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References
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There is no clearly dened timing for the return to normal activity after a renal
trauma. However, as a rule, bed rest and reduced activity are to be observed as long
as gross hematuria is present, and sports activities are suspended until microscopic
hematuria is resolved. It is hypothesized that sports activities might be resumed
2–6weeks after a minor or moderate renal injury or 6–12 months after a severe
one [13].
References
1. 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.
2. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan
ME. A revision of the trauma score. J Trauma. 1989;29(5):623–9. https://doi.
org/10.1097/00005373- 198905000- 00017.
3. Petrone P, Perez-Calvo J, Brathwaite CEM, Islam S, Joseph DK.Traumatic kidney injuries:
a systematic review and meta-analysis. Int J Surg. 2020;74:13–21. https://doi.org/10.1016/j.
ijsu.2019.12.013. Epub 2019 Dec 21.
4. Ho P, Hellenthal NJ. Independent predictors of mortality for patients with traumatic renal
injury. World J Urol. 2021;39(9):3685–90. https://doi.org/10.1007/s00345- 020- 03552- x. Epub
2021 Jan 5.
5. McAninch JW, Carroll PR, Armenakas NA.Renal gunshot wounds: methods of salvage and
reconstruction. J Trauma. 1993;35:279–83; discussion: 283–4.
6. Carroll PR, McAninch JW. Operative indications in penetrating renal trauma. J Trauma.
1985;25:587–93.
7. Bjurlin MA, Fantus RJ, Fantus RJ, Villines D.Comparison of nonoperative and surgical management of renal trauma: can we predict when nonoperative management fails? J Trauma
Acute Care Surg. 2017;82(2):356–61. https://doi.org/10.1097/TA.0000000000001316.
8. Shah PK, Frieben RW, Desouza RA.Delayed nephron sparing surgery for grade IV renal injury.
Case Rep Urol. 2013;2013:482320. https://doi.org/10.1155/2013/482320. Epub 2013 May 15.
9. 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.
10. Hoang VT, Pham NTT, Nguyen HQ, Van HAT, Vo MTT, Nguyen TTT, Chansomphou V, Trinh
CT.A case of arteriovenous stula after kidney trauma mimicking tumor. J Investig Med High
Impact Case Rep. 2020;8:2324709620967877. https://doi.org/10.1177/2324709620967877.
11. Starnes M, Demetriades D, Hadjizacharia P, Inaba K, Best C, Chan L.Complications following renal trauma. Arch Surg. 2010;145(4):377–81. https://doi.org/10.1001/archsurg.2010.30.
12. 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.
13. 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.
Special Cases inRenal Trauma
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The occurrence of trauma in ectopic kidneys, horseshoe kidneys (HSK), renal angiomyolipomas (AMLs), and kidney allografts is very rare, although they are more
prone to damage than normal kidneys when hit. A simple explanation is the extreme
rarity of these abnormal kidneys compared with normal kidneys.
10.1 Trauma inSimple Ectopic, Crossed Ectopic,
andCrossed-Fused Ectopic Kidneys
Only a dozen of cases of ectopic kidneys injuries have been reported in the literature, including pelvic, thoracic, and crossed-fused ectopic kidneys. Studies have
shown that these kidneys are likely to be injured by low-velocity impacts due to
their poor anatomical protection; thus, they have a lower rate of associated trauma
with other abdominal organs and a lower ISS [1]. The scantiness of cases does not
plead for any reliable guideline to be formulated, and the traumatized ectopic kidney should be treated in the same way as the orthotopic one, i.e., conservatively
even for high grades (IV–V), as long as the patients are hemodynamically stable
[2–4]. And when there is a post-traumatic pseudoaneurysm of the ectopic kidney
artery, this can be excluded through endovascular approach in the same way as for
normal kidneys [5] (Fig.10.1a–e).
There are also reports about trauma on crossed ectopic kidneys, either fused or
not who were successfully managed conservatively or with minimally invasive procedures [6–8].
© 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_10
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ab
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10 Special Cases inRenal Trauma
c
Fig. 10.1 (a–c) CT scan showing left pelvic kidney and distal pseudoaneurysm of one of the renal
artery branches. (d) Selective arteriography of the left renal artery showing a pseudoaneurysm. (e)
Angiography control: pseudoaneurysm exclusion and permeability of other branches of the renal
artery. (Reproduced from Ibrahimi A etal. [5], with permission from Elsevier Masson SAS)
10.2 Trauma onHorseshoe Kidneys (HSK)
There are roughly a dozen cases of trauma on HSK reported in the literature, the
oldest having been written as far back as 1964 [9].
HSK is vulnerable even to speeds lower than 15km/h, and its injury is managed
in the same manner as normal kidneys with conservative management being the rst
ab
ab
10.2 Trauma onHorseshoe Kidneys (HSK)
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87
choice, followed by endovascular management, and surgery being reserved for
exceptional situations with severe bleeding and hemodynamically unstable patients
[10–12] (Figs.10.2a, b and 10.3a, b).
Fig. 10.2 CT angiography in axial view, showing an active contrast extravasation from accessory
right renal artery and retroperitoneal hematoma (a, b) (black arrow). (From Krutsri etal. [11].
Creative Commons Attribution License)
Fig. 10.3 CT angiography in coronal view, showing an active contrast extravasation from accessory right renal artery and retroperitoneal hematoma (a, b) (black arrow). (From Krutsri etal. [11].
Creative Commons Attribution License)
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10 Special Cases inRenal Trauma
10.3 Trauma onRenal Angiomyolipoma (AML)
AML is known to have a propensity to rupture, especially if larger than 4cm. This
rupture can occur spontaneously in a so-called Wunderlich syndrome (up to 50% of
cases), or following trauma (even low velocity), or during pregnancy [13]. Most of
the modern reported cases were successfully managed with angioembolization or,
rarely, surgery with nephrectomy for hemodynamically unstable patients [13–15].
10.4 Trauma andKidney Allograft
The transplanted kidney is exposed to trauma in the iliac fossa. However, here again
reported cases can be counted on the ngers of both hands. The rare cases are generally low-grade injuries happening after mild blunt trauma.
The trauma factor might just consist of a seat belt compression during a lowspeed vehicle accident [16, 17] or a cat jumping on the patient’s abdomen [18].
Most of the cases have been managed conservatively, even for high-grade injuries
[19]. Some required superselective embolization considering the necessity of maximum preservation of the renal function in this situation (solitary functioning kidney) [20] (Figs.10.4 and 10.5a, b).
Because of continuous bleeding with expanding and compressive hematoma,
other patients required surgical exploration and renorrhaphy [21].
The same complications occurring in normal kidneys can be encountered in kidney allograft trauma, including urinomas, delayed hemorrhage, infections, pseudoaneurysm, arteriovenous stula formation, and renal insufciency.
Fig. 10.4 Large peri-graft
hematoma with grade III
laceration (the patient had
combined pancreas and
kidney transplantation).
(From Rajagopal P [20].
Creative Commons
Attribution License)
ab
10.4 Trauma andKidney Allograft
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Fig. 10.5 The injured branch of the renal artery. (a) Pre-embolization. (b) Post-embolization.
(From Rajagopal P etal. [20]. Creative Commons Attribution License)
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Reports on kidney allograft loss are exceptional. In one of them, the cause of the
trauma was the patient’s cat jumping on his abdomen 1 week before his presentation
to the hospital where he was found to have a large subcapsular hematoma on
CT-scan (grade II) and developed acute page kidney few days later [18].
Another factor worth noting is the possible occurrence of an iatrogenic injury of
a transplant kidney during cesarean delivery. This warning is justied by the
increased number of childbearing women receiving a transplant kidney nowadays.
Moreover, a systematic review and meta-analysis showed that the cesarean rate in
post-renal transplant women was higher than in the general American population,
with values of 56.9% and 31.9%, respectively [22]. This fact was observed to an
even greater extent in a Norwegian national cohort study which found that postkidney transplant pregnant women had a vefold increased risk of undergoing
cesarean section compared with the non-transplanted pregnant women [23].
However, despite the increased number of cesarean sections, iatrogenic injuries
to the renal graft or ureter are seldom reported. One of the discussed cases mentioned a laceration of the renal graft during traction, which was treated with pressure
and renorrhaphy using a 3-0 pledgeted prolene [24].
Before closing this chapter, it should be remembered that spontaneous renal
allograft rupture is by far more frequently encountered than traumatic injury.
Fortunately, it is still a rare phenomenon occurring in 0.3–3% of cases of renal
transplantations [25].
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10 Special Cases inRenal Trauma
It is reported to happen at around 2 weeks post-transplantation. Incriminated
etiological factors include acute rejection as the main cause, followed by renal vein
thrombosis, and acute tubular necrosis. It is a life-threatening condition requiring
urgent surgical intervention and frequently ending up in graft nephrectomy, which
reached 70% in one series [26].
References
1. Schmidlin FR, Iselin CE, Naimi A, Rohner S, Borst F, Farshad M, Niederer P, Graber
P.The higher injury risk of abnormal kidneys in blunt renal trauma. Scand J Urol Nephrol.
1998;32(6):388–92. https://doi.org/10.1080/003655998750015151.
2. Becker AB, Baig MB, Becker AM.Conservative management of a grade V injury to an ectopic
pelvic kidney following blunt trauma to the lower abdomen: a case report. J Med Case Rep.
2010;4:224. https://doi.org/10.1186/1752- 1947- 4- 224.
3. Hani MA, Sallami S, Ben Achour J, Zoghlami A, Najah N.Trauma of an ectopic kidney. A
case report. Tunis Med. 2004;82(1):69–71.
4. Ho SW, Yeh YT, Yeh CB. Rupture of ectopic pelvic dysplastic kidney after blunt abdominal
trauma presenting as left lower quadrant pain. J Emerg Med. 2013;44(2):e173–5. https://doi.
org/10.1016/j.jemermed.2012.02.072. Epub 2012 Aug 24.
5. Ibrahimi A, Zahdi O, Dergamoun H, Ziani I, El Sayegh H, Benslimane L, Lekehal B, Nouini
Y.Traumatic renal artery pseudoaneurysm on a pelvic kidney. J Med Vasc. 2020;45(3):158–60.
https://doi.org/10.1016/j.jdmv.2020.03.003. Epub 2020 Mar 27.
6. Jindal T, Kamal MR, Mukherjee S, Mandal SN, Karmakar D.Management of an iatrogenic
injury in a crossed ectopic kidney without fusion. Korean J Urol. 2014;55(8):554–6. https://
doi.org/10.4111/kju.2014.55.8.554. Epub 2014 Aug 8.
7. Asanad K, Remulla D, Nassiri N, Nabhani J.Grade IV renal laceration in a 13-year-old boy
with cross-fused renal ectopia. Urology. 2020;145:243–6. https://doi.org/10.1016/j.urol-
ogy.2020.06.011. Epub 2020 Jun 20.
8. Kim SW, Rudick DH, Cohen EL.Crossed fused renal ectopia presenting with blunt trauma.
Urology. 1978;12(1):69–70. https://doi.org/10.1016/0090- 4295(78)90372- 2.
9. Gibson GR.Ruptured horseshoe (fused) kidney: a review and report of a case with traumatic
renal hypertension. J Urol. 1964;92:374–6. https://doi.org/10.1016/s0022- 5347(17)63971- 5.
10. Cortese F, Fransvea P, Marcello R, Saputelli A, Lepre L, Gioffrè A, Sganga G. Challenging
case of horseshoe kidney double fracture. Int J Surg Case Rep. 2017;41:158–61. https://doi.
org/10.1016/j.ijscr.2017.08.070. Epub 2017 Oct 10.
11. Krutsri C, Singhatas P, Sumpritpradit P, Chaijareenont C, Viseshsindh W, Thampongsa T,
Choikrua P.Traumatic blunt force renal injury in a diseased horseshoe kidney with successful embolization to treat active bleeding: a case report and literature review. Case Rep Urol.
2020;2020:8897208. https://doi.org/10.1155/2020/8897208.
12. Boninsegna E, Simonini E, Crosara S, Sozzi C, Colopi S.Horseshoe kidney blunt trauma with
double laceration: endovascular management. Vasc Endovasc Surg. 2020;54(7):643–5. https://
doi.org/10.1177/1538574420940091. Epub 2020 Jul 8.
13. Lai CC, Fan WC, Chao CM, Liu WL, Hou CC.Traumatic rupture of a renal angiomyolipoma.
J Emerg Med. 2012;43(5):e339–40. https://doi.org/10.1016/j.jemermed.2011.05.059. Epub
2011 Aug 25
14. Hsu YP, Chen RJ, Fang JF, Lin BC.Traumatic rupture of renal angiomyolipoma managed
with angioembolization followed by elective surgery: a report of two cases. J Trauma.
2005;59(3):737–41.
15. Tsai CK, Lin YT, Lin TC.Traumatic rupture of bilateral huge renal angiomyolipomas in tuberous
sclerosis complex. J Trauma. 2010;69(2):477. https://doi.org/10.1097/TA.0b013e318180a428.
References
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16. Coulshed SJ, Caterson RJ, Mahony JF.Traumatic infarct at the lower pole of a renal transplant
secondary to seat belt compression. Nephrol Dial Transplant. 1995;10(8):1464–5.
17. McHugh PP, Clifford TM, Johnston TD, Banerjee AS, Gedaly R, Jeon H, Ranjan
D. Seatbelt injury resulting in functional loss of a transplanted kidney. Prog Transplant.
2008;18(3):199–202. https://doi.org/10.1177/152692480801800309.
18. Takahashi K, Prashar R, Putchakayala KG, etal. Allograft loss from acute page kidney secondary to trauma after kidney transplantation. World J Transplant. 2017;7(1):88–93. https://doi.
org/10.5500/wjt.v7.i1.88.
19. Papadakis G, Dost S, Kunduzi B, Olsburgh J, Brown C, Mamode N, Karydis N.High-grade
blunt traumatic rupture of kidney transplant: is conservative management an option? Ann
R Coll Surg Engl. 2022;104(4):e113–5. https://doi.org/10.1308/rcsann.2021.0167. Epub
2021 Nov 26.
20. Rajagopal P, Chughtai SA, Khan S, Ali A.Traumatic injury to renal allograft. Literature review
and case series. Trauma renal transplant recipient. A case report. Int J Collab Res Internal
Med Public Health. 2019;11(1). https://www.iomcworld.org/articles/traumatic-injury-to-
renal-allograft-literature-review-and-case-series-trauma-in-renal-transplant-recipient-a-casereport-18959.html#ai.
21. Martínez-Mier G, García-Almazán E, Esselente-Zetina N, etal. Blunt trauma in kidney transplant with preservation of renal function. Cir Cir. 2006;74(3):205–8.
22. Deshpande NA, James NT, Kucirka LM, Boyarsky BJ, Garonzik-Wang JM, Montgomery
RA, Segev DL. Pregnancy outcomes in kidney transplant recipients: a systematic review
and meta-analysis. Am J Transplant. 2011;11(11):2388–404. https://doi.org/10.1111/
j.1600- 6143.2011.03656.x. Epub 2011 Jul 27.
23. Majak GB, Sandven I, Lorentzen B, Vangen S, Reisaeter AV, Henriksen T, Michelsen
TM.Pregnancy outcomes following maternal kidney transplantation: a national cohort study.
Acta Obstet Gynecol Scand. 2016;95(10):1153–61.
24. Gordon CE, Tatsis V.Shearing-force injury of a kidney transplant graft during cesarean section:
a case report and review of the literature. BMC Nephrol. 2019;20:94. https://doi.org/10.1186/
s12882- 019- 1281- 6.
25. Shahrokh H, Rasouli H, Zargar MA, Karimi K, Zargar K.Spontaneous kidney allograft rupture.
Transplant Proc. 2005;37(7):3079–80. https://doi.org/10.1016/j.transproceed.2005.07.054.
26. Szenohradszky P, Smehák G, Szederkényi E, Marofka F, Csajbók E, Morvay Z, Ormos J,
Iványi B.Renal allograft rupture: a clinicopathologic study of 37 nephrectomy cases in a
series of 628 consecutive renal transplants. Transplant Proc. 1999;31(5):2107–11. https://doi.
org/10.1016/s0041- 1345(99)00277- 8.
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Part II
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Ureteral Trauma
The kidneys are essential for life, and ureters are essential for the kidneys.
This is enough to understand that damage to these thin and waving tubules
may turn your life into a nightmare.
Introduction toUreteral Trauma
Many researchers have credited Mr. Alfred Poland for the rst reported cases of
ureteral trauma in 1869. However, some of the cases described by Mr. Poland were
published earlier by other authors whom he clearly credited. He gave a detailed
account of six cases of traumatic ureteral rupture from blunt and penetrating trauma
with multiple associated injuries, and only two of them survived their injuries. For
those who succumbed, the diagnosis was conrmed only through autopsy. One of
the victims was the Archbishop of Paris who was wounded on 29th June 1848 by a
musket ball and died after 18 h.
with widespread urinary extravasation, as well as a division of the spine at the L3
level, and the ball was found in the psoas muscle [1].
Today, despite 150 years having elapsed, Mr. Poland’s report is not outdated.
Ureteric trauma is still very rare. However, due to the tremendous multiplication
of surgical procedures for the last half-century (endourological, gyneco-obstetrical,
and colorectal interventions), ureteral injury has become mostly iatrogenic nowa-
days and external trauma with penetrating agents is very rare as are blunt injuries
such as deceleration in RTA or blows. When caused by external trauma, ureteric
injuries are generally associated with other organs injury and are often missed.
From whatever cause, they have no immediate specic manifestations, making their
1
The autopsy revealed a division of the upper ureter
1
Further research on the biography of Bishops and Archbishops of Paris conrmed this fact, identifying the victim as Monsignor Denis-Auguste Affre, but there is a little discrepancy in the dates
of his death [2].
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diagnosis delayed in many instances, with signicant early-, mid-term, or late complications, including pain, urinary leak and urinoma, abscess with fever and sepsis,
peritonitis, uremia, ureteral stricture with loss of the ipsilateral kidney, and death.
Iatrogenic ureteral injury increases the length of the hospital stay for the patient.
In the USA, this caused an estimated overcharge of the treatment bill by an additional $31,000 [3], and 45% of ureteric injuries during gynecological procedures are
subjected to litigation against the institutions in Canada [4].
Timely recognition of a ureteral injury is therefore of paramount importance if
one aims at avoiding the grim consequences in the patient’s general health and a
lawsuit in the courts. This is compulsory during surgical interventions where preoperative preventive measures should be taken, and a low threshold of clinical suspicion is mandatory. But it remains very challenging in external or non-iatrogenic
trauma (penetrating or blunt) where the dramatic presentation and the frequent association with other intra-abdominal or bony trauma usually mask the ureteral damage
during the early post-traumatic period.
Ureteral Trauma
References
1. Poland A.On rupture of the ureter.Guy’s Hosp Rep.1869;14(85):85–98. https://
books.google.com.om/books?id=Ky1TAAAAcAAJ&printsec=frontcover&hl=
ar&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false.
2. https://fr.wikipedia.org/wiki/Liste_des_%C3%A9v%C3%AAques_puis_
archev%C3%AAques_de_Paris.
3. Halabi WJ, Jafari MD, Nguyen VQ, Carmichael JC, Mills S, Pigazzi A, Stamos
MJ.Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and
risk factors over a 10-year period in the United States. Dis Colon Rectum.
2014;57(2):179–86. https://doi.org/10.1097/DCR.0000000000000033.
4. Jacob GP, Vilos GA, Al Turki F, et al. Ureteric injury during gynaecological
surgery—lessons from 20 cases in Canada. Facts Views Vis Obgyn.
2020;12(1):31–42. Published 2020 May 7.
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