Brief description of renal trauma, Grading, its diagnostic investigations and Management Protocol.

1. Renal Trauma
Dr Adnan Bilal
PGR FCPS Urology, BVH.

2. Contents
• Definition & Epidemiology
• Anatomy
• Etiology
• Pathology & Classification
• Clinical Findings
• Investigations
• Management
• Follow up
• Complications

3. Definition & Epidemiology
• Renal Trauma is physical injury or wound to renal parenchyma
cause by intentional or unintentional extrinsic agent.
o Renal trauma is present in to up 5
%of all trauma cases.
o Renal injuries are the most common injuries of the urinary system.
o M:F =3:1

4. Anatomy
• Kidneys are retroperitoneal structures surrounded by perirenal fat, the vertebral
column and spinal muscles, the lower ribs, and abdominal contents.
• Children are more prone to injurybecause of the relatively greater size of the kidneys
in children, the smaller protective muscle mass and cushion of perirenal fat, and the
more pliable rib cage.

5. Key Points
• Eliciting a detailed history of the trauma
• Initial resuscitation according to ATLS guidelines
• Early imaging and diagnosis
• Conservative management unless the patient is unstable
• Awareness of complications

7. ( Rapid acceleration or deceleration)
• Blast Injuries
(Low / High Velocity)

10. AAST Organ InjurySeverity Scale
AAST Organ Injury Severity Scale

16. Clinical Presentation
• Hematuria (defined as >5erythrocytes per HPF or dipstick
positive)
– Blunt injury: Indicates significant renal injury
– Penetrating injury: May be absent
• Bruising in the flank / Seat belt marks
• Diffuse abdominal tenderness
• Penetrating Chest / Abdominal wounds
• Hypovolemic Shock

17. Diagnostic Evaluation
• History and Physical Examination
• Laboratory evaluation
• Imaging

20. Imaging

21. Imaging

22. Imaging Modalities
• Ultrasound (FAST)
• IVU
• CECT Scan –Modality of Choice
• MRI

23. Ultrasound (FAST)
• First imaging modality.
• Can identify
– Presence of Two Kidneys
– Renal vessel blood flow
– Retroperitoneal hematoma
• Cant identify
– Small Parenchymal tears
– Collecting system injuries
– Extravasation of urine in early phase
• Good for follow up of stable renal injury patients

25. Intravenous pyelography (IVU)
• Replaced by contrast- enhanced CT scan as the imaging study of choice in
patients with suspected renal trauma.
• Hemodynamic instability precludes Imaging.
• Indications:
a) Retroperitoneal hematoma
b) Renal injury likely to require nephrectomy
 Procedure:
A single shot X ray istaken 10 min after contrast administration (2ml /KG )

26. CECT
• Imaging modality of choice in hemodynamically stable patients
following blunt or penetrating trauma.
• Look for:
– Depth of parenchymal laceration
– Parenchymal enhancement
– Urinary extravasation
– Presence, size and position of retroperitoneal hematoma
– Adjacent organ injuries
– Presence of contralateral normal kidney

27. Grade 1

28. Grade 2

29. Grade 3

30. Grade 4

31. Grade 5

32. Management
• Non Operative
Most blunt (95%) and many penetrating renal injuries (50% of stab injuries and
25% of gunshot wounds) can be managed non- operatively.
– Conservative
– Interventional Radiology – Embolization (All grades)
• Operative

34. Selective angioembolization is used for active renal bleeding if there are
no other indications for immediate surgical exploration.

38. Operative Approach
• Exploration through a midline incision is preferred.
• Assess life-threatening bleeding, which is controlled with direct
pressure or packed to stabilize the critically ill patient.
• Assess and control hemorrhage from the liver, spleen, and major
retroperitoneal vessels prior to exposing the kidney.
• Ifstabilized with these maneuvers, consideration should be
made to leaving the perinephric space undisturbed.
• Explored if the hematoma is expanding or pulsatile, or if there is
suspicion of penetrating renal injury.

39. Procedure
• Transverse colon and small bowel are
retracted cephalad and to the right to
expose the root of the mesentery.
• Vascular control prior to exploring the
likelihood that nephrectomy.
• An incision is made in the
retroperitoneum over the aorta from
the level of the inferiormesenteric
artery to the ligament of Treitz . If
retroperitoneal hemorrhage obscures
the aorta, incision is made medial to
the inferior mesenteric vein, which is
readily identifiable in the mesentery.
• The renal artery to the kidney of
kidney has been shown to minimizethe
•
interest may be controlled as it
exits the aorta (inset). The left
renal vein coursing anterior to the
aorta isthe landmark.
Sweeping the duodenum off the
vena cava facilitates
identification of the right renal
artery.
• The artery and vein on the side of
interest are isolated with vessel
loops but not clamped unless
bleeding is uncontrollable.

41. Procedure
• The colon is then reflected medially by incising the line of Toldt
• Rapid blunt dissection exposes the kidney and surrounding
hematoma.
• Ifbrisk bleeding ensues, the previously isolated vessels may be
clamped or secured with Rummel tourniquets.

43. Polar Injury Repair

44. Mid-Renal Injury repair

45. Partial vessel Injury Repair

47. -(May eventually require nephrectomy)

48. o Loss of Kidney Function