Dr. med. Dirk Manski



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Renal Trauma: Injury of the Kidney

Review literature: (Diederichs and Mutze, 2003) (Kawashima et al, 2002) (Meria and Mazeman, 2000) (Vasile et al, 2000).

Etiology of Injuries of the Upper Urinary Tract

Penetrating Injuries:

Gunshot or stab wounds.

Blunt Trauma:

Direct blunt force (contusion, bruising of the abdomen or flank) leads to a rupture the kidneys. Deceleration in high-velocity accidents (falls from height oder motor vehicle accidents) damage the kidney, renal vessels or ureter by the inertia of the mass.

Epidemiology of renal trauma:

Signs and Symptoms of Renal Trauma

Acute signs and symptoms:

Late complications of renal trauma:

Diagnostic Work-up of Renal Trauma

Laboratory examinations:

Urine sediment, blood count, creatinine. The lack of hematuria does not exclude severe renal trauma.

Ultrasound imaging:

Abdominal (renal) ultrasound may be a valuable tool for initial evaluation of abdominal injuries to reveal free abdominal fluid, retroperitoneal hematoma, urinoma and hydronephrosis. Doppler ultrasound may be helpful to demonstrate renal pedicle injury or kidney infarction.

Computed tomography:

CT is the imaging technique of choice, if there is a high suspicion for renal injury: severe trauma, abnormalities in ultrasound imaging or hematuria. To exclude bladder injury in blunt abdominal trauma, the bladder should be filled with diluted contrast media before CT. [fig. CT imaging of renal trauma]. Contraindication of CT: patients with unstable circulation after initial resuscitation require surgical intervention without further imaging.

Urography (IVP):

The investigation is largely replaced by computed tomography. IVP may be indicated (as an alternative to CT) to exclude renal injury, e.g. with hematuria and normal ultrasound imaging, and if CT is not available. Urography has also a limited role in intraoperative imaging (single shot IVP).


CT imaging in renal trauma: Left image: left renal trauma grade I (subcapsular hematoma). Right image: left renal injury grade II (Retroperitoneal hematoma, renal laceration of less than 1 cm). With kind permission of Dr. G. Antes, Kempten.
Figure renal trauma CT imaging with retroperitoneal hematoma

Classification (Severity) Of Renal Trauma

Classification of the American Association for the Surgery of Trauma:

Grade I:

Renal contusion with hematuria or subcapsular hematoma.

Grade II:

Renal laceration of less than 1 cm, perirenal hematoma confined to the retroperitoneum.

Grade III:

Renal laceration of more than 1 cm, without urinary extravasation, perirenal hematoma confined to the retroperitoneum.

Grade IV:

Renal laceration extending through renal cortex, medulla and collection system with urinary extravasation. Renal artery or renal vein injury with contained hemorrhage (and partial devascularization of the kidney).

Grade V:

Completely shattered kidney. Avulsion of the renal hilum. Devascularization of the complete kidney.

Treatment of Renal Trauma

Conservative management:

Conservative management is possible in renal trauma with stable circulation and trauma severity grade I–III (no urinary extravasation). Important is bed rest until gross hematuria resolves and frequent monitoring of vital signs and blood count. Fever, dropping blood count or flank pain are indications for repeated imaging (ultrasonography or CT).

Internal ureteral stent:

Ureteral stenting is indicated for urinary extravasation in grade IV renal injury (MJ/DJ ureteral stent or percutaneous nephrostomy). Large (delayed diagnosed) urinomas are drained percutaneously. Antibiotic prophylaxis is often recommended.

Operative Management:

Absolute indications for operative management are:

Relative indications for operative management are:

Surgical technique:

Transperitoneal exposure using a midline laparotomy, cell saver and packed red blood cells for transfusion should be ready. Early vascular control before opening of Gerota's fascia improves renal salvage rate. Renal reconstruction can be done with temporary ischemia. Kidney defects may be sutured (renorrhaphy) and covered with omentum majus, absorbable mesh or retroperitoneal fat. Hemostatic agents are helpful in controlling the bleeding tissue. If necessary, urinary drainage is done via nephrostomy.

Indications for nephrectomy: extensive renal or vascular injury, unstable patient.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References

Diederichs und Mutze 2003 DIEDERICHS, W. ; MUTZE, S.:
[Renal trauma: is open surgery still up to date?].
In: Urologe A
42 (2003), Nr. 3, S. 322–7

Kawashima u.a. 2002 KAWASHIMA, A. ; SANDLER, C. M. ; CORL, F. M. ; WEST, O. C. ; TAMM, E. P. ; FISHMAN, E. K. ; GOLDMAN, S. M.:
Imaging evaluation of posttraumatic renal injuries.
In: Abdom Imaging
27 (2002), Nr. 2, S. 199–213

Meria und Mazeman 2000 MERIA, P. ; MAZEMAN, E.:
Immediate and delayed management of renal trauma.
In: Eur Urol
37 (2000), Nr. 1, S. 121–30

Vasile u.a. 2000 VASILE, M. ; BELLIN, M. F. ; HELENON, O. ; MOUREY, I. ; CLUZEL, P.:
Imaging evaluation of renal trauma.
In: Abdom Imaging
25 (2000), Nr. 4, S. 424–30

 

 

 

 

 

 

 

 



  Deutsche Version: Nierentrauma