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KEY POINTS

KEY POINTS

  • About 25% of kidneys receive accessory arterial branches directly from the aorta.

  • Approximately 90% of significant renal injuries are due to blunt trauma in the United States.

  • Injuries to the renal pedicle, including intimal disruption of the renal artery or renal devascularization, present with no hematuria in 20% to 33% of patients.

  • Advantages of computed tomography (CT) over intravenous pyelogram (IVP) include identification of contusion and subcapsular hematoma, definition of the location and depth of parenchymal lacerations, more reliable demonstration of the extravasation of contrast, and identification of injuries to the pedicle and artery.

  • Although hematuria is an important sign of ureteral injury, it may be absent 15% to 45% of the time.

  • Indications for renal exploration include hemodynamic instability or ongoing hemorrhage presumably related to the kidney, pulsatile or expanding perirenal hematoma at laparotomy, and avulsion of the pedicle.

  • Partial nephrectomy for polar lesions is performed using a “guillotine” technique with the transected vessels ligated and the collecting system closed.

  • Ninety percent of grade V renal injuries require urgent nephrectomy.

  • Delayed recognition of an injury to the ureter is managed with endoscopic or interventional radiology techniques due to local inflammation, edema, friability, and presence of a urinoma.

  • Nonoperative management of an extraperitoneal injury to the bladder is with an indwelling catheter for 10 to 14 days followed by a cystogram.

INTRODUCTION

Genitourinary injury occurs in 2% to 5% of all trauma patients and in at least 10% of patients with abdominal trauma, emphasizing the need for a close collaboration between the general and urologic trauma surgeon. This unique relationship that the urologist and general trauma surgeon share in the management of urologic injuries requires common philosophies of management to be applied.

Controversies exist in the approach to urologic trauma, and recent efforts to achieve a broad consensus in the management of diverse urologic injuries have resulted in numerous publications. One such effort, sponsored by the World Health Organization and the Societe Internationale d’Urologie, involved a 25-year review of world literature focusing on levels of evidence and the development of evidence-based management recommendations.1-4 Another effort through the European Association of Urology had a similar focus.5 Both produced useful syntheses of a large body of literature. The current discussion will offer a broadly applicable approach to the management of urologic trauma based on current literature, local experience, and local perspective.

ANATOMY

The contemporary surgical approach to the injured kidney is through an anterior midline abdominal incision. Access to the kidneys and ureters is generally obtained by reflecting the colon medially on either side and exposing Gerota’s fascial envelope. The exposure of an injured kidney may be achieved after obtaining vascular control of the renal vessels prior to entering the perirenal hematoma or by expeditious exploration of the retroperitoneum and manual renal control. Parenchymal compression is necessary in cases of active renal ...

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