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Trauma Surgery Questions : Renal Trauma

Which is the most common mode of renal injuries?

Renal injury is common, occurring in 8–10% of polytrauma cases. About 90% of renal injuries result from blunt force injury and 10% from penetrating trauma.

How good is USG for finding Renal injuries?

USG is relatively insensitive for detection of renal lacerations and contusions, extravasation of blood or urine, collecting system disruption and parenchymal haematoma
A positive ultrasound is more likely to find higher grades of renal injury, but a negative renal ultrasound does not rule out renal injury.

What is the gold standard investigation for Renal injuries?

CECT Abdomen is the gold standard investigation for renal injuries. As a rule, all patients with penetrating flank and back trauma should have a CT examination.

What are the indication of CECT if there is suspision of renal trauma?

  • Penetrating flank and back trauma Chest
  • Gross haematuria if haemodynamically stable or resuscitated 
  • Haemodynamically stable with microscopic haematuria, but other indications for abdominal–pelvic CT (+ abdominal examination, decreasing haematocrit, indeterminate result of peritoneal lavage or abdominal ultrasound, unreliable physical examination) 
  • Haemodynamically stable with or without microscopic haematuria with evidence of major flank impact (e.g. lower posterior rib or lumbar transverse process fracture) 

What are the situation where CECT will not be done?

Haemodynamically unstable requiring emergency surgery Intraoperative IVU when stabilized 
Haemodynamically stable with microscopic haematuria, but no other indication for abdominal–pelvic CT 

What is AAST grading for Renal Injuries?
Source: American Association for Surgery of Trauma

How to manage Renal injuries?

ABCDE first.

Followed by
  • Operate immediately if the patient is bleeding to death
  • Observe initially, but step in with metered responses as necessary
  • Use ureteral stents for symptomatic or growing urinoma
  • Use angioembolization for nonemergent bleeding or for urgent bleeding if those techniques are available at your center
  • Do open surgery when needed (Santucci, 2015, Am J of Surgery)

What is the non operative management of renal injuries?

  • Preferred for majority of stable patient with Renal injury Grade 1-4. 
  • Bed rest, Hydration, Antibiotics, Serial Imaging, Medications for hemostatsis (Hemostyptic Therapy), Vitals monitoring   
  • Management of complications after conservative management: Urinoma, Infection, Delayed Hemorrhage, Devitalized renal segment, Hypertension, Renal insufficiency 

What is the Operative Management of renal injuries? 
  • Goal-Control hemorrhage, Preserve renal tissue
  • Temporary vascular occlusion for brisk renal bleeding not well controlled by manual compression of the parenchyma
  • Sharp excision of all nonviable parenchyma
  • Meticulous hemostasis (particularly, arterial)
  • Watertight closure of the collecting system
  • Parenchymal defect closure by approximation of the capsular/parenchymal edges over a Gelfoam bolster or coverage with omentum, perinephric fat, peritoneum, or polyglycolic acid mesh
  • Interposition of an omental pedicle flap between any vascular, colonic, or pancreatic injury and the injured kidney
  • Ureteral stent placement for a renal pelvis or ureteral injury
  • Retroperitoneal drain placement: The authors prefer to use a Penrose drain. Unless drainage is excessive, the Penrose drain is removed after 48 hours. Additionally, the urinary tract injury and the pancreatic injury are always drained separately.
  • Partial or complete Nephrectomy
What are the indications for Nephrectomy in Renal Injuries
  • When primary vascular control is not achieved and massive bleeding is encountered, in the rush to control bleeding, a kidney that could have been salvaged may be unnecessarily sacrificed.
  • Nephrectomy is required when the patient is persistently hemodynamically unstable despite initial measures and, thus, is a life-saving maneuver.
  • Grade 5 injuries that are deemed irreparable(eg, major vascular pedicle injury, particularly on the right side)
  • Shattered kidney
  • Multiple concurrent injuries
  • Uncontrolled hemorrhage