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RENAL TRAUMA

RENAL INJURIES
The

kidneys are the most commonly injured


genitourinary organs from external trauma.
Advances in radiographic staging, improvements
in hemodynamic monitoring, and wider use of
angioembolization have improved the rates of
renal preservation and decreased unnecessary
surgery
The
majority
of
blunt
and
many
penetrating injuries to the kidneys no
longer require open surgical intervention.
Close follow-up of these patients and
timely treatment of nonoperative failures
or complications are still mandatory.

Presentation and
History
Motor

vehicle accidents, falls from heights,


and assaults contribute to the majority of
blunt renal trauma.
Direct transmission of kinetic energy and
rapid deceleration forces place the kidneys at
risk.
The
most important information to
obtain in the history of blunt renal injury
is the extent of deceleration involved in
high-velocity impact trauma. Significant
acceleration/deceleration can cause rare
but lethal renovascular injuries.

Presentation and
History
Penetrating

renal injuries most often


come from gunshot and stab wounds.
Gunshot wounds comprise the
great majority of the penetrating
trauma, with stab wounds a distant
second (86% vs. 14%).
Penetrating
mechanisms lead to
higher rates of significant and
persistent renal bleeding, need for
renorrhaphy/nephrectomy,

Presentation and
History
Physical

examination of all body systems must be


detailed and complete.
Rapid
resuscitation
according
to
American
Association for the Surgery of Trauma (AAST)
guidelines should be followed for polytrauma.
Examination of the abdomen, chest, and back must
be performed.
The presence of a flank hematoma, abdominal or
flank tenderness, rib fractures, and penetrating
injuries to the low thorax or flank indicate possible
renal injury.
Ipsilateral
rib fracture can increase the
incidence
of
significant
renal
trauma
threefold.

Presentation and
History

Hematuria
The best indicators of significant
urinary system injury include gross
and microscopic hematuria (>5 red
blood
cells/high-power
field
[RBCs/HPF]
or
positive
dipstick
finding), especially when associated
with acceleration/deceleration injury,
penetrating trauma, or hypotension
in the field or emergency room
(systolic blood pressure <90 mm Hg).

Although

critical
to
the
initial
evaluation of traumatic urinary tract
injury, the presence or absence of
hematuria should not be the sole
determinant in the assessment of a
patient with suspected renal trauma.
Because the significance of hematuria
varies
with
blunt
and
penetrating
mechanisms, the importance of proper
detection and staging of renal injuries,
usually by computed tomography (CT),
must be emphasized.

Evaluation of blunt renal trauma in adults

Evaluation of penetrating renal trauma


in adults

Classification
The

AAST
Organ
Injury
Scaling
Committee (Moore et al, 1989) provides
the most widely used and accepted
classification of renal injury (Table 50-1,
Fig. 50-1).
Based
on accurate grading made
possible by contrast-enhanced CT, the
AAST injury severity scale is a powerful
and valid predictive tool for clinical
outcomes in patients with renal trauma
(Santucci et al, 2001).

American Association for the


Surgery of Trauma Organ Injury
Severity Scale for the Kidney

Indications for Renal Imaging


The criteria for radiographic imaging include the
following:
1. All penetrating trauma with a likelihood of renal injury
(abdomen flank, or low chest entry/exit wound) who are
hemodynamically stable enough to have a CT (instead
of going right to the operating room or angiography
suite)
2. All blunt trauma with significant acceleration/
deceleration mechanism of injury, specifically rapid
deceleration as would occur in a high-speed motor
vehicle accident or a fall from heights
3. All blunt trauma with gross hematuria
4. All blunt trauma with microhematuria and hypotension
(defined as a systolic pressure of less than 90 mm Hg at
any time during evaluation and resuscitation)
5. All pediatric patients with greater than 5 RBCs/HPF

Imaging Studies
Contrast-enhanced CT is the gold standard
for genitourinary imaging in renal trauma
(Bretan et al, 1986; Federle et al, 1987).
Quick, highly sensitive, and specific, CT provides
the most definitive staging information
parenchymal lacerations are clearly defined;
extravasation of contrast-enhanced urine can
easily be detected (Fig. 50-3); associated injuries
to the bowel, pancreas, liver, spleen, and other
organs can be identified; and the degree of
retroperitoneal bleeding can be assessed by the
size of the retroperitoneal hematoma.

Findings

on CT that raise suspicion for major injury are


(1) medial hematoma, suggestingvascular injury; (2)
medial urinary extravasation, suggesting renal pelvis or
ureteropelvic junction avulsion injury; (3) global lack of
contrast enhancement of the parenchyma, suggesting
renal artery occlusion; and (4) the combination of two or
more of the following: large hematoma greater than 3.5
cm, medial renal laceration, and vascular contrast
extravasation (suggesting brisk active bleeding).
Patients with two or three of these last features (no. 4 in the
previous list) require open surgery or angioembolization nine
times more frequently than those with none or one of these
features (Dugi et al, 2010).
The widespread use and anatomic detail provided by CT imaging
has now supplanted the much less sensitive and less specific
excretory urography (IV pyelography [IVP]) for grading purposes.

Management Options For Renal


Trauma
Close

observation

Bed rest
Serial Hemoglobins
Antibiotics if urinary extravasation
Radiographic

Embolization
Urinary Diversion
Ureteral Stenting
Nephrostomy Drainage
Surgery

Renal Preservation / Reconstruction


Nephrectomy

Angioembolization
Renal arteriography and embolization is an
increasingly used modality in renal trauma.
In the right setting, it can be used to stop
significant renal bleeding without the need for
laparotomy.
Superselective embolization therapy for renal
trauma may provide an effective and less invasive
technique to avoid unnecessary exploration that
could otherwise result in a nephrectomy.
Initial failure is common, between 13% and 88%
(Breyer et al, 2008; Sugihara et al, 2012), but
subsequent embolization was highly successful in
at least one series (Hotaling et al, 2011).

Nonoperative
Management

Nonoperative management has become the


standard of care in hemodynamically stable,
well-staged patients with AAST grade I to III
renal injuries, regardless of mechanism
(Santucci et al, 2004b).
Most experts agree that patients with grade
IV and V injuries more often require surgical
exploration, but even these high-grade
injuries can be managed without renal
operation if carefully staged and selected
(Fig. 50-7) (Santucci and McAninch, 2000;
Santucci et al, 2004b; Buckley and McAninch 2006;
Umbreit et al 2009; Van der Wilden et al, 2013

Operative Management
Indications for renal exploration or speedy angioembolization after
trauma can be separated into absolute and relative (Voelzke and
McAninch, 2008).
Absolute indications include (1) hemodynamic instability
with shock, (2) expanding/pulsatile renal hematoma
(usually indicating renal artery laceration), (3) suspected
renal vascular pedicle avulsion (grade 5), and (4)
ureteropelvic junction disruption.
Relative indications are (1) urinary extravasation with
significant renal parenchymal devascularization (older data
suggest higher complication rate than average if watched,
but these also can be closely observed), (2) renal injury
together with colon/pancreatic injury (these patients have a
higher complication rate if their renal injury is not repaired
at the time of colon/ pancreatic injury, but the renal injury
may be closely observed after repair of the enteric injury),
and (3) a delayed diagnosis of arterial injury (which will
most likely need delayed nephrec

Renal Exploration
Surgical

exploration of the acutely injured


kidney is best done by a transabdominal
approach,
which
allows
complete
inspection of intra-abdominal organs and
bowel. In some reported series of penetrating
injuries, nonrenal 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 50-8 (McAninch and Carroll,
1989).

Renal Reconstruction
The principles of renal reconstruction
after trauma include complete renal
exposure, measures for temporary
vascular control, limited debridement of
nonviable tissue, hemostasis by
individual suture ligation of bleeding
vessels, watertight closure of the
collecting system if necessary/possible,
reapproximation of the parenchymal
defect, coverage with nearby
fascioadipose flaps (Gerota fascia or
omentum) if feasible, and liberal use of
drains (Fig. 50-9)

Damage Control
Coburn (2002) and Pursifull and colleagues
(2006) noted the benefit of damage control to
improve renal salvage after polytrauma.
The area around the injured kidney is packed
with laparotomy pads to control bleeding, with
a planned return in approximately 24 hours to
explore and evaluate the extent of injury.
Damage control may allow patients with
complex renal injuries to avoid unneeded
nephrectomy. This approach is commonly used
by trauma surgeons in patients with nonrenal
injuries.

Indications for Nephrectomy


The ability to reconstruct an injured kidney
depends on numerous factors.
In an unstable patient, if damage control is not an
option, total nephrectomy would be indicated
immediately when the patients life would be
threatened by attempted renal repair.
When Nash and colleagues (1995) examined the
reasons for nephrectomy in patients with renal
injuries, 77% required removal because of the
extent of parenchymal, vascular, or combined
injury. The remaining 23% required nephrectomy
in otherwise reconstructable kidneys because of
hemodynamic instability; this should be avoided.

Complications
Persistent

urinary extravasation can


result in urinoma, perinephricinfection,
and, rarely, renal loss.
Delayed renal bleeding can occur up to
several weeks after injury
Perinephric abscess rarely occurs after
renal
Hypertension is seldom noted in the
early post injury period (Monstrey et
al, 1989) but can occur later.