Editing Upper Urinary Tract Trauma (section)

=== Management ===

* Management of traumatic renal injuries has shifted from operative exploration to non-operative management in the vast majority of cases.
** Non-operative management of the vast majority of blunt renal injuries is firmly established; non-operative management of penetrating and high-grade renal injuries remains debatable

==== <span style="color:#ff0000">Indications for intervention</span> ====
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33053308/ 2020 AUA Urotrauma Guidelines]</span>'''
**'''<span style="color:#ff0000">Approach based on based on hemodynamic stability</span>'''
*** '''<span style="color:#ff0000">If hemodynamically stable: non-invasive management</span>'''
**** '''<span style="color:#ff0000">Non-invasive management includes (4):'''
****#'''<span style="color:#ff0000">Close hemodynamic monitoring'''
****#'''<span style="color:#ff0000">Bed rest'''
****#'''<span style="color:#ff0000">ICU admission'''
****#'''<span style="color:#ff0000">Blood transfusion (when indicated)'''
****#'''<span style="color:#ff0000">Imaging (when indicated)</span>'''
****#*'''<span style="color:#ff0000">Indications for follow-up CT imaging (after 48 hours) in renal trauma patients (2):</span><span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33053308/ ★]'''
****#*#'''<span style="color:#ff0000">Clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention)</span>'''
****#*# '''<span style="color:#ff0000">Deep lacerations (AAST Grade IV-V)</span>'''
****#*#*AAST Grade IV-V renal injuries are prone to developing troublesome complications such as urinoma or hemorrhage
****#*#*AAST Grade I-III injuries have a low risk of complications and rarely require intervention. Routine follow-up CT imaging is not advised for uncomplicated AAST Grade I-III injuries because it is not likely to change clinical management in these cases
****'''<span style="color:#ff0000">Patients initially managed noninvasively may still require treatments (surgical, endoscopic, or angiographic) at a later time, especially those with higher grade injuries.'''
*****'''<span style="color:#ff0000">Factors associated with increased risk of bleeding and need for intervention in grade 3 and 4 injuries (3):</span>'''
*****#'''<span style="color:#ff0000">Medial hematoma</span>'''
*****#'''<span style="color:#ff0000">Hematoma > 3.5-4 cm in thickness</span>'''
*****#'''<span style="color:#ff0000">Presence of a contrast extravasation from vessels on imaging</span>'''
*****Although devitalized parenchyma has been suggested as a risk factor for development of septic complications, evidence supporting intervention for this radiographic finding is inconclusive
****Delayed renal bleeding can occur up to several weeks after injury but usually occurs within 21 days.
***'''<span style="color:#ff0000">If hemodynamically unstable: immediate intervention (surgery or selective angioembolization)</span>'''
**** '''<span style="color:#ff0000">Perform immediate intervention for hemodynamically unstable patients with radiographic findings of large perirenal hematoma (> 4 cm) and/or vascular contrast extravasation in the setting of deep or complex renal laceration (AAST Grade 3-5)[https://pubmed.ncbi.nlm.nih.gov/33053308/ ★]'''
***** Perinephric hematoma size provides a rough radiographic estimate of the magnitude of renal bleeding, and increasing hematoma size has been incrementally associated with higher intervention rates.
****'''Selected patients with bleeding from segmental renal vessels may benefit from angioembolization as an effective yet minimally invasive treatment to control bleeding'''
*****Selective embolization provides an effective and minimally invasive means to stop active bleeding from parenchymal lacerations and segmental arterial injury
*****Increasingly used in renal trauma
****'''<span style="color:#ff0000">Patients who are hemodynamically unstable despite active resuscitation should be taken to the operating room rather than angiography'''
* '''[https://pubmed.ncbi.nlm.nih.gov/31827593/ 2019 World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) Guidelines]'''
** '''Non-operative management should be the treatment of choice for all hemodynamically or stabilized patients'''
**'''Isolated urinary extravasation, in itself, is not an absolute contra-indication to non-operative management in absence of other indications for laparotomy.''' 
**'''Hemodynamic stable or stabilized patients having damage to the renal pelvis not amenable to endoscopic/percutaneous techniques/stent should be considered for delayed OM in absence of other indications for immediate laparotomy.'''
**'''Hemodynamically unstable or non-responders to resuscitation should undergo operative management'''

==== <span style="color:#ff0000">Surgical management</span> ====
*Nephrectomy is a frequent result when hemodynamically unstable patients undergo surgical exploration
*'''<span style="color:#ff0000">Approach: transabdominal</span>'''
**'''Allows complete inspection of intra-abdominal organs and bowel.'''
*'''<span style="color:#ff0000">Principles of renal reconstruction after trauma include (8):</span>'''
*#'''Complete renal exposure'''
*#'''Measures for temporary vascular control'''
*#*'''<span style="color:#ff0000">Isolate the renal vessels before exploration</span> to provide the immediate capability to occlude them if massive bleeding should ensue when the Gerota fascia is opened'''
*#'''Limited debridement of nonviable tissue'''
*#'''Hemostasis by individual suture ligation of bleeding vessels'''
*#'''Watertight closure of the collecting system if necessary/possible'''
*#'''Reapproximation of the parenchymal defect'''
*#'''Coverage with nearby fascioadipose flaps (Gerota fascia or omentum) if feasible'''
*#*The open parenchyma should be covered when possible by a pedicle flap of omentum. The rich vascular and lymphatic supply of the omentum promotes wound healing and decreases the risk for delayed bleeding and urinary extravasation.
*#'''Liberal use of drains'''
*'''<span style="color:#ff0000">For major renovascular injuries in patients with 2 kidneys, speedy nephrectomy is advocated</span>'''
**In rare instances in which vascular repair is technically feasible, renal salvage rates are disappointingly low
*'''<span style="color:#ff0000">In damage control surgery, the area around the injured kidney is packed with laparotomy pads to control bleeding, with a planned return in approximately 24 hours to explore and evaluate the extent of injury.</span>'''
**This allows the cold, acidotic, and coagulopathic patient to be stabilized in the ICU before any attempt at potentially lengthy renal reconstruction is attempted.
*'''<span style="color:#ff0000">In an unstable patient, if damage control is not an option, total nephrectomy would be indicated immediately when the patient’s life would be threatened by attempted renal repair.</span>'''

==== Special Scenarios ====
===== Renal injury with urinary extravasation =====
*'''<span style="color:#ff0000">Persistent urinary extravasation can result in:'''
*#'''<span style="color:#ff0000">Urinoma'''
*#'''<span style="color:#ff0000">Perinephric infection'''
*#'''<span style="color:#ff0000">Renal loss (rarely)'''
*'''Stable patients where renal pelvis or proximal ureteral injury is not suspected: observation (AUA)'''
**'''Parenchymal collecting system injuries often resolve spontaneously.'''
***Urinary extravasation alone from a grade IV parenchymal laceration or forniceal rupture managed non-operatively has a spontaneous resolution of > 90%
*'''<span style="color:#ff0000">Indications for intervention (4):</span>'''
*#'''<span style="color:#ff0000">Suspected injury to renal pelvis or proximal ureteral avulsion</span>'''
*#*'''<span style="color:#ff0000">Suggested by large medial urinoma or contrast extravasation on delayed images without distal ureteral contrast</span>'''
*#*'''Management is either endoscopic or open depending on the clinical scenario'''
*#'''<span style="color:#ff0000">Urinoma increasing in size, purulence, or complexity</span> on follow-up imaging'''
*#'''<span style="color:#ff0000">Presence of complications such as fever, infection, increasing pain, ileus, or fistula.</span>'''
*# '''Severe renal injuries with <span style="color:#ff0000">continued urinary extravasation</span>''' (not described in 2020 AUA Guidelines)
*#*'''Placement of an internal ureteral stent for drainage may prevent prolonged urinary extravasation and decrease the chance of perirenal urinoma formation'''
* '''<span style="color:#ff0000">Options for intervention'''
*#'''<span style="color:#ff0000">Ureteral stent (preferred)'''
*#*An internalized ureteral stent is minimally invasive and alone may provide adequate drainage of the injured kidney
*#*'''A period of concomitant Foley catheter drainage may minimize pressure within the collecting system and enhance urinoma drainage'''
*# '''Percutaneous urinoma drain, percutaneous nephrostomy, or both may also be necessary'''

===== <span style="color:#ff0000">Hypertension and Renal Trauma</span> =====
*'''Hypertension is rarely noted in the early postinjury period but can occur later.'''
*'''<span style="color:#ff0000">Mechanisms for hypertension as a complication of renal trauma (4):</span>'''
*#'''<span style="color:#ff0000">Renal vascular injury, leading to stenosis or occlusion of the main renal artery or one of its branches</span>''' (one-clip, Goldblatt kidney)
*#'''<span style="color:#ff0000">Page kidney: compression of the renal parenchyma with extravasated blood or urine</span>'''
*#'''<span style="color:#ff0000">Post-trauma arteriovenous fistula</span>'''
*#'''<span style="color:#ff0000">Ureteral / UPJ obstruction</span>[https://www.ncbi.nlm.nih.gov/pubmed/29959876]'''
*#*In the first 3 scenarios, the renin-angiotensin axis is stimulated by partial renal ischemia, resulting in hypertension
* '''Can be treated with (3):'''
*#'''Anti-hypertensives'''
*#'''Observation'''
*#'''Nephrectomy (uncommonly)'''