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7 Treatment ofRenal Trauma. I.Conservative andMini-Invasive Management
ab
Fig. 7.4 Selective left renal arteriography shows a pseudoaneurysm (PSA) in a patient with a
percutaneous nephrostomy (a); the angiogram performed at the end of the embolization procedure
(carried out with microcoils) revealed complete exclusion of the PSA (b). (From Ierardi AM etal.
[20], with permission from Springer Nature)
ab c
Fig. 7.5 Selective right renal arteriography shows early opacication of draining veins (white
arrow) during the arterial phase due to postnephrostomy iatrogenic arteriovenous stula (a); an
8mm Amplatzer plug inside the delivery catheter (b); the angiogram performed at the end of the
procedure revealed closure of the arteriovenous stula (c). (From Ierardi AM etal. [20], with permission from Springer Nature)
REBOA might be associated with decreased mortality. However, like most of the
procedures performed in life-saving situations, it suffers the lack of randomized trials to support its use, and its complications should be kept in mind (air emboli,
lower limbs ischemia, aortic dissection, hematoma, rupture, perforation, pseudoaneurysm, etc.) [21, 22].
7.3 Special Management forPost-PCNL Renal Injury
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63
ab
Fig. 7.6 (a) Intraoperative uoroscopy. (b) Extraction of the nail by the ureteroscopy forceps with
uoroscopic guidance. (From Alothman AS etal. [23]. Creative Commons Attribution License)
7.2.2.2 Other Minimally Invasive Procedures
These may merely consist of a percutaneous drainage of urinoma and abscess, a
percutaneous nephrostomy (PCN), an antegrade or retrograde DJ stent insertion, a
percutaneous extraction of a nail under uoroscopy guidance, and so on [23]
(Fig.7.6a, b).
In very rare cases, CECT may show a traumatic occlusion of the main renal
artery which mandates an endovascular stent placement. Only short series are available in the literature, and one of them showed a high rate of kidney atrophy or
recanalization failure with extravasation prompting embolization [24].
7.3 Special Management forPost-PCNL Renal Injury
As a urologist, you are expected to be able to manage iatrogenic kidney damages
caused by yourself. The best example is a post-PCNL renal injury.
The following algorithm has been proposed for the management of post-PCNL
bleeding (Figs.7.7 and 7.8) [25, 26].
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7 Treatment ofRenal Trauma. I.Conservative andMini-Invasive Management
Fig. 7.7 Treatment algorithm for the management of post-PCNL hemorrhage. (From Long Li
etal. [25], with permission from Springer Nature)
ac
References
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65
b
d
Fig. 7.8 Superselective TAE of a renal artery branch pseudoaneurysm resulting in delayed postPCNL hemorrhage. (a) The right renal artery angiography revealed a pseudoaneurysm originated
from the anterior inferior segmental branch. (b) The parent arterial branch of the pseudoaneurysm
was catheterized superselectively using the microcatheter. (c) The right renal arteriography showed
that the parent arterial branch of the pseudoaneurysm was completely occluded by a microcoil. (d)
CT scan at 12-month follow-up showed the normal homogeneous density throughout the right
renal parenchyma and the parapelvic metal artifact resulting from the microcoil. TAE transcatheter
angiographic embolization. (From Long Li etal., with permission from Springer Nature)
References
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all injured kidneys to operating on almost none of them? Am J Surg. 2016;211(3):501–5.
https://doi.org/10.1016/j.amjsurg.2016.01.001. Epub 2016 Jan 6.
2. Al-Qudah HS, Santucci RA. Complications of renal trauma. Urol Clin North Am.
2006;33(1):41–53, vi. https://doi.org/10.1016/j.ucl.2005.10.005.
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3. Anderson RE, Keihani S, Das R, Hanson HA, McCrum ML, Hotaling JM, Myers
JB. Nephrectomy is associated with increased mortality after renal trauma: an analysis of
the National Trauma Data Bank from 2007-2016. J Urol. 2021;205(3):841–7. https://doi.
org/10.1097/JU.0000000000001366. Epub 2020 Oct 6.
4. Mingoli A, La Torre M, Migliori E, etal. Operative and nonoperative management for renal
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Manag. 2017;13:1127–38. Published 2017 Aug 31. https://doi.org/10.2147/TCRM.S139194.
5. LeeVan E, Zmora O, Cazzulino F, Burke RV, Zagory J, Upperman JS.Management of pediatric blunt renal trauma: a systematic review. J Trauma Acute Care Surg. 2016;80(3):519–28.
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6. Hagedorn JC, Fox N, Ellison JS, Russell R, Witt CE, Zeller K, Ferrada P, Draus JM Jr.
Pediatric blunt renal trauma practice management guidelines: collaboration between the
Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. J Trauma
Acute Care Surg. 2019;86(5):916–25. https://doi.org/10.1097/TA.0000000000002209.
7. Bjurlin MA, Fantus RJ, Fantus RJ, Villines D. Comparison of nonoperative and surgical
management of renal trauma. J Trauma Acute Care Surg. 2017;82(2):356–61. https://doi.
org/10.1097/ta.0000000000001316.
8. Keihani S, Xu Y, Presson AP, Hotaling JM, Nirula R, Piotrowski J, Dodgion CM, Black
CM, Mukherjee K, Morris BJ, Majercik S, Smith BP, Schwartz I, Elliott SP, DeSoucy ES,
Zakaluzny S, Thomsen PB, Erickson BA, Baradaran N, Breyer BN, Miller B, Santucci RA,
Carrick MM, Hewitt T, Burks FN, Kocik JF, Askari R, Myers JB, Genito-Urinary Trauma
Study Group, Contemporary management of high-grade renal trauma: results from the
American Association for the Surgery of Trauma Genitourinary Trauma study. J Trauma Acute
Care Surg. 2018;84(3):418–25. https://doi.org/10.1097/TA.0000000000001796. Erratum in: J
Trauma Acute Care Surg. 2018 May;84(5):826.
9. Sharma DM, Serafetinidis E, Sujenthiran A, Elshout PJ, Djakovic N, Gonsalves M, Kuehhas
FE, Lumen N, Kitrey ND, Summerton DJ, EAU Guidelines Panel on Urological Trauma.
Grey areas: challenges of developing guidelines in adult urological trauma. Eur Urol Focus.
2016;2(1):109–10. https://doi.org/10.1016/j.euf.2015.11.005. Epub 2015 Dec 8.
10. 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.
11. Santucci RA, McAninch JW, Sar M, Mario LA, Service S, Segal MR. Validation of the
American Association for the Surgery of Trauma organ injury severity scale for the kidney. J
Trauma. 2001;50(2):195–200. https://doi.org/10.1097/00005373- 200102000- 00002.
12. Aragona F, Pepe P, Patanè D, Malfa P, D’Arrigo L, Pennisi M. Management of severe blunt
renal trauma in adult patients: a 10-year retrospective review from an emergency hospital. BJU
Int. 2012;110(5):744–8. https://doi.org/10.1111/j.1464- 410X.2011.10901.x. Epub 2012 Feb 7.
13. Erlich T, Kitrey ND. Renal trauma: the current best practice. Ther Adv Urol.
2018;10(10):295–303. Published 2018 Jul 10. https://doi.org/10.1177/1756287218785828.
14. Lanchon C, Fiard G, Arnoux V, Descotes JL, Rambeaud JJ, Terrier N, Boillot B, Thuillier
C, Poncet D, Long JA. High grade blunt renal trauma: predictors of surgery and longterm outcomes of conservative management. A prospective single center study. J Urol.
2016;195(1):106–11. https://doi.org/10.1016/j.juro.2015.07.100. Epub 2015 Aug 6.
15. Buckley JC, McAninch JW. Selective management of isolated and nonisolated grade IV
renal injuries. J Urol. 2006;176(6 Pt 1):2498–502; discussion 2502. https://doi.org/10.1016/j.
juro.2006.07.141.
16. Sujenthiran A, Elshout PJ, Veskimae E, MacLennan S, Yuan Y, Serafetinidis E, Sharma DM,
Kitrey ND, Djakovic N, Lumen N, Kuehhas FE, Summerton DJ.Is nonoperative management
the best rst-line option for high-grade renal trauma? A systematic review. Eur Urol Focus.
2019;5(2):290–300. https://doi.org/10.1016/j.euf.2017.04.011.
17. Owattanapanich N, Benjamin E, Lewis M, Cai J, Demetriades D.Epidemiology and management of isolated blunt renal artery injuries. J Trauma Acute Care Surg. 2021;90(6):1003–8.
https://doi.org/10.1097/TA.0000000000003153.
7 Treatment ofRenal Trauma. I.Conservative andMini-Invasive Management
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18. Bjurlin MA, Jeng EI, Goble SM, Doherty JC, Merlotti GJ. Comparison of nonoperative
management with renorrhaphy and nephrectomy in penetrating renal injuries. J Trauma.
2011;71(3):554–8. https://doi.org/10.1097/TA.0b013e318203321a.
19. Lopez-Gonzalez DB, Zurkiya O. Interventional radiology in renal trauma. Semin Intervent
Radiol. 2021;38(1):113–22. https://doi.org/10.1055/s- 0041- 1726006.
20. Ierardi AM, Floridi C, Fontana F, Duka E, Pinto A, Petrillo M, Kehagias E, Tsetis D, Brunese
L, Carraello G.Transcatheter embolisation of iatrogenic renal vascular injuries. Radiol Med.
2014;119(4):261–8. https://doi.org/10.1007/s11547- 013- 0343- 2. Epub 2013 Dec 3.
21. Castellini G, Gianola S, Bif A, etal. Resuscitative endovascular balloon occlusion of the
aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg. 2021;16:41. https://doi.org/10.1186/
s13017- 021- 00386- 9.
22. Ribeiro Junior MAF, Feng CYD, Nguyen ATM, et al. The complications associated with
resuscitative endovascular balloon occlusion of the aorta (REBOA). World J Emerg Surg.
2018;13:20. https://doi.org/10.1186/s13017- 018- 0181- 6.
23. Alothman AS, Alhajress GI, Elshaer A, Bin HS.Nail gun penetrating renal injury: a case report.
Cureus. 2022;14(2):e22697. Published 2022 Feb 28. https://doi.org/10.7759/cureus.22697.
24. Lopera JE, Suri R, Kroma G, Gadani S, Dolmatch B.Traumatic occlusion and dissection of the
main renal artery: endovascular treatment. J Vasc Interv Radiol. 2011;22(11):1570–4. https://
doi.org/10.1016/j.jvir.2011.08.002. Epub 2011 Sep 19.
25. Li L, Zhang Y, Chen Y, etal. A multicentre retrospective study of transcatheter angiographic
embolization in the treatment of delayed haemorrhage after percutaneous nephrolithotomy.
Eur Radiol. 2015;25:1140–7.
26. 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.
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Treatment ofRenal Trauma. II: Operative
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Approaches
Repetition is the mother of learning, the father of action, which makes it the architect of
accomplishment (Zig Ziglar, American Author (1926–2012)).
Before discussing the operative approaches, it is important to reemphasize
that the patient’s hemodynamical status is considered the key criterion for
adopting either a non-invasive or an invasive approach.
It is never superuous to highlight once more that, when facing a stable patient,
expectant management prevails, and this applies for all grades, either minor (I–II),
intermediate (III), or severe (IV–V). However, if the patient is unstable, with no or
transient response to resuscitation, an immediate intervention must be performed,
consisting of surgery or angio-embolization [1–3].
With the strict use of the AAST grading system and the increasing place of conservative management, the overall rate of nephrectomy in kidney trauma has shown
a progressive decrease over decades, being 13% in 1995 [4] and decreasing to 7%
in 1997–1998, as shown by a population-based study that also revealed that roughly
11% or renal trauma victims required surgical management [5]. In this study,
nephrectomy was performed in 61% of operated patients.
Nowadays, the rate of nephrectomy is lower as suggested by the US National
Trauma Data Bank research data for the period 2010–2014 showing a failure rate of
2.7% for the nonoperative management in the rst 24h [6]. The same trend was
observed in the pediatric population where the rate of nephrectomy decreased from
decade to decade to reach 1.4% in some institutions [7]. By 2016, the decrease was
noteworthy with a rate reaching 7.5% for high-grade injury (III–V) [8]. However,
when specifying the study to penetrating renal injuries only, studies suggest that the
rate of nephrectomy is 22–27% and is mostly the consequence of gunshot wounds
rather than renal stab wounds [9, 10].
Predictors of failure of nonoperative management are injury severity score (ISS)
≥25, highest renal injury grade, the need for transfusion within 24h, penetrating
8
© 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_8
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Fig. 8.1 Proposed nomogram to predict the need for nephrectomy in renal trauma. (From
Shoobridge JJ etal. [13], with permission from Wolters Kluwer Health)
8 Treatment ofRenal Trauma. II: Operative Approaches
injury (Gunshot > Stabbing) with laceration, complete disruption, and vascular
injury, highest abdominal injury grade for nonrenal organs (low RTS = Revised
Trauma Score), low Glasgow Coma Scale (GCS score), and the presence of shock
on presentation [5, 6, 11]. In contrast, age, gender, and institutional characteristics
were not independent factors associated with nephrectomy [5, 12].
Shoobridge etal. proposed a nomogram to predict the odds of nephrectomy after
high-grade renal injury in 2013, based on the injury grade, the number of platelet
units transfused, the blood urea nitrogen (BUN) value, and the hemoglobin value on
presentation [13] (Fig.8.1).
More recently, the American Association for the Surgery of Trauma Multiinstitutional Genito-Urinary Trauma Study (MiGUTS) proposed a nomogram to
predict the need for bleeding interventions, namely, angio-embolization and
nephrectomy, after high-grade renal trauma [14] (Fig.8.2).
This nomogram successfully passed an external validation study through a
CT-scan study of 569 cases, after high-grade renal trauma: this showed that the
presence of vascular contrast extravasation was associated with a threefold
increase in the need for bleeding interventions and that every centimeter
increase in the hematoma rim distance carries a 66% increase in odds of interventions aiming at controlling the bleeding [15]. It is equally important to notice
that the odds of nephrectomy decrease with the time elapsed since admission as
shown by a multicentric review: 69% of nephrectomies were performed within 4h
and 89% were performed within 24h [9]. In the pediatric population also, higher
AAST grade and ISS were correlated with the odds of surgical intervention and
nephrectomy [16]. In general, cases of RTA with GUT are not directly referred to or
admitted under a urology department due to concerns about associated injuries,
being managed rst in emergency and trauma units [17]. However, this apparent
delay does not negatively impact the urology management itself, as the trauma level
8 Treatment ofRenal Trauma. II: Operative Approaches
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Fig. 8.2 Nomogram for the regression model predicting bleeding interventions after HGRT. (From
Keihani S etal. [14], with permission from Wolters Kluwer Health)
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designation (level I and nonlevel I) was not shown to be a predictive factor in the
likelihood of more aggressive approaches [16].
Whatever the importance of all the factors discussed above, the strict indication for surgical exploration remains the non-responding hemodynamical
instability. Other indications are severe renal vascular injuries (grade V vascular or
penetrating injury) with ongoing bleeding showing no self-limiting tendency with
expanding or pulsatile peri-renal hematoma. However, a shattered kidney per se is
not an indication for urgent surgical intervention as long as the patient is stable, nor
is a devascularized but non-bleeding kidney. Avulsion of the pyeloureteral junction
or pelvis rupture not amenable to antegrade or retrograde stenting should not prompt
an urgent repair [1, 3]. These patients are better managed conservatively with percutaneous drainage of the urinoma, and surgery might be considered later on if no
tendency for self-repair. When the decision to operate is taken, the preferred
approach is transperitoneal, and the early control of hilar vessels for nephrectomy,
in general, has been advocated for more than half a century [18]. In the context of
trauma, this maxim is even vital, and the surgeon must aim at controlling the renal
artery and vein before manipulating the hematoma or starting any parenchymal
repair (renorrhaphy) [19]. The strict observance of vessel control has shown a reduction in the rate of nephrectomy from 56% to 18% when two metachronous series
were compared in a single institution [20].
As a rule of thumb, if a stable hematoma is found during exploration, it
should not be disturbed and the surgery should be terminated without further
manipulation, as opposed to a central or expanding hematoma, which is correlated to major vessels injuries (e.g., renal vessels, aorta, and vena cava), calling for surgical exploration [21].
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8 Treatment ofRenal Trauma. II: Operative Approaches
Main renal artery repair is successful only in a small percentage of cases
(10–26%) depending on the ischemia duration and the degree of the lesion. However,
repair of isolated renal veins carries a larger success rate (51%) [22–24]. To date,
most cases of arterial or severe parenchymal injuries discovered intraoperatively
end in nephrectomy. However, efforts to repair an injured renal artery should always
be made and the expertise of a vascular surgeon be requested in patients with a solitary kidney or bilateral renal injuries, or a minimal arterial tear, as the success
depends on the incomplete nature of the injury which leaves some hope for a nonischemic kidney [3, 21].
In view of the lack of high-grade evidence and strong guidelines, especially in
intermingled scenarios, it is useful to follow some algorithms such as the one proposed by Santucci etal. for the management of unilateral renal artery injury, as well
as blunt and penetrating renal injuries in general, based on a consensus of experts
from the World Health Organization and the Societé Internationale d’Urologie
(Fig.8.3a–c).
Unilateral renal artery injury
No laparotomy
No flow
Observe Observe Observe
Flow
Stent
b
Prolonged ischemia
Laparotomy
Unstable
Hilar injury
NephrectomyRepair
Determine Haemodynamic Stability
Stable
Early dx.
Arterial flow
Blunt Renal Injury
Stable
Unstable-Any Haernatuna
Child <50 RBC/hpf
Adult Microhaematuria SBP >90 mm HGS
Observe
F/U UA in 3 weeks
Grade I and 2 Grade 3 & 4 Lacerations
Observe
Fig. 8.3 Algorithms for managing: (a) renal arterial injury; (b) blunt renal injury; and (c) pene-
trating renal injury. (From Santucci etal. [21], with permission from John Wiley and Sons)
Gross Haematuria
Child >50 RBC/hpf
Adult Microhaematuria S8P <90 mmHg
High index of suspicion for renal injury
Contrast enhanced spiral CT scan
with 10 minute delayed cuts
No intraperitoneal
injuries
Observe Bedrest SerialHCT
Selective Reimaging
Angiography/Embolization?
Ureteral Stenting?
Grade 4 vascular In Grade 5
Shattered destroyed kidney
Intrapentoneal injuries
requiring exploration
*except isolated renal artery thrombosis in patient with
normal contralateral kidney and no other associated
injuries
Normal IVP
Observe
Renal Pedicle trauma
On Table IVP
Expanding/Pulsatile
Abnormal IVP
Haematuria
Renal Exploration*
Reconstruction or
Nephrectonry
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