Urinary Trauma

Dr. Sami Mahjoub Taha Awad

Associated professor- University of Gezira-Faculty of medicne
MBBS (U of G) - General Surgery (MD) _ Urology (Fellowship)
MRCS (Edinburgh)-SIU-F –R.Meth (Dip)
Genito-urinary injuries form10% of
:all injuries & include
.Renal injuries-1
.Ureteric injuries-2
.Bladder injuries-3
.Urethral injuries-4
.Genital injuries-5
 Acute Trauma Life Support Program

American College of Surgeons Program

:ABCDE
.Airays with cervical spine protection-1
.Breathing -2
.Circulation-3
.Disability or neurological status-4
Exposure(undress&environmental -5
.temperature control
 Renal Injuries
.Commonest Urinary Injury
:Etiology
,Blunt Trauma 90% of renal injuries-1
.Penetrating Trauma: Stab or gunshot-2
:Pathology
.Parenchymal lacerations-
.Vascular injuries.thrombus,A-V fistula-
.Extravasations: urine\Blood-
 Clinical Evaluations of Renal
Injuries
,History: Type of trauma, haematuria
.renal disease & operations
:Examinations
.General: Vital signs (Shock)-1
.Associated injuries & fractures-2
.Abdomen:Flank contusions, swelling-3
.penetrating wounds(inlet & exit), discharge-
Genitalia: blood on external meats-4
Per rectal exam.PR-5
 Investigations in Renal Injuries
.Laboratory:Urinalysis,Blood picture cereatinine
:Imaging: Aims
.Idetentify&stage the injury-1
.Recognise preexisting renal disease-2
.Document function of opposite kidney-3
Identify associated injuries in other organs -4
Delineate lines of treatment: early or late-5
.surgical or no surgical
Indications OF Imaging in Renal Trauma

.Gross Haematuria-1
Microscopic haematuria & shock, BP<90-2
.Any haematuria in children<16years old-3
.Penetratig injuries with haematuria-4
.Rapid acceleration deceleration injuries-5
Major associated injuries requiring -6
hospitalyzations.Fracture of lower ribs,
. flank contusions with haematuria
 Imaging of Renal Injuries
.X-rays: If suspect fractures
:U/S
.CT with contrast: The standard
.IVP: Less sensitive than CT
On table IVP:2ml/kg single shot -10 min after contrast
admistration(+/- renal injury-conralateral kidney)
:Renal Angiography
.MRI: same as CT
.Retrograde pyelography: ureteric injury
:Follow up Imaging
 Classifications of renal Injuries
American Association of the surgery of Trauma organ Injury
:Severity Scale for the kidney

:Five grades are presented

.Parechymal contusions-1
Cortical lacerations <1cm&subcapsular lacerations-2
.Parenchymal lacerations>1cm&subcapsular haematoma-3
Parenchymal lacerations through cortex, medulla-4
.and collecting system
.Vascular: main artery or vein injury or thrombus-
.Complete shuttering of the kidney-5
– .Vascular avulsion-
.Pelvi-ureteric junction avulsion-
  Subcapsular hematoma (category I) in a 40-year-old man who had sustained blunt abdominal
trauma.
 Major renal laceration without involvement of the collecting system (category II) in a 32-year-
old woman who had sustained blunt abdominal trauma.
.  Major renal laceration involving the collecting system (category II) in an 8-year-old boy who
had sustained blunt abdominal trauma.
   Traumatic occlusion of the main renal artery (category III) in a 17-year-old boy who had
sustained blunt abdominal trauma.

a
  Active arterial extravasation (category III).
 Conservative Management of Renal
Injuries
:Indications
.Blunt trauma-1
.Microscopic haematuria-2
.Isolated Renal Injury-3
:Lines of treatment
.Close follow up-1
.Selective renal imaging-2
.Repeated investigations-3
Angiograhy&embolization of bleeding-4
.vessel
 Surgical Management of Renal Injuries

:Absolute Indications
Persistant life threatening renal-1
.bleeding
.Expanding perirenal haematoma-2
.Pulsatile perirenal haematoma-3
.Renal pedicle avulsion-4
:Absolute Indications

Drop in Hb% and PCV(Pt in follow-up)

Urinary extravasation and visceral injury
Surgical Management of Renal Injuries
.Indications,continued
Urinary extravasations,urinoma,or-1
abscess&failed PC or endoscopic repair
.Lacerations of renal pelvis or PUJ-2
Renal vascular injury after failed-3
.angiographic management
Surgical exploration before complete-4
imaging or abnormal intraoperative IVP
.Coexisting visceral injuries-5
.Reno-vascular hypertension-6
Operative Treatment of Renal
Injuries
.Transperitoneal approach-1
.Mobilization of the kidney-2
.Debridment of nonviable tissues-3
.Haemostasis -4
.Closure of the collecting system-5
.Closure of parenchymal defect-6
.Ureteric stent or nephostomy tube-7
.wound drain
.Operative Treatment of Renal Injuries
 Operative Treatment of Renal Injuries
continued
.Partial Nephrectomy for partial polar injury -
.Repair of vascular injuries if possible-
Pack & delayed repair after 24 hours if-
.severe injury & bad general condition
.Auto-transplantation if repair fails-
Nephrectomy: extensive renal damage-
.threatening life
 Pediatric Renal Injuries
& Most pediatric renal trauma is minor
.Poses no significant danger to the child
Severe renal injuries demand Immediate
evaluations&decision of operative versus non
.operative treatment
Recent advances in management of pediatric
renal injuries reduced renal explorations to
with renal salvage rates >98% 5-11%
 Complications of Renal Injuriesِ
:EARLY: Within weeks
Persistant urinary extravasations,urinoma,abscess-1
Treatment: antibiotics&drain by ureteric
.Catheter, PC or surgical
;Delayed renal bleeding within 21days-2
.Angiographic embolization of bleeding vessel
A-V fistula: usually closes. if not angiographic -3
.embolization
Pseudoaneurysm:Angiographic embolization-4
 Complications of Renal Injuries
Late
Hypertension in 5% of renal-1
.injuries
.Hydronephrosis-2
.Calclus formation-3
.Chronic pyelonephritis-4
.Impaired renal functions-5