1. DR. ABDULLAH GHAZI ASS. CONSULTANT PMAH 13/2/2014 RENAL TRAUMA

2. 10% of trauma involve genitourinary tract. 2% of them (solitary GU injury). Kidney is the most common injured organ.

3. Blunt:  MVA.  Fall down  Deceleration → vascular injury Penetrating:  Gunshot  Stab wound

4. Renal injury suspected:  Stab wound at upper abdomen, lower chest or flank.  # lower rids, thoracic vertebra or upper lumber. Note:  Gunshot is misleading.  Hematuria, (best indicator, not correlate with severity)

5. RENAL INJURY Evaluation: Hx:  Mechanism of trauma  Loss of consciousness  Hematuria  Voiding after trauma  Flank or supra-pubic pain  Previous GU anomalies

6. RENAL INJURY Evaluation: Ex:  Vital sign  Abd: bruises, wound, distension, masses, tenderness  Genitalia: peruses, wound, blood at the meatus  DRE: high riding prostate

7. Enhanced CT-scan Indication:  Gross Hematuria  Mic. Hematuria + shock SBP<90  Hx, Ex, suspecting. Note: children have more risk of injury.

8. CT finding suggest major injury:  Medial hematoma.  Medial urine extravasations.  Lack of parenchymal enhancement. Disadvantage: ? Venus injury.

20. 86% manage conservatively.  Restricted bed rest  IVF  NPO (? OR)  Hgb q8hr  ? Abx

21. BLUNT RENAL INJURY MANAGEMENT 89% of renal blunt trauma can managed conservatively Hotaling JMHotaling JM, J Urol. 2012 FebJ Urol. 71% of Grade V need surgical management. Thanapaisal CThanapaisal C, 2013 Sep

22. PENETRATING RENAL INJURY MANAGEMENT Grade IV need immediate repair Minor degree of injury (penetrating, gunshot), posterior to anterior auxiliary line can managed conservatively.

23. In case of failed conservative management:  Angioembolization:

25. Absolute indication of operation:  Persistent renal bleeding.  Expanding perirenal hematoma.  Pulsatile perirenal hematoma.

26. Relative indication of operation:  Urinary extravasation.  Nonviable tissue >20%.  Delay Dx of arterial injury.  Segmental arterial injury.

27. Renal Injury In case of unstable patient:  Immediate exploration  One-shot intraoperative IVP can be done (2mg/kg)

28. No vascular control groupVascular control group 2729No. 23.4 Y25.3 YAge 8 (31%)9 (31%)Nephrectomy 113 min127 minOperative time 0.91 L1.06 LBlood loss 8 (30%)11 (38%)Blood transfusion 5.2U/pt5.5 U/ptNo. of PRBCs trasn Conclusion: Vascular control may increase the operative time

30. Renal reconstruction principle:

31. Renovascular injury:.  Clamp the pedicel, suture.  Dx >8hrs, kidney cannot be salvaged.  >20% non-viable tissue → exploration Damage control: laparatomy pads & re-open after 24hrs. ?? Life → Nephrectomy

32. Persistent urinary extravasation, perinephric infection, renal loss. Delayed bleeding 21D. Perinephric abscess HTN

33. Follow Up Low grade injury  U/S High grade injury:  CT scan after 48-72 hrs  CT scan after 3 months  ?? DMSA

34. Thank You For Your Attention