Upper Tract Trauma

AAST renal injury severity, from AAST + Campbell's

Renal Trauma

IF... THEN...
Diagnosis Blunt trauma + GH Obtain CTU
Blunt trauma + MH + SBP < 90
Blunt trauma concerning for renal injury but no hematuria
Penetrating trauma near kidney with(out) hematuria
Exam (rib fx, flank bruising) concerning for renal injury
Unstable patient taken to OR without imaging Obtain on table IVP
2mL/kg contrast bolus
XR 10-15min later
MH, no hypotension, no concerning injury Can observe without imaging
Management Grade I-III injury Manage conservatively
Grade IV-V injury Repeat CT within 48hrs
Worsening flank pain
Worsening anemia
Abdominal distension
Expanding urinoma with:
  • Fever
  • Increased pain
  • Ileus
  • Fistula
  • Infection
Provide GU drainage
Stent preferred
Can consider PCN or drain
Urinary extravasation without above signs Can manage conservatively
Hemodynamically unstable not responding to resuscitation Absolute indication for embolization/exploration
Hemodynamically unstable + perirenal hematoma > 4cm or Grade 3-5 injury with contrast extravasation
Expanding/pulsatile renal hematoma
Suspected vascular pedicle avulsion
UPJ avulsion
Urine extravasation with significant parenchymal devascularization Relative indication for embolization/exploration
Renal + colon/pancreas injuries
Arterial thrombosis
Urine extravasation from parenchymal injury

CT findings concerning for major renal injury (9x more likely to require intervention)

  1. Medial hematoma: suggests vascular injury
  2. Medial urinary extravasation: suggests renal pelvis or UPJ avulsion
  3. Global lack of parenchymal enhancement: suggests renal artery occlusion
  4. Combination of 2+: large hematoma > 3.5cm, medial renal laceration, vascular contrast extravasation

Post-renal injury hypertension mechanisms (renin production stimulated by partial ischemia)

Renal injury tips

AAST ureteral injury severity, from AAST + Campbell's

Algorithm for ureteral injury from external trauma, from Campbell's

Algorithm for iatrogenic ureteral injury discovered intraoperatively, from Campbell's

Algorithm for iatrogenic ureteral injury discovered postoperatively, from Campbell's

Ureteral Trauma

IF... THEN...
Diagnosis Ureteral injury suspected (see renal criteria) CT urography
Assessing for intraoperative injury Inspect ureter
Inject dye IV or via renal pelvis
Contrast evaluation
Management Stable + contusion or crush injury Place stent
Debride if large injury
Stable + intraop laceration Place stent
Repair laceration
Unstable + intraop injury Ligate ureter with nonabsorbable stitch
Place PCN or cutaneous ureterostomy +/- stent
Delayed repair
Delayed identification:
  • Persistent flank/abdominal pain
  • Flank mass or abdominal distension
  • Ileus
  • Hydronephrosis
  • Elevated BUN/Cr
  • High surgical drain output
Retrograde pyelogram + stent placement
If fails, place PCN
Delayed repair
Ureterovaginal fistula Stent (64-76% success)
Delayed repair (100% success)

Prophylactic stenting

Ureteral repair principles

Ureteral injury tips