Complications of Renal Trauma

doi:10.1016/j.ucl.2005.10.005

Urologic Clinics of North America

Volume 33, Issue 1, February 2006, Pages 41-53

https://doi.org/10.1016/j.ucl.2005.10.005 Get rights and content

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Extravasation of urine

Extravasation of urine is the most common complication of renal trauma [8] and is present in all patients, by definition, with stage IV parenchymal renal trauma and also may be caused by forniceal rupture after lesser trauma [9]. The prevalence of extravasation is higher after penetrating injury (10%–30%) than after blunt trauma (2%–18%) [7], [10]. In rare cases, urinary extravasation may result from direct trauma to the renal pelvis or ureteropelvic junction (UPJ) injury [11], [12], [13].

Urinoma

Urinoma is a urine collection that may form after trauma when urine extravasates through major parenchymal disruptions or UPJ laceration. Urinoma may be worsened in cases of distal urinary obstruction [7], [32], [33]. Urinoma may be seen in 1% to 7% of renal trauma patients [7], [34], [35]. Urinoma may be seen more commonly in patients who present with penetrating trauma (7%–30%) [10], [34].

Perinephric abscess

Urinary tract infection is one of the main infections reported in all trauma patients in the intensive care unit [48]. In rare cases, urinary infections can be symptomatic of a more serious infection—a perinephric abscess. The preferred examination in suspected cases is CT scan [7].

Perinephric abscess is rare, and in a series of 25 patients only 4 had a traumatic etiology for the abscess [49]. Frank abscess occurs in less than 1% of renal trauma cases, [2], [10] and in 5% of penetrating renal

Coincident organ injury

The presence of coincident organ injury is not a complication itself, but it is a complicating factor of renal trauma. Associated organ injury is reported in 61% to 100% of reported cases of penetrating renal trauma [10], [51], [54], [55], and 35% to 65% of reported blunt renal trauma cases [6], [8], [56].

Hepatic injury is seen commonly in those with renal injury and may be seen in 73% of right penetrating renal trauma and 30% of blunt renal trauma [57]. Associated hepatic injury occurs in 26%

Unnecessary nephrectomy

Although not classically considered a “complication,” the authors consider the unnecessary removal of a kidney during the treatment of renal trauma to be an avoidable disaster second only to death or extreme debility. Although this problem occurs less frequently now that conservative management of renal trauma is more common, between 17% and 30% of traumatized kidneys were spared nephrectomy when conservative therapy became hospital policy [6], [24], [59], [60]. For patients who require

Impaired kidney function and renal insufficiency

Preservation of renal function while minimizing morbidity and eliminating renal-related mortality is the authors' goal when treating renal trauma patients. According to the literature, often this is possible. Wessells and colleagues [65] reported that renal function by radionuclide scan was 39% after renal reconstruction in 52 patients. Nineteen percent of patients had less than 33% function in the injured side, and only one patient had renal insufficiency requiring dialysis (bilateral kidney

Hypertension

Development of hypertension after renal trauma is a controversial issue. Although its occurrence has been widely reported, many series have not observed it [10], [20], [51], [54], [56], [59], [70], [73]. In general, it may occur an average in 5% of renal trauma patients [74]. Reports range widely from 0.2% to 55% [2], [24], [75], [76], [77], [78], [79]. In one study, the prevalence of hypertension in conservatively treated patients was 55% compared with 0% in surgically treated patients [78];

Page kidney

The first report of renin dependent hypertension was published by Page in 1939 [90]. Hypertension was induced by experimentally wrapping a canine kidney with cellophane. Page described formation of thick, dense, scar tissue around the kidney producing constrictive perinephritis and hypertension. The blood pressure returned to normal after nephrectomy. In 1955, Engel and Page reported the first clinical correlation with this experiment in a 19-year-old hypertensive man cured by removal of the

Specific complications of renal vascular injury

Of all the types of renal injury, renal vascular injury is the most dangerous. These injuries occur in 2.5% to 4% of renal trauma patients and in 16% of patients who present with penetrating abdominal injuries [1]. They usually occur in significantly injured patients and are associated with much higher risk for morbidity (transfusion rate, impaired kidney function, nephrectomy, and other complications) and mortality [7], [108]. Associated injuries occurs in most (72%–100%) [1], [86], [108],

Renal trauma and congenital anomalies

The reported incidence of congenital anomalies of the kidney in renal trauma varies in different series from 1% to 23% [4], [112], [113]. Preexisting congenital renal abnormalities seem to increase the risk for significant renal injury and to decrease the potential for renal salvage [114], [115]. For example, UPJ stenosis was believed to increase the chance of renal pelvic avulsion after renal trauma and to lower the threshold for renal bleeding following minor trauma [4], [57]. Significant

Secondary hemorrhage

Secondary hemorrhage is one of the most serious complications of renal trauma. It is more common in cases of deep cortical lacerations, especially in stab wounds patients treated conservatively [7], [64]. Some series have reported delayed bleeding in 13% to 25% of grade 3–4 blunt renal trauma patients who are treated conservatively [34] and in 18% to 23% of penetrating renal trauma patients who are treated conservatively [7], [54], [119], [120]. It must be noted, however, that a bleeding rate

Arteriovenous fistula

AVF is, most commonly, a result of renal biopsy [7], [125], but post-traumatic AVF rarely occurs, mostly in stab wound patients [126]. Reports of AVF complicating stab wounds ranged from 0% to 7% [10], [54], [126]. Watts and colleagues [74] reported 12 cases of AVF in a review paper of hypertension, 10 of them caused by penetrating trauma and two by blunt trauma. Unlike postbiopsy AVF, which resolve spontaneously in 50% to 70% of cases, post-traumatic AVF often need intervention, such as

Pseudoaneurysm

Pseudoaneurysm is a well-reported complication after parenchymal renal surgery [123]. Pseudoaneurysm is reported after percutaneous surgery, open surgery, renal biopsy, and endoscopic renal surgery [135]. Penetrating renal trauma is the second most common cause (after iatrogenic) and occurred in 6% of 93 patients after renal stab wounds [120]. Pseudoaneurysm also is described in several cases after blunt renal trauma [123], [136], [137], [138], [139], [140]. Pseudoaneurysm can grow over time,

Death

Mortality after renal trauma is influenced by several factors, including the nature of the trauma, quality and timing of resuscitation, associated injuries, and subsequent complications [4]. Mortality in patients who present with renal trauma is almost always a result of associated injuries, and mortality from renal trauma accounts for less than 0.1% of trauma deaths [7]. As expected, penetrating trauma has higher mortality rates than blunt trauma, ranging from 6% to 8% [51], [72]. Among

Postinjury hydronephrosis

Hydronephrosis after renal injury is reported in 0% to 3% of cases [78]. Some investigators have suggested that new hydronephrosis after injury is more common after conservative therapy than surgical therapy. Cass and colleagues [78] reported 62% of conservatively treated patients compared with 4% of surgically treated patients developed hydronephrosis. The etiology of new hydronephrosis after injury is not understood well. It may be caused by UPJ obstruction from perirenal and periureteral

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References (150)

N.E. Peterson
Complications of renal trauma
Urol Clin North Am
(1989)
C.C. Hammer et al.
Effect of an institutional policy of nonoperative treatment of grades I to IV renal injuries
J Urol
(2003)
L.A. Matthews et al.
Nonoperative treatment of major blunt renal lacerations with urinary extravasation
J Urol
(1997)
S.B. Brandes et al.
Reconstructive surgery for trauma of the upper urinary tract
Urol Clin North Am
(1999)
B.T. Kansas et al.
Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center
J Urol
(2004)
T.B. Boone et al.
Ureteropelvic junction disruption following blunt abdominal trauma
J Urol
(1993)
J.M. Mulligan et al.
Ureteropelvic junction disruption secondary to blunt trauma: excretory phase imaging (delayed films) should help prevent a missed diagnosis
J Urol
(1998)
E. Erturk et al.
Renal trauma: evaluation by computerized tomography
J Urol
(1985)
A.S. Cass et al.
Renal failure and mortality after nephrectomy for severe trauma in multiply-injured patient: no inordinate risk
Urology
(1987)
C.G. Rogers et al.
High-grade renal injuries in children–is conservative management possible?
Urology
(2004)

J.M. Philpott et al.

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children

J Pediatr Surg

(2003)

K. Horikami et al.

Treatment of post-traumatic urinoma by means of selective arterial embolization

J Vasc Interv Radiol

(1997)

D.A. Husmann et al.

Attempted nonoperative management of blunt renal lacerations extending through the corticomedullary junction: the short-term and long-term sequelae

J Urol

(1990)

N.E. Peterson

Fate of functionless post-traumatic renal segment

Urology

(1986)

H. Wessells et al.

Effect of colon injury on the management of simultaneous renal trauma

J Urol

(1996)

D. McInerney et al.

Urinoma

Clin Radiol

(1977)

M.K. Mansi et al.

Conservative management with percutaneous intervention of major blunt renal injuries

Am J Emerg Med

(1997)

J.U. Morano et al.

Percutaneous catheter drainage of post-traumatic urinoma

J Urol

(1985)

E.K. Lang et al.

Management of urinomas by percutaneous drainage procedures

Radiol Clin North Am

(1986)

M.V. Meng et al.

Current treatment and outcomes of perinephric abscesses

J Urol

(2002)

D.A. Husmann et al.

Major renal lacerations with a devitalized fragment following blunt abdominal trauma: a comparison between nonoperative (expectant) versus surgical management

J Urol

(1993)

M.A. Rosen et al.

Management of combined renal and pancreatic trauma

J Urol

(1994)

N.A. Armenakas et al.

Indications for nonoperative management of renal stab wounds

J Urol

(1999)

A. Ersay et al.

Experience with renal gunshot injuries in a rural setting

Urology

(1999)

H.M. Radwin et al.

A unified concept of renal trauma

J Urol

(1976)

J.A. Eastham et al.

Urological evaluation and management of renal-proximity stab wounds

J Urol

(1993)

C.F. Heyns et al.

Stab wounds associated with hematuria—a review of 67 cases

J Urol

(1983)

H. Wessells et al.

Preservation of renal function after reconstruction for trauma: quantitative assessment with radionuclide scintigraphy

J Urol

(1997)

R.P. Grant et al.

Renal trauma and hypertension

Am J Cardiol

(1971)

K.S. Miller et al.

Radiographic assessment of renal trauma: our 15-year experience

J Urol

(1995)

J. von Knorring et al.

Varying course of hypertension following renal trauma

J Urol

(1981)

D.P. Stables et al.

Traumatic renal artery occlusion: 21 cases

J Urol

(1976)

W.J. Engel et al.

Hypertension due to renal compression resulting from subcapsular hematoma

J Urol

(1955)

T.R. McCune et al.

Page kidney: case report and review of the literature

Am J Kidney Dis

(1991)

J.K. Wheatley et al.

Page kidney resulting from massive subcapsular hematoma. Complication of lumbar sympathetic nerve block

Urology

(1984)

T.J. Pintar et al.

Hyperreninemic hypertension secondary to a subcapsular perinephric hematoma in a patient with polyarteritis nodosa

Am J Kidney Dis

(1998)

P. Mufarrij et al.

Page kidney as a complication of percutaneous antegrade endopyelotomy

Urology

(2005)

B.R. Matlaga et al.

Subcapsular urinoma: an unusual form of page kidney in a high school wrestler

J Urol

(2002)

M.R. Patel et al.

Subcapsular urinoma: unusual form of “page kidney” in newborn

Urology

(1984)

R.A. Santucci et al.

Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee

BJU Int

(2004)

Z. Dobrowolski et al.

Renal and ureteric trauma: diagnosis and management in Poland

BJU Int

(2002)

J.C. Blankenship et al.

Importance of delayed imaging for blunt renal trauma

World J Surg

(2001)

C.D. Goff et al.

Management of renal trauma at a rural, level I trauma center

Am Surg

(1998)

S.B. Brandes et al.