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RENAL INJURIES
The
Presentation and
History
Motor
Presentation and
History
Penetrating
Presentation and
History
Physical
Presentation and
History
Hematuria
The best indicators of significant
urinary system injury include gross
and microscopic hematuria (>5 red
blood
cells/high-power
field
[RBCs/HPF]
or
positive
dipstick
finding), especially when associated
with acceleration/deceleration injury,
penetrating trauma, or hypotension
in the field or emergency room
(systolic blood pressure <90 mm Hg).
Although
critical
to
the
initial
evaluation of traumatic urinary tract
injury, the presence or absence of
hematuria should not be the sole
determinant in the assessment of a
patient with suspected renal trauma.
Because the significance of hematuria
varies
with
blunt
and
penetrating
mechanisms, the importance of proper
detection and staging of renal injuries,
usually by computed tomography (CT),
must be emphasized.
Classification
The
AAST
Organ
Injury
Scaling
Committee (Moore et al, 1989) provides
the most widely used and accepted
classification of renal injury (Table 50-1,
Fig. 50-1).
Based
on accurate grading made
possible by contrast-enhanced CT, the
AAST injury severity scale is a powerful
and valid predictive tool for clinical
outcomes in patients with renal trauma
(Santucci et al, 2001).
Imaging Studies
Contrast-enhanced CT is the gold standard
for genitourinary imaging in renal trauma
(Bretan et al, 1986; Federle et al, 1987).
Quick, highly sensitive, and specific, CT provides
the most definitive staging information
parenchymal lacerations are clearly defined;
extravasation of contrast-enhanced urine can
easily be detected (Fig. 50-3); associated injuries
to the bowel, pancreas, liver, spleen, and other
organs can be identified; and the degree of
retroperitoneal bleeding can be assessed by the
size of the retroperitoneal hematoma.
Findings
observation
Bed rest
Serial Hemoglobins
Antibiotics if urinary extravasation
Radiographic
Embolization
Urinary Diversion
Ureteral Stenting
Nephrostomy Drainage
Surgery
Angioembolization
Renal arteriography and embolization is an
increasingly used modality in renal trauma.
In the right setting, it can be used to stop
significant renal bleeding without the need for
laparotomy.
Superselective embolization therapy for renal
trauma may provide an effective and less invasive
technique to avoid unnecessary exploration that
could otherwise result in a nephrectomy.
Initial failure is common, between 13% and 88%
(Breyer et al, 2008; Sugihara et al, 2012), but
subsequent embolization was highly successful in
at least one series (Hotaling et al, 2011).
Nonoperative
Management
Operative Management
Indications for renal exploration or speedy angioembolization after
trauma can be separated into absolute and relative (Voelzke and
McAninch, 2008).
Absolute indications include (1) hemodynamic instability
with shock, (2) expanding/pulsatile renal hematoma
(usually indicating renal artery laceration), (3) suspected
renal vascular pedicle avulsion (grade 5), and (4)
ureteropelvic junction disruption.
Relative indications are (1) urinary extravasation with
significant renal parenchymal devascularization (older data
suggest higher complication rate than average if watched,
but these also can be closely observed), (2) renal injury
together with colon/pancreatic injury (these patients have a
higher complication rate if their renal injury is not repaired
at the time of colon/ pancreatic injury, but the renal injury
may be closely observed after repair of the enteric injury),
and (3) a delayed diagnosis of arterial injury (which will
most likely need delayed nephrec
Renal Exploration
Surgical
Renal Reconstruction
The principles of renal reconstruction
after trauma include complete renal
exposure, measures for temporary
vascular control, limited debridement of
nonviable tissue, hemostasis by
individual suture ligation of bleeding
vessels, watertight closure of the
collecting system if necessary/possible,
reapproximation of the parenchymal
defect, coverage with nearby
fascioadipose flaps (Gerota fascia or
omentum) if feasible, and liberal use of
drains (Fig. 50-9)
Damage Control
Coburn (2002) and Pursifull and colleagues
(2006) noted the benefit of damage control to
improve renal salvage after polytrauma.
The area around the injured kidney is packed
with laparotomy pads to control bleeding, with
a planned return in approximately 24 hours to
explore and evaluate the extent of injury.
Damage control may allow patients with
complex renal injuries to avoid unneeded
nephrectomy. This approach is commonly used
by trauma surgeons in patients with nonrenal
injuries.
Complications
Persistent