Introduction
? Injuries to the kidney from external trauma are the most
--- Content provided by FirstRanker.com ---
common
? Blunt renal injuries most often come from motor vehicle
--- Content provided by FirstRanker.com ---
accidents, fal s from heights and assaults? Penetrating renal injuries most often come from gunshot
and stab wounds
--- Content provided by FirstRanker.com ---
? Upper abdomen, flank, and lower chest are entry sites
commonly resulting in renal injury
? History
--- Content provided by FirstRanker.com ---
? Physical examination? In polytrauma, rapid resuscitation should be under way.
? Immobilization of the cervical spine
? The abdomen, chest, and back must be examined
? Fractures of the lower ribs and upper lumbar and lower
--- Content provided by FirstRanker.com ---
thoracic vertebrae are associated with renal injuries
Clinical manifestation
--- Content provided by FirstRanker.com ---
Hematuria:? Best indicator of traumatic urinary system injury
? Presence of microscopic (>5 red blood cel s/high-power
field [RBCs/HPF] or positive dipstick finding) or gross
--- Content provided by FirstRanker.com ---
hematuria is characteristic? Degree of hematuria and the severity of the renal injury do
not correlate consistently
--- Content provided by FirstRanker.com ---
Classification
--- Content provided by FirstRanker.com ---
Indications for Renal Imaging
All blunt trauma patients with:
--- Content provided by FirstRanker.com ---
? Gross hematuria? Microscopic hematuria and shock
Should undergo renal imaging usual y CT with
--- Content provided by FirstRanker.com ---
intravenous contrastPenetrating injuries with any degree of hematuria
should be imaged
--- Content provided by FirstRanker.com ---
Imaging Studies
Contrast -enhanced CT
--- Content provided by FirstRanker.com ---
Right renal stab wound (grade IV), demonstrating extensive urinaryextravasation and large retroperitoneal hematoma
Findings on CT that suggest major injury are:
--- Content provided by FirstRanker.com ---
? Medial hematoma: vascular injury? Medial urinary extravasation: renal pelvis or
ureteropelvic junction avulsion injury
--- Content provided by FirstRanker.com ---
? Lack of contrast enhancement of the parenchyma:
arterial injury
--- Content provided by FirstRanker.com ---
Excretory urography? "single-shot" intraoperative IVP
--- Content provided by FirstRanker.com ---
Non operative Management? Significant injuries (grades I to V) are found in only 5.4% of
renal trauma cases
--- Content provided by FirstRanker.com ---
? Hemodynamical y stable patient with an injury wel staged
by CT can usual y be managed without renal exploration
--- Content provided by FirstRanker.com ---
? 98% of blunt renal injuries can be managed non operatively? Grade IV and V injuries more often require surgical
exploration
--- Content provided by FirstRanker.com ---
Trauma--- Content provided by FirstRanker.com ---
Operative Management
--- Content provided by FirstRanker.com ---
Absolute indications
Relative indications
--- Content provided by FirstRanker.com ---
Urinary extravasationPersistent renal
bleeding
--- Content provided by FirstRanker.com ---
nonviable tissue
Expanding perirenal
--- Content provided by FirstRanker.com ---
delayed diagnosis of arterialhematoma
injury
--- Content provided by FirstRanker.com ---
incomplete stagingPulsatile perirenal
hematoma
--- Content provided by FirstRanker.com ---
segmental arterial injury
Renal Exploration
--- Content provided by FirstRanker.com ---
Surgical exploration of the acutely injured kidney is bestdone by a transabdominal approach which al ows complete
inspection of intra-abdominal organs and bowel
--- Content provided by FirstRanker.com ---
Obtaining early vascular control before opening Gerota's
fascia can decrease renal loss
--- Content provided by FirstRanker.com ---
Surgical approach to the renal vessels and kidney
Renal Reconstruction
--- Content provided by FirstRanker.com ---
Principles of renal reconstruction after trauma include:? Complete renal exposure
? Debridement of nonviable tissue
? Hemostasis by individual suture ligation of bleeding vessels
--- Content provided by FirstRanker.com ---
watertight closure of the collecting system? Coverage or approximation of the parenchymal defect
--- Content provided by FirstRanker.com ---
Renorrhaphy
Renovascular Injuries
--- Content provided by FirstRanker.com ---
? Segmental renal arterial injuries result in ischemicinfarction to a segment of the kidney
? These should be observed non operatively when diagnosed
--- Content provided by FirstRanker.com ---
unless associated with a parenchymal laceration
? Injuries to the main renal vein require repair with fine
--- Content provided by FirstRanker.com ---
vascular suture (5-0)
? Segmental venous injuries are best managed by ligation
--- Content provided by FirstRanker.com ---
of the vesselIndications for Nephrectomy
? Unstable patient with low body temperature and
--- Content provided by FirstRanker.com ---
poor coagulation
? Extensive renal injuries
Complications
--- Content provided by FirstRanker.com ---
? Urinoma
? Perinephric infection
? Renal loss
? Delayed renal bleeding
--- Content provided by FirstRanker.com ---
? HypertensionUreteral Injuries
? Ureteral injuries after external violence are rare
--- Content provided by FirstRanker.com ---
? Occurs in < 4% of cases of penetrating trauma and < 1%
of cases of blunt trauma
--- Content provided by FirstRanker.com ---
? Significant associated injuries? Degree of mortality approaches one third
--- Content provided by FirstRanker.com ---
American Association for the Surgery of Trauma Organ InjurySeverity Scale for the Ureter
Surgical Injury
--- Content provided by FirstRanker.com ---
? Hysterectomy (54%)
? Colorectal surgery (14%)
? Pelvic surgery such as ovarian tumor removal and
--- Content provided by FirstRanker.com ---
transabdominal urethropexy (8%)? Abdominal vascular surgery (6%)
(St Lezin and Stol er, 1991 )
--- Content provided by FirstRanker.com ---
? In open operation at least one third of ureteral injuries
are recognized immediately
--- Content provided by FirstRanker.com ---
? Fewer injuries to the ureter are immediately identified
after laparoscopy
--- Content provided by FirstRanker.com ---
? Avoidance of ureteral injury is predicated on intimateknowledge of its location
Ureteroscopic Injury
--- Content provided by FirstRanker.com ---
Factors associated with higher complicationrates during ureteroscopy
? Surgery times
? Treatment of renal calculi
--- Content provided by FirstRanker.com ---
? Surgeon inexperience? Previous irradiation
Diagnosis
--- Content provided by FirstRanker.com ---
Incidence of Hematuria? 25% to 45% cases of ureteral injury after violence do
not demonstrate even microscopic hematuria
--- Content provided by FirstRanker.com ---
Intraoperative RecognitionImaging Studies
? Excretory Urography
--- Content provided by FirstRanker.com ---
Excretory urography demonstrating extravasation in the upper right ureter
? Computed Tomography
--- Content provided by FirstRanker.com ---
? Retrograde Ureterography? To delineate the extent of ureteral injury seen on CT scan or
IVP if further clinical information is needed.
--- Content provided by FirstRanker.com ---
? Most commonly used to diagnose missed ureteral injuries,
as it allows the simultaneous placement of a ureteral stent if
--- Content provided by FirstRanker.com ---
possible? Antegrade Ureterography
--- Content provided by FirstRanker.com ---
ManagementExternal Trauma
? Contusion
--- Content provided by FirstRanker.com ---
? UreteroureterostomySevere/large areas of contusion treated with excision
of the damaged area and ureteroureterostomy
--- Content provided by FirstRanker.com ---
? Internal StentingMinor ureteral contusions can be treated with stent
placement
--- Content provided by FirstRanker.com ---
Management options for ureteral injuries at different levelsTechnique of ureteroureterostomy after traumatic disruption
--- Content provided by FirstRanker.com ---
? Upper Ureteral Injuries? Ureteroureterostomy
? Auto transplantation
? Bowel Interposition
--- Content provided by FirstRanker.com ---
? Mid ureteral Injuries
? Ureteroureterostomy: Transureteroureterostomy
Bringing the injured ureter across the midline and
--- Content provided by FirstRanker.com ---
anastomosing it end to side into the uninjured ureter
? Lower Ureteral Injuries
? Ureteroneocystostomy
--- Content provided by FirstRanker.com ---
? Psoas Bladder Hitch (high success rate : 95% to 100%)? Boari Flap (if long ureteral defects )
? Partial Transection
--- Content provided by FirstRanker.com ---
Principle of primary repair involve spatulated, watertight closureunder optical magnification, with interrupted or running 5-0 or 6-
0 absorbable monofilament
--- Content provided by FirstRanker.com ---
? Surgical Injury
? Ligation
--- Content provided by FirstRanker.com ---
? removal of the ligature? observation of ureter for viability
? If viability is in question, ureteroureterostomy or ureteral
reimplantation should be performed
--- Content provided by FirstRanker.com ---
? Transection
? Immediate Recognition
--- Content provided by FirstRanker.com ---
ureteroureterostomyomental wrapping of the repair
? Delayed Recognition
--- Content provided by FirstRanker.com ---
stent placement