Renal trauma can occur from blunt or penetrating mechanisms. CT imaging is the gold standard for evaluation. Most renal injuries can be managed non-operatively with conservative treatment. Higher grade injuries or those with signs of failure like hematuria may require intervention like stenting or embolization. Operative management is only indicated for life threatening hemorrhage or other injuries requiring exploration. With proper evaluation and treatment, complications can often be avoided and renal function preserved.

1. Renal Trauma
ALMUMTIN, AHMED

2. Introduction
Classification of renal injury.
Mechanisms of injury.
Evaluation.
Treatment.
Complications.

3. 1-5% of trauma patients.
4.9 injuries/100,000.
Kidney is the most commonly injured.
82-95% is by blunt trauma.
Most commonly encountered youth, and male
gender. 75% in those < 44 years.

4. Most pediatric renal injuries result from
sporting activities.
Higher grade injuries occur in the setting of
MVA , or falls.
Some congenital renal anomalies predispose
the pediatric kidney to injury.

5. The American Association for the Surgery of
Trauma scale for renal injury. (AAST).

6. Blunt Trauma.
50% have associated other injuries
MVA 70%, falls 22%, Pedestrian 5%
Frontal impact > kidney collides with abdominal wall or
ribs > acceleration towards the opposite end (secondary
collide)
Lateral impact > direct compression of the kidney mostly
between fracture ribs and lumbar vertebrae

8. Uretropelvic junction / renal pedicle
usually result from deceleration.
Generally, present with hematuria.
25-50% of UPJ and renal pedicle > no
hematuria.
Moderate > stretching of vessels >
may result in arterial +/- venous
thrombosis
Sever force may cause avulsion of the
pedicle.

9. Penetrating trauma:
Represent 16% of renal injuries.
Firearms 58%, Stab wounds 42%
Patients with penetrating trauma, are more likely
to have renal injuries.
Careful assessment of penetrating injury in term
of speed, energy kinetics, and location.

10. Penetrating injuries anterior to anterior
axillary line > more likely to result in higher
grade injuries.
Flank wounds posterior to the anterior
axillary line, result in lower grade, more
peripheral parenchymal injuries.

11. Initial evaluation:
ATLS protocol. ( ABCDE )
Look for the urethra, perineum, flank for
ecchymosis or visible bleeding.
Look for seat belt sign > it indicates significant
trauma.
Send urine for analysis (microscopic hematuria)

12. Indications for imaging:
Depend on the severity and mechanism, presence of
hematuria (micro/gross), presence of shock (SBP < 90
mmHg).
Combination of blunt trauma + Micro or gross hematuria
+ shock > imaging.
Blunt trauma + microscpic hematuria + stable > can be
observed UNLESS major acceleration/deceleration injury
(fall from hight) or High speed MVA.

13. Blunt trauma + Gross hematuria even if stable
> imaging.
All penetrating injuries should be evaluated
radiographically.

14. CT contrast, with 10-minute delayed scan is
the GOLD STANDARD.
If no perinephric, periuretric, or pelvic fluid
collection, no need for delayed CT.

16. Repeat imaging 48-72 hours for conservatively
managed patients is not required for grade 1,2
and 3 without hemodynamic instability.
Repeating images in grade 4,5 without clinical
indication (e.g. sepsis, unstable BP, increasing
hematuria or oliguria ) rarely change the
management.

17. IV- Urography:
almost entirely replaced by CT in stable patients.
has a rule in unstable patients who are directly
taken for O.R. its helpful in verifying the
presence of another functional kidney.
FAST: is used to assess fluid collection, low
sensitivity for detecting renal injuries.

18. A- Non-operative:
To reduce the risk of nephrectomy
Used to treat grade III and IV in stable
patient.
patients with mil-moderate trauma who
underwent renal exploration > twice the risk
of developing a complication (7.1% vs 3.3%)

19. Signs of failure of conservative management:
Absence of contrast material in the ipsilateral ureter.
Large separation between upper and lower poles.
Multiple areas of extravasation.
Larger transfusion requirements.
No association between diameter/location of extravasation and failure
of conservative management.

20. Retrograde ureteral stenting is advocated in:
Patients with pain from uretral clot
obstruction (by CT).
Fever > 38.5
Significant urine leakage on repeat CT 3-5
days later (increasing urinoma).

21. In hemodynamically stable patient, in the
abscence of peritoneal signs:
Obligatory exploration of penetrating
renal trauma is decreasing (initially with
stab wounds and now with GSW)

22. B- Operative management:
Absolute indications:
life threatening hemorrhage that is suspected to be of renal cause.
renal pedicle avulsion.
Expanding pulsatile or uncontained retroperitoneal hematoma.
–
Relative indications:
•
Incomplete radiographic staging.
•
Presence of concurrent injuries that require repair/exploration.
•
Extensive devitalized renal parenchyma
•
Urinary extravasation

23. •
Consider nephrectomy / hemostatic
intervention after renal trauma in:
•
Patients with sock or those who require
high 24-h transfusion rates.
•
Those with penetrating injury.
•
Higher grade laceration.

24. •
Embolization:
–
effective for renal hemorrhage after blunt or penetrating
trauma esp after failed conservative management.
–
Embolization should be the initial management for patients
with:
–
Grade 3 & 4 lacerations
–
Arteriovenous fistula
–
Pseudoanurysm with persistant bleeding.

26. Left grade III renal laceration, and concomitant
grade II splenic laceration

27. •
extravasation/urinoma: higher after penetrating injury, usually with
grade IV, V, 75-90% resolve spontanuously.
•
Arteriovenous fistula: rare (0-7%), usually after penetrating injury,
embolization is the treatment of choice
•
Pseudoanurysm formation: mostly occur after penetrating injury.
embolization is the treatment of choice
•
Secondary hmg: serious, occur 2-3 weeks after penetrating deep
lacerations caused by rupture of AV fistula or pseudoaneurysm.
embolization is the treatment of choice
•
Hypertension

28. •
Thank You