Renal trauma: the current best practice

Abstract

The kidneys are the most vulnerable genitourinary organ in trauma, as they are involved in up to 3.25% of trauma patients. The most common mechanism for renal injury is blunt trauma (predominantly by motor vehicle accidents and falls), while penetrating trauma (mainly caused by firearms and stab wound) comprise the rest. High-velocity weapons impose specifically problematic damage because of the high energy and collateral effect. The mainstay of renal trauma diagnosis is based on contrast-enhanced computed tomography (CT), which is indicated in all stable patients with gross hematuria and in patients presenting with microscopic hematuria and hypotension. Additionally, CT should be performed when the mechanism of injury or physical examination findings are suggestive of renal injury (e.g. rapid deceleration, rib fractures, flank ecchymosis, and every penetrating injury of the abdomen, flank or lower chest). Renal trauma management has evolved during the last decades, with a distinct evolution toward a nonoperative approach. The lion's share of renal trauma patients are managed nonoperatively with careful monitoring, reimaging when there is any deterioration, and the use of minimally invasive procedures. These procedures include angioembolization in cases of active bleeding and endourological stenting in cases of urine extravasation.

Management of grade IV blunt renal trauma in adults: Systematic review and meta-analysis

“…Among the grading classifications, grade IV is described as involvement of parenchymal laceration extending to the corticomedullary junction and the collecting system and vascular injury to the segmental renal artery or vein with contained hemorrhage/hematoma. [27][28][29] Although our study showed comparability between conservative and surgical managements in patients with grade IV blunt kidney trauma, the trend of mortality was more likely in the surgical group than in the conservative group. Based on this finding, several other studies have indicated the superiority of conservative management over surgical management.…”

“…27,28 In particular, blunt injury is more prevalent, accounting for 71%-95% of all trauma cases. 27,28 Deceleration injury in blunt trauma causes disturbances due to renal injury by the major surrounding attachment elements, such as renal pedicle and uretero-pelvic junction, whereas acceleration injury causes disturbances due to collision of the kidney with surrounding elements, such as the ribs and spine. 27,28 These two mechanisms lead to kidney injury with varying degrees of severity.…”

“…27,28 Deceleration injury in blunt trauma causes disturbances due to renal injury by the major surrounding attachment elements, such as renal pedicle and uretero-pelvic junction, whereas acceleration injury causes disturbances due to collision of the kidney with surrounding elements, such as the ribs and spine. 27,28 These two mechanisms lead to kidney injury with varying degrees of severity. This varying severity is now used as a treatment approach toward the condition, and the AAST classification system is among the most frequently used tools.…”

Transcatheter arterial embolisation of a haemorrhagic renal cyst

“…for operative management, including nephrectomy. 1 There are scarce case reports in the literature discussing the treatment of intracystic bleeding with transcatheter arterial embolisation, as was done with this patient. 2 Our patient's bleeding was well controlled with embolisation, which prevented the need to progress to surgery.…”

A Comparative Study of Conservation, Endovascular Embolization Therapy, and Surgery for Blunt Renal Trauma

“…There was no renal vascular injury on early CT, but arteriovenous fistula and pseudoaneurysm were found on angiography. Early angiography may be more helpful in the diagnosis of vascular injury, and selective embolization is often used in these patients [8,[10][11][12]. Simple embolization results in a lower rate of kidney loss and lower risk of infection.…”