2. Prepared by Group 4:
Morn Mariny
Un Soyien
Lav Honggech
Lim Chhunsrong
Leh Osiet
Kun Salim
3. Contents:
Definition & Epidemiology
Classification & Etiology
Pathology
Diagnosis
Management
Post Trauma & Care Follow Up
Complication
4. Definition
• Renal trauma is physical injury or wound caused by intentional or
unintentional extrinsic agent .
Anatomy
4
5. Epidemiology
• The incidence of renal trauma is around 245,000 cases each year
worldwide
• Renal trauma occurs in up to 5% of all trauma cases
• Ratio Male 3 : Female 1
• Both Kidneys are disposition for injury
• Blunt trauma 80–95% of all renal trauma (mostly cause by accident)
• Penetrating trauma represented 41% of all cases
5
6. Classifications of trauma
• Blunt trauma
o Motor vehicle collision
o Car accident (children are especially vulnerable to injury in car accidents)
o Fall
o Sports and assault
• Penetrating trauma
o Bullet
o Knife
o Any object piercing the body
6
7. Etiology
a) Blunt trauma
b) Penetrating trauma
c) Iatrogenic
o Endourologic procedures
o Extracorporeal shock wave lithotripsy
o Renal biopsy
o Intraoperative
d) Other
o Childbirth (may cause spontaneous renal lacerations)
Ureteroscopy
Percutaneous Nephrolithotomy 7
8. Pathology
• Laceration form blunt trauma: Usually occurs in the
transverse plan of the kidney
• The mechanism of injure: is assured to be force
transmitted from the center of the impact to the renal
parenchyma.
• In injury from rapid deceleration, kidney move upward
or downward, Causing sudden stretch on the renal
Pedicle and sometimes complete or partial avulsion.
• Acute thrombosis of the renal artery may be caused by
an intimal tear from rapid deceleration injury owing to
the sudden stretch.
8
9. Pathology (Cont.)
Grade 1
• Most common
• Renal contusion or bruising of the renal parenchyma.
• Microscopic hematuria is common, But cross hematuria can
occur rarely.
Grade 2
• Renal parenchymal laceration into the renal cortex (<1cm)
• Perirenal hematoma is usually small
9
10. Pathology (Cont.)
Grade 3
• Renal parenchymal laceration extending trough the
cortex and into the renal medulla (>1cm)
• Bleeding can be significant in the presence of large
retroperitoneal hematoma.
Grade 4
• Renal parenchymal laceration (Single or multiple
extending into the renal collecting system, also main
renal artery thrombosis from blunt trauma,
segmental renal vein, both , or artery injury with
contained bleeding
Grade III
Grade IV
10
11. Pathology (Cont.)
Grade V
• Multiple Grade 4 parenchymal lacerations, renal pedicle avulsion, or both main renal vein
or artery injury from penetrating trauma, main renal artery or vein thrombosis.
11
12. Pathology (Cont.)
Late Pathologic
1. Urinoma: Deep lacerations that are not repaired may result in persistent
urinary extravasation and late complications of a large perinephric renal mass
and, hydronephrosis and abscess formation.
2. Hydronephrosis
• Large hematomas in the retroperitoneum and associated urinary extravasation
may result in perinephric fibrosis engulfing the ureteropelvic junction, causing
hydronephrosis.
• Follow-up excretory urography is indicated in all cases of major renal trauma
12
13. Pathology (Cont.)
3. Arteriovenous fistula : May occur after penetrating injuries but are not common.
4. Renal vascular hypertension :
• The blood flow in tissue rendered nonviable by injury is compromised
• This results in renal vascular hypertension in less than 1% of cases.
• Fibrosis from surrounding trauma has also been reported to constrict the renal
artery and cause renal hypertension
13
14. Diagnosis
1. History – mode, mechanism
2. CC: Pain may be localized to one flank area or over the abdomen
3. Examination
4. Investigations
5. Laboratory
6. Imagery
• CT Scan
• Ultrasound
• Intravenous pyelogram
• MRI
14
15. MANAGEMENT
1. Non-operative management
• All grade 1-3 blunt and penetrating injuries in stable patients can be managed
conservatively with bed rest, hydration and antibiotics
• grade 1-4 blunt renal trauma, stable patients should be managed conservatively
with :
o Bed rest
o Prophylactic antibiotics, and
o Continuous monitoring of vital signs until hematuria resolves
15
16. INDICATIONS FOR EXPLORATION
Hemodynamic instability due to renal hemorrhage is an absolute indication
for renal exploration.
Grade 5 renal injury in a stable patient
expanding or pulsatile peri-renal hematoma seen at laparotomy for associated
injuries are other indications for renal exploration.
MANAGEMENT (Cont.)
16
17. 2. Surgery
• Goal of renal exploration following renal trauma is :
o Control of hemorrhage
o Renal salvage
• Trans-peritoneal
o Early control of renal pedicle
o Temporary occlusion of the pedicle during the exploration of kidney reduces blood loss
without increasing post-operative morbidity.
MANAGEMENT (Cont.)
17
18. • Renography or partial nephrectomy is used to manage parenchymal laceration.
o Attempt should be made for a watertight closure of collecting system.
o Raw areas should be minimized by using renal capsule, omentum or fibrin glue.
o 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 following renal exploration.
MANAGEMENT (Cont.)
18
19. Post-trauma care and follow up
• Within 3 months of major renal injury, patients’ follow-up should involve
o Physical examination
o Urinalysis
o Individualized radiological investigation
o Serial blood pressure measurement and
o Serum determination of renal function.
o Repeat imaging
• Long-term follow-up should be decided on a case-by-case basis but should at
the very least involve monitoring for renovascular hypertension.
19
20. Complications
• Early complications occur within the first month after injury and
can be
o Bleeding
o Infection
o Peri-nephric abscess
o Sepsis
o Urinary fistula
o Hypertension
o Urinary extravasation, and urinoma 20
21. Complications (Cont.)
• Delayed complications include
o Calculus formation
o Chronic pyelonephritis
o Hypertension
o Arteriovenous fistula
o Hydronephrosis, and
o Pseudoaneurysms
21