managing renal injury with focus on the penetrating variety for medical students, resident doctors and other health personnel

1. MANAGEMENT OF PENETRATING
RENAL INJURY
BY
DR GEORGE OWUSU
(REGISTRAR )
UROLOGY UNIT 3

2. OUTLINE
• Introduction
• Primary survey
• Secondary survey
– History
– Physical examination
– Investigation
– Definitive treatment
• Follow-up
• Complications
• Conclusion

3. INTRODUCTION
• Renal trauma accounts for approximately 3% of
all trauma admissions and as many 10% of
patients who sustain abdominal trauma.
• Penetrating injuries accounts for about 15-20% of
these injuries.
• In as much as it is less frequent than blunt
traumas, its occurrence usually leads to
devastating traumatic kidney injuries.
• Hence, prompt diagnosis and care is of
paramount importance.

4. INTRODUCTION
• GOALS OF MANAGEMENT:
– Identify and treat immediate life threatening
injuries.
– Control hemorrhage, pain, infection.
– Preserve and restore renal anatomy and function
– Maintain urinary drainage.
• Management is through the Advanced Trauma
Life Support protocol.

5. PRIMARY SURVEY
• Brief history
– Mode/mechanism of injury
– Timing of injury
• Identify life threatening injuries
– Secure airway and stabilise C-spine
– Breathing
– Control external bleeding and resuscitation of shock
• IV access with wide bore cannula
• Collect blood samples for investigations
• Start resuscitation with IV crystalloids (aim to maintain systolic BP
> 90 mmHg)
• Pass urethral catheter (monitor urinary output and aim @
0.5ml/kg/hr)
• Address other disabilities

6. SECONDARY SURVEY
• HISTORY:
• Biodata (age, sex, occupation)
• Presenting complaints:
– Abdominal/ flank pain
– Abdominal swelling
– Loin swelling
– Gross haematuria
– Nausea and vomiting

7. HISTORY (CONT’D)
• Details of injury:
– Mechanism
– Caliber of offending agent
– Caliber of instrument / bullet
• Pre-existing renal abnormalies/ surgeries
– Cyst
– Nephrolithiasis
– Hydronephrosis
– Nephrectomy
• Allergies/ medications
• Last oral intake

8. PHYSICAL EXAMINATION
• GENERAL : Painful distress, pale, febrile, dehydrated
• ABDOMEN:
• Obvious entry point/ object
• Ecchymosis in the flank or upper quadrant of the abdomen
• Abdominal distension
• Diffuse abdominal tenderness (free blood or urine in
peritoneal cavity following torn retroperitoneum
• Palpable abdominal mass (retroperitoneal hematoma or
extravasated urine).
• Bowel sounds may be absent

9. INVESTIGATIONS
• Baseline
• specific/ diagnostic
• Specialised
• Baseline investigations:
• Full blood count (serial Hb)
• SE/U/Cr
• Urinalysis
• Urine MCS

10. INVESTIGATIONS
• SPECIFIC / DIAGNOSTIC INVESTIGATIONS
• RENAL IMAGING:
– Abdominal contrast enhanced computed tomography scan
– ‘one shot’ intravenous urogram
– Standard intravenous urogram
• Useful in detecting and staging renal injuries
• It is indicated in all patients with penetrating renal
injury, who are haemodynamically stable
• With any degree of haematuria microscopic/ gross.

11. INVESTIGATIONS
• ABDOMINAL CONTRAST ENHANCED COMPUTED
TOMOGRAPHY SCAN:
• Gold standard in evaluation of renal injuries
• Best imaging study to detect and stage renal and
retroperitoneal injuries:
– Both sensitive and specific in detecting renal parenchymal
lacerations
– Size and extent of retroperitoneal hematoma
– Urinary extravasation
– Renal arterial and venous injuries
– Additionally, can detect other intra-abdominal injuries
(liver, spleen, pancreas)

12. INVESTIGATIONS
• ‘ONE SHOT’ INTRAVENOUS UROGRAM:
• Unstable patients for immediate operative
intervention
• Taken in the operating room
• Indicates the presence or absence of contralateral
kidney
• 2ml/kg of contrast medium is injected
intravenously and single shot taken after 10
minutes.

13. INVESTIGATIONS
• STANDARD INTRAVENOUS UROGRAM:
• Indicated for stable patients in the absence of CT.
• Non functioning kidneys on IVU may suggest extensive
trauma or renal pedicle injury.
• Other features include (extravasation, delayed excretion,
incomplete filling, distortions of pelvi-calyceal system).
• ABDOMINAL ULTRASONOGRAPHY:
• This is of little importance in the initial staging and
evaluation of renal trauma.
• It does not provide information about renal function or
urine leak.
• Useful in follow-up of stable renal injury patient.

14. INVESTIGATIONS
• SPECIALISED INVESTIGATIONS:
• ANGIOGRAPHY:
• Arterial thrombosis and avulsion of renal pedicle are best
diagnosed by arteriography.
• It is indicated when the kidneys are not visualised on IVU:
– Total pedicle avulsion
– Arterial thrombosis
– Severe contusion with vascular spasm
– Absence of kidneys (congenital / surgery)
• RADIONUCLIDE RENAL SCAN:
• Could be used in staging renal trauma
• However, less sensitive than arteriography and CT Scan in
emergency.

15. TREATMENT
• Historically, all penetrating renal injuries
underwent laparotomies but with modern
radiological advances and following adequate
staging of renal injuries, modalities of
treatment include:
– Conservative / expectant management
– Minimally invasive procedures
(angioembolisation)
– Surgical exploration

16. TREATMENT
• CONSERVATIVE / EXPECTANT MANAGEMENT:
• Indications:
• Lower grade injuries (I-III) in a haemodinamically stable
patient with no urinary extravasation
• Modalities:
• Bed rest (until haematuria resolves)
• Adequate hydration and antibiotics
• Serial haematocrit
• Repeat CT imaging after 48hrs of initial staging scan

17. TREATMENT
• ANGIOEMBOLISATION:
• Available evidence regarding angioemboli-
sation in penetrating renal trauma is sparse.
• Indication:
• Non- life threatening bleeding isolated to a
segmental renal or vein in the setting of
expanding perirenal hematoma or refractory
hypovolemia.

18. TREATMENT
• SURGICAL EXPLORATION:
• In about 80% of cases of penetrating
abdominal injuries, other associated organ
injury requires operation.
• Thus, renal exploration may be an extension
of procedure.
• GOAL OF SURGERY:
– Control hemorrhage
– Renal salvage

19. TREATMENT
• INDICATIONS FOR SURGICAL EXPLORATION:
• ABSOLUTE:
– Persistent life threatening haemorrhage
– Renal pedicle avulsion (Grade V injury)
– Expanding, pulsatile or uncontained retroperitoneal hematoma
• RELATIVE:
– Large laceration of renal pelvis or avulsion of the pelvic-ureteric junction
– Co-existing bowel / pancreatic injuries
– Persistent urinary leakage, post injury urinoma, perinephric abscess with
failed percutanous or endoscopic management.
– Abnormal intra-operative one shot IVU
– Devitalised parenchymal segment with associated urinary leak
– Complete renal artery thrombosis of both kidneys or solitary kidneys when
renal perfusion appear preserved.
– Renal vascular injuries after failed angiographic management
– Incomplete staging

20. TREATMENT
• PRINCIPLES OF RENAL SURGICAL EXPLORATION:
• Anterior abdominal midline incision and transperitoneal
approach
• Early vascular control
• Complete renal exposure
• Sharp debridement of non-viable tissue
• Oversewing of bleeding vessels for haemostasis
• Water tight collecting system closure
• Achieving renal coverage
• Loose approximation of available renal capsule over
thrombogenic substance (thrombin soaked gel foam)
• Or placement of omental flap over reconstructed kidney

22. TREATMENT
• Renorrhaphy or partial nephrectomy is used to
manage parenchymal laceration.
– Attempt should be made for a watertight closure of collectingsystem.
– Raw areas should be minimized by using renal capsule, omentum or
fibrin glue.
• Repair of Grade 5 renal injury is rarely successful and
nephrectomy is usually the best option, except in case of a
solitary kidney.
• Retroperitoneum should be drained followingrenal
exploration.

24. FOLLOW-UP
• Repeat imaging 2-4 days after trauma minimises the
risk of missed complications, especially in grade 3-5
blunt injuries.
• Do CT scan if fever, unexplained decreased
haematocrit or significant flank pain.
• Repeat imaging can be safely omitted for patients
with grade 1-4 injuries as long as they remain clinically
well.
• Nuclear scans are useful for documenting and tracking
functional recovery following renal reconstruction

25. FOLLOW-UP
• Follow up should involve:
– Physical examination
– Urinalysis
– Individualised radiological investigations
– Serial blood pressure measurements
– Serum determination of renal function
• Follow up examination should continue until:
– Healing is documented
– Laboratory findings have stabilised
– However checking for latent renovascular
hypertension may continue for years.

26. COMPLICATIONS

27. COMPLICATIONS

28. CONCLUSION
• Penetrating renal injuries could be life
threatening and requires a high index of
suspicion for early recognition and prompt
intervention.
• Bearing in mind the multi-organ affectation
following abdominal penetration, an early
multidisciplinary review with the surgeons,
interventional radiologist and the Urologist
should be instituted for holistic care.