Renal trauma
Dr. Ravi Roshan Khadka
MBBS MS
Urologist
Introduction
Trauma is the sixth leading cause of
death worldwide, accounting for 10% of
all mortalities.
The kidney is the most commonly
injured organ in the urinary system.
Introduction
Most renal injuries can be managed conservatively
The first hour of care after a major injury is extremely
important and requires rapid assessment of the
injuries and resuscitation.
The mnemonic “ABCDE” defines these priorities in
order of importance:
A, airway with cervical spine protection;
B, breathing;
C, circulation and control of external bleeding;
D, disability or neurologic status; and
E, exposure (undress) and environment (temperature
control)
Mode of injury to kidney
Blunt renal injuries
Motor vehicle accidents (m0st common cause) , falls
from heights, and assaults contribute to the majority of blunt
renal trauma.
Sudden deceleration may result in injury to the renal hilum
(renal vessels).
Penetrating renal injuries
It most often come from gunshot and stab wounds .
Bullets have the potential for greater parenchymal
destruction and are most often associated with multiple-
organ injuries .
Penetrating injury produces direct tissue disruption of the
parenchyma, vascular pedicles, or collecting system.
Classification of renal injury
Classification of renal injury
Diagnosis
History + examinations +
Investigations
Symptoms
Patient should be managed ATLS protocol
(Primary survey by ABCDE ) and only go for detail
diagnosis and management.
1. History of trauma
Possible indicators of major injury include
a history of a rapid deceleration event (fall, high-
speed MVAs) or
a direct blow to the flank.
pre-existing abnormality ( hydronephrosis ,cysts and
tumors)
Symptoms
2Microscopic /gross hematuria
Haematuria following trauma to the abdomen
indicates injury to the urinary tract.
The degree of renal injury does not correspond
to the degree of hematuria.
grosshematuria may occur in minor renal trauma and
only mild haematuria in major trauma.
3. Pain
It may be localized to one flank area or over the
abdomen.
Physical examination/Signs
1. Vital signs should be
recorded throughout the
diagnostic evaluation ecchymoses
(patient may develop
hemorrhagic shock).
2. Examine back, flank, lower
thorax or upper abdomen;
Look for ecchymoses,
abrasions, Fractured lower
ribs (Blunt trauma)
Look for penetrating
trauma from a stab or
bullet entry or exit wounds.
Physical examination/Signs
3. Abdominal tenderness
Diffuse
Itmay be found on
palpation; an “acute
abdomen” usually indicates
free blood in the peritoneal
cavity .
Localized
Localized flank tenderness
and distention
(retroperitoneal bleed)
Laboratory evaluation
Urinalysis;
RBC (degree of hematuria and the severity of
the renal injury do not consistently correlate )
CBC
Haematocrit; a decrease in haematocrit is indirect
signs of blood loss
Decreased Haemoglobin
Serum creatinine
Baseline creatinine measurement reflects renal
function prior to the injury
CT scan of abdomen and pelvis
CECT is the imaging modality of
choice .
Can diagnose renal injury as well as
grade them.
Also diagnose other associated visceral
injuries
30-year-old man after motor vehicle accident. CT
showing;
Small right subcapsular hematoma (arrow) is present
without evidence of underlying cortical injury
grade 1 right renal injury
32-year-old woman with h/o fall from second-story
balcony.
Small (< 1 cm) cortical laceration (arrow) is present with
large perirenal hematoma.
with grade 2 left renal injury
43-year-old man with h/o being struck by car
while walking.
Wedge-shaped perfusion defect (arrow) is present in
interpolar region of left kidney with surrounding
hematoma.
with grade 4 left renal injury
Other investigations
Abdominal Ultrasound
FAST (Focused Assessment Sonography in Trauma) is used to identify
haemoperitoneum .
USG is insensitive to solid abdominal organ injury hence usually not
appropriate in renal trauma
Intravenous urogram (IVU):
Usually not done now a days (replaced by CT scan)
Single shot intra operative IVU is done in haemodynamically
unstable patient at OT to assess the presence of a functioning
contralateral kidney and to radiographically stage the injured side
Renal arteriography:
may demonstrate the source of haemorrhage
may permit therapeutic embolization
rarely used for diagnosis
Treatment/Management
1. Emergency Management (ABCDE)
2. Conservative Management
3. Surgical Management
Emergency Measures
The objectives of early management are ;
prompt treatment of shock and hemorrhage,
complete resuscitation, and
evaluation of associated injuries.
Follow ATLS protocol
Primary survey and Resuscitation
ABCDE
Secondary survey and specific management
Conservative management
85% of cases and do not usually require operation.
Indications
Haemodynamically stable patient with grade 1,2 and 3
How to manage??
Open IV line ,secure intravenous access and blood Cross-matching.
Bed-rest while there is macroscopic haematuria and restrict
activity for a week after the urine clears.
Administer appropriate analgesia and antibiotics
Observations
Vitals (hourly), flank pain, fever
Check the urine for haematuria
Serial Haematocrit /CBC
CT scan abdomen
After 2-4 days in grade3
If Worsening sign
Surgical management
Indications
Haemodynamically unstable patients with shock
Expanding/pulsatile renal hematoma (usually indicating renal artery
laceration)
Suspected renal vascular pedicle avulsion (grade 5), and
Ureteropelvic junction disruption.
Options
Renal Injury
Renorrhaphy (Renal reconstruction)
Partial nephrectomy
Simple nephrectomy (grade 5 )
Vascular injury
Vascular embolization (segmental vessel; grade 3)
Vascular reconstruction
Indications of Nephrectomy
Hemodynamically unstable patient, with low
body temperature and poor coagulation, with a
normal contralateral kidney.
Extensive renal injuries when the patient’s life
would be threatened by an attempt at renal repair.
Already poorly functioning hydronephrotic
kidney with continuous bleeding
Renorrhaphy
Partial Nephrectomy
Vascular injuries repair
1
After RTA, a young male presented with non
pulsatile retroperitoneal hematoma.
On table IVU was done. Right kidney was not
visualized. Left kidney showed immediate
excretion of dye.
What is next step in the management?
a. Nephrectomy
b. Open Gerotas fascia and explore proximal renal
vessels
c. Perform retrograde pyelography
d. Perform on table angiography
Open Gerotas fascia and explore proximal renal vessels
After sustaining a blunt abdominal injury, a
15-year-old by presents with hematuria and pain in the
left side of abdomen.
On examination, he has a pulse rate of 96/ minute
with a BP of 110/70 mm Hg. His Hb is 10.8 gm% with a
PCV of 31%.
Abdominal examination revealed tenderness in left
lumbar region but no palpable mass. The most
appropriate investigation to diagnose and find the
extent of renal injury would be:
a. Sonographic evaluation of abdomen
b. Intravenous pyelography
c. Contrast enhanced computed tomography
d. MR urography
Contrast enhanced computed tomography
During renal rupture the nephrectomy
is not attempted until:
a. Fluid replacement
b. Antibiotics covers
c. Contralateral renal function is ascertained
d. Renal angiogram
Contralateral renal function is ascertained
A 25-year-old male presents to emergency with history
of road traffic accident two hours ago. The patient is
hemodynamically stable. Abdomen is soft.
On catheterization of the bladder, hematuria is
noticed. The next step in the management should be:
a. Immediate laparotomy
b. Retrograde cystouretherography (RGU)
c. Diagnostic peritoneal lavage (DPL)
d. Contrast enhanced computed tomography (CECT) of
abdomen
Contrast enhanced computed tomography (CECT) of abdomen
Home work
A 25 years old male presented to you at emergency
department with the history of car accident and
haematuria. On examination his BP=90/60 mmhg,
pulse 110/min but conscious. There was a localized
detention and tenderness at left flank.
What is your diagnosis?
What is your immediate management?
Discuss further investigations and management.
THANK YOU
Reference
European association of Urology
guidelines
Cambell and walsh Urology
Bailey & Love's Short Practice of
Surgery
Smith & Tanagho's General Urology
