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164 C HA P TER 10 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).
166 C HA P TER 10 Trauma to the urinary tract

Renal trauma: clinical and radiological


assessment
History includes mechanism of the trauma (blunt,
penetrating).
Examination
• Pulse rate, systolic blood pressure, respiratory rate,
• location of entry and exit wounds,
• flank bruising, and rib fractures need to be assessed.
Remember, in young adults and children, hypotension is a late
manifestation of hypovolemia; blood pressure is maintained until
there has been substantial blood loss, thus making shock a less reliable
indicator.
Indications for renal imaging 99.8% correct
1) gross hematuria
2) 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,
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, and degree of
hematuria and the severity of renal injury is neither predictable nor
reliable.
R E N AL T R A U M A: C L IN IC AL AND R A D IOLO G IC A
L 167
ASSESSMENT

Box 10.1 Staging of the renal injury


Using CT, renal injuries are staged according to the American
Association for the Surgery of Trauma (AAST) Organ Injury Severity
Scale. Higher injury severity scales are associated with poorer
outcomes.

Grade I Contusion or subcapsular hematoma with no parenchy-


mal laceration
Grade II Parenchymallaceration of cortex <1 cm deep, no
extravasation of urine (i.e., collecting system intact)
(Fig.10.1)
Grade III Parenchymallaceration of cortex >1 cm deep, no
extravasation of urine (i.e., collecting system
intact)
Grade IV Parenchymallaceration involvingcortex, medulla, and
collectingsystem OR segmental renal artery or renal vein
injury with contained hemorrhage
Grade V Completely shattered kidney OR avulsionof renal hilum

Table 10.1 Renal injury as indicated by hematuria and S B P


Degree of hematuria; systolic BP (mmHg) Significant renal injury
Microhematuria;*SBP >90 0.2%
Gross hematuria; SBP >90 10%
Gross or microhematuria;SB P <90 10%
* Dipstick or microscopic
hematuria
168 C HA P TER 10 Trauma to the urinary tract

The hemodynamically unstable patient


Such patients may need to be taken to the operating room immediately
to control bleeding. In this situation, 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 AL AND R A D IOLO G IC A
L 169
ASSESSMENT

Figure 10.1 Renal CT with IV contrast in blunt trauma patent shows


a superficial (grade 2) laceration amenable to nonoperative management.
170 C HA P TER 10 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.

D ipstick or m icroscopichematuria:If systolic B P since injury has always


been >90 mmHg and there is no history of deceleration, im aging
and admission is not required. Outpatient follow-up of microhematuria
should be considered.

Gross hem aturia:In a hemodynamically stable patient whose injury has


been staged with CT,admit for bed rest, (1) antibiotics, (2) serial labs,
and
(3) observation until the hematuria resolves (cross-match in case blood
pressure drops). High-grade injuriescan be managed nonoperatively if
they are cardiovascularly stable. However, grade IV and, especially, grade V
injuries may require prompt nephrectomy to control bleeding (grade V
injuries function poorly if repaired).

Surgical exploration (see Box 10.2)

This is indicated (whether blunt or penetrating injury) if


1. Expanding, large, or pulsatile perirenalhematoma is present
(suggests a renal pedicle avulsion; hematuria is absent in 20%).
2. The patient develops shock that does not respond to
resuscitation with fluids and/or blood transfusion.
3. The hemoglobin decreases(there are no strict definitions of
what represents a significant fall in hemoglobin).
4. There is urinary extravasation and associated bowel or
pancreatic injury.

Urinary extravasation

This is not an absolute indication for exploration. Almost 80–90% of


these injuries will heal spontaneously. The threshold for operative
repair is lower with associated bowel or pancreatic injury—bowel
contents mixing with urine is a recipe for sepsis. In these situations, the
renal repair should be well drained and omentum interposed between
the kidney and bowel or pancreas.
I f there is substantial contrast extravasation, consider placing a J J
stent and a Foley catheter.
Repeat CT im aging if the patient develops a prolonged ileus or a
fever, since these signs may indicate development of a urinoma, which
can be drained percutaneously. Renal exploration is needed for a
persistent leak.
R E N AL T R A U M A: C L IN IC AL AND R A D IOLO G IC A
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ASSESSMENT

Devitalized
segments

Exploration is usually not requiredfor patients with devitalized


segments of kidney (F ig. 10.2). If urinary extravasation is also present,
these patients may be at higher risk for septic complications.
R EN AL TRAUMA: 171
TREATMENT

Box 10.2 Technique of renal exploration


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

Preoperative or Action intraoperative


imaging
172 Normal
C HA P TER 10 Trauma
Leave theto the urinary
hematoma alone. tract
Abnormal Explore and repair kidn ey if major injury is
suspected (especiallyfor penetrating injury).Leave
hematoma alone unless pulsatile and/or patient is
unstable (especiallyblunt injuries).
None Consider 1-shot IV P on table. Explore and repair
renal injury if hematoma is pulsatile and patient is
unstable.
R EN AL TRAUMA: 173
TREATMENT

Figure 10.2 Left renal artery thrombosis after blunt trauma resulting
in devitalizedparenchyma successfullytreated nonoperatively.

Figure 10.3 Contrast CT after abdominalstab wound shows deep central


renal laceration and large perirenal hematoma with intravascularcontrast
extravasation. This patient remained unstable after 3 units of blood were
transfused and thus underwent nephrectomy. Notice the normal contralateral
kidney on this scan.
174 C HA P TER 10 Trauma to the urinary tract

Nephrectomy
For severe renal injuries producing life-threatening bleeding, prompt
nephrectomy is warranted. These are usually unstable patients who per-
sist in shock despite multiple transfusionsand have deep renal lacerations
near the hilum (Fig.10.3).
Hypertension and renal injury
Excess renin excretion occurs followingrenal ischemia from renal artery
injury or thrombosis or renal compression by hematoma or fibrosis. This
can lead to hypertension months or years after renal injury. The exact
inci- dence of post-traumatic hypertension is uncertain but felt to be rare.
Iatrogenic renal injury: renal hemorrhage after
percutaneous nephrolithotomy
Significantrenal injuries can occur during percutaneous nephrolithotomy
(PCNL) for kidney stones. This is the surgicalequivalent of a stab wound
and serious hemorrhage results in ~1% of cases.
Bleeding during or after PCNL can occur from vessels in the nephros-
tomy track itself, from an arteriovenous fistula, or from a
pseudoaneurysm that has ruptured. Track bleeding will usually
tamponade around a large- bore nephrostomy tube.
Traditionally,persistent bleedingthrough the nephrostomy tube is man-
aged by clampingthe nephrostomy tube and waiting for the clot to tam-
ponade the bleeding. While this may control bleeding in some cases, 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. 10.4 and 10.5). Failure to stop the
bleeding by this technique is an indicationfor renal exploration.
Arteriovenous fistulae can sometimes occur following open renal
surgery for stones or tumors, and arteriography with embolization can
also be used to stop the bleeding in these cases. However, the bleeding
usually occurs over a longer time course (days or even weeks), rather
than as acute hemorrhage causingshock.

1 Martin X (2000). Severe bleeding after nephrolithotomy: results of hyperselective


embolization.
Eur U rol37:136–139.
R EN AL TRAUMA: 175
TREATMENT

Figure 10.4 Renal arteriography after PCNL where severe bleeding


was encountered. An arteriovenous fistula was found and embolized.

Figure 10.5 Post-embolization of arteriovenous fistula. Note the embolization


coils in the lower pole.