Download MBBS Surgery Presentations 32 Kidney And Ureters Trauma Lecture Notes

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Kidney and Ureters

Trauma

Dept Of Surgery

Introduction

? Injuries to the kidney from external trauma are the most

common

? Blunt renal injuries most often come from motor vehicle

accidents, fal s from heights and assaults

? Penetrating renal injuries most often come from gunshot

and stab wounds

? Upper abdomen, flank, and lower chest are entry sites

commonly resulting in renal injury
? History
? 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

thoracic vertebrae are associated with renal injuries

Clinical manifestation

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
hematuria is characteristic

? Degree of hematuria and the severity of the renal injury do

not correlate consistently




Classification


Indications for Renal Imaging

All blunt trauma patients with:
? Gross hematuria
? Microscopic hematuria and shock

Should undergo renal imaging usual y CT with

intravenous contrast

Penetrating injuries with any degree of hematuria

should be imaged

Imaging Studies

Contrast -enhanced CT

Right renal stab wound (grade IV), demonstrating extensive urinary

extravasation and large retroperitoneal hematoma
Findings on CT that suggest major injury are:

? Medial hematoma: vascular injury

? Medial urinary extravasation: renal pelvis or

ureteropelvic junction avulsion injury

? Lack of contrast enhancement of the parenchyma:

arterial injury

Excretory urography

? "single-shot" intraoperative IVP


Non operative Management

? Significant injuries (grades I to V) are found in only 5.4% of

renal trauma cases

? Hemodynamical y stable patient with an injury wel staged

by CT can usual y be managed without renal exploration

? 98% of blunt renal injuries can be managed non operatively
? Grade IV and V injuries more often require surgical

exploration

Trauma








Operative Management

Absolute indications

Relative indications

Urinary extravasation

Persistent renal

bleeding

nonviable tissue

Expanding perirenal

delayed diagnosis of arterial

hematoma

injury
incomplete staging

Pulsatile perirenal

hematoma

segmental arterial injury

Renal Exploration

Surgical exploration of the acutely injured kidney is best

done by a transabdominal approach which al ows complete

inspection of intra-abdominal organs and bowel

Obtaining early vascular control before opening Gerota's

fascia can decrease renal loss


Surgical approach to the renal vessels and kidney

Renal Reconstruction

Principles of renal reconstruction after trauma include:
? Complete renal exposure
? Debridement of nonviable tissue
? Hemostasis by individual suture ligation of bleeding vessels

watertight closure of the collecting system

? Coverage or approximation of the parenchymal defect




Renorrhaphy

Renovascular Injuries
? Segmental renal arterial injuries result in ischemic

infarction to a segment of the kidney

? These should be observed non operatively when diagnosed

unless associated with a parenchymal laceration


? Injuries to the main renal vein require repair with fine

vascular suture (5-0)

? Segmental venous injuries are best managed by ligation

of the vessel

Indications for Nephrectomy

? Unstable patient with low body temperature and

poor coagulation

? Extensive renal injuries
Complications

? Urinoma
? Perinephric infection
? Renal loss
? Delayed renal bleeding
? Hypertension

Ureteral Injuries

? Ureteral injuries after external violence are rare

? Occurs in < 4% of cases of penetrating trauma and < 1%

of cases of blunt trauma

? Significant associated injuries

? Degree of mortality approaches one third


American Association for the Surgery of Trauma Organ Injury

Severity Scale for the Ureter

Surgical Injury

? Hysterectomy (54%)
? Colorectal surgery (14%)
? Pelvic surgery such as ovarian tumor removal and

transabdominal urethropexy (8%)

? Abdominal vascular surgery (6%)

(St Lezin and Stol er, 1991 )


? In open operation at least one third of ureteral injuries

are recognized immediately

? Fewer injuries to the ureter are immediately identified

after laparoscopy

? Avoidance of ureteral injury is predicated on intimate

knowledge of its location
Ureteroscopic Injury

Factors associated with higher complication

rates during ureteroscopy
? Surgery times
? Treatment of renal calculi
? Surgeon inexperience
? Previous irradiation

Diagnosis

Incidence of Hematuria
? 25% to 45% cases of ureteral injury after violence do

not demonstrate even microscopic hematuria

Intraoperative Recognition

Imaging Studies
? Excretory Urography


Excretory urography demonstrating extravasation in the upper right ureter

? Computed Tomography

? Retrograde Ureterography

? To delineate the extent of ureteral injury seen on CT scan or

IVP if further clinical information is needed.

? Most commonly used to diagnose missed ureteral injuries,

as it allows the simultaneous placement of a ureteral stent if

possible

? Antegrade Ureterography


Management

External Trauma
? Contusion

? Ureteroureterostomy
Severe/large areas of contusion treated with excision

of the damaged area and ureteroureterostomy

? Internal Stenting
Minor ureteral contusions can be treated with stent

placement

Management options for ureteral injuries at different levels


Technique of ureteroureterostomy after traumatic disruption

? Upper Ureteral Injuries

? Ureteroureterostomy
? Auto transplantation
? Bowel Interposition

? Mid ureteral Injuries

? Ureteroureterostomy: Transureteroureterostomy
Bringing the injured ureter across the midline and

anastomosing it end to side into the uninjured ureter
? Lower Ureteral Injuries

? Ureteroneocystostomy
? Psoas Bladder Hitch (high success rate : 95% to 100%)
? Boari Flap (if long ureteral defects )

? Partial Transection

Principle of primary repair involve spatulated, watertight closure

under optical magnification, with interrupted or running 5-0 or 6-

0 absorbable monofilament

? Surgical Injury

? Ligation

? removal of the ligature
? observation of ureter for viability
? If viability is in question, ureteroureterostomy or ureteral

reimplantation should be performed

? Transection

? Immediate Recognition

ureteroureterostomy
omental wrapping of the repair

? Delayed Recognition

stent placement