Renal Trauma

Subkhan
 Introduction
 Renal trauma occurs in 3 % patient hospilazed
 8-10% in all patient with abdominal trauma
 RENAL INJURY : Cause
 Rapid deceleration
 Blunt trauma( 70-
80%)
 Penetrating low
velocity
 Penetrating high
velocity
 When to suspect renal injury
 Any deceleration injury
 Stab or other low-velocity penetration in upper
abdomen, flank, lower chest
 Lower rib fractures
 Gunshot anywhere in trunk
 Multiple trauma
 Initial approach
 ABC
 Trauma kinetics history
 Abdomen, chest, back examination, look for
rib fractures
 Hematuria in GU injury
Hematuria is often indicative, BUT
1. Not specific to organ
2. May be absent in serious renal vascular
injury due to blunt trauma
3. Doesn’t correlate well with trauma severity
 Pediatric Patients
Children have a high output of
catecholamines after trauma. They
can show no signs of shock until 50%
of blood volume is lost! any degree
of hematuria in children require
imaging.
 Imaging – who’s getting CT?
 Blunt trauma patients with gross hematuria
 Children with micro/gross hematuria
 Microhematuria with shock (BP <90)
 Al penetrating injuries with any degree of hematuria
 Other organs trauma considered

Adult patient with blunt injury with microhematuria and

not in shock – observe, hold the CT.
Imaging – contrast enhanced CT
Finding that suggest major injury:
 Medial hematoma – vascular injury

 Medial urinary extravasation – pelvic rupture,

UPJ avulsion
 Lack of parenchyma enhancement – arterial
injury
Classification of renal
injuries
 Classification of renal injury
 95% of all injuries – grade I
 5% grades II – V
 Renovascular injury
 A result of rapid deceleration:
Stretch of renal artery
Intimal tear
Arterial Thrombosis
Kidney ischemia
Suspected renal
injury –
what to do?
 Treatment :Non – operative
management
Actually, 98% of all renal injuries can be
managed nonoperatively
If no indications for surgery but gross
hematuria present – admit and observe.
Treatment:Operative management

 Absolute indications:
1. Persistent renal bleeding
2. Expanding perirenal hematoma
3. Pulsatile perirenal hematoma

 Relative indications: urinary extravasation,

nonviable tissue, delayed diagnosis of arterial
injury, incomplete staging.
 Intraoperative imaging
 Unexpected retroperineal hematoma
 A need for nephrectomy - is other kidney
functional?

“one-shot” IVP on the table: inject 2ml/kg of

contrast and film 10 min later
 Treatment: Nephrectomy

 If other kidney present and has adequate

functioning!
 Unstable patient with hypothermia and
coagulation problems

 Another option – packing the wound,

correcting hypothermia, metabolic and
coagulation problems and reexploration in
24 hours
 Ureteral Injury
 Iatrogenic injury
 Blunt trauma
 Penitrating injury
 Open surgery
 Hysterectomy 54%
 Colorectal 14%
 Pelvic
 Abdominovascular

Only 1/3 is recognized during surgery…

URETER LIGATION
STENT INSERTION
 Recognizing intraoperative
ureteral injury
 If such an unfortunate event suspected,
injection of 1-2 ml of methylene blue into
renal pelvis can show leakage (ligation?)
 “one-shot” IVP
 Laparoscopy
 Mostly after gynocological procedures, seldom
recognized immediately 

Ureteroscopy can also result in ureteral injury

When to suspect ureteral injury?
 History of trauma or surgery and:
 Fever
 Flank pain and low abdominal pain
 Peritoneal inflammation signs
 Hematuria
 Often paralytic ileus
 Imaging
 IVP is the best diagnostic test available, but
it’s not sensitive enough too..
 Retrograde ureterography
 CT-IVP
Treatment – penetrating injury
 Treatment – penetrating injury
 If high velocity transection suspected –
debridment of 2 cm above and 2 cm below is
required
 Treatment
surgery induced ureteric injury
 If recognized immediately – primary
uretoroureterostomy vs. nephrectomy

 Delayed recognition: retrograde stent,

nephrostomy + anterograde stent, nephrostomy
and open repair later
 Bladder injury
 Blunt – due to pelvic fracture. Often car-to-
man accident
 Penetrating – commonly associated with other
major abdominal injuries
 Symptoms and signs
 Presence of pelvic trauma

 Hematuria
 Low abdominal pain
 Unable to urinate
 Pelvic hematoma
 Late recognition
 Fever
 Urinary retention
 Peritoneal signs
 ARF
 Diagnosis
 Two step retrograde cystography (filling and
voiding)

 CT with contrast material through catheter

 Classification of bladder injury
 Contusion
 Extraperitoneal – most of serious injuries
 Intraperitoneal
 Combined
 Treatment
 Contusion (hematuria only) – just observe
 Extraperitoneal – percutaneous dranaige only
unless:
 Bone fragments
 Open pelvic fracture
 Rectal perforation
 Need for surgery for other reasons
 Intraperitoneal – surgery

After 10 days – cystography. If no extravasation –

remove the catheter
Injury to urethra
 prostatic
membranous

bulbar

pendulous
 Posterior urethra injuries –
causes
 Blunt pelvic trauma
and pelvic fractures
 Symptoms and Signs
 Blood at the urethral meatus. Do not, do not,
do not try to pass the catheter if it’s present!!!
 Inability to urinate
 Palpapable bladder
 Pelvic hematoma
 Superiorly dispalced prostate
 Diagnosis
 Immediate retrograde urethrogam.
Posterior urethra laceration
Posterior urethra transection
Posterior urethra –complete
tear
 DD
 Bladder rupture can be associated with
urethral trauma, and it can present same
symptomatology
 Treatment
 Suprapubic cystotomy

 If incomplete laceration – spontaneous healing in 2-3

weeks
 Complete laceration – reconstruction after 3 months

 Primary repair – not recommended. Surgery is

difficult because of hematomas and impotence rates
about 50%
 Suspected low UT
injury – what to do
and what not to do?
 Conclusion
 No Foley if you suspect urethral trauma
 Gross hematuria OR microhematuria +
Shock = GU Trauma.
 Pelvic # + Microhematuria GU
investigation
 Don’t remove Foley if you suspect a
partial tear of urethra afterwards.
 Microhematuria alone : No imaging …but
F/U.
 In peds: Imaging for ALL hematuria.