eMedicine Specialties > Urology > Trauma

Renal Trauma

Author: Douglas M Geehan, MD, Associate Professor, Department of Surgery, University of Missouri at Kansas City
Coauthor(s): Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Contributor Information and Disclosures

Updated: Jan 27, 2010

Introduction

Renal trauma may manifest in a dramatic fashion for both the patient and the clinician. The incidence of renal trauma somewhat depends on the patient population being considered. Renal trauma accounts for approximately 3% of all trauma admissions and as many as 10% of patients who sustain abdominal trauma. Also, renal trauma may occur in settings other than those thought of as a classic trauma setting. The approach to renal injuries has changed over time, requiring diligent attention to recent literature. Namely, the tolerance for nonoperative or expectant management has increased, even in the most seriously injured kidneys, replacing the past tendency toward aggressive renorrhaphy.

Problem

Most renal trauma occurs as a result of blunt trauma. Renal injuries may be generally divided into 3 groups: renal laceration, renal contusion, and renal vascular injury. All subsets of renal trauma require a high index of clinical awareness and prompt evaluation and management.

Frequency

The frequency of renal injury somewhat depends on the patient population being considered. Renal trauma accounts for approximately 3% of all trauma admissions and as many as 10% of patients who sustain abdominal trauma.

Etiology

The mechanism of injury should alert the clinician to the possibility of renal trauma. The following list is not all-inclusive, but it highlights the major mechanisms that generate renal injuries.

  • Penetrating (eg, gunshot wounds, stab wounds)
  • Blunt (eg, pedestrian struck, motor vehicle crash, sports, fall)
  • Iatrogenic (eg, endourologic procedures, extracorporeal shock-wave lithotripsy,1 renal biopsy, percutaneous renal procedures)
  • Intraoperative (eg, diagnostic peritoneal lavage2 )
  • Other (eg, renal transplant rejection, childbirth3 [may cause spontaneous renal lacerations])

Presentation

The diagnosis of renal injury begins with a high index of clinical awareness. The mechanism of injury provides the framework for the clinical assessment. Particular attention should be paid to complaints of flank or abdominal pain. Urinalysis, both gross and, if necessary, microscopic, should be performed in patients who are thought to have renal trauma. Based on these initial measures, radiographic or operative investigation may follow.

Indications

Most blunt renal injuries are low-grade; therefore, they are usually amenable to treatment with observation and bed rest alone. Penetrating trauma is more likely to be associated with more severe renal injury, thus requiring a higher index of clinical awareness. Further, penetrating trauma is more often associated with other abdominal injuries requiring laparotomy, thus providing the opportunity for intraoperative renal staging and/or repair.

Patients with indications for emergent exploration include those with hemodynamic instability. Expanding hematomas or active hemorrhage suggests the possibility of high-grade renal injury. Patients with penetrating trauma who are stable and do not require urgent laparotomy for other possible intra-abdominal injuries may be observed without immediate renal exploration.

Unrelenting gross hematuria may require urgent exploration. However, the presence of a renal contusion does not typically require specific intervention. Findings from imaging studies may appear quite alarming, but most renal contusions resolve, particularly if the lesion appears to be of grade I-III.

Relevant Anatomy

In most instances, the kidneys are paired retroperitoneal structures. They lie against the psoas muscles. The superior aspect of the kidneys is somewhat protected by the lower ribs. However, the lower poles are inferior to the 12th ribs. The parenchyma of the kidney has a segmental arterial supply. This anatomic arrangement becomes important in the management of renal lacerations. Blunt injuries tend to fracture along the planes between the segmental vessels, while penetrating injuries cross the segmental vessels. Numerous anatomic variations exist, including pelvic kidneys; horseshoe kidneys; and multiple renal arterial, venous, and ureteral duplications.

Contraindications

For all practical purposes, no specific contraindications exist for surgical exploration of possible renal trauma. However, the general trend is toward a more selective approach.

More on Renal Trauma

Overview: Renal Trauma
Workup: Renal Trauma
Treatment: Renal Trauma
Follow-up: Renal Trauma
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Fukumori T, Yamamoto A, Ashida S, et al. Extracorporeal shock wave lithotripsy-induced renal laceration. Int J Urol. Jul 1997;4(4):419-21. [Medline].

  2. Barba CA, Kauder D, Schwab CW, Turek PJ. Pelvic kidney laceration: an unusual complication of percutaneous diagnostic peritoneal lavage--case report. J Trauma. Feb 1994;36(2):277-9. [Medline].

  3. Onuora VC, al Ariyan R, Koko AH, et al. Major injuries to the urinary tract in association with childbirth. East Afr Med J. Aug 1997;74(8):523-6. [Medline].

  4. Heyns CF, van Vollenhoven P. Increasing role of angiography and segmental artery embolization in the management of renal stab wounds. J Urol. May 1992;147(5):1231-4. [Medline].

  5. Ahmed S, Morris LL. Renal parenchymal injuries secondary to blunt abdominal trauma in childhood: a 10-year review. Br J Urol. Oct 1982;54(5):470-7. [Medline].

  6. Al-Qudah HS, Santucci RA. Complications of renal trauma. Urol Clin North Am. Feb 2006;33(1):41-53, vi. [Medline].

  7. [Guideline] Brandes SB, McAninch JW. Renal trauma: a practical guide to evaluation and management. ScientificWorldJournal. Jun 7 2004;4 Suppl 1:31-40. [Medline].

  8. Broghammer JA, Fisher MB, Santucci RA. Conservative management of renal trauma: a review. Urology. Oct 2007;70(4):623-9. [Medline].

  9. Cass AS. Blunt renal trauma in children. J Trauma. Feb 1983;23(2):123-7. [Medline].

  10. Cass AS, Bubrick M, Luxenberg M, et al. Renal trauma found during laparotomy for intra-abdominal injury. J Trauma. Oct 1985;25(10):997-1000. [Medline].

  11. Cass AS, Cass BP. Immediate surgical management of severe renal injuries in multiple-injured patients. Urology. Feb 1983;21(2):140-5. [Medline].

  12. Cass AS, Luxenberg M, Gleich P, Smith C. Type of blunt renal injury rather than associated extravasation should determine treatment. Urology. Sep 1985;26(3):249-51. [Medline].

  13. Chang J, Katzen BT, Sullivan KP. Transcatheter gelfoam embolization of posttraumatic bleeding pseudoaneurysms. AJR Am J Roentgenol. Oct 1978;131(4):645-50. [Medline].

  14. Clark RA. Traumatic renal artery occlusion. J Trauma. Apr 1979;19(4):270-4. [Medline].

  15. Colli J, Kandzari S. Renal trauma: a case report of a laceration and avulsion of the kidney. W V Med J. Nov-Dec 1997;93(6):320-2. [Medline].

  16. Fraser JD, Aguayo P, Ostlie DJ, St Peter SD. Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int. Feb 2009;25(2):125-32. [Medline].

  17. Gill B, Palmer LS, Reda E, et al. Optimal renal preservation with timely percutaneous intervention: a changing concept in the management of blunt renal trauma in children in the 1990s. Br J Urol. Sep 1994;74(3):370-4. [Medline].

  18. Grieco JG, Perry JF Jr. Retroperitoneal hematoma following trauma: its clinical importance. J Trauma. Sep 1980;20(9):733-6. [Medline].

  19. Hardeman SW, Husmann DA, Chinn HK, Peters PC. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. J Urol. Jul 1987;138(1):99-101. [Medline].

  20. Hellier WP, Higgs B. Severe renal laceration from blunt trauma presenting with microhaematuria and a normal intravenous urogram. Br J Urol. Aug 1996;78(2):309-10. [Medline].

  21. Homan WP, Cheigh JS, Kim SJ, et al. Renal allograft fracture: clinicopathological study of 21 cases. Ann Surg. Dec 1977;186(6):700-3. [Medline].

  22. Husmann DA, Gilling PJ, Perry MO, et al. Major renal lacerations with a devitalized fragment following blunt abdominal trauma: a comparison between nonoperative (expectant) versus surgical management. J Urol. Dec 1993;150(6):1774-7. [Medline].

  23. Husmann DA, Morris JS. Attempted nonoperative management of blunt renal lacerations extending through the corticomedullary junction: the short-term and long-term sequelae. J Urol. Apr 1990;143(4):682-4. [Medline].

  24. Kulmala R, Seppanen J, Heikkinen A, Auvinen O. Aetiology, diagnosis and treatment of patients with renal trauma. A survey on patients in the Tampere area during two decades. Ann Chir Gynaecol Suppl. 1993;206:84-9. [Medline].

  25. Lee WJ, Smith AD, Cubelli V, et al. Complications of percutaneous nephrolithotomy. AJR Am J Roentgenol. Jan 1987;148(1):177-80. [Medline].

  26. Lee YJ, Oh SN, Rha SE, Byun JY. Renal trauma. Radiol Clin North Am. May 2007;45(3):581-92, ix. [Medline].

  27. Leppaniemi AK, Haapiainen RK, Lehtonen TA. Diagnosis and treatment of patients with renal trauma. Br J Urol. Jul 1989;64(1):13-7. [Medline].

  28. Lindekleiv H, Haro S, Nordhus K, Eggen T, Due J. Renal artery pseudoaneurysm secondary to blunt trauma nine years earlier: case report and review of the literature. Scand J Urol Nephrol. 2008;42(5):488-91. [Medline].

  29. McAninch JW. Renal trauma. J Urol. Dec 1993;150(6):1778. [Medline].

  30. McAninch JW, Carroll PR. Renal trauma: kidney preservation through improved vascular control-a refined approach. J Trauma. Apr 1982;22(4):285-90. [Medline].

  31. McAninch JW, Carroll PR, Armenakas NA, Lee P. Renal gunshot wounds: methods of salvage and reconstruction. J Trauma. Aug 1993;35(2):279-83; discussion 283-4. [Medline].

  32. Mejia JC, Myers JG, Stewart RM, Dent DL, Connaughton JC. A right renal vein pseudoaneurysm secondary to blunt abdominal trauma: a case report and review of the literature. J Trauma. May 2006;60(5):1124-8. [Medline].

  33. Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma. Dec 1989;29(12):1664-6. [Medline].

  34. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol. Dec 1996;156(6):2014-8. [Medline].

  35. Nicol AJ, Theunissen D. Renal salvage in penetrating kidney injuries: a prospective analysis. J Trauma. Aug 2002;53(2):351-3. [Medline].

  36. Peterson NE. Intermediate-degree blunt renal trauma. J Trauma. Jun 1977;17(6):425-35. [Medline].

  37. Peterson NE. Re: Attempted nonoperative management of blunt renal lacerations extending through the corticomedullary junction: the short-term and long-term sequelae. J Urol. Jan 1991;145(1):154. [Medline].

  38. Peterson NE. Genitourinary trauma. In: Mattox KL, Feliciano DV, Moore EE, eds. Trauma. 4th ed. New York, NY: McGraw-Hill; 2000:839-78.

  39. Pinto IT, Chimeno PC. Treatment of a urinoma and a post-traumatic pseudoaneurysm using selective arterial embolization. Cardiovasc Intervent Radiol. Nov-Dec 1998;21(6):506-8. [Medline].

  40. Rao AR, Cherian J, Arya N, Kapasi F, Shergill IS, Potluri B. Urological emergency: diagnosis and management of renal trauma. Br J Hosp Med (Lond). Nov 2005;66(11):634-7. [Medline].

  41. Rosen MA, McAninch JW. Management of combined renal and pancreatic trauma. J Urol. Jul 1994;152(1):22-5. [Medline].

  42. Sagalowsky AI, McConnell JD, Peters PC. Renal trauma requiring surgery: an analysis of 185 cases. J Trauma. Feb 1983;23(2):128-31. [Medline].

  43. Santucci RA, Fisher MB. The literature increasingly supports expectant (conservative) management of renal trauma--a systematic review. J Trauma. Aug 2005;59(2):493-503. [Medline].

  44. Schwartz BF, Stoller ML. Complications of retrograde balloon cautery endopyelotomy. J Urol. Nov 1999;162(5):1594-8. [Medline].

  45. Surana R, Khan A, Fitzgerald RJ. Scarring following renal trauma in children. Br J Urol. May 1995;75(5):663-5. [Medline].

  46. Umbreit EC, Routh JC, Husmann DA. Nonoperative management of nonvascular grade IV blunt renal trauma in children: meta-analysis and systematic review. Urology. Sep 2009;74(3):579-82. [Medline].

  47. Wein AJ, Arger PH, Murphy JJ. Controversial aspects of blunt renal trauma. J Trauma. Sep 1977;17(9):662-6. [Medline].

  48. Werkman HA, Jansen C, Klein JP, Ten Duis HJ. Urinary tract injuries in multiply-injured patients: a rational guideline for the initial assessment. Injury. Nov 1991;22(6):471-4. [Medline].

  49. White RA, Ramos SM, Delany HM. Renorrhaphy using knitted polyglycolic acid mesh. J Trauma. Jun 1987;27(6):689-90. [Medline].

[ CLOSE WINDOW ]

Keywords

renal trauma, renal laceration, renal contusion, kidney trauma, kidney laceration, abdominal trauma, blunt trauma, blunt force trauma, renal vascular injury, gunshot wound, stab wound, motor vehicle crash, sports injury, urologic endoscopy, endourologic procedures, extracorporeal shock-wave lithotripsy, ESWL, renal biopsy, percutaneous renal procedure, diagnostic peritoneal lavage, missile injury, hematuria

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Douglas M Geehan, MD, Associate Professor, Department of Surgery, University of Missouri at Kansas City
Douglas M Geehan, MD is a member of the following medical societies: American College of Surgeons, American Institute of Ultrasound in Medicine, American Medical Association, Association for Academic Surgery, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Disclosure: Nothing to disclose.

Medical Editor

Peter Langenstroer, MD, Associate Professor, Department of Urology, Medical College of Wisconsin
Peter Langenstroer, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.