RENAL TRAUMA

EAU Guideline 2020 & WSES-AAST

Guidelines
EPIDEMIOLOGY

Urogenital trauma has a cumulative incidence of 10-20%

The kidney is involved in 65–90% of the time

Males are involved 3 times more than females

ETIOLOGY
Renal
Trauma

Penetrating
Blunt Injury
Injury

Sporting Assault Gunshot

MVAs Fall Stab Wound
Injury Wound
CLASSIFICATION OF TRAUMA
WSES KIDNEY TRAUMA
CLASSIFICATION
WSES Grade AAST Hemodynamic
Minor WSES grade I I-II Stable
Moderate WSES grade II III or Segmental Stable
Vascular Injuries
Severe WSES grade III IV-V or any grade Stable
parenchymal lesion
with main vessel
dissection/occlusion

WSES grade IV Any Unstable

EVALUATION

• Vital signs
Initial Evaluation • Unstable condition post resucitation 
Emergency Laparatomy

• History and Mechanism of Trauma

Anamnesis & Physical • Flank bruising, stab wounds,
Examination • Bullet entry or exit wounds
• Abdominal tenderness.
LABORATORY EVALUATION

Urinalisis Hematocrit Baseline Creatine

• Hematuria ( Visible or • Evaluation source • Increased Cr  Pre-
Non Visible) active bleeding existing renal
pathology
IMAGING STUDIES
CT - Scan
• Hemodynamic stable
patients
• Accurately identify grade
of renal injury
• Quick, widely available
Ultrasonography IVP
• FAST identify • CT is not available
hemoperitoneum as cause • One shot IVP
of haemorrhage and • Functioning
hypovolemia contralateral kidney
• Extravasation
• Quality imaging  poor
IMAGING STUDIES
MANAGEMENT DISEASE

Conservative

Non Operative
Management (NOM)

Angioembolisation
Management Disease

Operative
Renal Exploration
Management
NON OPERATIVE
MANAGEMENT
• Treated with NOM
Grade I-II • Several studies no need nephrectomy and rare indication renal
exploration
• Renal trauma can be treated with NOM, by active monitoring
Grade III
and use of angioembolization if indicated

• Most grade IV blunt renal injuries are treated nonoperatively, 

Grade IV-V Low incidence of nephrectomy.
• Blunt renal trauma who are hemodynamically stable should
have the opportunity for NOM with active surveillance
 Non-operative management
(NOM)

Without evidence of associated Classification of Degree of

Treatment of choice for all injuries, with negative serial Injury and Associated Injuries
hemodynamical stable without physical examinations and with CT-Scan (IV Contrast)
other indication open surgical negative first level imaging and delayed urographic is
and blood tests. mandatory
 Non-operative management
(NOM)

Stabilized patients a CT scan

Penetrating lateral kidney is
NOM  Higher renal with contrast together with
feasible and effective but
preservation rate, Shorter delayed images is the gold
accurate patient selection is
hospital stay standard to select patients for
crucial
NOM
 Non-operative management
(NOM)

Isolated urinary extravasation

NOM in severe injuries 
Close clinical observation and
hemodynamic monitoring in a
high dependency/intensive
care
 not an absolute contra- NOM may be used selectively
indication to NOM in absence if a system for
of
immediate transfer to a higher
other indications for level of care facility exists.
laparotomy.
 RETROSPECTIVE STUDY WITH A COHORT
(SUCCESSFUL NONOPERATIVE MANAGEMENT OF HIGH-GRADE BLUNT RENAL INJURIES)
Of 47 patients with blunt grade IV or V injuries

3 (6.4%) were IO(Operatif Heart rate at admission and

patient) and 44 (95.6%) NOM. concomitant liver injury were
predictive of need for immediate
operative intervention

Conclusion: Decisions should be

Nonoperative management had
made based on grade of injury in
fewer days in ICU, less
conjunction with hemodynamic
transfusion requirements, and
status rather than solely on grade
fewer complications
of injury
 Angioembolisation (AE)
Limitation :
• No validated criteria to identify
patients who require AE
The non-operative • Use in renal trauma remains
management of all grades of heterogeneous
renal injury  Haemodynamic • Increasing grade of renal injury is
Stability associated with increased risk of
failed AE
Advantages :
• Can reduce nephrectomy rates
• Successfully to treat acute
haemorrhage, AVF and pseudo-
aneurysms resulting from
penetrating renal trauma
MANAGEMENT DISEASE
MANAGEMENT OF RENAL TRAUMA (EAU GUIDELINE 2020)
MANAGEMENT OF RENAL TRAUMA (WSES-AAST GUIDELINES)
MANAGEMENT DISEASE
SURGICAL MANAGEMENT

The goals of exploration following renal trauma are control of

haemorrhage and renal salvage

Exploration is influenced by aetiology and grade of injury,

transfusion requirements, the need to explore associated abdominal
injurie

Absolute indication
Persistent haemodynamic instability
Grade 5 vascular injury
Expanding or pulsatile peri-renal haematoma
 OPERATIVE FINDINGS

Most series recommend the transperitoneal

approach for surgery

Entering the retroperitoneum and leaving the

confined haematoma undisturbed within the
perinephric fascia

Access to the pedicle is obtained either through

the posterior parietal peritoneum, which is
incised over the aorta, just medial to the inferior
mesenteric vein.
RECONSTRUCTION

Reconstruction

Partial
Renorrhaphy
nephrectomy
PARTIAL NEPHRECTOMY
RENORRHAPHY
FOLLOW UP
Physical Examination

Urinalysis

Diagnostic imaging

Blood pressure measurement

Serum Creatinine

The risk of complications relates to aetiology, injury grade, and mode of management
COMPLICATION
• Bleeding
• Infection
• Perinephric Abscess
Early • Sepsis
• Urinary Fistula
• Urinoma
• Extravasation Urine
• Hydronephrosis
• Calculus formation
• Chronic Pyelonephritis
Delayed • Hypertension
• AVF
• Pseudo-Aneurysm
THANK YOU