Clinical Challenges in Trauma Surgery: Renal Trauma

4 snips

Apr 13, 2023

Guest

Rishi Rattan

Eva Rechuga, a PGY4 general surgery resident, joins experts Yuri Niman, a trauma surgeon, and Rishi Rattan, a trauma attending, to tackle the complexities of renal trauma. They discuss key decision-making points, like when to take a patient to surgery versus adopting a non-operative approach. Emphasis is placed on the importance of hemodynamic stability and when to involve interventional radiology for drainage. They also debate the management of penetrating zone II injuries, offering valuable insights for trauma care.

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INSIGHT

Nonoperative Management Is The Norm

Most kidney injuries (upwards of 95%) can be managed non-operatively when the patient is stable.
Hemodynamic stability, not AAST grade alone, largely dictates immediate operative need.

ADVICE

Get Delayed CT Urogram For Flank Trauma

In a stable patient with flank trauma get a CT including delayed excretory phase to evaluate collecting-system injury.
Add head/neck/chest imaging based on mechanism and examination.

ADVICE

Place Foley Only When It Will Change Care

Do not delay CT for a Foley unless lower GU injury or gross hematuria is suspected.
Place a Foley early if macrohematuria would change management or the patient is unstable.

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To operate or not to operate, to drain the urine leak or to not drain it, those are the questions. Join our Miami Trauma team including Drs. Urréchaga, Neeman, and Rattan- in their final episode together! - as they discuss how to navigate the ins and outs of renal trauma!

Learning Objectives:
· Define the different renal injury grades and how to manage each,
· Identify when to take the renal trauma patient to the operating room,
· Discuss when to involve IR for urinary drainage or embolization.
· Explain when and how to perform a nephrectomy.
· Debate the treatment of penetrating zone two injuries- to explore or not explore?

Quick Hits:
1. Most kidney injuries, the vast majority, can be non-operatively managed.
2. For pretty much all AAST grade of injury, the choice to go to the OR immediately lies in whether the patient is stable or unstable.
3. If there is a urinary leak seen on imaging, it can usually just be observed and followed with repeat imaging to determine the need for drainage, unless the injury is significant or if there is injury to the renal pelvis- then the patient will usually need a drainage procedure.
4. Consider IR in any stable patient found to have active extravasation, fistula, or pseudoaneurysm.
5. In the case of an unstable patient, except very rare circumstances, you should be going to the OR
6. If there is another cause of instability, address that first. If you’re opening Gerota’s fascia, be prepared to commit to a nephrectomy.
7. In penetrating injury, the formal teaching is mandatory exploration of a renal hematoma. Real world experience shows that this isn’t always necessary- such as in tangential injuries or injuries to the periphery- on a case-by-case basis.

References
1. Federico C, Moore Ernest E, Yoram K, Walter B, Aari L, Yosuke M, et al. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg 2019;14:54.
2. Morey AF, Brandes S, Dugi DD 3rd et al: Urotrauma: AUA guideline. J Urol 2014, 192: 327. Published 2014; Amended 2017, 2020.
3. Aziz HA, Bugaev N, Baltazar G, Brown Z, Haines K, Gupta S, Yeung L, Posluszny J, Como J, Freeman J, Kasotakis G. Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma. BMC Surg. 2023 Jan 27;23(1):22. doi: 10.1186/s12893-023-01914-x. PMID: 36707832; PMCID: PMC9881253.
4. Petrone P, Perez-Calvo J, Brathwaite CEM, Islam S, Joseph DK. Traumatic kidney injuries: A systematic review and meta-analysis. Int J Surg. 2020 Feb;74:13-21. doi: 10.1016/j.ijsu.2019.12.013. Epub 2019 Dec 21. PMID: 31870753.

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