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
Bureau of Medicine and Surgery
Department of the Navy
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Washington, D.C
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Operational Medicine
Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
NAVMED P-5139
January 1, 2001 |
United States Special Operations Command
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MacDill AFB, Florida
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