Evaluation and Management of Urological Injuries

Location

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  Paired retroperitoneal structures at the level of T12-L3 vertebra

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  Right kidney slightly inferior to the left due to liver

Covered with superficial to the deep with:

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  pararenal fat.

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  renal fascia (Gerota’s fascia or perirenal fascia): It encloses the kidneys and the suprarenal glands.

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  Perirenal fat.

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  Renal capsule.

Renal hilum

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  Deep fissure on the medial margin of each kidney

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  Structures at the hilum from anterior to posterior

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    Renal vein

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    Renal artery

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    Ureter

Anatomical relations

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  Left kidney

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    Superior

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      Left suprarenal gland

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    Anterior

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      Spleen

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      Pancreas

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      Stomach

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      Splenic flexure of the colon

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    Posterior

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      Diaphragm

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      11th and 12th ribs

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      Psoas major, quadratus lumborum, and transversus abdominis muscles

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      Subcostal, iliohypogastric, and ilioinguinal nerves

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  Right kidney

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    Superior

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      Right suprarenal gland

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    Anterior

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      Liver

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      Duodenum

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      Right colic (hepatic) flexure

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    Posterior

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      Diaphragm

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      12th rib

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      Psoas major, quadratus lumborum, and transversus abdominis muscles

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      Subcostal, iliohypogastric, and ilioinguinal nerves

Arterial supply

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  Renal arteries

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    One for each kidney

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    Direct branch from the abdominal aorta, just distal to the origin of the superior mesenteric artery (SMA) at the level of L2 vertebra

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    Right renal artery is longer and lies posterior to the inferior vena cava (IVC).

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    Renal arteries enter the kidney at the renal hilum.

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    Renal artery divides into an anterior and a posterior division at the hilum.

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    Each division of the renal arteries further divides into five segmental arteries.

Venous drainage

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  Renal veins

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    Right and left renal veins drain directly into the IVC.

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    Located anterior to the renal arteries at the renal hilum

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    Left renal vein is longer and travels anteriorly to the abdominal aorta below the origin of the SMA.

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  Left renal vein receives:

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    left adrenal vein.

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    lumbar vein.

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    left gonadal vein.

Blunt trauma

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  Most common mechanism of injury

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  Frequently due to high-velocity deceleration mechanism

Penetrating trauma

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  Less common mechanism of injury

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  May be due to low-energy stab wound or high-energy gunshot wound (GSW)

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  Renal vascular injuries are more frequent after penetrating trauma.

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  Usually associated with other injuries

Focused Assessment with Sonography for Trauma (FAST)

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  Low sensitivity and specificity for renal trauma evaluation

IV contrast-enhanced CT of the abdomen and pelvis with delayed urographic phase

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  Preferred test in hemodynamic stable blunt or penetrating injuries

Intravenous urography

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  May be used to identify renal injuries intraoperatively in hemodynamically unstable patients where CT was not performed

Grade I

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  Subcapsular hematoma and/or parenchymal contusion without laceration

Grade II

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  Perirenal hematoma confined to Gerota’s fascia

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  Renal parenchymal laceration <1 cm depth without urinary extravasation

Grade III

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  Renal parenchymal laceration >1 cm depth without collecting system rupture or urinary extravasation

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  Any injury in the presence of a kidney vascular injury or active bleeding contained within Gerota’s fascia

Grade IV

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  Parenchymal laceration extending into urinary collecting system with urinary extravasation

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  Renal pelvis laceration and/or complete ureteropelvic disruption

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  Segmental renal vein or artery injury

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  Active bleeding beyond Gerota’s fascia into the retroperitoneum or peritoneum

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  Segmental or complete kidney infarction(s) due to vessel thrombosis without active bleeding

Grade V

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  Main renal artery or vein laceration or avulsion of hilum

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  Devascularized kidney with active bleeding

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  Shattered kidney with loss of identifiable parenchymal renal anatomy. More than one grade of kidney injury may be present and should be classified by the higher grade injury . Advance one grade for multiple injuries up to Grade III .

Grades I, II, and III

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  Nonoperative management

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    If no other associated injuries that require abdominal exploration

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    Evaluation with angiogram for possible angioembolization indicated if CT positive for blush

Grades IV and V

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  Nonoperative management

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    If no other associated injuries that require exploratory laparotomy

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    Evaluation with angiogram and possible angioembolization are possible if CT abdomen is suggestive for:

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      arterial contrast extravasation.

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        Extended perirenal hematoma

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        Pseudoaneurysm

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        Arteriovenous fistula

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    Non-self-limiting gross hematuria may need evaluation with angiogram and angioembolization.

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    Renal artery injury in CT should be evaluated for stent or stent graft.

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    Endoscopic evaluation for renal pelvic injury

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      May require ureteric stent or surgical management

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  Operative management

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    Indications

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      Evidence of associated intraabdominal injuries in CT abdomen

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      Severe renal arterial injury with persistent bleeding and failed embolization

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      Main renal venous injury

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      Peritonitis

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      Expanding or pulsatile hematoma

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      Pyeloureteral injury not amenable to endoscopic/percutaneous techniques/stent

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    Operative procedures may include:

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      exploration of hematoma and bleeding control.

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        Active bleeding

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        Expanding hematoma

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        Pulsatile bleeding

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      Nephrectomy

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        Shattered kidney

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        Severe arterial injury

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        Severe right renal venous injury requiring ligation. Ligation of the left renal vein does not require nephrectomy.

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      Partial nephrectomy for upper or lower pole renal injury

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      Repair of laceration

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      Repair of pyeloureteric injury

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      Repair of renal artery

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      Ligation of renal vein

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        Right renal vein ligation requires nephrectomy because lack of venous collaterals results in renal infarct.

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        Left renal vein ligation does not require nephrectomy because of its collaterals from suprarenal vein, lumbar vein, and left gonadal vein.

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      Renal salvage procedures for solitary or bilateral injuries

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        Segmental angioembolization

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        Percutaneous revascularization with stent or stent graft may be considered in patients with limited warm ischemia time (<240 min). Warm ischemia time >60 min results in significant losses in kidney function.

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        Repair of renal pelvis with nephrostomy tube and stent placement

Grades I, II, and III

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  Nonoperative management

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    If isolated low-energy injuries without any other associated injury

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    Evaluation with angiogram for possible angioembolization is indicated if CT is positive for blush.

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  Operative management

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    High-energy penetrating injury

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    Renal injury associated with other intraabdominal injuries

Grades IV and V

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  Operative management including:

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    nephrectomy if nonsalvageable injury.

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      Shattered kidney

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      Severe arterial injury

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      Severe right venous injury requiring ligation. Ligation of left renal vein does not require nephrectomy.

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    Partial nephrectomy

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    Repair of laceration

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    Repair of pyeloureteric injury

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    Attempt for renal salvage for solitary or bilateral injuries as discussed in blunt injury

Exploratory laparotomy

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  Procedures depend on the grade of injury.

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  Grades I, II, and III

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    Retroperitoneal hematoma is explored if:

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      expanding.

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      ruptured.

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      pulsatile.

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    Control of bleeding

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      Surgical bleeding control

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      Packing with hemostatic agents

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    Postoperative evaluation after resuscitation

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      IV contrast-enhanced CT with urogram after resuscitation

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      Postoperative evaluation with angiogram for angioembolization

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  Grades IV and V

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    Nephrectomy

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      Uncontrollable life-threatening hemorrhage with avulsion of the renal pedicle

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      Pulsating and/or expanding retroperitoneal hematoma or renal vein lesion without self-limiting hemorrhage

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      Shattered kidney

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      Severe arterial injury

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      Severe right renal venous injury. Ligation of left renal vein does not require nephrectomy.

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    Partial nephrectomy if injury is at the upper or lower pole.

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    Exploration of hematoma with control of bleeding/repair of laceration. Indications of exploration include:

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      Active bleeding with hematoma

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      Expanding hematoma

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      Pulsatile bleeding

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    Repair of laceration

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    Ligation of vein

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      Right renal vein ligation requires nephrectomy.

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      Left renal vein ligation does not require nephrectomy.

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    Repair of pyeloureteric injury

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      Endoscopic treatment or surgical treatment after resuscitation

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    Attempt for renal salvage for solitary or bilateral injuries as discussed in blunt injury

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      IV contrast-enhanced CT abdomen with urogram after resuscitation

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      Angiogram and evaluation for angioembolization

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      Endoscopic evaluation after resuscitation for ureteric repair or stent

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      Percutaneous revascularization with stent or stent graft may be considered in patients with limited warm ischemia time (<240 min). Warm ischemia time >60 min results in significant losses in kidney function.

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      Repair of renal pelvis with nephrostomy tube and stent placement

Exploratory laparotomy

Procedures depending on the grade of injury

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  Grades I, II, and III

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    Retroperitoneal hematoma is explored to control bleeding/repair of laceration.

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    Postoperative evaluation after resuscitation

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      IV contrast-enhanced CT with urogram after resuscitation

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      Evaluation with angiogram if bleeding noted in CT

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  Grades IV and V

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    Nephrectomy

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      Uncontrollable life-threatening hemorrhage renal pedicle injury

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      Pulsating and/or expanding retroperitoneal hematoma or renal vein lesion without self-limiting hemorrhage

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      Severe renal laceration

      

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      Severe arterial injury

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      Severe right renal venous injury. Ligation of left renal vein does not require nephrectomy.

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    Partial nephrectomy if injury at the upper or lower pole

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    Exploration of hematoma with control of bleeding/repair of laceration

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    Repair of laceration

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    Ligation of vein

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      Right renal vein ligation requires nephrectomy.

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      Left renal vein ligation does not require nephrectomy.

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    Repair of pyeloureteric injury

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      Endoscopic treatment or surgical treatment after resuscitation

  • ■

    Attempt for renal salvage for solitary or bilateral injuries

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      Damage-control procedure to control bleeding

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      Postoperative evaluation after resuscitation and reexploration

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        IV contrast-enhanced CT abdomen with urogram after resuscitation

      • ■

        Angiogram and evaluation for angioembolization

      • ■

        Endoscopic evaluation after resuscitation for ureteric repair or stent

      • ■

        Percutaneous revascularization with stent or stent graft may be considered in patients with limited warm ischemia time (<240 min). Warm ischemia time >60 min results in significant losses in kidney function.

      • ■

        Repair of renal pelvis with nephrostomy tube and stent placement

Enlarging urinoma; can be treated with:

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  percutaneous drainage of urinoma.

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  percutaneous nephrostomy.

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  ureteral stent.

Fistula

Infection

Ileus