Renal Trauma AUA guidelines

Renal Trauma AUA Guidelines 

1. Clinicians should perform diagnostic imaging with intravenous (IV) contrast enhanced computed tomography (CT) in stable blunt trauma patients with gross hematuria or microscopic hematuria and systolic blood pressure < 90mmHG. (Standard; Evidence Strength: Grade B)

2. Clinicians should perform diagnostic imaging with IV contrast enhanced CT in stable trauma patients with mechanism of injury or physical exam findings concerning for renal injury (e.g., rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest). (Recommendation; Evidence Strength: Grade C)

3. Clinicians should perform IV contrast enhanced abdominal/pelvic CT with immediate and delayed images when there is suspicion of renal injury. (Clinical Principle)

4. Clinicians should use non-invasive management strategies in hemodynamically stable patients with renal injury. (Standard; Evidence Strength: Grade B)

5. The surgical team must perform immediate intervention (surgery or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation. (Standard; Evidence Strength: Grade B)

6. Clinicians may initially observe patients with renal parenchymal injury and urinary extravasation. (Clinical Principle)

7. Clinicians should perform follow-up CT imaging for renal trauma patients having either (a) deep lacerations (AAST Grade IV-V) or (b) clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention). (Recommendation; Evidence Strength: Grade C)

Follow-up CT imaging (after 48 hours) is prudent in patients with deep renal injuries (AAST Grade IV-V) because these 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.^39, 53Routine 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.^54-61 Routine DMSA or other functional nuclear scans are also not advised. Benefits of forgoing routine follow-up imaging in low-grade renal injuries include simplicity in follow-up, decreased radiation exposure and IV contrast complications, patient convenience, and lower cost. Clinicians should not hesitate to perform follow-up imaging studies when a complication of renal injury is suspected. Periodic monitoring of blood pressure up to a year after the injury may uncover the rare instances of post-injury renovascular hypertension.

8. Clinicians should perform urinary drainage in the presence of complications such as enlarging urinoma, fever, increasing pain, ileus, fistula or infection. (Recommendation; Evidence Strength: Grade C) Drainage should be achieved via ureteral stent and may be augmented by percutaneous urinoma drain, percutaneous nephrostomy or both. (Expert Opinion)

EAU Guidelines 

Dagnostic evaluation

• Haemodynamic stability should be assessed upon admission.

• History: time and setting of incident, past renal surgery, known renal abnormalities.

• Lab: visible haematuria, dipstick urine analysis, serial hae- matocrit, baseline serum creatinine.

• In blunt trauma with visible- or non-visible haematuria and hypotension, a history of rapid deceleration injury and/or significant associated injuries should undergo radiographic evaluation.

• Any degree of haematuria after penetrating abdominal or thoracic injury requires urgent imaging.

• Imaging: computed tomography (CT) scan, with and with- out intravenous contrast material, in haemodynamically stable patients.

• Ultrasound (US) may be helpful during the primary evalua- tion or follow-up of recuperating patients.

• Angiography can be used for diagnosis and simultaneous selective embolisation of bleeding vessels if necessary.

Management

• Following blunt renal trauma, stable patients should be managed conservatively with close monitoring of vital signs.

• Isolated grade 1-3 stab and low-velocity gunshot wounds in stable patients, after complete staging, should be managed expectantly.

• Indications for renal exploration include:

• • •

haemodynamic instability; exploration for associated injuries; expanding or pulsatile peri-renal haematoma identified during laparotomy; grade 5 vascular injury (Figs. 1 & 2).

• • Radiological embolisation is indicated in patients with

active bleeding from renal injury, but without other indica-

tions for immediate abdominal operation. • Intraoperatively, renal reconstruction should be attempted

once haemorrhage is controlled and there is sufficient viable renal parenchyma.

Interventional radiology is indicated in patients with active bleeding from renal injury but without other indications for immediate abdominal operation.

Post-operative care, follow-up and complications

• Repeat imaging is recommended in cases of suspected complications, cases of fever, flank pain, or falling haematocrit.

• Nuclear scintigraphy is useful for documenting functional recovery.

• First follow up should be at approximately 3 months after major renal injury with hospitalisation and should include: physical examination, urinalysis, individualised radiologi- cal investigation, blood pressure measurement and serum determination of renal function.

• Long-term follow-up should be decided on a case-by-case basis.

• Complications following renal trauma require a thorough radiographic evaluation.

• Medical management and minimally invasive techniques should be the first choice for the management of complica- tions.

EAU Guidelines Blunt renal trauma

EAU Guidelines Penetrating renal trauma

Ureteral Injuries

Management

• Partial injury can be managed with ureteral stenting or urinary diversion by a nephrostomy.

• In complete injuries, ureteral reconstruction following temporary urinary diversion is required.

• The type of repair procedure depends on the site of the injury (Table 2), and it should follow the principles outlined in Table 3.

• Proximal- and mid-ureteral injuries can often be managed by primary uretero-ureterostomy, while a distal injury is often treated with ureteral reimplantation.