Urologic Trauma

C.R. Chapple and W.D. Steers (eds.), Practical Urology: Essential Principles and Practice,

497

DOI: 10.1007/978-1-84882-034-0_36, © Springer-Verlag London Limited 2011

498

Practical Urology: EssEntial PrinciPlEs and PracticE

kidney has been injured.Among the most impor-

and nonexpanding without parenchymal lacer-

tant aspects of the history is the presence of a

ation). Grade 2 injuries include hematoma (non-

rapid deceleration injury, as occurs in MVA or

expanding and perirenal; confined to renal

fall from height, as these can lead to renal pedicle

retroperitoneum) and laceration (<0.1 cm paren-

avulsion and may not result in hematuria.5

chymal depth with no urinary extravasation).

Guidelines for imaging patients with suspected

Grade 3 injuries are lacerations >0.1 cm without

renal trauma are given in Fig. 36.1. Importantly,

injury to the collecting system or urinary

though renal injury resulting from penetrating

extravasation.Grade 4 includes lacerations exten-

trauma often presents with hematuria, there is

ding through the renal cortex, medulla, and col-

no correlation between severity of injury and

lecting system or vascular injury to the main

the degree of hematuria.6 Therefore, patients

renal artery or vein with contained hemorrhage.

with penetrating trauma and any degree of

Grade 5 injuries include shattered kidney (lac-

hematuria should undergo radiologic evalua-

eration) or avulsion of the renal hilum (vascu-

tion. Following blunt trauma, imaging should be

lar). Grade is advanced by one for bilateral

reserved for those with gross hematuria, micro-

injuries up to grade 3.

scopic hematuria and a single SBP < 90 mmHg,

Nonoperative management has traditionally

or rapid deceleration injuries; these criteria will

been favored for those with minor (grade 1 and

detect greater than 99% of significant (grade 2

2) renal lacerations following blunt trauma, and

or greater) renal injuries.5

now a number of trauma centers have demon-

Renal injuries are graded according to a sys-

strated that patients with major renal lacera-

tem developed by the American Association for

tions from blunt8,10 and penetrating11,12 trauma,

the Surgery of Trauma Organ Injury Scaling

with or without urinary extravasation, can be

Committee,7 represented graphically in Fig. 36.2.

managed nonoperatively with no apparent increase

Grade 1 injuries include contusion (defined as

in acute or long-term morbidity13.

microscopic or gross hematuria with normal

Nonoperative management of grade 5 renal

urologic studies) and hematoma (subcapsular

parenchymal injuries has been reported,14 but we

500

Practical Urology: EssEntial PrinciPlEs and PracticE

Endovascular Therapy

preserve as much renal function as reasonably

possible. Though principles of damage control

Angio-embolization is an effective therapy for

and preservation of renal function may initially

select patients with renal hemorrhage.17 The fol-

be at odds, it is clear that early control of the

lowing criteria have been proposed for angio-

renal hilum is rapid, easily accomplished, and

embolization: Persistent bleeding from a renal

reduces the need for nephrectomy.20,21 Thus, we

segmental artery; unstable condition with grade

believe that renal exploration should only be

3–4 injury; arteriovenous fistula or pseudoan-

approached with early control of the renal

eurysm; persistent gross hematuria and/or rap-

pedicle.

idly decreasing hematocrit requiring 2 U blood.18

In select patients who may not tolerate repair,

Patients with shattered kidney or injury to the

it is reasonable to pack the retroperitoneum and

main renal artery or vein should be surgically

return 24 h later for exploration and repair.

treated, as embolization does not seem to be

Renal exploration should be approached

effective in these patients and can delay appro-

transperitoneally through a midline incision,

priate treatment in an unstable patient, leading

which should be carried up to the xiphoid pro-

to significant morbidity or even mortality.

cess in order to permit adequate exposure of the

Endovascular stenting is not generally useful in

upper retroperitoneum. The peritoneum is

the trauma patient, as it requires anticoagula-

incised over the aorta from the level of the IMA

tion, which is typically contraindicated in the

to the level of the left renal vein. If the aorta is

patient with multiple organ-system injury.

obscured by a retroperitoneal hematoma, the

incision can be made medial to the IMV, which

Operative Intervention

is usually readily identified. The left renal vein is

secured with a vessel loop and then the left renal

The patient who requires operative intervention

artery, right renal vein, and right renal artery are

secured in that order. If there is uncontrolled

following renal trauma is usually unstable and

bleeding, the vessel loops can be used to occlude

rushed to the operating room without adequate

the artery, though often manual compression of

imaging. However, it remains essential to radio-

the kidney is sufficient.

graphically stage the injury. Though IVP is much

Principles of renal reconstruction in the

less reliable than CT – especially for parenchymal

trauma setting include exposure of the entire

injuries11 – a one-shot IVP is simple to perform

(for technique, see “Imaging” section), does not

kidney, early vascular control, debridement of

nonviable tissue, meticulous hemostasis, water-

typically prolong the procedure, and may identify

tight closure of the collecting system, careful

an injury that would otherwise be missed, leading

reapproximation of the parenchymal edges or

to potentially life-threatening complications post-

coverage of the parenchymal defect, and drain

operatively. Most importantly, the IVP will iden-

placement.22 Individual vessels should be suture-

tify the presence or absence of a contralateral

ligated with 4-0 chromic suture, and collecting

kidney, which cannot be accurately determined

system tears should be oversewn with running

by palpation.19 When there is a high index of sus-

picion,especially in the case of penetrating trauma

4-0 chromic suture. Typically, large parenchy-

mal defects are approximated in a tension-free

where the trajectory is suggestive of injury to the

manner over a bolster made of thrombin-soaked

collecting system or ureter, it is reasonable to

Gelfoam that is tied at 1 cm intervals with an

inject 1–2 cc of dilute methylene blue into the

absorbable suture. In the setting of contamina-

renal pelvis. One or more laparotomy pads can be

tion from bowel or pancreatic injuries, pledgets

placed into the retroperitoneum to identify the

should be made from absorbable material, such

source, and the ureter can be occluded to further

as vicryl mesh or peritoneum.

help identify an occult leak from the kidney.