1 of 24

Upper Urinary Tract Trauma

  • Kidney

​

  • Ureter

2 of 24

Kidney Injury

  • Blunt trauma: 80-90%
  • Rapid deceleration / Direct blow
  • MUST be suspected if
    • Trauma to back / flank / lower thorax / upper abdomen
    • Flank pain / low rib Fx
    • Hematuria / Ecchymosis over the flanks
    • Sudden decelaration / Fall from height.
    • Lumbar transverse process Fx

3 of 24

Indications for renal imaging:

    • Macroscopic hematuria (gross)
    • Microscopic [>5 red blood cells (RBCs) /HPF] or dipstick hematuria a hypotensive patient (SBP <90mmHg )
    • A history of a rapid acceleration or deceleration
    • Any child with microscopic or dipstick hematuria who has sustained trauma.
    • Penetrating chest, flank, and abdominal wounds

​

4 of 24

What Imaging Study?

  • IVU:
      • replaced by the contrast-enhanced CT scan
      • On-table IVU if patient is transferred immediately to the operating theatre without having had a CT scan and a retroperitoneal haematoma is found,
    • Spiral CT: does not allow accurate staging

5 of 24

What Imaging Study?

    • Renal US:
      • Advantages:
        • can certainly establish the presence of two kidneys
        • the presence of a retroperitoneal hematoma
        • power Doppler can identify the presence of blood flow in the renal vessels.
      • Disadvantages:
        • cannot accurately identify parenchymal tears, collecting system injuries, or extravasations of urine until a later stage when a urine collection has had time to accumulate.
    • Contrast-enhanced CT:
      • the imaging study of choice
      • accurate, rapid, images other intra-abdominal structures

6 of 24

Classification of Injury

  • 5 Classes of Renal Injury :

Organ Injury Scaling

Committee

Moore et al. Organ Injury Scaling: Sleen, Liver and Kidney, The Journal of Trauma, 29: 1664; 1989.

​

7 of 24

Grade I

  • Contusion
    • Hematuria
    • Urologic studies N

​

  • Hematoma
    • Subcapsular
    • Non expanding
    • Parenchyma N

8 of 24

Grade II

  • Hematoma
    • Perirenal
    • Nonexpanding

​

  • Laceration
    • < 1.0 cm
    • Renal cortex only
    • No urinary extravasation

9 of 24

Grade III

​

  • Laceration
    • > 1.0 cm
    • Renal cortex only
    • No urinary extravasation
    • Intact collecting system

10 of 24

Grade IV

  • Laceration
    • Renal cortex
    • Renal medulla
    • Collecting system

​

  • Vascular
    • Main renal artery/vein injury with contained hemorrage.

11 of 24

Grade V

  • Completely shattered kidney.

​

  • Avulsion of renal hilum (pedicule) which devascularizes kidney.

12 of 24

Pedicule Injury

13 of 24

  • Management:
    • Conservative:
      • Over 95% of blunt injuries
      • 50% of renal stab injuries and 25% of renal gunshot wounds.
      • Include:
        • Wide Bore IV line.
        • IV antibiotics.
        • Bed rest
        • serial CBC (Htc)
        • F/up US &/or CT.
        • 2-3 wks.

​

​

14 of 24

Management

1- Nonoperative

​

2- Operative

​

  • Absolute indication for Surgery:
    • hemodynamic instability with shock
    • expanding/pulsatile renal hematoma (usually indicating renal artery avulsion)
    • suspectedrenal pedicle avulsion (grade 5)
    • Ureteropelvic junction disruption

15 of 24

16 of 24

URETERIC INJURIES

  • Causes and Mechanisms :

​

    • External Trauma

​

    • Internal Trauma (iatrogenic)

17 of 24

  • External Trauma:
    • Rare
    • Severe force is required
    • Blunt or penetrating.
    • usually be associated with multiple other injuries
    • Knife or bullet wound

18 of 24

  • Internal Trauma
    • Uncommon, but is more common than external trauma
    • Surgery:
      • Hysterectomy, oophorectomy, and sigmoidcolectomy
      • Ureteroscopy
      • Caesarean section
      • Aortoiliac vascular graft placement,
      • Laparoscopic procedures,
      • Orthopedic operations

19 of 24

  • Diagnosis:
    • Requires a high index of suspicion
    • Intraoperative:
    • Late:
      • 1. ileus: the presence of urine within the peritoneal cavity
      • 2. Prolonged postoperative fever or overt urinary sepsis
      • 3. Persistent drainage of fluid from abdominal or pelvic drains, from the abdominal wound, or from the vagina.
      • 4. Flank pain if the ureter has been ligated
      • 5. An abdominal mass, representing a urinoma
      • 6. Vague abdominal pain
      • 7. The pathology report on the organ that has been removed may note the presence of a segment of ureter!

20 of 24

  • Treatment options:
    • JJ stenting
    • Primary closure of partial transection
    • Direct ureter to ureter anastomosis
    • Reimplantation of the ureter into the bladder (ureteroneocystostomy), either using a psoas hitch or a Boari flap
    • Transureteroureterostomy
    • Autotransplantation of the kidney into the pelvis
    • Replacement of the ureter with ileum
    • Permanent cutaneous ureterostomy
    • Nephrectomy

21 of 24

22 of 24

23 of 24

24 of 24

The End

The End