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14. Kansas BT, Eddy MJ, Mydlo JH, Uzzo RG.Incidence and management of penetrating renal
trauma in patients with multiorgan injury: extended experience at an inner city trauma center. J
Urol. 2004;172(4 Pt 1):1355–60. https://doi.org/10.1097/01.ju.0000138532.40285.44.
15. Hotaling JM, Wang J, Sorensen MD, etal. A national study of trauma level designation and renal
trauma outcomes. J Urol. 2012;187(2):536–41. https://doi.org/10.1016/j.juro.2011.09.155.
16. Erlich T, Kitrey ND.Renal trauma: the current best practice. Ther Adv Urol. 2018;10:295–303.
https://doi.org/10.1177/1756287218785828.
17. Dangle PP, Fuller TW, Gaines B, Cannon GM, Schneck FX, Stephany HA, Ost MC.Evolving
mechanisms of injury and management of pediatric blunt renal trauma—20 years of experience.
Urology. 2016;90:159–63. https://doi.org/10.1016/j.urology.2016.01.017. Epub 2016 Jan 26.
2 Epidemiology ofRenal Trauma
Etiology andAnatomopathology
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ofKidney Trauma
The causes of renal trauma strongly correlate with the anatomopathology of the
injury and can be divided into two major groups: blunt and penetrating trauma.
However, two more groups will be added in the following discussion as they require
special attention: pediatric and iatrogenic renal trauma.
3.1 Blunt Trauma
Motor vehicle collisions (MVC) are the main causes of blunt renal injury in the
adult population being encountered in 63–70% of the cases, followed by falls, sports
trauma, and pedestrian accidents representing 43%, 11%, and 4%, respectively [1–3].
3
3.2 Penetrating trauma
A systematic literature review recruiting a total of 1793 penetrating renal injuries
showed that rearms were more common than stab wounds in a proportion of 65%
and 35%, respectively [2]. However, these proportions vary considerably among
countries. Due to the permissive laws and the easy procurement of rearms, the
USA has a very high record of gunshot injuries, accounting for 72.2% of all penetrating renal injuries, while other countries such as the United Kingdom and Canada
have a higher rate of stabbing wound representing 87.3% and 88% of penetrating
renal traumas, respectively [4–6].
From an anatomopathological point of view, an American population-based
study showed 64% of patients with contusions/hematoma, while 26.3% had lacerations, 5.3% had parenchymal disruption, and 4% had vascular injuries. However,
when considering penetrating injuries alone, 74% had lacerations, 15% had parenchymal disruption, and 11% had vascular injuries [7].
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_3
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3 Etiology andAnatomopathology ofKidney Trauma
3.3 Pediatric Population
If subjected to an equal force of trauma, children are hypothetically more susceptible to kidney injury than adults due to the lack of perirenal fat cushion, the relatively
larger size of the pediatric kidney in relation to the body, and the decreased protection from the abdominal wall muscles and the less ossied pediatric thoracic cage
[8]. A systematic review recruiting a total of 458 blunt pediatric renal traumas
showed that, while motor vehicle collisions (MVC) are still the most frequent cause
in this age category, their proportion is lower than in the adult group (30% vs 63%),
and the proportions of falls and pedestrian accidents are much higher being 27%
and 13%, respectively [2].
Some studies are even clearly showing the predominance of falls as the rst
cause of trauma in children. Indeed, the Pennsylvania Trauma System Foundation
has recorded over two decades (1993–2013) a total of 354 children who suffered
blunt renal trauma, of whom 228 cases were sufciently imaged and graded. This
study showed that falls comprised 20.6% of all cases, followed by all-terrain vehicles (ATV) (18.9%), bikes (17.1%), MVC (12.7%), sport (11.4%), Ski-Sled (6.6%),
pedestrian accidents (6.1%), and others (6.6%) [9]. This research sounded the alarm
about the widespread use of recreational motor vehicles (RMV) by children despite
the restrictive recommendations in this age category.
3.4 Iatrogenic Causes
Iatrogenic causes of kidney trauma include many procedures: extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), percutaneous
nephrostomy (PCN), renal biopsy, nephron-sparing surgery (partial nephrectomy),
ureterorenoscopy, renal angiography or renal artery stenting with guidewire-induced
arterial perforation, endopyelotomy, or pyeloplasty. Hereinafter, the most frequent
of them are developed, and a brief account of their management is given.
3.4.1 Extracorporeal Shockwave Lithotripsy (ESWL)
Most of the time ESWL is safe. However, complications have been described such
as symptomatic subcapsular or perirenal hematoma (0.7%) with decreased hemoglobin [10, 11] (Fig.3.1a, b). While clinically signicant or symptomatic hematomas are rare after ESWL, it is important to remember that, strictly speaking, the
incidence of hematomas would rise up to 4.1% if one proceeds to systematic imaging after the treatment (ultrasound and CT scan) [11].
Pre-existing hypertension appears to be a signicant risk factor as it was
found in 57% of patients who developed post-ESWL perirenal hematoma [10].
The patient’s age is another risk factor with each 10-year increase in age carrying a
1.67 times greater probability of hematoma [11]. Other associated factors were urinary tract infections (UTI) and simultaneous bilateral treatment [10]. On the
ab
3.4 Iatrogenic Causes
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Fig. 3.1 (a, b) Coronal and sagittal views of a plain CT abdomen showing a large post-ESWL
subcapsular hematoma (H) of the left kidney
23
contrary, no correlation was found between the occurrence of post-ESWL subcapsular or perinephric hematoma and the stones’ number, size, or location, the history
of renal surgery, the presence of kidney malformations, the patient body habitus
(size and weight), the number of shock waves, and the level of energy applied
[10, 11].
In general, these hematomas are managed conservatively and resolve rapidly
within weeks. Rarely, however, the hemorrhage may be severe necessitating embolization [12, 13], or sometimes percutaneous drainage [14].
3.4.2 Percutaneous Nephrolithotomy (PCNL)
Bleeding is a worrisome complication of PCNL.Its incidence is decreasing with the
introduction of miniaturized techniques, evolving from standard PCNL to MiniPerc
and MicroPerc. Depending on the published series, it occurs in a wide range of
frequency from 0.5% to 2.4% for severe bleeding requiring intervention (embolization) and from 3.4% to 24% for those only requiring blood transfusion, and many
contributing factors have been incriminated: stone complexity (Guy’s stone score
Grades 3 and 4) and high Hounseld Unit (HU) value, high body mass index (BMI),
prolonged operating time, the thickness of the renal parenchyma and absence of
hydronephrosis, history of ipsilateral renal stone surgery, occurrence of
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3 Etiology andAnatomopathology ofKidney Trauma
intraoperative pelvicalyceal perforation, upper calyceal puncture, multiple access
tracts, method of tract dilatation (balloon dilatation decreases bleeding), presence of
diabetes mellitus (DM), preoperative urinary infection, surgeon’s inexperience, and
so on. [15].
3.4.3 Flexible andRigid Ureteroscopy
Ureteroscopy carries potential risks for the ureters but is generally safe for the kidneys [16]. Rarely, however, especially when a ureteral access sheath is not used in
retrograde intrarenal surgery (RIRS), extravasation and peri-renal collection may
occur. Exceptional cases of peri-renal hematoma and nephroenteric stula have also
been reported following ureteroscopic laser lithotripsy [17, 18].
References
1. McGeady JB, Breyer BN.Current epidemiology of genitourinary trauma. Urol Clin North Am.
2013;40(3):323–34. https://doi.org/10.1016/j.ucl.2013.04.001.
2. Voelzke BB, Leddy L.The epidemiology of renal trauma. Transl Androl Urol. 2014;3(2):143–9.
https://doi.org/10.3978/j.issn.2223- 4683.2014.04.11.
3. Nance ML. National Trauma Data Bank 2012 annual report. 2012. Available: https://www.
facs.org/media/ebgfrtdn/ntdb- annual- report- 2012.pdf.
4. Bjurlin MA, Fantus RJ, Fantus RJ, etal. Comparison of nonoperative and surgical management of renal trauma: can we predict when nonoperative management fails? J Trauma Acute
Care Surg. 2017;82:356–61.
5. Hadjipavlou M, Grouse E, Gray R, etal. Managing penetrating renal trauma: experience from
two major trauma centres in the UK.BJU Int. 2018;121:928–34.
6. Mann U, Zemp L, Rourke KF. Contemporary management of renal trauma in Canada: a
10-year experience at a level 1 trauma Centre. Can Urol Assoc J. 2019;13:E177–82.
7. Wessells H, Suh D, Porter JR, Rivara F, MacKenzie EJ, Jurkovich GJ, Nathens AB. Renal
injury and operative management in the United States: results of a population-based study. J
Trauma. 2003;54(3):423–30. https://doi.org/10.1097/01.ta.0000051932.28456.f4.
8. Buckley JC, McAninch JW.The diagnosis, management, and outcomes of pediatric renal injuries. Urol Clin North Am. 2006;33(1):33–40.
9. Dangle PP, Fuller TW, Gaines B, Cannon GM, Schneck FX, Stephany HA, Ost MC.Evolving
mechanisms of injury and management of pediatric blunt renal trauma—20 years of experience.
Urology. 2016;90:159–63. https://doi.org/10.1016/j.urology.2016.01.017. Epub 2016 Jan 26.
10. Knapp PM, Kulb TB, Lingeman JE, Newman DM, Mertz JHO, Mosbaugh PG, Steele
RE. Extracorporeal shock wave lithotripsy-induced perirenal hematomas. J Urol.
1988;139(4):700–3. https://doi.org/10.1016/s0022- 5347(17)42604- 8.
11. Dhar N, Thornton J, Karafa M, Streem S.A multivariate analysis of risk factors associated
with subcapsular hematoma formation following electromagnetic shock wave lithotripsy. J
Urol. 2004;172(6):2271–4. https://doi.org/10.1097/01.ju.0000143459.03836.2d.
12. Silberstein J, Lakin CM, Kellogg PJ.Shock wave lithotripsy and renal hemorrhage. Rev Urol.
2008;10(3):236–41.
13. Assaf E, Abou Zahr R, Ghabi E, Ghantous I.Perinephric hematoma with active arterial hemorrhage following extracorporeal shockwave lithotripsy. Case Rep Urol. 2019;2019:1–3. https://
doi.org/10.1155/2019/1547437.
References
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14. Jang YB, Kang KP, Lee S, Kim W, Kim MK, Kim YG, Park SK.Treatment of subcapsular haematoma, a complication of extracorporeal shock wave lithotripsy (ESWL), by percutaneous
drainage. Nephrol Dial Transplant. 2006;21(4):1117–8. https://doi.org/10.1093/ndt/gfk002.
15. Poudyal S.Current insights on haemorrhagic complications in percutaneous nephrolithotomy.
Asian J Urol. 2021;9:81. https://doi.org/10.1016/j.ajur.2021.05.007.
16. Alenezi H, Denstedt JD.Flexible ureteroscopy: technological advancements, current indications and outcomes in the treatment of urolithiasis. Asian J Urol. 2015;2(3):133–41. https://
doi.org/10.1016/j.ajur.2015.06.002.
17. Zhang P, Hu W.Sudden onset of a huge subcapsular renal hematoma following minimally invasive ureteroscopic holmium laser lithotripsy: a case report. Exp Ther Med. 2015;10(1):335–7.
18. Correia DC, Antunes RM, Ferreira P.Nephroenteric stula after lithotripsy: a rare complication. Int J Radiol Imaging Technol. 2019;5:048. https://doi.org/10.23937/2572- 3235.1510048.
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Mechanism andPhysiopathology
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ofKidney Trauma
4.1 Blunt Trauma
The kidneys are anatomically protected by the 10th, 11th, and 12th ribs and the
strong lumbar muscles posteriorly and laterally, namely, the erector spinae, quadratus lumborum, and psoas major, the transverse and oblique muscles. Anteriorly,
they are cushioned by the abdominal viscera. However, despite this anatomical
shield, they are the most often traumatized genitourinary organs, in deceleration
(MVA, fall from a height) or acceleration injuries (pedestrian, kick at the lumbar
area during sports or assaults) because they are held in place only by the renal
pedicle and the pelviureteric junction (PUJ) [1].
Moreover, pathologically enlarged or abnormally located kidneys such as
hydronephrotic kidney, polycystic kidney, cystic kidney, ectopic kidney, duplication, horseshoe kidneys, angiomyolipoma, and malignancies make them vulnerable even to minor trauma, and their association with renal trauma was
found to be 19% [2]. An attempt to explain the high vulnerability of these
pathological kidneys, especially those with fluid-filled lesions, to blunt trauma
was provided by a computerized simulation where the force of the trauma
impact was amplified by the presence of a liquid-filled incompressible compartment. It has been observed that maximum stress concentrations were found
at the periphery of the kidney model and corresponded to the clinically observed
injury sites [3].
Studies addressing the biochemical response of pig kidneys to pendulum impacts
identied an energy-based injury threshold: A strain energy density of 21kJ/m3
corresponded to a 50% risk of renal injury level AIS 3 (AAST grade III) or
higher.
1
4
1
Details of AAST and AIS grading are available in Chap. 5.
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_4
27
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4 Mechanism andPhysiopathology ofKidney Trauma
Further experimental results conrmed the prediction of renal capsule rupture
and underlying parenchyma viscoelastic failure from a nite element model of the
human kidney at a threshold of an impact energy level of 4.0J, which is therefore
considered a threshold of AAST grade III renal injury [4] (Fig.4.1). Furthermore,
in blunt lateral abdominal impact, the kidney is squeezed between the fractured
ribcage and the lumbar spine, and impact velocities between 5.2 and 6.5m/s were
predicted to cause tearing or contusion of the renal parenchyma (AAST grade I or
II injury), but not renal capsule rupture, and the threshold speed for kidney rupture
was predicted to be 6.7 m/s (AAST grade III or higher) (Fig. 4.2). This model
Fig. 4.1 Average grade on the AAST renal injury scale for different impact energy intervals and
different pendulum masses. (From K.-U.Schmitt and J.G. Snedeker [4], with permission from the
authors)
Fig. 4.2 Typical injuries observed include rupture of the renal membrane (right) and the parenchyma (left). (From K.-U.Schmitt and J.G. Snedeker [4], with permission from the authors and
from Taylor & Francis)
4.1 Blunt Trauma
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29
permits a hypothetical prediction of the grade of injury from the impact severity and
impact geometry [4, 5].
Four components have been proposed in the mechanism of collision in a motor
vehicle crash: collision between the vehicle and the external object (another car,
tree, wall, rock, etc.), collision of the unrestrained occupant (driver or passenger)
and the interior of the vehicle, collision between the occupant organs and the body
walls (skull, chest wall, abdominal wall), and the collision between the occupants
and loose objects within the vehicle [6]. Logically, another component can be added
for some victims of a high-speed car accident: a collision of the ejected unrestrained
occupant with an object outside the vehicle.
The medical literature contains a handful of cases of diaphragmatic rupture after
blunt abdominal trauma, with intrathoracic herniation of the kidney. This occurs
mostly on the left side as the right side is protected by liver interposition. Very
scanty reports mention a renal injury in association with this migration. By now, we
can only hypothesize that the “give way” of the diaphragm acts as a safety valve in
addition to the role of the internal airbag played by the lungs. One can understand
that this mechanism might logically protect the renal parenchyma from being shattered but would not prevent avulsion of the herniated kidney vessels in high- speed
blunt trauma which calls for urgent life-saving surgical intervention [7, 8].
The body damages are caused not only by deceleration but also by a direct hit.
The deceleration magnitude may be reduced by the deformability of the vehicle.
This is the reason why new vehicles are designed to have a higher deforming ability
during crashes, absorbing partially the effect of the impact on the occupants [6].
Seat belts were designed in 1885, and the front lap belt use became widely distributed in 1964 and was upgraded into a three-point harness in 1973 [9]. Their use
was shown to reduce head injury by a third (from 46.0% to 30.6%) and the mortality
rate by half (from 12% to 6%) [10]. However, no statistical difference was observed
for abdominal organs in general or genito-urinary tract trauma in particular, and
controversies arose with regard to their possible harmfulness being incriminated in
provoking increased deceleration injury to intraabdominal organs [11]. Nevertheless,
seat belt compliance, and especially the correct use of three-point restraints, has
been shown to be inversely proportionate to the rate of fatal accidents [12] (Fig.4.3).
The same controversy has been raised for airbags; however, more advantages
were again demonstrated than detrimental effects [6]. The risks also vary with the
individual role and position inside the car. Being a passenger, especially in the right
outboard position, increases the odds of serious abdominal injury by 2.67. These
odds are reduced by front airbag deployment. A frontal impact is associated with
decreased odds of severe abdominal injury than a side impact [13]. Moreover, when
seatbelt restraints are combined with an airbag, there is statistically better protection
including for intra-abdominal organs. A study of the Crash Injury Research and
Engineering Network (CIREN) database for a period of over a decade (1996–2008)
showed that frontal airbags and side airbags were associated with a 45.3% and
52.8% reduction in renal injury, respectively, after adjusting for the change in velocity [14] (Tables 4.1 and 4.2).
30
nF
, change in velocity.
< 40 kph
> 40 kph
Renal injury
nF
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4 Mechanism andPhysiopathology ofKidney Trauma
Fig. 4.3 Linear regression
between seatbelt
compliance and road trafc
death rates in 46 highincome countries. (From
Abbas etal. [12]. Creative
Commons Attribution
License)
Table 4.1 Front impact renal injury stratied by a change in velocity
Renal injury
No
Yes
Total
No NoYes
n
Frequency
66
86.8
13.2
10
76
Air bag: front Air bag: front
624
641
17
Frequency
97.4
2.7
Total, n
690
27
717
Renal injuryn
No
Yes
Total
Frequency
64
4685.9
94.1 679
706
Yes
n
27
From Thomas G.Smith III etal. [14], with permission from Wolters Kluwer Health
requency
96.2
3.8
Total, n
743
31
774
Table 4.2 Side impact renal injury stratied by change in velocity
< 40 kph
No
n
Frequency
No
Yes
Total
, change in velocity.
356
384
92.7
7.3
28
From Thomas G.Smith III etal. [14], with permission from Wolters Kluwer Health
Scarce articles have studied the specic protection of these devices against urogenital trauma. A review of the NTDB research data for a 3-year period (2010,
2011, and 2012) recruited 3846 renal injuries and demonstrated that those without
a protective device had a higher rate of high-grade renal injuries (45.1%) than those
with seat belts, airbags, and combined seatbelts with airbags with 39.9%, 42.3%,
and 34.7%, respectively [15].
Among patients with high-grade renal injury, those who used no protective
device had a higher nephrectomy rate (56.2%) compared with those who used seat
Air bag: side Air bag: side
84
88
n
4
Yes
Frequency
95.5
4.6
Renal
injury
Total, n
440
No
Yes
Total
165
14
179
32
472
No
Frequency
92.2
7.8
> 40 kph
n
22
1
23
Yes
requency
95.65
4.35
Total, n
187
15
202
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