Dr. Debasis Maity

Remember

• The kidneys = most common genitourinary organs injured from external trauma
• 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 places the kidneys at risk.
• Penetrating renal injuries most often comes from gunshot and stab wounds.
• Bullet size and velocity has the greatest effect on soft tissue damage as predicted by the following equation:
  • Kinetic Energy = ½·mass·velocity²
• The best indicators of significant urinary system injury = haematuria

  • Microscopic: > 5 RBCs/HPF or positive dipstick finding

  • Gross hematuria and hypotension: SP < 90 mm Hg

    The degree of hematuria and severity of renal injury do not consistently correlate

Grade

Indication of renal imaging:

1. All penetrating trauma patients with a likelihood of renal injury (abdomen, flank, or low chest) who are hemodynamically stable.
2. All blunt trauma with significant mechanism of injury, specifically rapid deceleration.
3. All blunt trauma with gross hematuria.
4. All blunt trauma with hypotension ( SP < 90 mm Hg) at any time during evaluation and resuscitation.
5. All pediatric patients with > 5 RBCs/HPF.

• Patients with microscopic hematuria without shock can be observed clinically without imaging studies.
• Penetrating injuries with any degree of hematuria should be imaged.

Imaging:

CECT

• gold standard

• Highly sensitive and specific

• Provides most definitive staging information:

  • Parenchymal lacerations clearly defined.
  • Extravasation of Contrast enhanced urine easily be detected.
  • Associated injuries to the bowel, pancreas, liver, spleen, and other organs identified.
  • Degree of retroperitoneal bleeding assessed.
  • Lack of uptake of contrast material in the parenchyma suggests arterial injury.

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• Findings on CT that raise suspicion for major injury:
  1. Medial hematoma, suggesting vascular injury.
  2. Medial urinary extravasation, suggesting renal pelvis or ureteropelvic junction avulsion injury.
  3. Lack of contrast enhancement of the parenchyma, suggesting arterial injury.

IVP:

• When the surgeon encounters an unexpected retroperitoneal hematoma surrounding a kidney during abdominal exploration.

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Management:

Operative management:

• Absolute indications
  1. Hemodynamic instability with shock
  2. Expanding/pulsatile renal hematoma
  3. Suspected renal pedicle avulsion (grade 5)
  4. Ureteropelvic junction disruption
• Relative indications (rare)
  1. Urinary extravasation together with nonviable tissue
  2. Renal injury together with colon/pancreatic injury
  3. A delayed diagnosis of arterial injury (which most likely will need delayed nephrectomy)
  4. The management of the intraoperative nonexpanding retroperitoneal hematoma is controversial → Nonoperative therapy is recommended, regardless of mechanism
  5. Urinary extravasation from grade IV parenchymal laceration or forniceal rupture can be managed nonoperatively - spontaneous resolution > 90%
  6. Nonviable tissue > 25% with parenchymal laceration or urinary extravasation or both = operative management is recommended
  7. Segmental renal artery injury with renal laceration results in nonviable tissue (> 20%) → Currently, nonoperative management is favored in hemodynamically stable patientss, although concerns include delayed bleeding and urinoma formation

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.

Technique:

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Renal reconstruction:

• The principles of renal reconstruction:
  • Complete renal exposure, measures for temporary vascular control, debridement of nonviable tissue
  • Hemostasis by individual suture ligation of bleeding vessels
  • Watertight closure of the collecting system if possible
  • Coverage or reapproximation of the parenchymal defect
  • Judicious use of drains

Technique of renorrhapy:

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Technique of partial nephrectomy:

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