Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXI: Wounds and Injuries of the Genitourinary Tract

Wounds of the Kidney

United States Department of Defense

Renal injuries, except for renal pedicle injuries, are usually not life threatening, however, if not diagnosed or treated properly, they may cause significant morbidity. The diagnosis of renal injury should be suspected based upon the type of trauma sustained, the physical examination, and the urinalysis. Microscopic or gross hematuria is usually present; however, the absence of hematuria does not exclude renal trauma. Renal injury must be suspected in the presence of associated findings such as multiple rib fractures, vertebral body or transverse process fractures, crushing injuries of the chest of thorax, or any penetrating injury to the flank or upper abdomen.

The primary radiographic study used to diagnose renal trauma is the intravenous pyelogram (IVP). This study will usually define renal anatomy, showing injury to the affected kidney. Of equal importance, the IVP should also confirm the presence and functional status of the contralateral kidney and the presence or absence of congenital anomalies, such as horseshoe or congenital single kidney. Delayed films may be necessary to visualize contrast extravasation. If the functional status of the unaffected kidney is not ascertained prior to surgical exploration, an intravenous pyelogram must be performed on the operating table prior to any attempt at exploration of the injured kidney. It has been a generally accepted practice to perform preoperative IVPs on all individuals with abdominal wounds who require laparotomy.

Rena I trauma, either blunt or penetrating, may be classified according to the degree or extent of anatomical damage to the kidney. Minor injuries consist of renal contusions or shallow cortical lacerations. Major injuries are comprised of deep cortical lacerations, shattered kidneys, renal vascular pedicle injuries, or total avulsion of the renal pelvis.

Some renal injuries will be minor and may be managed nonoperatively with hydration and bedrest. Major injuries usually require operative intervention with debridement of nonviable renal tissue (partial nephrectomy), closure of the collecting system, and drainage of the retroperitoneal area. In some instances, total nephrectomy may be required. Since there is an 80% incidence of associated visceral injuries with major renal trauma, most cases will require a laparotomy for evaluation and repair of intraperitoneal injuries. Hemodynamically significant injuries are 'addressed first. If control of hemorrhage requires exploration of the renal space, it is imperative to first gain vascular control of the renal pedicle prior to opening the perirenal fascia and releasing the relatively hemostatic tamponade. Vascular control is obtained by using a periaortic approach to the renal vascular pedicle. The small intestine is retracted superiorly and the posterior peritoneum is incised over the aorta. Since the left renal vein crosses anterior to the aorta, over the origin of both the right and left renal arteries, it must be mobilized to gain control of the origin of either renal artery. After applying atraumatic vascular clamps to the appropriate renal artery and vein, the respective colon may then be mobilized and reflected medially, The perirenal fascia is then opened and the renal wound evaluated.

Operative treatment consists of hemostasis, local debridement and suture, total nephrectomy, or rarely, partial nephrectomy. Urinary diversion in the form of tube nephrostomy or a ureteral stent is recommended in the presence of associated injuries of the duodenum, pancreas, or large bowel. If the tactical situation rules out immediate surgical treatment for major renal injury and the patient is hemodynamically stable, he should be supported with intravenous fluids until evacuation.

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Operational Medicine 2001

Health Care in Military Settings

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