Renal Trauma

1. Renal Trauma Presented By Dr. Mohammad Amin K Mirza Saudi Board of General Surgery, R5 Al-Noor Specialist hospital Holy Makkah– K.S.A May 2008

2. Background • Urologic injuries are rarely life-threatening, • The kidney is the most commonly injured structure in the urinary tract,accounting for 1 percent of all traumatic injuries. • only approximately 10 percent of renal injuries needed surgical intervention • The Kidney: • Along T10 - L4 • Ribs 10-12 • Fixed only through pedicle. • 1.2L of blood / min

3. Blunt trauma • Blunt trauma: 80-90% • Caused by direct blow to the abdomen • Acceleration – deceleration injury in fall down • Indirect injury is much less common • Injury to the renal pedicle in 85 %of cases 90 per cent of these occur in patients under 25 years of age. • The artery is injured in 70 %of patients, • The vein in 20 % • Both vessels in the remaining 10 % • The mortality rate approaches 50 %, due mainly to the severity of associated injuries.

4. Penetrating injury • 90 % of gunshot wounds and 60 % of stab wounds to the kidney are associated with intra-abdominal injuries.

7. Mechanism of injury ( Blant trauma )

8. OrganInjurySeverityScale

10. Mechanism of injury ( penetrating trauma )

12. When to suspect renal injury • Trauma to back / flank / lower thorax / upper abdomen • Flank pain / low rib # • Hematuria / Ecchymosis over the flanks • Sudden decelaration / Fall from height. • Lumbar transverse process #

13. Lumbar Transverse Process Fractures • Prospective study (1994-1999) • Lumbar spine # • 191 patients • Transverse # in 29% • Abdominal organ injuries 47% • Kidney: 1/3 • Liver: 1/3 • Spleen: 1/4 Miller et al. Lumbar transverse process fractures: a sentinel marker of abdominal organ injuries. Injury. 31:773; 2000.

16. Grade I • Contusion • Hematuria • Urologic studies N • Hematoma • Subcapsular • Non expanding • Parenchyma N

17. Grade II • Hematoma • Perirenal • Nonexpanding • Laceration • < 1.0 cm • Renal cortex only • No urinary extravasation

18. Grade III • Laceration • > 1.0 cm • Renal cortex only • No urinary extravasation • Intact collecting

20. Grade IV • Laceration • Renal cortex • Renal medulla • Collecting system • Vascular • Main renal artery/vein injury with contained hemorrage.

21. Grade IV

22. Grade V • Completely shattered kidney. • Avulsion of renal hilum (pedicule) which devascularizes kidney.

28. OrganInjurySeverityScale • Validated lately: Journal of Trauma, 2001 • Predicts the need for surgery • Need for surgery ; nephrectomy rates: • Grade I: 0 ; 0% • Grade II: 15 ; 0% • Grade III: 76 ; 3% • Grade IV: 78 ; 9% • Grade V: 93 ; 86% Santucci et al. Validation of the American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney. J Trauma; 50:195-200; 2001.

32. Conservative management - 50 % of all penetrating renal injuries and fewer than 5% of blunt injuries necessitate operative management. • All grade I and II renal injuries, regardless of the mechanism of injury, can be managed with observation alone because the risk of delayed bleeding is extremely low. • Most grade III and IV injuries, including those with devitalized parenchymal fragments and urinary extravasation, can be managed nonoperatively with close monitoring, serial hematocrit measurement, and repeat imaging in selected cases. • Active arterial bleeding, in the absence of other associated injuries, can be treated with emergency arteriography and angioembolization. • Thrombosis of the renal artery or its branches is treated expectantly unless the contralateral kidney is absent or injured, in which case emergency revascularization is indicated. • Endoluminal stenting and thrombolytic therapy is a promising

33. Management in summery • Absolute indication for Surgery: • Uncontrollable renal hemorrage • Multiply lacerated, shattered kidney • Main renal vessels avulsed • Penetrating injuries usually • Grade I-II • conservative • Grade III-IV • Conservative if stable hemodynamically vs. surgery • Grade V • Surgery

35. Complication • The first 4 weeks of injury include: • delayed bleeding, • abscess, • sepsis, • urinary fistula, • urinary extravasation and urinoma, • hypertension • Late complications : • arteriovenous fistula, • hydronephrosis, • hypertension, • calculus formation • chronic pyelonephritis

36. To be excellent at dealing with a trauma patient NEEDS To be good in ABCDE management of trauma

37. Thank You Thank You Thank You