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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_902_Библиотеки_им_академика_М_И_Перельмана
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8.1 Surgical Technique
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73
Ponetrating Renal Injury
Determine Haemodyrumie Stability
Stable - Any degree of haematuria
High Index of suspieion for Renal Injury
Contrast enhanced spiral CT scan with 10
Grade 1 and 2
Observe
No intraperitonea
Bedrest Serial HCT
Selective Reimaging
Angiography/Embelization?
Ureteral Stenting?
minute delayed imaging
Grade 3 & 4 Lacerations
injuries
Observe
Intraperitoneal injuries
requiring exploration
Normal IVP
Observe
Grade 4 vascular & Grade 5
Injuries
Renal Pedioe trauma
Shattered destoryed kidney
Unstable-Needs Laparotomy
Any Haematuria
Retroperitoneal Haematoma
On Table IVP
Abnormal IVP
Expanding/Pulsatile
Haematoma
Renal Exploration &
Reconstruction or
Nephrectomy
Fig. 8.3 (continued)
8.1 Surgical Technique
As mentioned above, intraperitoneal access is the preferred approach. Once the
Gerota’s fascia is opened and the kidney is exposed, the parenchymal tear must be
identied. When the kidney is deemed salvageable and there is diffuse bleeding, a
renal packing might be all that is needed, and if there is focal bleeding from a
parenchymal tear, renorrhaphy can be undertaken after control of the main vessels
and debridement of necrotic tissues. While proceeding to identify the main vessels,
manual compression of the kidney should be started to temporarily control the
bleeding. The technique of renorrhaphy is more or less the same as for partial
nephrectomy. Any eventual breach in the collecting system must be closed with 4/0
absorbable suture material. To ensure watertightness of the PCS closure, the eventual leak may be identied by clamping the proximal ureter with a bulldog and
injecting 2–3mL of methylene blue into the renal pelvis using a 22-gauge or smaller
buttery [19, 25] (Fig.8.4).
The renal parenchyma and capsule should be closed using tension-free 4-0 polypropylene sutures through protective pledgets (Surgicel, etc.) (Fig.8.5). If the defect
is very large, it should be lled by autologous or exogenous materials such as an
omental pedicle ap, brin sealant, or thrombin-soaked Gelfoam bolsters, and the
capsule should be closed above the interposed material using the same technique
described above [25] (Fig.8.6).
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Fig. 8.4 Intraoperative
evaluation of the integrity
of the collecting system.
Insertion of a 22-gauge
needle into the proximal
ureter, with bulldog clamp
applied distally, and
injection of 2–3mL of
methylene blue into the
renal pelvis. Extravasation
of the methylene blue
(circle) conrms injury to
the collective system.
(From Doumanian etal.
[25], with permission from
Cambridge University
Press)
8 Treatment ofRenal Trauma. II: Operative Approaches
Fig. 8.5 (a) Suturing of pledgets on intact renal capsule edges, for primary repair of injury. (b)
Denitive, tension-free repair of left kidney injury using pledgets. (From Doumanian etal. [25],
with permission from Cambridge University Press)
ab
8.1 Surgical Technique
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Fig. 8.6 (a) Omental pedicle ap may be used to ll in large parenchymal defects, not amenable
to primary repair. The ap is anchored to the capsule with sutures (circles). (b) Hemostatic bolster
used to repair a large defect that cannot be closed primarily without tension, with closure of the
capsule over the bolster. (From Doumanian et al. [25], with permission from Cambridge
University Press)
75
Sometimes, a partial nephrectomy is required when there is a signicant loss of
viability either at the upper or the lower pole. Here maximal exposure of the kidney
is required, as complete removal of nonviable tissue, bleeding control with sutures,
and again watertightness of the PCS and hemostasis have to be ensured [19, 25]
(Fig.8.7). In all cases, peri-renal drainage has to be maintained for at least 48h.
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8 Treatment ofRenal Trauma. II: Operative Approaches
a
b
c
Fig. 8.7 (a) Extensive damage to the lower pole of the kidney is best managed with partial
nephrectomy. (b) Partial lower pole nephrectomy with the raw surface covered with absorbable
materials such as Gelfoam, which can be sutured to the remaining renal capsule. (c) Partial lower
pole nephrectomy with preservation of the capsule. The capsule can be closed over the raw surface
of the kidney. (From Doumanian etal. [25], with permission from Cambridge University Press)
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24. McAninch JW, Carroll PR, Klosterman PW, Dixon CM, Greenblatt MN.Renal reconstruction after injury. J Urol. 1991;145(5):932–7. ISSN: 0022-5347. https://doi.org/10.1016/
S0022- 5347(17)38494- X.
25. Doumanian L, Best C, Keeley J, Varga S.Urological trauma. In: Demetriades D, Velhamos G,
editors. Atlas of surgical techniques in trauma. Cambridge University Press; 2019. p.253–67.
https://doi.org/10.1017/9781108698665.032.
8 Treatment ofRenal Trauma. II: Operative Approaches
Prognosis, Complications,
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andFollow-Up ofKidney Trauma
Analysis of over 40,000 high-grade renal injury victims from the NTDB showed
that mortality was associated with the following factors: nephrectomy, lower
Glasgow Coma Scale (GCS) score, higher Injury Severity Score (ISS), lower
Revised Trauma Score, 1 hypotension, blood transfusion, penetrating mechanism of
the trauma, age, and non-White race [1].
A meta-analysis conrmed the better outcome of nonoperative management
compared with interventional approaches with mortality rates of 5.5% and 13.4%,
respectively [3]. However, a study including nearly 5000 cases of renal trauma
failed to nd an increased likelihood of mortality with angioembolization and open
renal surgery but conrmed the association with black race, age>45years, penetrating trauma, and ISS >15 with mortality [4]. Anyway, the contradiction between
these studies is only apparent because the latter study included all renal trauma
injuries and not only the high grades. And rather than creating confusion in our
mind, this should teach us that surgical exploration and nephrectomy must be
avoided as much as possible and be performed only under strict indications as
already discussed.
Not surprisingly, mortality after penetrating injury is higher than after blunt
trauma and ranges from 6% to 7.5%, being highest after gunshot injury [5, 6]. It
should be borne in mind that sole renal injuries account for a low rate of mortality
and associated injuries play a large part in this grim outcome. Therefore, efforts
made by researchers to differentiate between the specic cause of mortality helped
9
1
The Revised Trauma Score (RTS) was introduced in 1989 by Champion etal. [2]. It aimed at
including the Glasgow Coma Scale (GCS) score, the systolic blood pressure (SBP), and the respiratory rate (RR), while excluding capillary rell and respiratory expansion, as the last two are
difcult to assess in the accident eld. It is calculated by adding the scores of GCS (0–4 points),
SBP (0–4 points), and RR (0–4 points) after multiplying them by a weighted coefcient: Thus,
RTS = 0.9368 (GCS score)+0.7326 (SBP score) + 0.2908 (RR score). In a post-trauma triage,
RTS score of 12 is labeled delayed, 11 is urgent, and 3–10 is immediate. Below 3, the patient is
declared dead or dying. The scores of GCS, SBP, and RR are given in Table9.1.
© 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_9
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9 Prognosis, Complications, andFollow-Up ofKidney Trauma
elicit an overall mortality of 6.5% and a specic renal injury mortality of as low as
0.6% [3].
After throwing so many stones at the operative management, it is important to
also mention that nonoperative management is not devoid of complications, and
pneumonia (7.3%), urinary tract infection (UTI) (3.0%), deep vein thrombosis
(DVT) (2.75%), acute respiratory distress syndrome (ARDS) (1.6%), unplanned
intubation (1.4%), bleeding (0.4%), and urinoma (<0.1%) have been described [7,
8] (Fig.9.1).
Al-Qudah and Santucci reported widely varying post-renal trauma complication
rates of 3–33%, where urinary extravasation was the most frequently encountered
with an occurrence of 10–30% in penetrating injury and 2–18% in blunt trauma [9].
Fig. 9.1 Urinoma seen on
repeat CT abdomen and
pelvis with contrast after
placement of ureteral stent.
(From Shah PK, etal. [8].
Creative Commons
Attribution License)
cd
9 Prognosis, Complications, andFollow-Up ofKidney Trauma
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81
Other complications are urinoma (1–7% overall, 7–30% after penetrating injury),
perinephric abscess (<1% overall, 5% after penetrating injury), unnecessary
nephrectomy,, hypertension (5%), page kidney, UTI or pyelonephritis (2.3%),
chronic ank pain (2%), impaired kidney function and renal insufciency (1.3%),
persistent or secondary bleeding (1.2%), vascular thrombosis (0.5%), pseudoaneurysm (0.3%), post-injury hydronephrosis (0–3%), reno-cutaneous stula (mostly
after partial nephrectomy, renorrhaphy, open drainage of collection), infarct and
parenchymal loss (0.2%), arteriovenous stula (0.1%) (Figs.9.2 and 9.3), pulmonary complications (e.g., pneumonia, bronchitis, atelectasis, and iatrogenic pneumothorax), chylous ascites, and so on [10, 11].
It is recommended to observe a regular follow-up of post-renal trauma patients
for early detection and management of these complications. The follow-up includes
physical examination, urinalysis, diagnostic imaging (CT scan, ultrasonography, or
radionuclides), regular measurement of blood pressure measurement, and serum
creatinine. Ultrasonography is the preferred imaging modality for the pediatric population. However, by consensus, imaging follow-up for minor (AAST I–II) injuries
might not be necessary according to experts’ panels [12, 13].
a
Fig. 9.2 Computed tomography images of unenhanced phase (a) and contrast-enhanced phases
with the arterial (b), venous (c), and delayed (d). Arteriovenous stula mimicking tumor in the
right pelvis renal. Manifesting as a mass, enhancement in the arterial phase, and washout in the
venous and delayed phase. They seemed to match the blood pool in every single phase of contrast
enhancement (arrows). Note that there were several stones in the lower renal calyx (arrowheads).
(From Hoang VT etal. [10], with permission from SAGE Publishing)
b
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9 Prognosis, Complications, andFollow-Up ofKidney Trauma
a
b
Fig. 9.3 Interventional therapy for right renal arteriovenous stula (AVF) with digital subtraction
angiography. (a) The catheter tip image in the right main renal artery (arrow). (b) After the injection of contrast, the AVF bulge was detected (arrowhead). (c) Push the tip of the catheter into the
middle renal artery branch adjacent to AVF (arrow). (d) Inject more contrast material to identify
the lesion. (e) Injecting embolization material to cause AVF obstruction. (f) The lesion was gone,
and the renal blood vessels were circulated normally. (From Hoang VT etal. [10], with permission
from SAGE Publishing)
c
d
e
f
Table 9.1 Revised Trauma Score variable breakpoints (from Champion HR etal. [2], with per-
mission from Wolters Kluwer Health)
Glasgow Coma Scale
13–15 >89 10–29 4
9–12 76–89 >29 3
6–8 50–75 6–9 2
4–5 1–49 1–5 1
3 0 0 0
Systolic blood pressure (mmHg) Respiratory rate
Coded value
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