Consensus on GU Trauma

Consensus on GU Trauma from Sun YaiCheng

Consensus on GU Trauma
Evaluation and management of renal injuries:
consensus statement of the renal trauma subcommittee
BJU International Volume 93 Issue 7 Page 937-954, May 2004

INITIAL EVALUATION OF THE PATIENT WITH RENAL INJURY
URINE ANALYSIS

• The urine analysis is the most important laboratory study used to assess the patient with suspected renal injury.
• Hematuria is a common sign of renal trauma, being present in 80–94% of cases.
• There is no absolute relationship between the presence, absence or degree of hematuria and the severity of the renal injury.

PENETRATING TRAUMA

• It is strongly recommended that patients with suspected penetrating kidney injuries have complete radiographic staging or renal exploration.

BLUNT TRAUMA IN ADULTS

• Hemodynamically stable adults with blunt trauma should undergo radiographic evaluation if they have gross hematuria, microhematuria and SBP < 90 mmHg. 
• Despite the absence of hematuria or shock, vertical deceleration injuries, in particular those associated with multiple-system injuries and/or physical signs of potential renal injury (flank ecchymosis, flank pain), demand renal imaging. 

BLUNT TRAUMA IN CHILDREN 

• Most children with microscopic hematuria do not require imaging.
• Hemodynamically stable children with blunt trauma should undergo radiographic evaluation if they have gross hematuria or > 50 RBCs/high-power field on microscopic urine analysis.

INITIAL IMAGING OF RENAL TRAUMA
CT

• Abdominal CT with contrast medium is the best initial imaging study in patients with suspected renal injury.
• CT accurately identifies vascular injury, parenchyma laceration, urinary extravasation and perirenal haematoma.

 
 INTRAOPERATIVE ONE-SHOT IVU

• When blunt or penetrating injuries cause massive hemorrhage and require immediate laparotomy, CT is contraindicated.
• Intra-operative one-shot IVU, in conjunction with findings at laparotomy, can be used to exclude life-threatening renal injury and confirm the existence of a contralateral functioning kidney.

US

• US is not invasive and has a high negative predictive value (96–98%), and therefore it is a good screening test for children and adults with presumed minor trauma.

IVU

• The reported accuracy of IVU in renal trauma varies from 65% to 95%, but the presence of abnormality on IVU usually requires CT or angiography to delineate the precise extent of injury.
• Its main usefulness may be to detect a normally functioning kidney on the uninjured side.

RENAL ARTERIOGRAPHY

• Indications for angiography include suspected renal arterial thrombosis or segmental arterial injuries for which embolization or stenting is considered.
• In renal artery injuries, CT can be diagnostic and hasten operative intervention without angiography.

Indications for Renal Exploration
Absolute

1. Persistent, life-threatening haemorrhage believed to stem from renal injury
2. Renal pedicle avulsion (grade 5 injury)
3. Expanding, pulsatile or uncontained retroperitoneal haematoma (thought to indicate renal pedicle avulsion)

Relative

1. A large laceration of the renal pelvis, or avulsion of the PUJ
2. Coexisting bowel or pancreatic injuries
3. Persistent urinary leakage, postinjury urinoma or perinephric abscess with failed percutaneous or endoscopic management
4. Abnormal intra-operative one-shot IVU
5. Devitalized parenchymal segment with associated urine leak
6. Complete renal artery thrombosis of both kidneys, or of a solitary kidney, or when renal perfusion appears to be preserved
7. Renal vascular injuries after failed angiographic management
8. Renovascular hypertension

OPERATIVE MANAGEMENT OF RENAL INJURIES

EARLY VASCULAR CONTROL 

RENAL RECONSTRUCTION 

NEPHRECTOMY

• The nephrectomy rate for immediate exploration of major renal lacerations in clinically unstable patients may reach 100%.

RENOVASCULAR REPAIR

• Nephrectomy is still the most expeditious method of managing renal vascular injuries, and whereas renal artery repair is rarely possible and seldom successful.

ANGIO-EMBOLIZATION

• Successful selective renal artery embolization for managing hemorrhage in stable patients after blunt and penetrating renal trauma was reported by several centres.
• Primary angiographic management of renal vascular injuries has been advocated with surgical exploration reserved for those in whom it fails.