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Upper Urinary Tract Trauma: Difference between revisions

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===== History =====
===== History =====


* '''<span style="color:#ff0000">Most important information in blunt renal injury is the extent of deceleration''' involved in high-velocity impact trauma
* '''<span style="color:#ff0000">Extent of deceleration''' involved in high-velocity impact trauma
* '''<span style="color:#ff0000">Trauma to the anterior axillary line is more likely to damage important renal structures such as the renal hilum and pedicle compared to the posterior axially line, which more commonly results in parenchymal injury'''
**'''<span style="color:#ff0000">Most important information in blunt renal injury'''
* '''<span style="color:#ff0000">Trauma anterior vs. posterior to the axillary line'''
**'''<span style="color:#ff0000">Trauma anterior to axially line is more likely to damage important renal structures such as the renal hilum and pedicle compared to the posterior axially line, which more commonly results in parenchymal injury'''


===== Physical Exam =====
===== Physical Exam =====
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# '''<span style="color:#ff0000">Rib fractures'''  
# '''<span style="color:#ff0000">Rib fractures'''  
#* Ipsilateral rib fracture can increase the incidence of significant renal trauma by 3x
#* Ipsilateral rib fracture can increase the incidence of significant renal trauma by 3x
# '''<span style="color:#ff0000">Penetrating injuries to the low thorax or flank'''
# '''<span style="color:#ff0000">Hematuria'''
# '''<span style="color:#ff0000">Hematuria'''  
#* '''<span style="color:#ff0000">The degree of hematuria and the severity of the renal injury do not consistently correlate'''; presence or absence of hematuria should not be the sole determinant in the assessment of a patient with suspected renal trauma
#* '''<span style="color:#ff0000">The degree of hematuria and the severity of the renal injury do not consistently correlate'''; presence or absence of hematuria should not be the sole determinant in the assessment of a patient with suspected renal trauma
#'''<span style="color:#ff0000">Penetrating injuries to the low thorax or flank'''


==== Imaging ====
==== Imaging ====


* '''<span style="color:#ff0000">Indications'''
===== Indications =====
** '''<span style="color:#ff0000">AUA: indications for imaging (contrast enhanced CT with immediate and delayed films) in stable trauma patients (5):'''  
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33053308/ 2020 AUA Urotrauma Guidelines]'''
**'''<span style="color:#ff0000">Indications for imaging (contrast enhanced CT with immediate and delayed films) in stable trauma patients (5):'''  
**# '''<span style="color:#ff0000">Gross hematuria'''  
**# '''<span style="color:#ff0000">Gross hematuria'''  
**# '''<span style="color:#ff0000">Microscopic hematuria and systolic blood pressure < 90mmHG'''
**# '''<span style="color:#ff0000">Microscopic hematuria and systolic blood pressure < 90mmHG'''
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**# '''<span style="color:#ff0000">Penetrating injury of abdomen, flank, or lower chest'''  
**# '''<span style="color:#ff0000">Penetrating injury of abdomen, flank, or lower chest'''  
*** '''<span style="color:#ff0000">Generally, children can be imaged using the same criteria as adults. Children, however, often do not exhibit hypotension as adults do.'''
*** '''<span style="color:#ff0000">Generally, children can be imaged using the same criteria as adults. Children, however, often do not exhibit hypotension as adults do.'''
**Campbell’s indications for imaging (similar to AUA indications but worded differently)
**#All blunt trauma with gross hematuria
**#All blunt trauma with microhematuria and hypotension (defined as a SBP <90 mm Hg at any time during evaluation and resuscitation)
**#All blunt trauma with significant acceleration/deceleration mechanism of injury, specifically rapid deceleration as would occur in a high-speed motor vehicle accident or a fall from heights
**#All penetrating trauma with a likelihood of renal injury (abdomen, flank, or low chest entry/exit wound) who are hemodynamically stable enough to have a CT (instead of going right to the operating room or angiography suite)
**#All pediatric patients with greater than 5 RBCs/HPF


* '''<span style="color:#ff0000">Modality'''
===== Modality =====
** '''<span style="color:#ff0000">CT abdomen/pelvis with IV contrast (with immediate and delayed images) should be performed when there is suspicion of renal injury''' (AUA)
* '''<span style="color:#ff0000">CT abdomen/pelvis with IV contrast (with immediate and delayed images) should be performed when there is suspicion of renal injury''' (AUA)
*** In children, ultrasound may be used, although CT is preferred
** In children, ultrasound may be used, although CT is preferred
*** An intraoperative one-shot IVP (2 mL/kg IV bolus of contrast with a single image obtained 10-15 minutes later) may be used to confirm that a contralateral functioning kidney is present in rare cases where the patient is taken to the operating room without preliminary CT scan if surgeons are considering renal exploration or nephrectomy
** In rare cases where the patient is taken to the operating room without preliminary CT scan and surgeons are considering renal exploration or nephrectomy, an intraoperative one-shot IVP (2 mL/kg IV bolus of contrast with a single image obtained 10-15 minutes later) may be used to confirm that a contralateral functioning kidney is present
*** '''<span style="color:#ff0000">Major limitation of CT scan in renal trauma: inability to adequately define a renal venous injury adequately.'''  
** '''<span style="color:#ff0000">Major limitation of CT scan in renal trauma: inability to adequately define a renal venous injury adequately.'''  
**** '''<span style="color:#ff0000">A medial hematoma strongly suggests a venous injury, however, there is no imaging modality which can accurately diagnose a venous injury'''
*** '''<span style="color:#ff0000">A medial hematoma strongly suggests a venous injury, however, there is no imaging modality which can accurately diagnose a venous injury'''


* '''<span style="color:#ff0000">CT findings suspicious for significant renal injury include (6):'''  
===== Findings =====
*'''<span style="color:#ff0000">CT findings suspicious for significant renal injury include (6):'''  
*# '''<span style="color:#ff0000">Medial laceration'''
*# '''<span style="color:#ff0000">Medial laceration'''
*# '''<span style="color:#ff0000">Medial hematoma (vascular pedicle injury)'''
*# '''<span style="color:#ff0000">Medial hematoma (vascular pedicle injury)'''
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*# '''<span style="color:#ff0000">Lack of contrast enhancement of the parenchyma (main renal arterial injury)'''
*# '''<span style="color:#ff0000">Lack of contrast enhancement of the parenchyma (main renal arterial injury)'''
*# '''<span style="color:#ff0000">Active intravascular contrast extravasation (arterial injury with brisk bleeding)'''
*# '''<span style="color:#ff0000">Active intravascular contrast extravasation (arterial injury with brisk bleeding)'''
[[File:Leftrenalarteryinjury.png|center|thumb|600x600px|CT scan showing left renal artery injury[[commons:File:Leftrenalarteryinjury.png|Source]]]]  
[[File:Leftrenalarteryinjury.png|center|thumb|600x600px|Axial CT scan with contrast, red arrow showing left renal artery injury with extravasation. [[commons:File:Leftrenalarteryinjury.png|Source]]]]  


* '''<span style="color:#ff0000">Differential diagnosis of fluid collections seen on serial imaging for renal trauma (3):'''
* '''<span style="color:#ff0000">Differential diagnosis of fluid collections seen on serial imaging for renal trauma (3):'''


# '''<span style="color:#ff0000">Hematomas''' - density is almost always > 30 HU
# '''<span style="color:#ff0000">Hematoma''' - density is almost always > 30 HU
# '''<span style="color:#ff0000">Urinomas''' - density ranges from 0-20 Hounsfield units (HU)
# '''<span style="color:#ff0000">Urinoma''' - density ranges from 0-20 Hounsfield units (HU)
# '''<span style="color:#ff0000">Abscesses''' - associated with rim enhancement; perinephric abscess rarely occurs after renal injury
# '''<span style="color:#ff0000">Abscess''' - associated with rim enhancement; perinephric abscess rarely occurs after renal injury
 
==== Grading ====


==== [https://www.aast.org/resources-detail/injury-scoring-scale#kidney AAST Grading] ====
==== [https://www.aast.org/resources-detail/injury-scoring-scale#kidney AAST Grading] ====
(Table to be created)  
{| class="wikitable"
 
|'''<span style="color:#ff0000">Grade'''
|'''<span style="color:#ff0000">Imaging criteria (CT findings)'''
|-
|'''<span style="color:#ff0000">I'''
|
* '''Subcapsular hematoma and/or parenchymal <span style="color:#ff0000">contusion</span> without laceration'''
|-
|'''<span style="color:#ff0000">II'''
|
* '''Perirenal hematoma confined to Gerota fascia'''
* '''Parenchymal <span style="color:#ff0000">laceration ≤1 cm depth without urinary extravasation'''
|-
|'''<span style="color:#ff0000">III'''
|
* '''Parenchymal <span style="color:#ff0000">laceration >1 cm depth without collecting system rupture or urinary extravasation'''
* '''<span style="color:#ff0000">Any injury in the presence of a kidney vascular injury (pseudoaneurysm or AV fistula) or active bleeding contained within Gerota fascia'''
|-
|'''<span style="color:#ff0000">IV'''
|
* '''Parenchymal <span style="color:#ff0000">laceration extending into urinary collecting system with urinary extravasation'''
* '''<span style="color:#ff0000">Active bleeding beyond Gerota fascia</span> into the retroperitoneum or peritoneum'''
* '''<span style="color:#ff0000">Renal pelvis laceration and/or complete ureteropelvic disruption'''
* '''<span style="color:#ff0000">Segmental renal vein or artery injury'''
* '''<span style="color:#ff0000">Segmental or complete kidney infarction(s) due to vessel thrombosis without active bleeding'''
|-
|'''<span style="color:#ff0000">V'''
|
* '''<span style="color:#ff0000">Main renal artery or vein laceration or avulsion of hilum'''
* '''<span style="color:#ff0000">Devascularized kidney</span> with active bleeding'''
* '''<span style="color:#ff0000">Shattered kidney</span> with loss of identifiable parenchymal renal anatomy'''
|}
<nowiki>*</nowiki>Advance one grade for bilateral injury up to grade III
<nowiki>*</nowiki>Advance one grade for bilateral injury up to grade III
[[File:Abdotrauma.png|center|thumb|600x600px|What Grade of injury is this based on the AAST classification?[[commons:File:Abdotrauma.PNG|Source]]]]
[[File:Abdotrauma.png|center|thumb|600x600px|What Grade of injury is this based on the AAST classification? [[commons:File:Abdotrauma.PNG|Source]]]]


=== Management ===
=== Management ===
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==== <span style="color:#ff0000">Indications for intervention</span> ====
==== <span style="color:#ff0000">Indications for intervention</span> ====
* '''<span style="color:#ff0000">AUA: based on hemodynamic stability</span>'''
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33053308/ 2020 AUA Urotrauma Guidelines]</span>'''
** '''<span style="color:#ff0000">If hemodynamically stable: non-invasive management</span>'''
**'''<span style="color:#ff0000">Approach based on based on hemodynamic stability</span>'''
*** Non-invasive management includes close hemodynamic monitoring, bed rest, ICU admission, and blood transfusion (when indicated)
*** '''<span style="color:#ff0000">If hemodynamically stable: non-invasive management</span>'''
*** '''Patients initially managed noninvasively may still require surgical, endoscopic, or angiographic treatments at a later time, especially those with higher grade injuries.'''
**** '''<span style="color:#ff0000">Non-invasive management includes (4):'''
***'''<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">Close hemodynamic monitoring'''
***#'''<span style="color:#ff0000">Medial hematoma</span>'''
****#'''<span style="color:#ff0000">Bed rest'''
***#'''<span style="color:#ff0000">Hematoma > 3.5-4 cm in thickness</span>'''
****#'''<span style="color:#ff0000">ICU admission'''
***#'''<span style="color:#ff0000">Presence of a contrast extravasation from vessels on imaging</span>'''
****#'''<span style="color:#ff0000">Blood transfusion (when indicated)'''
***'''Although devitalized parenchyma has been suggested as a risk factor for development of septic complications, evidence supporting intervention for this radiographic finding is inconclusive'''
****#'''<span style="color:#ff0000">Imaging (when indicated)</span>'''
***'''<span style="color:#ff0000">All patients with high-grade injuries selected for nonoperative management should be closely observed with serial hematocrit readings and vital signs </span>'''(Campbell’s)
****#*'''<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/ ★]'''
****'''Some empirically prescribe bed rest until gross hematuria resolves, though insufficient evidence to support its efficacy'''
****#*#'''<span style="color:#ff0000">Clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention)</span>'''
**'''<span style="color:#ff0000">If hemodynamically unstable: immediate intervention (surgery or selective angioembolization)</span>'''
****#*# '''<span style="color:#ff0000">Deep lacerations (AAST Grade IV-V)</span>'''
*** '''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), surgeons should perform immediate intervention'''
****#*#*AAST Grade IV-V renal injuries are prone to developing troublesome complications such as urinoma or hemorrhage
**** 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.
****#*#*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
***'''Selected patients with bleeding from segmental renal vessels may benefit from angioembolization as an effective yet minimally invasive treatment to control bleeding'''
****'''<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.'''
****Selective embolization provides an effective and minimally invasive means to stop active bleeding from parenchymal lacerations and segmental arterial injury
*****'''<span style="color:#ff0000">Factors associated with increased risk of bleeding and need for intervention in grade 3 and 4 injuries (3):</span>'''
****Increasingly used in renal trauma
*****#'''<span style="color:#ff0000">Medial hematoma</span>'''
***'''Patients who are hemodynamically unstable despite active resuscitation should be taken to the operating room rather than angiography'''
*****#'''<span style="color:#ff0000">Hematoma > 3.5-4 cm in thickness</span>'''
*'''<span style="color:#ff0000">Campbell’s 11th edition</span>'''
*****#'''<span style="color:#ff0000">Presence of a contrast extravasation from vessels on imaging</span>'''
** '''<span style="color:#ff0000">Indications for operative management</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
*** '''<span style="color:#ff0000">Absolute (4) </span><span style="color:#0000ff">5PUPS:</span>'''
****Delayed renal bleeding can occur up to several weeks after injury but usually occurs within 21 days.
***#'''<span style="color:#ff0000">Suspected grade </span><span style="color:#0000ff">5</span><span style="color:#ff0000"> injury (renal vascular pedicle avulsion)</span>'''
***'''<span style="color:#ff0000">If hemodynamically unstable: immediate intervention (surgery or selective angioembolization)</span>'''
***#'''<span style="color:#ff0000">Expanding/</span><span style="color:#0000ff">P</span><span style="color:#ff0000">ulsatile renal hematoma (usually indicating renal artery laceration)</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/ ★]'''
***#*Some blunt and penetrating abdominal trauma may require laparotomy because of associated non-urologic injury, but even in these cases it is not necessary to explore the kidney additionally. However, exploration is needed in the case of a pulsatile and expanding retroperitoneal hematoma that suggests renal artery laceration
***** 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.
***#'''<span style="color:#0000ff">U</span><span style="color:#ff0000">retero</span><span style="color:#0000ff">P</span><span style="color:#ff0000">elvic junction disruption</span>'''
****'''Selected patients with bleeding from segmental renal vessels may benefit from angioembolization as an effective yet minimally invasive treatment to control bleeding'''
***#'''<span style="color:#ff0000">Hemodynamic instability with </span><span style="color:#0000ff">S</span><span style="color:#ff0000">hock</span>'''
*****Selective embolization provides an effective and minimally invasive means to stop active bleeding from parenchymal lacerations and segmental arterial injury
***'''<span style="color:#ff0000">Relative indications (3):</span>'''
*****Increasingly used in renal trauma
***#'''<span style="color:#ff0000">Renal injury together with colon/pancreatic injury</span>'''
****'''<span style="color:#ff0000">Patients who are hemodynamically unstable despite active resuscitation should be taken to the operating room rather than angiography'''
***#'''<span style="color:#ff0000">Urinary extravasation with significant renal parenchymal devascularization</span>'''
* '''[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]'''
***#'''<span style="color:#ff0000">Delayed diagnosis of arterial injury</span>'''
** '''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> ====
==== <span style="color:#ff0000">Surgical management</span> ====
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**This allows the cold, acidotic, and coagulopathic patient to be stabilized in the ICU before any attempt at potentially lengthy renal reconstruction is attempted.
**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>'''
*'''<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>'''
*Delayed renal bleeding can occur up to several weeks after injury but usually occurs within 21 days.


==== <span style="color:#ff0000">Renal injury with urinary extravasation</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)'''
*'''Stable patients where renal pelvis or proximal ureteral injury is not suspected: observation (AUA)'''
**'''Parenchymal collecting system injuries often resolve spontaneously.'''
**'''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%
***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">Indications for intervention (4):</span>'''
*#'''<span style="color:#ff0000">Suspected injury to renal pelvis or proximal ureteral avulsion</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>'''
*#*'''<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'''
*#*'''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">Urinoma increasing in size, purulence, or complexity</span> on follow-up imaging'''
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*# '''Severe renal injuries with <span style="color:#ff0000">continued urinary extravasation</span>''' (not described in 2020 AUA Guidelines)
*# '''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'''
*#*'''Placement of an internal ureteral stent for drainage may prevent prolonged urinary extravasation and decrease the chance of perirenal urinoma formation'''
*#**Persistent urinary extravasation can result in urinoma, perinephric infection, and, rarely, renal loss.
* '''<span style="color:#ff0000">Options for intervention'''
* '''Options for intervention'''
*#'''<span style="color:#ff0000">Ureteral stent (preferred)'''
*#'''Ureteral stent (preferred)'''
*#*An internalized ureteral stent is minimally invasive and alone may provide adequate drainage of the injured kidney
*#*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'''
*#*'''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'''
*# '''Percutaneous urinoma drain, percutaneous nephrostomy, or both may also be necessary'''


==== <span style="color:#ff0000">Follow-up in patient's managed non-operatively</span> ====
===== <span style="color:#ff0000">Hypertension and Renal Trauma</span> =====
*'''<span style="color:#ff0000">Indications for follow-up CT imaging (after 48 hours) in renal trauma patients (2):</span>''' (AUA)
*#'''<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">Hypertension and Renal Trauma</span> ====
*'''Hypertension is rarely noted in the early postinjury period but can occur later.'''
*'''Hypertension is rarely noted in the early postinjury period but can occur later.'''
** '''Rare cases of acute renovascular hypertension have been described, and can be treated with antihypertensives, observation, or uncommonly, nephrectomy'''
*'''<span style="color:#ff0000">Mechanisms for hypertension as a complication of renal trauma (4):</span>'''
**'''<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">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">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">Post-trauma arteriovenous fistula</span>'''
*#'''<span style="color:#ff0000">Ureteral / UPJ obstruction</span>[https://www.ncbi.nlm.nih.gov/pubmed/29959876]'''
**#'''<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
**#*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)'''


== Ureteral Trauma ==
== Ureteral Trauma ==
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****# '''<span style="color:#ff0000">Direct inspection'''  
****# '''<span style="color:#ff0000">Direct inspection'''  
****#* '''<span style="color:#ff0000">Purposefully opening the retroperitoneum''' before or after hysterectomy has been advocated to avoid ureteral injury or at least allow intraoperative detection.
****#* '''<span style="color:#ff0000">Purposefully opening the retroperitoneum''' before or after hysterectomy has been advocated to avoid ureteral injury or at least allow intraoperative detection.
****# '''<span style="color:#ff0000">Injection of 5-10 mL of IV methylene blue or indigo carmine dye followed by cystoscopy'''   
****# '''<span style="color:#ff0000">Retrograde pyelography'''
****#'''<span style="color:#ff0000">Injection of 5-10 mL of IV methylene blue or indigo carmine dye followed by cystoscopy'''   
****#* '''<span style="color:#ff0000">Poor predictor of injury'''
****#* '''<span style="color:#ff0000">Poor predictor of injury'''
****#* '''<span style="color:#ff0000">Goal of cystoscopy is to document the absence of hematuria and the presence of bilateral ureteral jets'''
****#* '''<span style="color:#ff0000">Goal of cystoscopy is to document the absence of hematuria and the presence of bilateral ureteral jets'''
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****#**# '''Pregnancy'''
****#**# '''Pregnancy'''
****#*** IV indigo carmine has been implicated in rare but serious cases of bronchospasm, bradycardia, hypertension, hypotension (most common), and anaphylactoid reactions.
****#*** IV indigo carmine has been implicated in rare but serious cases of bronchospasm, bradycardia, hypertension, hypotension (most common), and anaphylactoid reactions.
****# '''<span style="color:#ff0000">Retrograde pyelography'''
***** '''Not effective methods'''   
***** '''Not effective methods'''   
****** '''Intraoperative single-shot IVP'''
****** '''Intraoperative single-shot IVP'''
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*# '''With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition to isolate the repair when possible'''
*# '''With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition to isolate the repair when possible'''
* '''<span style="color:#ff0000">Surgical management'''
* '''<span style="color:#ff0000">Surgical management'''
** '''<span style="color:#ff0000">See Surgical repair section in Management of Upper Urinary Tract Obstruction Chapter Notes'''
** '''<span style="color:#ff0000">See [[Ureteric Stricture Disease|Ureteric Stricture Disease Chapter Notes]]'''
** '''<span style="color:#ff0000">Options for repair/reconstruction,</span> choice depends on location and length of injury'''
** '''<span style="color:#ff0000">Options for repair/reconstruction,</span> choice depends on location and length of injury'''
*** '''<span style="color:#ff0000">Upper ureteral injuries (above iliac vessesls)'''
*** '''<span style="color:#ff0000">Upper ureteral injuries (above iliac vessesls)'''
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