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Urological Trauma (Kidney and Ureter)

10% of all injuries involve genitourinary system.
  1. Initial assessment includes: ABC (Airway, bleeding control, establishing circulation).
  2. General examination Other than BP, Pulse etc. includes: specifically look for rib fracture (Mainly 9th to 12th), Pelvic Fracture, Other visceral injuries, Blood at urethral meatus, Perineal hematoma or contusion. 
  1. Catheterization And Assessment Of Injury:
    1. Catheterization is contraindicated if blood is present at urethral meatus.
    2. In these cases RGU should be done prior to catheterization.
    3. Urine is collected for microscopic and gross hematuria.
    4. IVP helps in staging and in evaluation of renal injuries.
    5. Arteriography helps in renal parenchymal and vascular injuries.
    6. CT scan is the investigation of choice - If vital stable in abdominal trauma patient. Q
    7. Abdominal ultrasound can be used as a screening modality.
      Now it is indicated in every abdominal trauma patient. Q
  2. Renal Trauma: Blunt trauma over abdomen, flank or back is the most common mechanism (80-85%).
  3. Grading for renal trauma (AAST) (Ref: Schwartz's Principles of Surgery 9th Edition Ch 40)
American Association for the Surgery of Trauma Renal Injury Scale
Grade Injury Type Description
1 Contusion Microscopic or gross hematuria with normal imaging
Hematoma Subcapsular, nonexpanding without parenchymal laceration
2 Hematoma Nonexpanding perirenal hematoma confined to renal retroperitoneum
  <1 cm in depth without urinary extravasation
3 Laceration >1 cm in depth without collecting system rupture or urinary extravasation
Laceration Parenchymal laceration through cortex, medulla, and collecting system
Vascular Main renal artery or vein injury with contained hemorrhage
Laceration Completely shattered kidney
Laceration Avulsion of renal hilum leading to devascularized kidney
  1. Classification:
    1. Minor Renal Trauma:
      1. Accounts for 90% of all renal injuries.
      2. Renal contusion or bruising is the most common lesion.
      3. Other minor traumas are: subcapsular contusion and superficial cortical lacerations.
    2. Major Renal Trauma:
      1. Accounts for 15% of all cases.
      2. This includes: deep cortico-medullary lacerations extending into the collecting system (causing extravasation of urine), Large retroperitoneal/ perinephric haematoma or shattered kidney.
    3. Vascular Injury:
      1. <1% of all trauma cases.
      2. There may be total avulsion of the artery or vein or partial avulsion of the segmental branches of these vessels.
      3. Renal artery thrombosis (Usually presents late).is another way of presentation.
      4. Grade I & II are minor. Grade II, IV and V are major.
  2. Late Features
    1. Urinoma:
      Missed deep cortico-medullary laceration (Grade IV) causes extarvasation and urinoma formation.
      This leads to large peri nephric mass and eventually hydronephrosis or abscess.
Indications for Surgical Intervention for Renal Trauma
Absolute indications
  1. Persistent, life-threatening hemorrhage from probable renal injury
  2. Renal pedicle avulsion (grade V injury)
  3. Expanding, pulsatile, or uncontained retroperitoneal hematoma
Relative indications
  1. Large laceration of the renal pelvis or avulsion of the ureteropelvic junction
  2. Coexisting bowel or pancreatic injuries
  3. Persistent urinary leakage, postinjury urinoma, or perinephric abscess with failed percutaneous or endoscopic management
  4. Abnormal intraoperative one-shot IV urogram
  5. Devitalized parenchymal segment with associated urine leak
  1. Complete renal artery thrombosis of both kidneys or of a solitary kidney when renal perfusion appears preserved
  2. Renal vascular injuries after failed angiographic management
  3. Renovascular hypertension
  1. Hydronephrosis:
    1. Large perinephric hematoma or extravasation causes fibroses, which later on engulfs PUJ
    2. Follow up IVP is indicated in all cases of major trauma.
  2. AV Fistula:
    1. This occurs after penetrating injuries, but is not common.   

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