula. Figure 10.