Renal trauma - Kidney trauma

1. Renal Trauma
Teacher: YOK RATANA,MD,UROLOGIST
WORKING AT CALMETTE HOSPITAL
ACADEMIC YEAR 2021-2022

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
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4.  Definition
• Renal trauma is physical injury or wound caused by intentional or
unintentional extrinsic agent .
 Anatomy
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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
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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
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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.
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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
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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
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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.
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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
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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
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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
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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
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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.)
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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.)
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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.)
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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.
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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
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22. Reference
• https://pubmed.ncbi.nlm.nih.gov/15371841/#:~:text=Penetrating%20trau
ma%20represented%2041%25%20of,radiographically%20if%20they%20we
re%20stable
• https://afju.springeropen.com/articles/10.1186/s12301-020-00073-
2#:~:text=The%20incidence%20of%20renal%20trauma,8%2C9%2C10%5D
• https://www.urologyhealth.org/urology-a-z/k/kidney-(renal)-trauma
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