Editing Upper Urinary Tract Trauma (section)

==== <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'''