Conservative Management Of Grade IV Renal Trauma · A B S T R A C T Dept. of Urology, Deenanath Mangeshkar Hospital and Research Centre, Erandwane, Pune Authors: Dr. Hrishikesh S.

AB

ST

RA

CT

Dept. of Urology, Deenanath Mangeshkar Hospital and Research Centre, Erandwane, Pune

Authors: Dr. Hrishikesh S. Deshmukh, Dr. Subodh Shivde, Dr. Raja Langer, Dr. Pankaj Joshi, Dr. Nilesh Sadavarte

Dr. Jaydeep Date,

Dis

cu

ss

ion

1. Campbell Walsh Urology, 9th International edition, Vol. 2 Chapter 39, Renal and Ureteral trauma Pages 1274-1281

2. Haas CA,Reigle MD, Selzman AA, Elder JS, Spirnak JP, Role of ureteral stents in the management of major renal trauma with urinary extravasation: is there a role? J Endourol. 1998 Dec;

12(6):545-9.

3. Costa Healy, Mohamed Hobeldin, Anies Mahomed, Conservative management of grade 1V renal injury with complete transection: a case report, Cases J. 2008; Vol. 1: 129.Re

fere

nc

es

Conservative Management OfGrade IV Renal Trauma

13 year old boy suffered renal and splenic trauma due to fall from a tree. He was managed conservatively in a peripheral center for 2 weeks. On referral to our tertiary care center he was stable haemodynamically with no fever or haematuria. He was diagnosed to have grade IV renal injury with splenic injury. He was managed conservatively with DJ stenting in view of Stable Haemodynamics, Late Presentation, No hypertension, No haematuria. He presented again with continuous low grade fever after a few weeks. CT scan revealed persistence of urinoma with nonfunctional lower pole. On retrograde pylography the leak was noted from the upper calyceal infundibulum whereas the lower pole of the kidney was shattered due to trauma with urinoma. DJ stent was replaced to drain the upper calyx and the urinoma also was drained .Drain was removed after 3 days and patient was discharged. Follow up CT Scan demonstrated resolution of urinoma with non functional lower pole. The DJ stent was removed. In our case the patient presented to us with grade IV renal injury. Normally it would have required exploratory laparotomy, debridement and SOS partial nephrectomy. The patient in our case presented to us late with stable haemodynamics and no haematuria, no hypertension. Laparotomy with partial nephrectomy would have missed the leak which was from upper calyceal infundibulum. We decided to conserve and attempted DJ Stenting across the leaking infundibulum and successfully avoided the laparotomy, managed the leak and saved the renal tissue.Key words: Renal trauma, DJ Stenting, Retrograde pyography.

?13 yr boy. ?Presented late to our tertiary care center after a week of conservative ?Sustained abdominal trauma and both upper limb fractures due to fall from a management at a peripheral center.

tree. ?CT scan was done.

CT SCAN

URS

Fig 12 & 13: DJStenting (C-arm),Retrograde pylography.

Fig 3: with contrast showing the leakand non functional lower pole.

Coronal section images Fig 4: kidney shattered with collection inthe peri-renal space - urinaryleak + hematoma.

Lower pole of the left

Fig 1 & 2: pole with leak.

Plain and Contrast scan showing the nonfunctional lower Fig 5 & 6: lower pole.

Transverse section with the leak and nonfunctional

Fig 7 & 8: stent in situ.

Coronal section showing the persistant leak with Fig 9 & 10: showing the urinoma with shattered lower pole.

3-D reconstruction

?

managed conservatively in view of

› Stable Haemodynamics,› Late Presentation,› No hypertension› No Haematuria

?DJ stenting was done to drain the pelvicalyceal system and to allow time for natural healing.

?Pt was discharged after 3 days of observation with adequate antibiotic prophylaxis and advised bed rest.

?Pt presented at 3rd week with continuous low grade fever.

?Repeat CT Scan was done to reassess the injury.

Splenic and renal injury was

?On RGP the stent was found draining lower pelvi- calyceal system.?However the leak was noted at upper calyceal infundibulum which was not drained by the stent.?The stent was replaced to drain the upper calyx and the urinoma also was drained.

• The drain was removed after 3 days as it stopped draining. • Pt was followed up after 6 weeks after the second procedure. • A Repeat Scan was performed.

Fig 14 & 15: The lower pole of the kidney was non functional.

Urinoma has resolved. The DJ was in place. Fig 16 & 17: lower pole.

Coronal/ sagital section showing the nonfunctional Fig 17 & 18: lower pole.

Contrast scan showing the nonfunctional

?

removed.?T h e p a t i e n t h a s

followed up after 6 weeks and is doing well.

The DJ stent was

Grades of Renal Trauma

Grade Type Description

I Contusion Microscopic or gross hematuria, urologic studies normal

Hematoma Subcapsular, nonexpanding without parenchymal

laceration.

II Hematoma Nonexpanding perirenal hematoma confined to renal

retroperitoneum. Laceration <1 cm parenchymal depth of renal

cortex without urinary extravasation.

III Laceration >1 cm parenchymal depth of renal cortex without collecting

system rupture or urinary extravasation.

IV Laceration Parenchymal laceration extending through rena cortex, medulla,

and collecting system. Vascular Main renal artery or vein injury

with contained hemorrhage.

V Laceration Completely shattered kidney Vascular Avulsion of renal hilum,

devascularizing the kidney.

?The management of renal trauma ranges from an emergency laparotomy for haemodynamic compromise to observation without intervention in minor lacerations.

?Recently there has been a shift towards conservative management even in grade IV renal trauma.

?Traditionally grade IV renal injuries have been treated aggressively with open surgery with the justification that urinomas may lead to perirenal fibrosis with complications of obstruction, infection and hypertension.

?The options for treating urinomas are, open drainage, with or without surgical repair, ureteric stents, percutaneous drains or just observation.

?In our case the patient presented to us with grade IV renal injury.

?Normally it would have required exploratory laparotomy, debridement and SOS partial nephrectomy.

?The patient in our case presented to us late with stable haemodynamics and no hematuria, no hypertension.

?Laparotomy with partial nephrectomy would have missed the leak which was from upper calyceal infundibulum.

?We decided to conserve and attempted DJ Stenting across the leaking infundibulum and successfully avoided the laparotomy, managed the leak and saved the renal tissue.

CA

SE

HIS

TO

RY

C-Arm