This document discusses renal trauma, including causes such as blunt trauma from motor vehicle accidents or falls, as well as penetrating trauma. It outlines the grading system for renal injuries from Grade I to V. Mild injuries under Grade III are often managed conservatively with bed rest and monitoring, while more severe injuries may require angioembolization, stenting, or surgery. Surgical exploration is indicated for hemodynamic instability, expanding hematomas, or uncontrolled bleeding, while nephrectomy is considered for Grade V injuries or when the contralateral kidney is compromised.

1. Renal Trauma
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2

3. - 1 percent of all traumatic injuries.
- 10 percent need surgical intervention
 Fixed only through pedicle.
 1.2L of blood / min
INTRODUCTION
Dept Of Urology, KMC and GRH, Chennai 3

4.  Blunt trauma
 Penetrating trauma
 Iatrogenic
Mechanism of injury
Dept Of Urology, KMC and GRH, Chennai 4

5. Blunt trauma
 Blunt trauma: 80-90%
 motor vehicle collision
 falls
 vehicle-associated
pedestrian accidents
 sports and assault
 frontal impact.
 side impact
 Sudden deceleration
Dept Of Urology, KMC and GRH, Chennai 5

6. Renal vascular injuries
 < 5% of blunt abdominal
trauma
 Renal artery occlusion -
rapid deceleration injuries.
 The mechanism is arterial
traction-tear in the inelastic
intima- subsequent
haemorrhage into the vessel
wall - thrombosis
Dept Of Urology, KMC and GRH, Chennai 6

7. Penetrating injury
90 % of gunshot wounds
60 % of stab wounds
are associated with intra-
abdominal injuries.
Dept Of Urology, KMC and GRH, Chennai 7

8.  rare but carries the potential for significant morbidity
 percutaneous renal biopsy,PCN, PCNL, endopyelotomy, and
partial nephrectomy,ESWL
 hemorrhage
 hematoma
 pseudoaneurysm and AVF
 disruption of the renal pelvicalyceal system,
Iatrogenic Renal Injury
Dept Of Urology, KMC and GRH, Chennai 8

9. Trauma to abnormal kidney
 Ptotic
 Pelvic
 Fused
 horse shoe kidney
 transplanted kidney -more susceptible to trauma than
normal kidney
Dept Of Urology, KMC and GRH, Chennai 9

10.  PUJO- forniceal rupture and extravasation
 Renal tumours, simple cysts and ADPKD –bleed or rupture with
minor trauma
 sustain higher grades of renal injury with lower energy
trauma and are more likely to require surgery than those
without
 decreased tissue strength in hydronephrotic kidneys
 altered tissue deformation of the renal cortex
Dept Of Urology, KMC and GRH, Chennai 10

11. 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 #
Dept Of Urology, KMC and GRH, Chennai 11

12. American association of surgeons in
trauma
Dept Of Urology, KMC and GRH, Chennai 12

13.  Contusion
 Urologic studies N
 Hematoma
 Subcapsular
 Non expanding
 Parenchyma N
Grade I
Dept Of Urology, KMC and GRH, Chennai 13

14.  Hematoma
 Perirenal
 Nonexpanding
 Laceration
 < 1.0 cm
 Renal cortex only
 No urinary extravasation
Grade II
Dept Of Urology, KMC and GRH, Chennai 14

15. Grade III
Laceration
> 1.0 cm
Renal cortex only
No urinary
extravasation
Dept Of Urology, KMC and GRH, Chennai 15

16.  Laceration
 Renal cortex
 Renal medulla
 Collecting system with
urinary extravasation
 Vascular
 Main renal artery/vein
injury with contained
hemorrage.
Grade IV
Dept Of Urology, KMC and GRH, Chennai 16

17.  Completely
shattered kidney.
 Avulsion of renal
hilum which
devascularizes
kidney.
Grade V
Dept Of Urology, KMC and GRH, Chennai 17

18.  Penetrating trauma
 Gross hematuria
 Microscopic hematuria (>3-5 RBC/HPF) with
hemodynamic instability—systolic BP<90 at any time
 Persistent microscopic hematuria
 Significant deceleration mechanisms
Indications for imaging for renal
trauma
Dept Of Urology, KMC and GRH, Chennai 18

19.  CECT is the best imaging study for diagnosis and staging renal
injuries in hemodynamically stable patients
 one-shot IVU -Unstable patients who require emergency
surgical exploration
 Angiography can be used for diagnosis and simultaneous
selective embolization of bleeding vessels
Guidelines on radiographic assessment
Dept Of Urology, KMC and GRH, Chennai 19

20. Focussed assessment for
sonography in trauma(FAST)
 Extension of physical
examination of the trauma
patient
 Can be done during primary
survey
 Primary goal of FAST is to
identify intraabdominal free
fluid.
 Draw back:
 Blood versus extravasated
fluid /urine leak
 Low sensitivity for
retroperitoneal blood. Perirenal hematoma
Dept Of Urology, KMC and GRH, Chennai 20

21.  Replaced by CT
 One shot intra-operative IVU
 unstable patients prior to immediate operative intervention -
decision making as to the function of the C/L kidney and renal
injury
 Iodinated contrast of 2ml/kg body weight followed by plain film
after 10 minutes
Intravenous Urography
Dept Of Urology, KMC and GRH, Chennai 21

22.  Fractures of lower ribs &/TP of L. vertebrae
 Scoliosis concave to injured side
 Loss of psoas shadow
 Loss of renal outline
 displacement of bowel or diaphragm
TRAUMA FINDINGS ON X-RAY
Dept Of Urology, KMC and GRH, Chennai 22

23. IVU FINDINGS
 Filling defects in Pelvis/Calyces-clots
 Distortion of calyces/renal pelvis-haematoma
 Elongation of renal shadow -transverse
rupture
 Delayed excretion on injured side
 Perirenal soft tissue mass -blood/urine
 Intra-renal &/extra-renal extravasation of dye
Dept Of Urology, KMC and GRH, Chennai 23

24.  Gold standard method
 Detects all grades of injuries
 Superior anatomical detail and fast
 Detects associated injuries
 Urography phase gives functional details.
Contrast Computed Tomography
Dept Of Urology, KMC and GRH, Chennai 24

25.  Initial nonenhanced study - detecting acute bleeding or intraparenchymal
hematoma
 Late cortical or early nephrographic phase(45-60sec)- parenchymal injuries
 excretory phase(3-5min) - leakage of contrast-enhanced urine or significant
perinephric or periureteral fluid is found
 Delayed CT may also be useful in distinguishing between active bleeding and
pseudo aneurysms
CECT technique
Dept Of Urology, KMC and GRH, Chennai 25

26. Contusions:
ill-defined and poorly
marginated hypo dense
area of decreased
enhancement on the
nephrographic phase that
may show delayed or
persistent enhancement.
Dept Of Urology, KMC and GRH, Chennai 26

27.  Infarcts are wedged shaped sharply marginated hypo
dense area seen on the nephrographic phase and shows
no delayed enhancement.
 Infarcts can be confused with Contusions
Infarction
Dept Of Urology, KMC and GRH, Chennai 27

28.  Subcapsular hematomas are seen as cresentic or biconvex
area of blood collection along the renal contour causing
flattening or depression of the underlying renal surface
Subcapsular Hematoma
Dept Of Urology, KMC and GRH, Chennai 28

29.  Perinephric hematoma is confined between the renal
parenchyma and Gerota's Fascia
Perinephric hematoma
Dept Of Urology, KMC and GRH, Chennai 29

30.  Lacerations are irregular
linear hypo dense areas
of parenchymal defect
reaching up to surface
causing disruption of the
parenchymal continuity
 They also show no
enhancement
Laceration
Dept Of Urology, KMC and GRH, Chennai 30

31. Shattered Kidney
 Multiple lacerations
causing gross disruption
and fragmentation of the
renal parenchyma
Dept Of Urology, KMC and GRH, Chennai 31

32. Pseudo aneurysm
 Focal rounded well
circumscribed lesion
 intense enhancement similar
to that of the attenuation of
the blood pool and wash out
synchronous to blood pool
 There is no expansion on the
delayed scans
Dept Of Urology, KMC and GRH, Chennai 32

33.  Focal ill defined areas of
contrast leak with different
configurations with high
attenuation values(85-370 HU)
on early scans
 more hyper attenuating than
blood pool and show spread
and expansion in to
surrounding tissue on a delayed
scans
Active arterial extravasation
Dept Of Urology, KMC and GRH, Chennai 33

34.  Diffuse non-perfusion of kidney
 Most often from a clot that forms in an incompletely torn renal
artery
Devascularized kidney
Dept Of Urology, KMC and GRH, Chennai 34

35.  Occurs due to sheering
injury at the fixation
point as it gets stretched
over the transverse
process due to
hyperextension
 Partial / complete
PUJ avulsion
Dept Of Urology, KMC and GRH, Chennai 35

36.  Pregnant patients
 Previous contrast allergy
 Time consuming
 Not ideal for trauma setting
MRI
Dept Of Urology, KMC and GRH, Chennai 36

37.  Stable patients who are candidates for radiological
control of hemorrhage defined on CT
 Non enhancing Kidney on CT
 More specific than CT in defining vascular injury
 Renal vein injury
Angiography
Dept Of Urology, KMC and GRH, Chennai 37

38. Management of renal trauma
Dept Of Urology, KMC and GRH, Chennai 38

39.  Pertains to 85-90% of cases
 grade I and II - observation
 grade III and IV injuries- managed nonoperatively
 Grade 5- treated expectantly unless the contralateral kidney is absent or
injured, in which case emergency revascularization is indicated.
 Isolated active arterial bleeding-emergency arteriography and
angioembolization.
- Endoluminal stenting and thrombolytic therapy is promising
Conservative management
Dept Of Urology, KMC and GRH, Chennai 39

40. • strict Bed-rest
• hydration and blood replacement
• Analgesia
• antibiotics
 Regular Clinical Examination:
Blood Pressure
Pulse
Abdomen girth
Loin
Bed side management
Dept Of Urology, KMC and GRH, Chennai 40

41.  Urine routine for hematuria
 Serial hematocrit measurement
 Creatinine measurement reflects renal
function prior to the injury
Laboratory evaluation
Dept Of Urology, KMC and GRH, Chennai 41

42.  urinary extravasation is unchanged or worsening
 collecting system hematoma
 fractured kidney
 sepsis
 large segment of devascularized parenchyma (>25%)
 percutaneous drain can be placed to maximize
drainage.
Urinary Stenting/Drainage
Dept Of Urology, KMC and GRH, Chennai 42

43.  selective segmental arterial embolization
 non–life-threatening bleeding isolated to a segmental
renal artery or vein
 Endoluminal stenting for intimal dissection and luminal
stenosis
 Complication- nephron loss
ANGIOEMBOLIZATION
Dept Of Urology, KMC and GRH, Chennai 43

44. Embolization in active renal vascular
injury
Dept Of Urology, KMC and GRH, Chennai 44

45. Endocoil placement in
pseudoaneurysm
Dept Of Urology, KMC and GRH, Chennai 45

46. Absolute indications
- progressive blood loss
- expanding perinephric hematoma
- perirenal infection
- Hemodynamically unstable
- The renal vessels are injured
- other organ involvement cannot be excluded.
Indications for Exploration
Dept Of Urology, KMC and GRH, Chennai 46

47. Relative indications
-urinary extravasation
-nonviable tissue
-delayed diagnosis of arterial injury
-segmental arterial injury
-
incomplete staging.
Dept Of Urology, KMC and GRH, Chennai 47

48. RENAL EXPLORATION
 Warm ischemic time should not greatly exceed 30 minutes, in order to avoid
permanent renal ischemic damage.
Dept Of Urology, KMC and GRH, Chennai 49

49.  principles of renal reconstructions:
 early vascular control
 complete renal exposure
 sharp debridement of nonviable tissue
 oversewing of bleeding vessels for hemostasis
 watertight collecting system closure
 Parenchymal defect closure over a Gel-foam or coverage with omentum
 Retroperitoneal drain placement
Renal Reconstruction
Dept Of Urology, KMC and GRH, Chennai 50

50. Renorrhaphy
Dept Of Urology, KMC and GRH, Chennai 51

51. Vicryl mesh
 wrapping the kidney with semi-elastic Vicryl mesh for
control of hemorrhage and preservation of renal
function in which nephrectomy was indicated clinically.
Dept Of Urology, KMC and GRH, Chennai 52

52. Partial nephrectomy
Dept Of Urology, KMC and GRH, Chennai 53

53. VASCULAR RECONSTRUCTION
Dept Of Urology, KMC and GRH, Chennai 54

54.  The unstable patient, cannot risk an attempt at renal repair if
a normal contralateral kidney is present
 Grade 5 injuries that are deemed irreparable(eg, major
vascular pedicle injury, particularly on the right side)
 Shattered kidney
 Multiple concurrent injuries
 Uncontrolled hemorrhage
INDICATIONS FOR NEPHRECTOMY
Dept Of Urology, KMC and GRH, Chennai 55

55. Laparoscopy
 Still considered contra-indicated in
acute renal trauma

To plan Laparoscopy in acute
trauma, case selection is important.
 It should be attempted only in a
stable patient without head injury
and no thoracic trauma.
 Laparoscopic exploration :
transperitoneal/retroperitoneal
approach
 Renorhhaphy and nephrectomy can
be performed
Dept Of Urology, KMC and GRH, Chennai 56

56. 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
Dept Of Urology, KMC and GRH, Chennai 57

57.  Most commonly injured abdominal organ in blunt trauma
– Fetal lobulations predispose to renal separation
– Less protection by pliable thoracic cage and less developed
musculature
– Higher incidence of pedicle injury & PUJ avulsion
 80% with renal injury have associated non renal injuries
 Imaging and management protocols similar to adults
Pediatric Renal Trauma
Dept Of Urology, KMC and GRH, Chennai 58

58.  Repeat imaging is recommended for all hospitalized patients
within 2-4 days following renal trauma
 within 3 months of major renal trauma , patients follow-up
should involve :
 Routine examination & imaging
 Long-term follow-up should be decided on a case-by-case
basis
Guidelines on post-operative management and
follow-up
Dept Of Urology, KMC and GRH, Chennai 59

59.  The approach to the diagnosis and management of renal
trauma continues to evolve.
 operative exploration remains the diagnostic and therapeutic
modality of choice in hemodynamic instability
 A progressive trend is towards nonoperative management of
renal trauma of any grade
 Interventional radiology and endourologic manipulation have
increased the ability to successfully treat patients without
surgery and to address common complications of renal trauma.
To conclude
Dept Of Urology, KMC and GRH, Chennai 60

60.  THANK YOU
Dept Of Urology, KMC and GRH, Chennai 61