This document discusses renal trauma, providing information on evaluation and management. It notes that the kidney is the most commonly injured abdominal organ in trauma cases. Evaluation involves clinical examination looking for hematuria, hypotension, and flank tenderness, as well as imaging like CT or IVU to grade injuries. Most grade I-III injuries can be managed conservatively with bed rest, but higher grade injuries involving the renal parenchyma or vessels often require surgical exploration or angiography. Surgical management principles include debridement, hemostasis and repair of lacerations. Complications of renal trauma include urinoma, abscess, impaired renal function and death in severe cases.

1. RENAL TRAUMA
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
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2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai
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3. Introduction
 Most commonly injured organ
 10 % of abdominal trauma cases
 Children more susceptible
 Pre existing congenital renal abnormalities
increases the risk
Dept Of Urology, KMC and GRH, Chennai
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4. Renal trauma
Penetrating
Blunt
1.GUN SHOT
2.STAB
RTAs
FALLs
ASSAULTs
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Chennai
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5. BLUNT INJURIES
Dept Of Urology, KMC and GRH,
Chennai
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6. PENETRATING INJURIES
Dept Of Urology, KMC and GRH,
Chennai
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7. Evaluation
 Degree of deceleration
 Rapid deceleration can cause vascular damage to
the renal vessels,
o renal artery thrombosis,
o renal vein disruption,
o renal pedicle avulsion.
Dept Of Urology, KMC and GRH, Chennai
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8.  Movement of the kidney
from blunt trauma
(deceleration injury)
causes stretch on the
renal artery, resulting in
rupture of the arterial
intima and formation of
a thrombus.
Dept Of Urology, KMC and GRH,
Chennai
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9. Clinical evaluation
 Haematuria
 Hypotension
 Flank haematoma
 Abdominal / flank tenderness
 Fractures of the lower ribs
 Penetrating injuries to the lower thorax or flank
Dept Of Urology, KMC and GRH, Chennai
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10. Haematuria
Adults
 >5 RBCs/HPF
 Dipstick evaluation
 Gross haematuria
Paediatric
 Penetrating > 5 RBCs/HPF
 Blunt >50 RBCs/HPF
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11. Haematuria
 Low correlation between the degree of
haematuria and the severity of the renal injury
 Haematuria is absent
 36% of renal pedicle injuries
 24 % of renal Artery occlusions
Dept Of Urology, KMC and GRH, Chennai
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12. Hypotension
 Systolic blood pressure <90 mm Hg at any time before
resuscitation . Signifies significant haemorrhage (renal
parenchyma/pedicle)
Dept Of Urology, KMC and GRH, Chennai
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13. Renal Imaging
 USG
 CECT
 Single shot IVU
 Angiography
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14. Contrast-enhanced CT
 Gold standard
 Rapid
 Widely available
 Three dimensional data
 Anatomic / functional data
 Concomitant abdominal injuries
Dept Of Urology, KMC and GRH, Chennai
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15. CT KUB
 Medial haematoma- vascular injury
 Medial urinary extravasation- pelvis or
ureteropelvic junction avulsion injury
 Lack of contrast enhancement of the parenchyma -
arterial injury.
Dept Of Urology, KMC and GRH, Chennai
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16. American association for the surgery of trauma
organ injury severity scale for the kidney
 Grade I
Hematoma : Non
expanding sub
capsular hematoma.
Contusion: Micro or
Gross hematuria with
normal imaging
studies.
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17. Grade I Injuries
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18. Grade II
 Hematoma: Non
expanding Perirenal
Hematoma confined to
Renal retroperitoneum.
 Laceration:
Parenchymal
(cortical) laceration <
1cm without urinary
extravasation.
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19. Grade II Injuries
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20. Grade III
 Laceration:
> 1cm parenchymal
cortical laceration,
without collecting
system rupture,
urinary extravasation
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21. Grade III injuries
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22. Grade IV
 Laceration: laceration
involving cortex,
medulla and
collecting system,
urinary extravasation
 Vascular Injury: Main
Renal Artery, Renal
Vein Injury with
contained Hge.
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23. Grade IV injuries
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24. Grade IV injury
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25. Computed tomography of a left kidney with renal artery
thrombosis, demonstrating lack of contrast perfusion to the
kidney.
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26. Grade V
Laceration: Completely
Shattered kidney.
Vascular: Avulsion of
Renal Hilum,
devascularizing the
kidney
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27. Grade V injuries
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28. IVU
 Single shot ivu
 Unexpected retroperitoneal or perinephric haematoma
 2ml/kg
 10 min film
 Functional status of normal side
 Staging of injured side
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29. Single shot IVU
 Kidney trauma. One-shot
intravenous pyelogram,
normal. Ten-minute
radiograph taken after
intravenous contrast
administration on a patient
with a stab wound to the
back shows normal
kidneys and ureters
bilaterally.
Dept Of Urology, KMC and GRH,
Chennai
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30. IVU
 Focal nephrogram loss
 Extravasation of
opacified urine
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Chennai
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31. Angiography
 Penetrating injuries
 Stage significant injuries
 SELECTIVE ARTERIAL EMBOLISATION
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32. Indication of angiography
 Renal segmental artery
 Unstable grade 3 or 4 injury
 AV fistula
 Pseudoaneurysm
 Blood loss more than 2 units in 24 hrs.
 Renal artery thrombosis with intimal flaps.
Dept Of Urology, KMC and GRH, Chennai
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33. Arteriography demonstrating complete occlusion of
the left renal artery secondary to thrombus formation.
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34. USG
 Efficacy in trauma lacking
 Inferior to CT (78% false negative)
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35. Surgical evaluation
 Pts too unstable to undergo complete clinical or
radiological evaluation
 Single shot IVU
Dept Of Urology, KMC and GRH, Chennai
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36. Conservative Management
Indications :
 Grade I , II & III.
 contusion,
 intrarenal haematoma,
 small subcapsular haematoma,
 a laceration that does not communicate with
the collecting system,
 small segmental infarcts
Dept Of Urology, KMC and GRH, Chennai
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37. Conservative Management
 Absolute bed rest – till gross haematuria resolves.
 Fluid management.
 Antibiotics.
 Careful clinical follow-up.
 Repeat imaging if – fever, flank pain, dropping
haematocrit.
Dept Of Urology, KMC and GRH, Chennai
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38. Renal Exploration - Indications
 Absolute
Persistent renal bleeding - hypotension,
Renal pedicle avulsion
Expanding perirenal haematoma,
Pulsatile perirenal haematoma.
Suspected ureteropelvic junction disruption
Dept Of Urology, KMC and GRH, Chennai
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39. Renal Exploration-Indications
 Relative
Urinary extravasation with laceration,
Nonviable tissue > 20%,
Delayed diagnosis of arterial injury,
Incomplete staging – complete it surgically
Other organ injuries – pancreatic/colon
Dept Of Urology, KMC and GRH, Chennai
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40. Principles of reconstruction
 Broad exposure
 Temporary vascular control
 Non viable parenchyma debridement
 Haemostasis
 Water tight closure
 Reapproximate edges
 Omental interposition
 Retroperitoneal drain
Dept Of Urology, KMC and GRH, Chennai
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41. Resuscitation
Dept Of Urology, KMC and GRH,
Chennai
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42.  anatomic relationships of
the renal vessels
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Chennai
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43.  retroperitoneal incision
lateral to the colon,
exposing the kidney
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Chennai
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44. Technique of renorrhaphy
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45. Parenchymal repair
 Gelatin foam bolsters in
the repair site.
 Omental flap
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Chennai
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46. Partial nephrectomy
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47. Collecting system closure
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48. Laceration
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49. Laceration closure
Dept Of Urology, KMC and GRH, Chennai
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50. Renovasular injuries
 Uncommon
 Salvage rate only 33% in renal artery repair
 Endovascular stenting
 Delay in diagnosis >8 hrs kidney cannot be
salvaged
Dept Of Urology, KMC and GRH, Chennai
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51. Dept Of Urology, KMC and GRH, Chennai
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52. Damage control surgery
 Laparotomy pads around kidney
 To control bleeding
 Rexplore after 24 hrs.
 Evaluate the extent of injury
Dept Of Urology, KMC and GRH, Chennai
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53. Indications of nephrectomy
 Haemodynamically Unstable
 Hypoxia
 Hypothermia
 Acidosis
 coagulopathy
Dept Of Urology, KMC and GRH, Chennai
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54. complications
 Extravasation of urine
 Urinoma
 Perinephric abscess
 Co incident organ injury
 Impaired renal function
 Hypertension
Dept Of Urology, KMC and GRH, Chennai
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55. Complications
 Page kidney
 Renal vascular injury
 Secondary haemorrhage
 AV fistulas
 Pseudo aneurysms
 Death
Dept Of Urology, KMC and GRH, Chennai
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56. complications
 Miscellaneous
 Post injury hydronephrosis
 Flank pain
 Fistula
 Pulmonary complication
Dept Of Urology, KMC and GRH, Chennai
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57. Thank you
Dept Of Urology, KMC and GRH, Chennai
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