Renal Trauma: Classification and Grading: Trauma To The Urinary Tract
Renal Trauma: Classification and Grading: Trauma To The Urinary Tract
Urinary extravasation
Devitalized
segments
Figure 10.2 Left renal artery thrombosis after blunt trauma resulting
in devitalizedparenchyma successfullytreated nonoperatively.
Nephrectomy
For severe renal injuries producing life-threatening bleeding, prompt
nephrectomy is warranted. These are usually unstable patients who per-
sist in shock despite multiple transfusionsand have deep renal lacerations
near the hilum (Fig.10.3).
Hypertension and renal injury
Excess renin excretion occurs followingrenal ischemia from renal artery
injury or thrombosis or renal compression by hematoma or fibrosis. This
can lead to hypertension months or years after renal injury. The exact
inci- dence of post-traumatic hypertension is uncertain but felt to be rare.
Iatrogenic renal injury: renal hemorrhage after
percutaneous nephrolithotomy
Significantrenal injuries can occur during percutaneous nephrolithotomy
(PCNL) for kidney stones. This is the surgicalequivalent of a stab wound
and serious hemorrhage results in ~1% of cases.
Bleeding during or after PCNL can occur from vessels in the nephros-
tomy track itself, from an arteriovenous fistula, or from a
pseudoaneurysm that has ruptured. Track bleeding will usually
tamponade around a large- bore nephrostomy tube.
Traditionally,persistent bleedingthrough the nephrostomy tube is man-
aged by clampingthe nephrostomy tube and waiting for the clot to tam-
ponade the bleeding. While this may control bleeding in some cases, in
others a rising or persistently elevated pulse rate (with later
hypotension) indicates the possibility of persistent bleeding and is an
indication for renal arteriography and embolization of the arteriovenous
fistula or pseudoaneurysm (Figs. 10.4 and 10.5). Failure to stop the
bleeding by this technique is an indicationfor renal exploration.
Arteriovenous fistulae can sometimes occur following open renal
surgery for stones or tumors, and arteriography with embolization can
also be used to stop the bleeding in these cases. However, the bleeding
usually occurs over a longer time course (days or even weeks), rather
than as acute hemorrhage causingshock.