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6 Symptoms, Signs, andDiagnostic Means ofRenal Trauma
6.2 Laboratory Tests
The clinician should rapidly request a complete blood count (CBC) (hemoglobin
and hematocrit), blood crossmatching, renal function tests, coagulation prole, as
well as urine analysis to detect microscopic hematuria. Depending on the presentation, other blood tests might also be useful (amylase, troponin, D-dimer, C-RP, etc.).
6.3 Imaging
6.3.1 Contrast-Enhanced Computerized Tomography (CECT)
For more than two decades, intravenous urography (IVU) has been supplanted by
CECT which is now the gold standard imaging means to dene and grade the
renal injury either for blunt or penetrating renal trauma. However, being timeconsuming, CECT should be performed only in a stable patient as recommended by
Experts’ panel guidelines [2, 3].
Because of the poor correlation between hematuria and the injury grade, radiological investigations are recommended in all patients with penetrating injuries. For
those with blunt trauma, due to the absence of prospective randomized trials, there
is a consensus that hemodynamically stable patients with suspected renal trauma
should undergo imaging examinations, the suspicion being built upon history and
the presence of gross hematuria or microhematuria [4].
In this setting, it has been shown that patients with blunt trauma, microscopic
hematuria, and systolic blood pressure>90 mmHg have a very low incidence of
major renal injury (0.2%) and do not require imaging investigations. On the contrary, those who have BP<90mmHg have 12.5% of major renal injury [5].
In addition, despite the total absence of hematuria, radiological investigations
should be performed in patients with a suggestive history of deceleration injuries or
those with multiple associated injuries: high-speed motor vehicle accident (MVA)
and falls from height [4–6].
As the patient’s hemodynamic stability status is a key factor in deciding on the
management, it is important to refresh the readers’ mind with some denitions [7]:
In adult patients, hemodynamic instability is dened by:
– Systolic blood pressure <90 mmHg + signs of skin vasoconstriction (cool,
decreased capillary rell), altered level of consciousness, and/or shortness of
breath or
– BP >90 mmHg but requiring bolus infusions or transfusions and/or inotropic
support, and/or base excess (BE)>−5 mmol/L, and/or shock index 1 >1, and/or
transfusion requirement of at least 4–6 units of packed red blood cells within the
rst 24 h
1
The shock index (SI) is the ratio between heart rate and systolic blood pressure in mmHg (HR/
SBP). It helps to detect early hemorrhagic shock and to determine the severity of the trauma.
6.3 Imaging
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In pediatric patients, hemodynamic stability is considered as:
– A systolic blood pressure of 90 mmHg plus twice the child’s age in years (the
lower limit is inferior to 70 mmHg plus twice the child’s age in years or inferior
to 50 mmHg in some studies)
As a rule of thumb, based on general consensus, experts’ panels [2, 3, 8, 9] recommend performing diagnostic imaging with CECT in hemodynamically stable
patients presenting with the following:
– Blunt trauma with visible (gross, macroscopic) haematuria
– Blunt trauma with non-visible (microscopic) haematuria + one episode of hypo-
tension (syst BP<90mmHg)
– History of rapid deceleration injury and/or signicant associated injuries
– Penetrating trauma
– Clinical signs suggestive of renal trauma (ank pain, abrasions, fractured ribs,
abdominal distension, and/or mass or tenderness elicited on palpation)
A complete CT study should include four phases [9]:
– Precontrast: help identifying renal calculi or intraparenchymal hematoma.
– Postcontrast arterial (35s postintravenous injection): identify parenchymal and
vascular damage, eventual presence of active extravasation, and another solid
organ injury.
– Postcontrast nephrogenic/portal venous (75s postintravenous injection): identify
active extravasation and optimally demonstrate parenchymal contusions and
lacerations.
– Delayed (5–10min postintravenous injection): identify eventual collecting sys-
tem and ureteral injury and urinoma.
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After an initial imaging, general consensus also prevails that reimaging with a
repeat CECT should be obtained for high-grade renal injuries after 2–4 days to
reevaluate the progress or be requested whenever there are signs of complications
such as fever, abdominal distension, unexplained decrease Hb and Hct, or signicant ank pain [2, 3, 9].
6.3.2 Ultrasonography (U/S)
U/S is inferior to CECT and has limited use. However, it may help detect renal lacerations and hematoma but is unable to dene the nature of a collecting uid (urine
or blood). It is useful in the follow-up of hydronephrosis and uid resorption, with
the advantage of being radiation-free, especially in the pediatric population [9].
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6 Symptoms, Signs, andDiagnostic Means ofRenal Trauma
6.3.3 Intravenous Urography (IVU) or Intravenous
Pyelography (IVP)
IVP has become obsolete nowadays due to the widespread distribution of crosssectional imaging (CT scan). Nonetheless, the European Association of Urology
(EAU) recommends proceeding to a rapid one-shot intra-operative IVP to conrm
the presence of the contralateral kidney before engaging in a surgical exploration in
unstable patients who cannot undergo a CT scan beforehand: Practically, a bolus of
2mL/kg of contrast is given followed by a single plain X-ray lm after 10min [2].
6.3.4 Other Imaging Modalities
Magnetic resonance imaging (MRI) is impracticable in the setting of a trauma as
it requires a tedious arrangement and is not superior to CECT.However, MRI may
be useful in a stable pregnant woman or in patients who are allergic to iodine [7].
Radionuclide studies have a role in the follow-up to evaluate scarring and loss of
kidney or secondary obstruction.
References
1. McClung CD, Hotaling JM, Wang J, Wessells H, Voelzke BB. Contemporary trends in the
immediate surgical management of renal trauma using a national database. J Trauma Acute
Care Surg. 2013;75(4):602–6. https://doi.org/10.1097/TA.0b013e3182a53ac2.
2. EAU Guidelines. Edn. presented at the EAU annual congress Amsterdam, Mar 2022. ISBN:
978-94-92671-16-5. https://d56bochluxqnz.cloudfront.net/documents/full- guideline/EAU-
Guidelines- on- Urological- Trauma- 2022_2022- 03- 24- 104100_fwda.pdf.
3. Morey AF, Brandes S, Dugi DD 3rd, Armstrong JH, Breyer BN, Broghammer JA, Erickson
BA, Holzbeierlein J, Hudak SJ, Pruitt JH, Reston JT, Santucci RA, Smith TG 3rd, Wessells
H, American Urological Assocation. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–35.
https://doi.org/10.1016/j.juro.2014.05.004. Epub 2014 May 20.
4. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW, Nash P, Schmidlin
F.Evaluation and management of renal injuries: consensus statement of the renal trauma sub-
committee. BJU Int. 2004;93(7):937–54. https://doi.org/10.1111/j.1464- 4096.2004.04820.x.
5. Mee SL, McAninch JW, Robinson AL, Auerbach PS, Carroll PR.Radiographic assessment of
renal trauma: a 10-year prospective study of patient selection. J Urol. 1989;141:1095–8.
6. Ramchandani P, Buckler PM. Imaging of genitourinary trauma. AJR Am J Roentgenol.
2009;192(6):1514–23. https://doi.org/10.2214/AJR.09.2470.
7. Coccolini F, Moore EE, Kluger Y, et al. Kidney and uro-trauma: WSES-AAST guidelines.
World J Emerg Surg. 2019;14:54. https://doi.org/10.1186/s13017- 019- 0274- x.
8. Serafetinides E, Kitrey ND, Djakovic N, etal. Review of the current management of upper
urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 2015;67:930–6.
9. Erlich T, Kitrey ND. Renal trauma: the current best practice. Ther Adv Urol.
2018;10(10):295–303. https://doi.org/10.1177/1756287218785828.
Treatment ofRenal Trauma.
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I.Conservative andMini-Invasive
Management
Following a long period of lethargy with scarce publications about the conservative
management of renal trauma in the post-World War II period, a new era of explosive
interest in this subject arose in the mid-2000s [1].
Success was once considered when a patient survived a renal trauma and nephrectomy was frequently performed for any severe trauma to reach this goal. Then emotional progress was made in the management of renal trauma over the last 20years.
Nowadays, while still aiming at the patient’s survival, true success is increasingly
considered as salvaging the injured kidney. More and more researchers and clinicians rightly consider the unnecessary removal of a kidney during the treatment of
renal trauma as “an avoidable disaster second only to death or extreme debility” and
preconize preserving renal function while minimizing morbidity and eliminating
kidney-related mortality [2].
Moreover, analysis of high-grade renal trauma patients in the National Trauma
Data Bank (NTDB) for a 10-year period from 2007 to 2016 showed that nephrectomy is an independent factor associated with increased risk of mortality after
adjusting for injury characteristics, overall injury severity, and patient demographics. In this study, nephrectomy was associated with 82% increased odds of death in
multivariable logistic regression [3].
With the exception of critical scenarios where the patient is unstable and expectative management is obviously deemed dangerous, the great fear of the treating
team in the approach of a renal trauma should be to do more harm than good. A
meta-analysis has shown that nonoperative approaches result in lower mortality
compared with operating management even when considering solely high-grade
blunt as well as penetrating injuries [4] (Fig.7.1a–d).
The conservative management or minimally invasive approaches for grades IV
and V blunt renal trauma have also been supported in the pediatric population by
systemic reviews which demonstrated short- and long-term favorable outcomes [5]
and a lower rate of kidney loss with angioembolization than with surgical intervention [6].
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_7
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7 Treatment ofRenal Trauma. I.Conservative andMini-Invasive Management
a
b
c
d
Fig. 7.1 (a–d) An 18-year-old sherman who fell and sustained abdominal trauma resulting in a
shattered right kidney (AAST grade V) and largely associated intra and perinephric hematoma
(127×115×85 mm) (H) and extravasation (E): (a–c) Axial, coronal and sagittal image of the right
kidney and hematoma. (d) The patient was stable, only a DJ stent (St) was inserted and the rest of
management was conservative. (e) Follow-up repeat CT showed nearly complete healing at
8months
7 Treatment ofRenal Trauma. I.Conservative andMini-Invasive Management
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e
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Fig. 7.1 (continued)
The National Trauma Data Bank (NTDB) research in the USA shows that 83.4%
of renal traumata were managed nonoperatively, and only 16.6% were treated with
interventional therapy for the period 2010–2014 [7].
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Even when specifying high-grade injuries only (AAST grade III–V) for the
period 2014–2017, data still show that 70% were managed nonoperatively, 11%
underwent minimally invasive management, 19% were operated on, and 67% of the
operated patients underwent nephrectomy. Thus, the overall nephrectomy rate for
all patients with high-grade injury was 13%, and more specically 0.4%, 15%, and
62% for grades III, IV, and V, respectively [8].
7 Treatment ofRenal Trauma. I.Conservative andMini-Invasive Management
7.1 Supportive andAdjunctive Treatments
The critically sick and shocked patient is better resuscitated in a high dependency or
intensive care unit with continuous monitoring, intravenous crystalloid infusion,
blood transfusions, inotropic support if required, oxygen supplement if required,
central venous pressure line, urine output monitoring, intubation, and so on. The
details are outside the scope of this book. For most of the patients, there is no clear
recommendation on DVT thromboprophylaxis, antibiotic prophylaxis, and mobilization due to a lack of evidence [9].
Consensus pleads, however, for antibiotic prophylaxis with a single dose, with
the possibility to continue the antibiotic therapy in cases of urinary extravasation or
high-grade injury. Also, putting into balance the ongoing or possible sudden occurrence of bleeding weighed against the risk of thrombosis in a traumatized bedridden
patient with kidney trauma, compression stockings are advised while low molecular
heparin can be given in selected cases only after risk balancing. Catheterization is
advised in patients with high-grade trauma or in those with heavy hematuria.
7.2 Minimally Invasive Approach
7.2.1 The Rationale ofMinimally Invasive Approach
Prioritizing less invasive management applies to all ages, and pediatric patients
should be treated in the same way as adults, either in blunt or penetrating urogenital
injuries [10].
However, experts’ opinion states that non-invasive management in severe injuries should be supported by the availability of close clinical observation and hemodynamic monitoring facilities (ideally in high dependency/intensive care units),
proper laboratory tests, and immediate procurement of whole blood, packed cells,
and other blood products. Also, diagnostic means should be readily available, as
well as immediate access to interventional radiology (angioembolization) and surgery [10].
While still considering the hemodynamical status of the patient as the key factor
to decide on either nonoperative or operative management, the second factor that
should be considered is the AAST grade, not because this will directly and immediately dictate the management option, but because it has a correlation with the
hemodynamical status and will keep the clinician on alert:
7.2 Minimally Invasive Approach
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– Grade I: Nonoperative management. These patients rarely require any interven-
tion, and no nephrectomy has been associated with this grade.
– Grade II: Nonoperative management. Rarely require any intervention. However,
due to small parenchymal laceration (<1cm), persistent moderate pain might be
present due to a larger subcapsular hematoma than in grade I.No nephrectomy
has been associated with this grade.
– Grade III: Again, nonoperative management must be considered for any stable
patient. However, as there is a deeper laceration of the cortex (>1cm), a larger
subcapsular hematoma is expected with subsequent increased pain requiring
more analgesia and also the need for blood transfusion, percutaneous drainage if
the hematoma is expanding, and even selective arterial embolization if the
patient’s Hb drops requiring repeated blood transfusion.
– Rarely, if embolization is ineffective, exploration might be needed to remove the
hematoma and proceed to hemostatic renorrhaphy of the laceration. Failure to
control the bleeding might lead to nephrectomy. Old studies showed higher rates
of nephrectomy (3–9%) in grade III renal injury [11], which signicantly
decreased with the introduction of angioembolization to almost completely dis-
appear [12].
– Grade IV: Conservative management has still a large place in grade IV blunt
renal injury [13].
– However, when remembering the denition of this grade with deeper parenchy-
mal laceration up to the collecting system and main renal artery or vein injury,
one can expect the presence of a larger possibly pulsating hematoma, with a drop
of hemoglobin requiring frequent blood transfusion and the presence of urinoma.
– Therefore, the need for interventional management must be permanently kept in
mind consisting of percutaneous urinoma drainage, placement of a DJ stent, an
angioembolization in the presence of continuous bleeding with expansive hema-
toma, and even surgical exploration in case of failed embolization, or severe
pain, or sepsis from an infected hematoma or abscess.
– The chances of nephrectomy are higher in grade IV than in grade III, even if the
trend is going down due to the development of angioembolization. A study
showed that angioembolization and ureteral stent placement were necessary in
22 patients out of 124 (18%) patients with grade IV injury [14], and a 25-year
retrospective study of 153 cases of grade IV kidney injury concluded in 2006
showed 67% (two-thirds) of cases treated operatively and 33% (one-third) treated
nonoperatively [15]. Nephrectomy was performed in 15 patients from this
cohort (9.8%).
– More recent research showed a higher rate of successful nonoperative manage-
ment of grade IV renal injury (82%) and only 2 patients out of 124 underwent
partial nephrectomy (1.6%) and 2 others total nephrectomy [14].
– Grade V injury: Again, a stable patient can still be managed conservatively.
– Indeed, in our practice, we have successfully managed conservatively cases of
grade V trauma with shattered kidney, some of them without even a minimally
invasive procedure (Fig.7.1). More frequently, however, these patients require
either a DJ stent insertion or angioembolization. Nonetheless, due to the higher
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possibility of a rapidly expansive hematoma or the presence of a completely
shattered kidney, a higher rate (52%) of grade V injuries requires operative
exploration (half of the patients) with a rate of nephrectomy 23% of cases [14].
– Angioembolization is of great interest in avulsed main renal vessels when one is
planning to proceed to exploration and removal of the kidney as it will minimize
the bleeding during mobilization of the kidney and removal of the hematoma. It
can also be considered for segmental arteries in shattered kidney with no main
vessels’ avulsion. It has a decreased rate of renal unit loss compared with surgi-
cal intervention in stable patients with persistent or delayed bleeding [6].
In the pediatric population also, there are robust data supporting conservative
management protocols for high-grade (III, IV, and V) blunt renal trauma as these
have favorable short- and long-term outcomes [5].
A European systematic review found a signicant heterogeneity in the outcomes
of high-grade renal trauma management according to the published series. However,
when comparing the nonoperative with the operative approaches, it found that the
overall mortality, renal preservation, and complication rates are signicantly better
in the nonoperative management group than in the operative one, with values of
0–3% vs. 0–29%, 84–100% vs. 0–82%, and 5–32% vs. 10–76%, respectively [16].
A great change has occurred in the last decade with the majority of isolated blunt
renal artery injuries being also treated conservatively leaving only a minority of
cases for nephrectomy, endovascular stenting, or open renal artery repair [17].
Another important factor to keep in mind after considering the patient’s hemodynamic status and the AAST injury grade is the mechanism of injury. As for the
AAST grade, the importance of the mechanism lies in its correlation with the
patient’s hemodynamic status. Penetrating injuries have shown a higher rate of
interventions than blunt trauma despite still being managed nonoperatively in
the majority of cases: 40% nonoperative, 38% renorrhaphy, and 22% nephrec-
tomy. And among penetrating injuries, renal gunshot wounds were mostly managed
surgically with 26% and 42% requiring nephrectomy and renorrhaphy, respectively,
while only 32% were successfully managed nonoperatively [18] (Fig.7.2).
7 Treatment ofRenal Trauma. I.Conservative andMini-Invasive Management
7.2.2 Minimally Invasive Procedures
7.2.2.1 Angioembolization
Angiography in a patient after a renal trauma may reveal actively bleeding vessels,
pseudoaneurysms, arteriovenous stulas, or arterio-calyceal stula or may show no
abnormality or bleeding.
The technique of angioembolization is performed under local anesthesia, and
the common femoral artery is the preferred approach. The patient’s vital signs are
monitored. The kidney side of interest is selected, and when the area of bleeding is
visualized, a super-selective approach is undertaken so that distal embolization is
limited to the site to avoid the devascularization of unaffected parenchyma. For this
reason, the embolizing material should be positioned at, or beyond, the interlobar
cd
7.2 Minimally Invasive Approach
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Fig. 7.2 Incidence of nonoperative management, renorrhaphy, and nephrectomy of penetrating
renal injury grades I–V. (From Bjurlin MA etal. [18], with permission from Lippincott Williams
and Wilkins (Wolters Kluwer Health))
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ab
Fig. 7.3 Grade 4 left renal laceration after fall. Axial (a) and coronal (b) CT images showing
laceration of the left kidney with hyperdense material (red arrow) showing active hemorrhage.
Angiography (c) shows the area of bleeding in the inferior pole (white arrow). After coil embolization (d), the bleeding is controlled. The lack of parenchymal contrast peripheral to the coils in the
medial inferior pole represents devascularized tissue. (From Lopez-Gonzalez DB etal. [19], with
permission from Georg Thieme Verlag KG)
artery. Various materials may be utilized for an effective embolization: microcoils,
gelfoam, polyvinyl-alcohol (PVA) particles, and vascular plug (Amplatzer) [19, 20]
(Figs.7.3, 7.4, and 7.5).
The combination of these materials might be used to potentiate their effects.
A review of angioembolization for iatrogenic kidney injury showed a 100% technical success rate and a 95% clinical success rate.
After the failure of the initial angioembolization, a repeat procedure should be
considered in hemodynamically stable patients who have a continuous active bleeding with no other indications for surgical intervention [10].
Resuscitative endovascular balloon occlusion of the aorta (i.e., REBOA) may be
used in hemodynamically unstable patients as a bridge for hemorrhage control until
a more denitive procedure is performed [10].
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