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374 Challenging Concepts in Urological Surgery
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and thus is a compartment syndrome of the penis. This results in venous stasis within the corpora
cavernosa due to obstruction and subsequently leads to intracavernosal acidosis, anoxia, hypercarbia,
and glucopaenia.
Non- ischaemic or high- flow priapism
This is a persistent erection caused by unregulated inflow of the cavernosal arteries.1 The patient
typically reports a non- painful, partial erection. Non- ischaemic priapism is most commonly caused
following perineal trauma whereby fistulation occurs between the cavernosal artery and the sinusoidal
tissue. This unregulated arterial inflow leads to incomplete tumescence as the veno- occlusive
mechanisms created by smooth muscle relaxation are not activated. Therefore, the corporal tissues
remain well oxygenated and thus are not at high risk of becoming ischaemic.
Stuttering priapism
This refers to a condition whereby patients experience frequent, recurrent episodes of priapism,
which typically presents in a similar fashion to ischaemic priapism but tends to be self- limiting.
Tumescence tends to last for <3 hours and is most commonly seen in patients with SCD. Although
most presentations of stuttering priapism are self- limiting, a small proportion of patients may develop
a prolonged, ischaemic priapism which requires urgent intervention and management as with any
ischaemic priapism presentation.
Learning point Ischaemic priapism in SCD
Patients with SCD are an important subgroup of those presenting with priapism and their underlying
condition often warrants additional management considerations. While a comprehensive overview
of the genetics and pathophysiology of SCD is beyond the scope of this case, in brief, this comprises
a group of autosomal recessive inherited disorders caused by mutations in the HBB gene, which
encodes the beta- globin protein. Beta- globin, together with alpha- globin, makes up HbA, the most
common form of haemoglobin in adults. HbA containing two mutant beta- globin subunits, known
as HbS, is able to polymerize when under conditions of deoxygenation, leading to the formation of
fibrous precipitates that distort the shape of erythrocytes (known as sickling) which in turn reduces
their elasticity and renders them susceptible to haemolysis.
One of the hallmark complications in patients with SCD is vaso- occlusive crisis in which a complex
interplay between a number of mechanisms results in the obstruction of blood vessels by sickled
erythrocytes, leading to ischaemia, pain, haemolytic anaemia, and organ injury.8 The clinical
manifestations, severity, and duration of vaso- occlusive crises vary significantly and depend on
the organ system involved. Occlusion of venous outflow from the corpora cavernosum leads to
ischaemic priapism, which constitutes >95% of priapism presentations in patients with SCD.
contemporary research has shown that mechanical obstruction of flow is only one component of
the pathophysiology of priapism in SCD, with studies suggesting that defects in erectile regulatory
pathways, such as aberrant nitric oxide signalling, also play an important role.
The prevalence of priapism in men with SCD is in the order of 35%, with episodes usually beginning
after onset of puberty.11 Although the majority present as ischaemic events, a small proportion
experience stuttering priapism, with recurrent transient and self- limiting episodes. Erections do not
typically occur in the setting of another vaso- occlusive illness, although other sites of pain are often
present. While precipitating factors include those common to other complications of SCD, such as
infection and dehydration, episodes may also occur upon waking or following sexual intercourse.
5
7
9
However,
10
11
Clinical tip Ischaemic priapism in SCD
As well as the standard clinical assessment, it is important to identify any precipitating factors or
other complications of vaso- occlusive crises. Many episodes of priapism are brief and resolve with
conservative measures such as hydration, exercise, and masturbation with ejaculation. If the erection
persists >4 hours, patients should present to the emergency department and be managed in the
manner outlined in Figure 38.1. Additionally, dehydration should be corrected with intravenous fluids,
oxygen supplementation if hypoxic, and treatment of any underlying precipitating illness. Pain should
Priapism
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375Case 38 Priapism
Non-ischaemic
Figure 38.1 Management of ischaemic and non- ischaemic priapism.
Adapted from the BAUS Section of Andrology and Genitourethral Surgery (2018),14 Salonia et al. (2014),15 and
Zacharakis et al. (2014)17.
be controlled adequately and early involvement of a haematologist is fundamental, with patients
ideally being managed jointly in a specialist unit with expertise in SCD.
Over 20% of patients with SCD will go on to develop ED and therefore early education and prompt
management are fundamental.11 Conservative approaches such as avoidance of known precipitants should
be employed. There is limited evidence to support the use of medical prophylaxis, with some small series
describing improved outcomes with use of hydroxyurea, pseudoephedrine, sildenafil, and leuprolide.
Ischaemic
12
A local anaesthetic penile ring block was performed, using 10 mL 1% lidocaine.
This improved the pain and allowed for lateral puncture of the right corpus cavernosum to be performed using a 19- gauge ‘butterfly’ needle. The first blood aspirated
was sent for blood gas analysis. This demonstrated hypoxia, acidosis, and hypercarbia
(pH of 6.8, PO2 of 0.7 kPa, PCO2 of 7.5 kPa, and lactate of 7.1 mmol/ L) in keeping with
an ischaemic priapism. Recurrent aspirations and irrigation with saline solution were
attempted. However, due to the significant ischaemic change, very little blood could be
withdrawn and therefore this procedure was unsuccessful in achieving detumescence.
Expert comment SCD
In patients with SCD, priapism can
be part of a sickle cell crisis, hence
systemic management should
include supportive measures
such as fluid resuscitation, oxygen
administration, and potentially
blood exchange transfusion. This is
in addition to managing the actual
priapism as in idiopathic type.
Learning point Investigations
All patients presenting with a priapism of any type must undergo full blood count analysis and, in
selected cases, a blood film should be performed to ensure haematological disorders are identified
as a potential underlying cause. As an initial test to elucidate the nature of the priapism, corporal
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blood gas analysis must be performed for estimation of PO2, pH, and glucose using a standard blood
gas analyser. The presence of hypoxia, acidosis, and glucopenia confirms a diagnosis of ischaemic
priapism. Normoxia correlated with the clinical history indicates that this is a non- ischaemic priapism;
however, this should be confirmed with penile Doppler studies.
Clinical tip Aspiration and blood gas analysis
Prior to aspiration of blood, a penile block should be administered. The most prevalent agent in the
authors’ practice is 1% lidocaine (which must not contain adrenaline) and can be administered as a
ring block or dorsal penile nerve block. Subsequently, a 19- gauge needle or butterfly must be inserted
into the corpus cavernosum, either through the lateral penile shaft (towards the base of the penis) or
through the glans penis into the tip of the corpus cavernosum, followed by aspiration of blood from
the corpora. The first blood aspirated should be sent for blood gas analysis. It is advisable to use a 10
mL syringe for aspiration, as larger- volume syringes may create too high a pressure and thus prevent
straightforward aspiration. If the aspirated blood is highly viscous and dark, this indicates ongoing
hypoxia of the corporal tissues and ideally aspiration should continue until bright red arterial blood is
present. If aspiration is not possible, or failing to achieve tumescence, this should be abandoned and
instillation of sympathomimetic agent should be trialled.
The patient was placed on cardiac monitoring and intracorporal instillation of
phenylephrine was performed in 200 mcg aliquots at 5- minute intervals. Detumescence
was achieved after injection of 400 mcg of phenylephrine. The patient did not require
further intervention for re- tumescence and was discharged on a course of co- amoxiclav.
Expert comment Monitoring
during phenylephrine instillation
It is not always possible to perform
phenylephrine instillation in a bed
equipped with cardiac monitoring
equipment. If this is the case, it is
advisable to utilize an automatic
observation machine which can
regularly monitor blood pressure
and heart rate via pulse oximetry
and, if possible, apply defibrillator
pads (on a monitoring setting)
which allow for continuous heart
tracing to ensure no arrhythmias
are caused.
Clinical tip Preparing and administering phenylephrine
Administration of a sympathomimetic agent is a fundamental step in the management of ischaemic
priapism. Phenylephrine is the usual drug of choice, owing to its high selectivity for the alpha- 1adrenergic receptor with minimal beta- adrenergic receptor- mediated adrenergic or chronotropic
effects.13 Given the potential for potentially life- threatening adverse effects it is fundamental that
the drug is prepared and administered correctly, with provision for appropriate patient monitoring.
A practical guide, as adapted from the British Association of Urological Surgeons consensus document
for the management of priapism14 and European Association of Urology guidelines,15 is given below:
1. Phenylephrine ampules are usually available as 10 mg in 1 mL. Dilute this in 49 mL of normal
saline using a 50 mL syringe, giving a final concentration of 200 mcg/ mL.
2. Establish the baseline heart rate and blood pressure prior to giving the initial injection and repeat
these measurements at a minimum of every 15 minutes. Exercise particular vigilance in those with
pre- existing cardiovascular disease.
3. Administer a 1 mL (200 mcg) aliquot directly into the corpus cavernosum at the 3 or 9 o’clock
position towards the base of the penis, thereby avoiding the urethra and the course of the dorsal
neurovascular bundle.
4. Give further aliquots every 3– 5 minutes up to a maximum dosage of 1000 mcg for no more
than 1 hour.
5. If the priapism persists despite the above, then proceed to the next step in the management
pathway, as outlined in Figure 38.1.
Unfortunately, the patient continued to use cocaine and therefore represented 2
weeks later. Similarly, blood gas analysis demonstrated ischaemic priapism which
required phenylephrine to achieve detumescence. On subsequent outpatient assessment, the patient reported that he had erectile dysfunction (ED) despite use of overthe- counter sildenafil. He was trialled on regular phosphodiesterase type 5 inhibitors
unsuccessfully.
A magnetic resonance imaging (MRI) scan was performed which demonstrated bi-
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lateral corporal fibrosis, as shown in Figure 38.2. The patient subsequently underwent
implantation of an inflatable penile prosthesis.
Learning point Imaging
In unclear or refractory cases, penile Doppler studies may note a paradoxically increased systolic
velocity in the proximal penile shaft. This is especially relevant if aspiration or shunt surgery has already
been attempted or when there is fibrosis starting to develop in the distal corpus cavernosum.
If no underlying cause if clearly identified, it is imperative that abdominal and pelvic imaging using
computed tomography or MRI is performed in order to ensure that underlying pelvic or abdominal
malignancy is not overlooked (Table 38.1).
Penile MRI, as demonstrated in Figure 38.2, may provide useful information regarding the viability
of the corporal tissue in refractory cases as well as aiding in the decision to proceed with penile
prosthesis surgery.
Learning point Management of ischaemic priapism
Ischaemic priapism constitutes a compartment syndrome and therefore warrants prompt
emergency intervention. The aim of treatment is to alleviate pain and achieve detumescence while
ameliorating hypoxia, acidosis, and glucopenia within the corpora and thus prevent progression to
smooth muscle necrosis with subsequent fibrosis and ED. Following confirmation of the diagnosis,
treatment should follow a stepwise approach, as outlined in Figure 38.1. Given that the prognosis is
directly related to the duration of priapism, contemporary guidelines suggest categorizing patients
into three groups: <48 hours, 48– 72 hours, and >72 hours.14 In patients presenting after 48 hours it
is unlikely that aspiration or sympathomimetic agent instillation will be effective. Therefore, in such
377Case 38 Priapism
Figure 38.2 MRI scan demonstrating corporal fibrosis (arrow A) and healthy corporal tissue
(arrow B).
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Expert comment Penile
prosthesis
Immediate insertion of malleable
penile prosthesis should be
considered in prolonged priapism
(>48 hours) and in those refractory
to intracavernosal vasoactive
treatment and/ or failed shunting.
Penile prosthesis is mainly to avoid
penile shortening that ensues due
to cavernosal fibrosis because of
prolonged ischaemia.
Expert comment Recurrent
ischaemic priapism
In stuttering priapism, each acute
episode should be managed
as ischaemic type. Recurrent
presentations with ischaemic
priapism and subsequent
numerous cavernosal aspirations
may lead to the conversion of the
priapism type from ischaemic to
non- ischaemic.
Evidence base Management
of priapism
Priapism is a rare condition, with
an estimated incidence of 5.34 per
100,000 men per year in the US.28
This, combined with the fact that
ischaemic priapism is a urological
emergency that mandates urgent
detumescence, renders the design
and execution of high- quality
randomized studies challenging.
Consequentially the evidence
surrounding the management of
priapism is of generally low level,
with current guidelines based
largely on small retrospective series
and expert consensus.
2,14,15
patients a ‘shunt’ procedure is often required. The commonest, and most straightforward approach
is a ‘T- shunt’. This involves using a No. 10 blade scalpel and making a stab incision through the
glans penis into the corporal head and then rotating the blade 90° laterally. This procedure creates
a fistula between the cavernosal blood and the corpus spongiosum, thus allowing venous drainage
and detumescence. In those patients for whom this is ineffective, or those presenting after 72 hours,
it is likely there is little or no viable smooth muscle within the corpus cavernosum and so long- term
ED is almost inevitable.16 Some authors therefore advocate early insertion of a penile prosthesis in
this patient group as this not only treats the inevitable ED and prevents shortening, but is also easier
to perform and associated with fewer complications than a delayed procedure due to the absence
of corporal fibrosis.
15,17– 19
Learning point Management of non- ischaemic priapism
In non- ischaemic priapism, the blood within the corpus cavernosum is well oxygenated and therefore
the risk of smooth muscle necrosis with progression to fibrosis is low. This form of priapism is
therefore not considered a urological emergency and hence there is time for appropriate evaluation
and patient counselling prior to instigating definitive management.
As with ischaemic priapism, treatment generally follows a stepwise approach, as demonstrated
in Figure 38.1. Although conservative approaches are successful in 60– 70% of cases, ED has been
reported in up to 30% and so referral to a specialist andrology unit for selective arterial embolization
is usually the modality of choice for those that fail to respond.20 A number of different embolization
materials have been described and are generally classified as either temporary, such as autologous
blood clot,
trials have been conducted, small series report success rates of up to 89%, with restoration of potency
in around 80% of cases.
21,22
or permanent, such as metallic coils or acrylic glue.
15,24
Surgical management involves selective ligation of the fistula but is
22,23
Although no randomized
associated with a number of risks and is therefore reserved for those unsuitable for or have failed
embolization.
Learning point Management of stuttering priapism
Stuttering priapism represents a rare subset and hence there is a paucity of published literature
concerning management. Emergency management is required for acute episodes while longer- term
treatment is aimed at preventing future episodes. The principal approach in patients with idiopathic
stuttering priapism is the reduction of circulating androgens using gonadotropin- releasing hormone
agonists/ antagonists or antiandrogens such as bicalutamide, although these should be reserved
for those who have reached full sexual maturation.
described, including 5- alpha- reductase inhibitors, alpha- adrenergic agonists, phosphodiesterase type
5 inhibitors, and intracavernosal injections of sympathomimetic agents.
stuttering priapism in patients with SCD warrants additional considerations.
25,26
A range of other agents have also been
2,15,27
The management of
A final word from the expert
Priapism (among genital emergencies) is a relatively rare condition and clinicians are often
unfamiliar with it. It can occur in all ages and requires prompt assessment and management.
Due to the rarity of this condition, there are no unified guidelines and therefore treatment
recommendations of priapism are an outcome of clinical studies and level 4 evidence at
most. Recent recommendations and consensus statements have been published by the British
Association of Urological Surgeons Section of Andrology and Genito- Urethral Surgery.
The management of priapism is mainly to resolve the consequential pain in the short term
and to restore erectile function in the long term. Clinical assessment of priapism starts from
taking a careful history, exploring its onset, precipitating factors, and paying special attention to
14
possible systemic causes such as illicit drugs, medications, pelvic malignancy, haematological
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disorders, and genital trauma. Clinical assessment should include abdominal, rectal, and penile
examination.
Treatment of priapism depends on its onset and type. Simple measures such as physical exercise
or a cold shower may suffice in simple cases. The treatment algorithm for each type is detailed
in the main body of this article. Awareness of the basic management of priapism and early
discussion with a specialist centre is vital to minimize the risk of irreversible consequences (such
as cavernosal fibrosis) that may result from a delay in treatment.
379Case 38 Priapism
References
1. Broderick GA, Kadioglu A, Bivalacqua TJ, Ghanem H, Nehra A, Shamloul R.
Priapism: pathogenesis, epidemiology, and management. J Sex Med. 2010;7(1 Pt 2):476– 500.
2. Montague DK, Jarow J, Broderick GA, et al. American Urological Association guideline on
the management of priapism. J Urol. 2003;170(4 Pt 1):1318– 1324.
3. Burnett AL, Bivalacqua TJ. Priapism: new concepts in medical and surgical management.
Urol Clin North Am. 2011;38(2):185– 194.
4. Cherian J, Rao A, Thwaini A, Kapasi F, Shergill I, Samman R. Medical and surgical management of priapism. Postgrad Med J. 2006;82(964):89– 94.
5. Muneer A, Minhas S, Freeman A, Kumar P, Ralph DJ. Investigating the effects of highdose phenylephrine in the management of prolonged ischaemic priapism. J Sex Med.
2008;5(9):2152– 2159.
6. Johnson MJ, Hallerstrom M, Alnajjar HM, et al. Which patients with ischaemic priapism
require further investigation for malignancy? Int J Impot Res. 2020;32(2):195– 200.
7. Kato GJ, Piel FB, Reid CD, et al. Sickle cell disease. Nat Rev Dis Primers. 2018;4:18010.
8. Manwani D, Frenette PS. Vaso- occlusion in sickle cell disease: pathophysiology and novel
targeted therapies. Blood. 2013;122(24):3892– 3898.
9. Broderick GA. Priapism and sickle- cell anemia: diagnosis and nonsurgical therapy. J Sex
Med. 2012;9(1):88– 103.
10. Bivalacqua TJ, Musicki B, Kutlu O, Burnett AL. New insights into the pathophysiology of
sickle cell disease- associated priapism. J Sex Med. 2012;9(1):79– 87.
11. Adeyoju A, Olujohungbe A, Morris J, et al. Priapism in sickle- cell disease; incidence, risk
factors and complications— an international multicentre study. BJU Int. 2002;90(9):898– 902.
12. Kato GJ. Priapism in sickle- cell disease: a hematologist’s perspective. J Sex Med.
2012;9(1):70– 78.
13. Lee M, Cannon B, Sharifi R. Chart for preparation of dilutions of alpha- adrenergic agonists
for intracavernous use in treatment of priapism. J Urol. 1995;153(4):1182– 1183.
14. British Association of Urological Surgeons Section of Andrology and Genito- Urethral
Surgery, Muneer A, Brown G, et al. BAUS consensus document for the management of male
genital emergencies: priapism. BJU Int. 2018;121(6):835– 839.
15. Salonia A, Eardley I, Giuliano F, et al. European Association of Urology guidelines on priapism. Eur Urol. 2014;65(2):480– 489.
16. Spycher M, Hauri D. The ultrastructure of the erectile tissue in priapism. J Urol.
1986;135(1):142– 147.
17. Zacharakis E, Garaffa G, Raheem AA, Christopher AN, Muneer A, Ralph DJ. Penile prosthesis insertion in patients with refractory ischaemic priapism: early vs delayed implantation. BJU Int. 2014;114(4):576– 581.
18. Rees R, Kalsi J, Minhas S, Peters J, Kell P, Ralph D. The management of low- flow priapism
with the immediate insertion of a penile prosthesis. BJU Int. 2002;90(9):893– 897.
19. Sedigh O, Rolle L, Negro C, et al. Early insertion of inflatable prosthesis for intractable ischemic
priapism: our experience and review of the literature. Int J Impot Res. 2011;23(4):158– 164.
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20. Shigehara K, Namiki M. Clinical management of priapism: a review. World J Mens Health.
2016;34(1):1– 8.
21. Numan F, Cantasdemir M, Ozbayrak M, et al. Posttraumatic nonischemic priapism treated
with autologous blood clot embolization. J Sex Med. 2008;5(1):173– 179.
22. Kim KR, Shin JH, Song HY, et al. Treatment of high- flow priapism with superselective
transcatheter embolization in 27 patients: a multicenter study. J Vasc Interv Radiol.
2007;18(10):1222– 1226.
23. Liu BX, Xin ZC, Zou YH, et al. High- flow priapism: superselective cavernous artery embolization with microcoils. Urology. 2008;72(3):571– 573.
24. Muneer A, Ralph D. Guideline of guidelines: priapism. BJU Int. 2017;119(2):204– 208.
25. Muneer A, Garaffa G, Minhas S, Ralph D. The management of stuttering priapism within a
specialist unit— a 25- year experience. Br J Med Surg Urol. 2009;2(1):11– 16.
26. Muneer A, Minhas S, Arya M, Ralph D. Stuttering priapism— a review of the therapeutic
options. Int J Clin Pract. 2008;62(8):1265– 1270.
27. Yuan J, DeSouza R, Westney OL, Wang R. Insights of priapism mechanism and rationale
treatment for recurrent priapism. Asian J Androl. 2008;10(1):88– 101.
28. Roghmann F, Becker A, Sammon JD, et al. Incidence of priapism in emergency departments
in the United States. J Urol. 2013;190(4):1275– 1280.
CASE
39
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Renal trauma
Hack Jae Lee
Expert commentary Christopher Anderson and
Davendra M. Sharma
Case history
An otherwise fit and well 16- year- old male was found to be stabbed twice to his left flank
on the street. He was air- lifted to the hospital as a trauma call. He complained of pain
to his abdomen. He was given 1 g of tranexamic acid and was fluid resuscitated on his
way to the hospital. He was examined as per Advanced Trauma Life Support® (ATLS®)
protocol and was found with two stab wounds, both to his left flank with evisceration of
large bowel. His observations were PO2 100% on 15 L, respiratory rate of 20 breaths per
minute, blood pressure of 110/ 85 mmHg, and heart rate of 110 beats per minute. Bloods
showed a haemoglobin level of 90 g/ dL, white cell count of 3.8 × 109/ L, platelet count
of 109 × 109/ L, creatinine level of 130 μmol/ L, and international normalized ratio of 1.5.
His chest X- ray was normal and did not reveal any pneumoperitoneum.
He was stable enough to have a trauma computed tomography (CT) scan
(Figure 39.1). The report revealed:
1. ‘Laceration of the left kidney extending through the renal pelvis. There were active
contrast extravasation and large volume retroperitoneal and intraperitoneal haematoma. Underlying vascular injury could not be excluded. Collecting system injury
was felt high likely.’
2. ‘Extruded loops of descending colon through abdominal wall defect. There was an
abnormally thickened loop of bowel at the splenic flexure which was poorly enhancing concerning for ischaemic compromise. The remainder of the bowel were
within normal limits.’
3. ‘There were no thoracic injuries.’
Learning point American Association for the Surgery of Trauma renal injury scale
Renal injury can be subclassified depending on the severity of the injury using the American
Association for the Surgery of Trauma (AAST) renal injury scale.
● Grade 1: subcapsular, non- expanding haematoma without parenchymal laceration.
● Grade 2: superficial laceration ≤1 cm parenchymal depth without urinary extravasation. Non- expanding
perirenal haematoma.
● Grade 3: laceration >1 cm parenchymal depth not involving the collecting system. Vascular injury
or active bleeding confined within the perirenal fascia.
● Grade 4: laceration involving the collecting system with urinary extravasation. Laceration of
the renal pelvis and/ or complete ureteropelvic disruption. Main renal artery or vein injury with
contained haemorrhage.
● Grade 5: shattered kidney with loss of identifiable parenchymal renal anatomy. Avulsion of renal
hilum which devascularizes the kidney.
1
Expert comment AAST renal
injury scale
The AAST renal injury scale is a
useful tool to classify renal injury
in order of severity. It is used
worldwide and useful to predict
clinical outcome. It correlates with
the need for intervention and
mortality. Its most recent revised
version was in 2018.
1
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Figure 39.1 CT abdomen and pelvis with contrast following penetrating injury to left flank. (a) Extruded
loops of descending colon can be seen through abdominal wall defect. (b) Large volume of retroperitoneal
haematoma. (c) Complete laceration of the left kidney extending to the renal pelvis.
The patient’s care involved various specialists including general surgeons, urologists, vascular surgeons, and interventional radiologists. Initial thought was to take the
patient to theatre for damage control, washout of the abdomen, wound packing, and
to re- look a few days later. Interventional radiology planned to embolize the kidney if
the patient became unstable. However, after a multidisciplinary team discussion, the
decision made was to take the patient to theatre for explorative laparotomy given his
Expert comment
Multidisciplinary approach
to polytrauma patients
Patients with renal trauma
often have injuries to other
visceral organs. It is important
to discuss these patients with
other specialities and adopt a
multidisciplinary approach in
management as in this case to
give the patient the best optimal
care. Note how the management
of this patient changed after a
multidisciplinary team discussion.
high- risk of bowel injury.
Learning point Management of major trauma
Penetrative trauma is becoming increasingly common with around 1600 major trauma cases a year
in London (UK) alone.2 When approaching a patient with suspected renal injury, taking a history and
clinical examination is important. Patients will often have other significant injuries and is important
to intervene as required. However, a definitive diagnosis will be achieved either by explorative
laparotomy in haemodynamically unstable patients or with diagnostic imaging in those who are
clinically stable. Explorative laparotomy and damage control have been the traditional teaching when
managing penetrative abdominal injuries. Peritonitis, haemodynamic instability, and hollow viscus
injury are all absolute indications for laparotomy.3 There were concerns about bowel laceration and
the patient became more haemodynamically unstable, therefore laparotomy was warranted.
Better understanding of potential organ injury with improved radiographic imaging has shifted
managing abdominal injuries towards non- operative management in selective cases.4 Demetriades
et al. showed that out of 152 patients with penetrating injuries to abdominal solid viscera, 45 were
stabbed. Out of the 45 patients with isolated organ injuries (liver 73%, kidney 30.3%, spleen 30.3%), 41
were managed without laparotomy and had a significantly shorter hospital stay than patients treated
operatively.5 However, this study did not include bowel injuries and this type of injury should almost
always be explored.
On table, there was a through and through injury to the splenic flexure of the colon
and lower pole of the left kidney. The patient also had a very large retroperitoneal
haematoma. The patient had the injured part of the bowel resected and stapled off. As
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the hilum and the upper pole of the kidney appeared intact, a partial nephrectomy was
carried out. The partial nephrectomy was performed by whole clamping of the renal
artery and vein. The inferior pole was cut via the line of laceration. The collecting
system was repaired with 2/ 0 Vicryl®, followed by two- layer renorrhaphy with V- Loc™
and sliding Hem- o- Lok® clip. Warm ischaemic time was 13 minutes. The patient had a
re- look laparotomy 48 hours after. During the re- look, the patient had a washout and
colic- colic anastomosis.
Learning point Management of renal trauma
Renal trauma can cause injury to the renal parenchyma, hilum, and/ or the collecting system.
It accounts for approximately 1– 5% of all trauma cases. The vast majority are blunt trauma but
penetrating renal injury accounts for 20% in urban areas.7 Management of these injuries has evolved
over time with non- surgical management becoming increasingly common where possible. This has
been possible because of improved patient selection using CT imaging and advancement of arterial
embolization. The aim is to preserve as much renal parenchyma as possible and recurrent bleeding
post embolization can be well managed with repeated embolization.8 Expectant management for
blunt renal trauma is fast becoming the standard of care worldwide. Non- operative management for
penetrating renal injury is also becoming slowly accepted. However, patients with major blood loss,
major renal parenchymal injury, renal vascular injury, and associated intra- abdominal injury should be
considered for explorative laparotomy.
The management of renal trauma is summarized in Figure 39.2.
9
383Case 39 Renal trauma
Expert comment Sliding- clip
renorrhaphy
Renorrhaphy when performing
partial nephrectomy has been a
challenging part of the operation
for the surgeon. Using sliding- clip
renorrhaphy, which is performed
by the use of Weck® Hem- o- Lok®
clips that are slid into place, has
shown to significantly shorten
the overall procedure time and
warm ischaemic time compared to
traditional tied suture.
6
Figure 39.2 Management of renal trauma. Ht, haematocrit; SAE, selective angioembolization.
* Excluding grade 5 penetrating injuries. ** Antibiotics should be administered for all penetrating
injuries. - - - If haemodynamically unstable.
Adapted from EAU guidelines on urological trauma (2020).
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