RENAL INJURIES

PRESENTED BY:
ABHISHEK KALWAR
SUJAN KATHAYAT
 Injuries to kidney

 Usually result from either direct blows or

falls on loin or crushing injury to abdomen
 Typically in road traffic accident
 Often associated with other abdominal

injuries eg. Liver, Spleen, Bowel etc.

 Haematuria after trivial injury suggest pre-

existing disease
eg.Calculus,Hydronephrosis,Tuberculosis
 Injuries to kidney

 Ranges from small subcapsular haematoma to

complete tear through kidney
 Close renal injury ; usually extra-peritonel
 Young children with little extra-peritoneal fat
 Peritoneum can tear with the renal capsule,

leaking blood and urine into the peritoneum

 Clinical Features

 Local pain and tenderness

 Sometimes superficial soft tissue bruising
 Features of shock
 Haematuria :Profuse bleeding may cause clot
colic
 Severe delayed haematuria: Sudden profuse
hematuria between 3rd day and 3rd week after
trauma, due to clot becoming dislodged
 Meteorism: Abdominal distension 24-48 hours,
as a result of retroperitoneal haematoma
 Management
 Watchful treatment of closed renal trauma is
often successful
 Cross-match blood and secure intravenous

access if there is any evidence of

hypovolaemic shock or continuing
haemorrhage.
 Advise bed-rest while there is macroscopic

haematuria and restrict activity for a week

after the urine clears
 Administer appropriate analgesia.
 Keep hourly observations
 Prophylactic antibiotic
 Check the urine passed for haematuria and

chart the result.

 Intravenous urography , contrast-enhance CT

done to assess damage to kidney and show

other kidney is normal
 Surgical Exploration
 Necessary in less than 10% of closed injuries
 Indications
 Progressive blood loss
 Expanding mass in the loin
 Renal areteriogram performed preoperatively,
embolisation may arrest haemorrhage if
bleeding vessel identified
 Small tear: Sutured over haemostatic sponge or
piece of detached muscle
 Large single rents delated by passing tube
nephrostomy through defect and suturing renal
tissue around it
 Kidney avulsed from pedicle: Nephrectomy
 Complications

 Heavy haematuria
 Pararenal pseudohydronephrosis
 Hypertension, resistant to drugs from renal

fibrosis
 Post-traumatic aneurysm of renal artery
 Injuries to the Ureter
 Rupture of ureter
Uncommon result of hyperextension
injury of spine
Diagnosis: Swelling in loin or iliac fossa
associated with reduced urinary output
 Injury during pelvic surgery

Most often during vaginal or abdominal

hysterectomy
Pre-emptive ureteric catheterisation makes
easier to identify ureter
Injuries not recognised at the time of
operation

Unilateral injuries:
3 possibilities
1. No symptoms
Ligation of ureter may lead to silent
atrophy of kidney
2. Loin pain and fever
Pyonephrosis, Infection of obstructed
system
3. Urinary fistula
Through abdominal or vaginal wound
Injuries not recognised at the time of
operation

Bilateral injuries:
◦ Ligation of both ureters leads to
anuria
◦ Ureteric catheter will not pass and
urgent nephrostomy or immediate
surgery essential
 Imaging

Contrast-enhanced CT or a
complete IVP is accurate for the
detection of ureteral trauma.
Repair of Injured Ureter
Psoas Hitch of Bladder Transureterouretostomy
 Boari Operation
 Flap of bladder wall is fashioned into tube
to replace the lower ureter
Injury to Urinary Bladder
 Causes of bladder injury
 Trauma:
• RTA
• Kick or blow on abdomen, with full bladder
• Penetrating injury

 Surgical:
• Inguinal or femoral herniotomy
• Hysterectomy
• Excision of rectum
 Types
1. Intraperitoneal rupture(20%): Secondary to a
blow or fall on a distended bladder, more rarely
to surgical damage
 Clinical features
◦ Sudden severe suprapubic pain, hypotension/syncope
and shock
◦ Lower abdominal guarding and rigidity occurs after
few hour of injury
◦ Distension
◦ Urinary retention
◦ Presents as anuria
◦ Unable to palpate bladder
 Contd….
2. Extra peritoneal rupture: (80%)
 Trauma either penetrating or blunt injury with

fracture of pubis (RTA in a non distended Bladder)

 Difficult to distinguish clinically from an injury to

the membranous urethra

 Clinical Features
 Extravasations of fluid: Collection of urine and

blood in the extra peritoneal space in front, with

fullness, diffuse pain and tenderness in lower
abdomen
 Swelling of scrotum and labia, and abdominal wall
 Inability to pass urine
 Investigations

1. Plain x-ray: lower abdomen shows ground

glass appearance
2. IVU: extravasations of the dye into peritoneal
cavity or intraperitoneally, confirm the leak
3. Retrograde cysto-urethrogram: conforms the
site of leak. Confirm the diagnosis
However CT cystography is the investigation
of choice today
Cystography of a patient who has fallen over and developed
severe abdominal pain. Leakage of contrast into the
peritoneal cavity is seen.
 Treatment
 Intraperitoneal rupture
◦ Laparotomy, repair of bladder in 2 layers
◦ Drain suprapubic space with tube drain
◦ Catheter should be laced for 10-14 days for
bladder decompression
 Extra peritoneal rupture:
◦ Expose the bladder with a suprapubic midline
incision and repair
◦ Drainage with tube drain
 Types of urethral injury

 AnteriorUrethra injury
◦ Includes the bulbar and penile urethral

 PosteriorUrethral injury
◦ Includes prostatic and membranous
urethra
 Anterior Urethra injury
Causes
◦ Straddle injury
◦ Direct trauma to penis
 Bulbar urethra is crushed upwards against the
pubic rami by straddle type injuries
 H/o blow to the perineum due to fall astride

on a projecting object
 Cycling accidents, loose manhole covers
 Clinical features
 Unable to pass urine
 Perineal haematoma
 Massive perineal swelling
 Blood at meatus
 Digital rectal exam – high-riding prostate
Preliminary assessment & treatment
 Appropriate analgesics
 If urethral rupture is suspected, the patient
should be discouraged from passing urine
 Percutaneous suprapubic drainage of the
bladder
◦ Reduces urinary extravasation and allows
investigation to establish the extent of urethral injury
 Retrograde urethrogram or Flexible cystoscopy

 Prophylactic antibiotics
 Treatment of choice
 Blunt and penetrating injuries (most) –
immediate exploration, debridement, and direct
repair
 An injury from a high-velocity gunshot –
suprapubic cystostomy and delayed repair after
clear demarcation of injured tissues
 Proximal injuries approached through a perineal
incision
 Distal injuries approached by making a
circumferential, sub coronal incision and de-
gloving the penis
 Treatment contd…
 Complete urethral tear – suprapubic catheter
until arrangements made for repair
◦ Early open repair of urethra with excision of
traumatized section & spatulated end-end
reanastomosis of urethra

Open urethral repair

Complications of anterior urethral injury
 Complete rupture – Subcutaneous
extravasation of urine occurs if patient
attempts to pass urine
 Infection
 Stricture a common sequel to urethral trauma

◦ In partial or complete tear

◦ Peri-urethral bruising
 Posterior Urethral injury
 Occurs in the context of pelvic fractures
 Urethral Foley should be placed across injury

when possible
 Guidewire can be placed across the aligned

urethra to permit insertion of a Foley catheter

 Completely disrupted urethra cannot be

aligned – definitive repair in 4 to 6 months

 Rupture of Membranous Urethra
 Usually a result of pelvic fracture
 Occurs near apex of the prostate
 About 10–15% of cases of fractured pelvis have

associated urethral injury

 Diagnosis
 Plain X ray
◦ Significant displacement of pelvic bones
 DRE
◦ Displaced prostate
 Urethrogram
 Treatment including pelvic
 RTA being the most common cause of Pelvic
◦ Injuries to the head, thorax, long bones and abdomen should be
ruled out
◦ Resuscitation
◦ Primary survey
◦ Secondary survey ( head to toe examination)
 Suprapubic catheter should be inserted as soon as
practicable
 Exploration needed if there is evidence of rupture of
bladder
 If there is significant bladder rupture it must be repaired
, suprapubic catheter inserted and retroperitoneal space
drained
 Complications
 Stricture
 Urinary Incontinence
 Erectile dysfunction
 Extravasation of urine
◦ Superficial
 Bulbar urethra rupture
◦ Deep
 Extra peritoneal rupture of the bladder or intra pelvic
rupture of the urethra or ureter damage or
perforation of the prostatic capsule or bladder during
transurethral resection.
 Treatment – suprapubic cystostomy and drainage of
retropubic space
 References

 Bailey And Love Short Practice of Surgery, 25th

edition.
 Schwartz's Principles of surgery, 8th edition.