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1. KIDNEY INJURIES
Sunil Kumar Daha

2. INJURIES TO KIDNEY
 Commonly it is due to a blunt injury.
 Often it is associated with other abdominal
injuries—of liver, spleen, bowel, mesentery, etc.
 Per se renal injury is extraperitoneal.

3. Types
1. Small subcapsular.
2. Large subcapsular.
3. Cortical laceration.
4. Laceration with perinephric haematoma.
5. Medullary laceration with bleeding into the renal
pelvis.
6. Corticomedullary complete rupture.
7. Hilar injury (most dangerous).

5. Grading of renal injury
1. Subcapsular nonexpanding haematoma without
parenchymal laceration
2. Cortical laceration < 1 cm of parenchymal depth,
no extravasation; perirenal haematoma
3. Cortical laceration > 1 cm depth; no urine
extravasation
4. Parenchymal laceration extending through cortex
and medulla with collecting system; with
extravasation of urine
5. Renal pedicle avulsion; shattered kidney

6. Clinical Features
 Features of shock.
 Hematuria—may be mild to profuse depending on
the type of injury.
(Sudden delayed profuse hemorrhage causing
hematuria can occur between 3rd day to 3rd
week after trauma.)
 Clot colic.
 Bruising, swelling and tenderness in the loin.
 Paralytic ileus with abdominal distension occurs
due to retroperitoneal haematoma implicating
splanchnic nerves

7. Investigations
1. IVU (high dose): It is the investigation of choice. Here
function of not only the injured kidney but also of the
contralateral kidney can be seen. It is observed that often
opposite renal artery undergoes a reflex spasm, temporarily
ceasing the function of the contralateral kidney.
2. U/S abdomen: Done to see the type of injury, amount of
haematoma and other associated injuries in the abdomen.
 U/S is repeated at regular intervals to see the progress (at 12-
24 hourly).
3. Blood urea and serum creatinine should be repeated at
regular intervals.
4. Blood grouping and cross-matching for blood transfusion.
5. Emergency CT scan is very useful.

8. Treatment
I. Initially always conservative:
 Catheterize and watch the urine color and output.
 Blood transfusion.
 Strict observation with regular monitoring of the
pulse, BP, temperature, U/S follow-up daily.
 Sedation, analgesic and antibiotics.
 75% of patients respond to conservative manag
ement.

9. Cont….
 While treating conservatively, regular monitoring
of blood urea and serum creatinine is a must.
 If the patient goes in for renal failure,
hemodialysis should be done for 6-8 weeks.
Mean while, other kidney starts functioning again
and patient recovers without any further problem.

10. II. Indications for surgical intervention:
 When there are signs of progressive blood
loss with the
 condition of the patient deteriorating.
 Formation of progressive perinephric
haematoma.
 When there are associated other injuries.
 Hilar injury.

11. Surgery (Only in 10-20% of
Patients)
Options:
 Gentle suturing of the laceration. Often kidney is
friable, this is not possible.
 Then nephrostomy (Cabot’s) is done.
 When the injury is in the poles partial
nephrectomy is done.
 In hilar injury and severe laceration, nephrectomy
is the only choice

12.  I Only bruise/contusion
 II Breach in calyceal
system rupture of one of
the small branches of
renal artery
 III Rupture of pelvi-
calyceal system/renal
substance
Types Treatment
 Conservative
 Conservative/
nephrectomy
 Nephrectomy

13. Complications
 Clot retention in the bladder and may go for
renal failure
 Pararenal pseudohydronephrosis
 Infection
 Perinephric abscess
 Aneurysm of the renal artery
 Renal failure
 Hypertension occurs 3 months later

14. URETER INJURY

15. Injuries to the Ureter
 Rupture of ureter
 Uncommon result of hyperextension injury of
spine
 Swelling in loin or iliac fossa associated with
reduced urinary output
 Injury during pelvic surgery
 Most often during vaginal or abdominal
hysterectomy
 Pre-emptive ureteric catheterisation makes
easier to identify ureter

16. Injuries recognized at the time of
operation
 Ureterovesical continuity should be restored
 Deliberate ligation of proximal ureter and
temporary percutaneous nephrostomy

17. Injuries not recognized at the time
of operation
Unilateral injuries:
3 possibilities
1. No symptoms
Ligation of ureter may lead to silent
atrophy of kidney
2. Loin pain and fever
Pyonephrosis, Infection of obstructed
system
3. Urinary fistula
Through abdominal or vaginal wound

18. Injuries not recognized at the time
of operation
Bilateral injuries:
 Ligation of both ureters leads to anuria
 Ureteric catheter will not pass and urgent
nephrostomy or immediate surgery essential

19. Imaging
Contrast-enhanced CT or a complete
IVP is accurate for the detection of
ureteral
trauma.

20. Repair of Injured Ureter

21. Psoas Hitch of Bladder Transureterouretostomy

22. Boari Operation
 Flap of bladder wall is fashioned into tube to
replace the lower ureter

23. BLADDER INJURY

24. Causes of bladder injury
 Trauma:
• RTA
• Kick or blow on
abdomen, with full
bladder
• Penetrating injury
• Surgical:
• Inguinal or femoral
herniotomy
• Hysterectomy
• Excision of rectum

25.  Intraperitoneal rupture (20%)
 Extraperitoneal rupture (80%)
Types

26. Intraperitoneal rupture
 Secondary to a blow or fall on a distended bladder,
more rarely to surgical damage
 Clinical features
 Sudden severe suprapubic pain, hypotension/syncope
and shock
 Lower abdominal guarding and rigidity occurs after few
hour of injury
 Distension
 Urinary retention
 Presents as anuria
 Unable to palpate bladder

27. Extraperitoneal rupture
 Trauma either penetrating or blunt injury with
fracture of pubis (RTA in a non distended
Bladder)
 Difficult to distinguish clinically from an injury to
the membranous urethra

28.  Clinical Features
 Extravasations of fluid: Collection of urine and blood
in the extra peritoneal space in front, with fullness,
diffuse pain and tenderness in lower abdomen
 Swelling of scrotum and labia, and abdominal wall
 inability to pass urine
 Often blood in the external meatus is noted.
 Gross haematuria can be absent

29. Intra vs Extra peritoneal Rupture of
Bladder

30. Investigations
 Plain x-ray
Lower abdomen shows ground glass appearance
 IVU
Extravasations of the dye into peritoneal cavity or
intraperitoneally, confirm the leak
 Retrograde cysto-urethrogram
Conforms the site of leak. Confirm the diagnosis
However CT cystography is the investigation of
choice today

31. Cystography of a patient who had had trauma. Leakage of contrast into the
peritoneal cavity is seen.

32. Treatment
 Intraperitoneal rupture
 Laparotomy, repair of bladder in 2 layers
 Drain suprapubic space with tube drain
 Catheter should be placed for 10-14 days for
bladder decompression
 Extra peritoneal rupture:
 Catheter drainage for 10 days

33. Urethral Injury

34. Types of urethral injury
 Anterior Urethra injury
 Includes the bulbar and penile urethral
 Posterior Urethral injury
 Includes prostatic and membranous urethra

35. Anterior Urethra injury
Causes
 Straddle injury
 Direct trauma to penis
 Pelvic fractures- rare
 More distal injuries are contained by Buck's
fascia and resulting hematomas dissect along
the penile shaft
 More proximal injuries of urethra may be
contained by Colles' fascia and produce a
perineal hematoma

36. Anterior Urethral injuries
(contd..)
 Bulbar urethra is crushed upwards against the
pubic rami by straddle type injuries
 H/o blow to the perineum due to fall astride on
a projecting object
 Cycling accidents, loose manhole covers, and
gymnasium accidents

37. Clinical features
 Perineal haematoma (butterfly distribution)
 Massive perineal swelling
 Bleeding from urethral meatus
 Retention of urine

38. Preliminary assessment &
treatment
 Appropriate analgesics & antibiotics
 The patient should be discouraged from
passing urine
 Percutaneous suprapubic drainage of the
bladder
 Reduces urinary extravasation and allows
investigation to establish the extent of urethral
injury
 Retrograde urethrogram or Flexible cystoscopy

39. Treatment of choice
 Blunt and penetrating injuries (most) –
immediate exploration, debridement, and direct
repair
 An injury from a high-velocity gunshot –
suprapubic cystostomy and delayed repair after
clear demarcation of injured tissues

40. Treatment Contd…
 Proximal injuries approached through a
perineal incision
 Distal injuries approached by making a
circumferential, sub coronal incision and de-
gloving the penis

41. Treatment contd…
 Complete urethral tear – suprapubic catheter
until arrangements made for repair
 Early open repair of urethra with excision of
traumatized section & spatulated end-end
reanastomosis of urethra
 Other options are:
 Catheter alignment followed by delayed repair

42. Complications of anterior urethral
injury
 Complete rupture – Subcutaneous
extravasation of urine occurs if patient attempts
to pass urine
 Infection
 Stricture- a common sequel
 In partial or complete tear
 Peri-urethral bruising

44. Posterior Urethral injury
 Occurs in association of pelvic fractures and
extraperitoneal rupture of bladder

45. Rupture of Membranous
Urethra
 Usually a result of pelvic fracture
 Occurs near apex of the prostate
 About 5% of cases of fractured pelvis have
associated urethral injury

46.  Urinary retention
 Blood at urethral meatus
 DRE: high riding prostate
Clinical features

47. Investigations
 Plain X ray
 Significant displacement of pelvic bones
 Urethrogram
 If there is doubt
 Confirmatory

48. Treatment
 Suprapubic catheter should be placed across
injury when possible (USG guided)
 Exploration needed if there is evidence of
rupture of bladder
 If there is significant bladder rupture it must be
repaired , suprapubic catheter inserted and
retroperitoneal space drained

49. Treatment including pelvic #
 RTA being the most common cause of Pelvic #
 Injuries to the head, thorax, long bones and
abdomen should be ruled out
 Resuscitation
 Primary survey
 Secondary survey ( head to toe examination)

50. Complications
 Stricture
 Urinary Incontinence
 Erectile dysfunction
 Extravasation of urine
 Superficial
 Bulbar urethra rupture
 Deep
 Extra peritoneal rupture of the bladder or intra pelvic rupture
of the urethra or ureter damage or perforation of the
prostatic capsule or bladder during transurethral resection.
 Treatment – suprapubic cystostomy and drainage of
retropubic space

51. References
 Bailey And Love Short Practice of Surgery, 26th
edition.
 Schwartz's Principles of surgery, 8th edition.
 SRB’s manual of surgery 3rd edition

52. THANK YOU