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Management of perirenal hematoma found during laparotomy in patient with multiple injuries
MANAGEMENT
OF PERIRENAL
HEMATOMA
FOUND DURING LAPAROTOMY
IN PATIENT
WITH MULTIPLE
INJURIES
A. S. CASS, M.B.B.S. M. LUXENBERG P GLEICH,
M.D.
J. HOLLANDER, C. SMITH,
M.D.
M.D.
From the Department of Urology, St. Paul, and Division of Urology, Minneapolis, Minnesota
St. Paul-Ramsey Medical Center, Hennepin County Medical Center,
ABSTRACTThe medical records of 158 patients with perirenal hematoma found during laparotomy for intra-abdominal injury from external trauma were analyzed. Small perirenal hematomas were usually associated with renal contusions and renal artery thrombosis, while large perirenal hematomas often were present with large renal lacerations, renal ruptures, and renal pedicle injuries with rupture of the renal vein, renal artery, polar artery, or branch of the renal artery. The management of the perirenal hematoma found during laparotomy depends on the degree of the underlying renal injury and not on the size or extent of the perirenal hematoma.
During laparotomy in a patient with multiple injuries from external trauma, conservative management of a perirenal hematoma can be time-saving and appealing, but may increase morbidity during the postoperative course and lead to loss of renal tissue. The signs, radiologic evaluation, and management of 158 patients with a perirenal hematoma found during a laparotomy for intra-abdominal injury from external trauma were evaluated. Material
and Methods
From 1959 to 1983, 1,522 patients were admitted with renal injury, and 513 had a laparotomy for associated intra-abdominal injury. During laparotomy, a perirenal hematoma was found in 158 patients, with 1 patient having bilateral perirenal hematomas. Patients with a retroperitoneal hematoma from other retro-
546
peritoneal structures, such as pancreas, duodenum, adrenal, and vessels were excluded. Also patients with ureteropelvic disruptions were not included in this study. Before 1969, the initial excretory urogram (IVP) was performed after the laparotomy was completed; but since 1969 the IVP was performed during laparotomy.’ With preliminary renal pedicle control, immediate surgical exploration of the perirenal hematoma found during laparotomy was started in 1969 when the initial IVP showed extravasation, nonfunction, incomplete filling, and delayed visualization.2 There were 66 patients (42 % ) under twenty years of age, 67 (42%) between twenty and thirty-nine years, 19 (12%) between forty and fifty-nine, and 6 (4%) over sixty years. One hundred twenty-five patients (79 %) were males.
UROLOGY
/
DECEMBER
1985
i
VOLUXIE
XXVI,
NUMBER
6
TABLE I.
type of renal injury
Initial IVP finding, degree of hematuria, and diagnosis of in 158 patients with a perirenal hematoma found at laparotomy Initial IVP Finding
Data
Extravasation (7) 0 0 0 1 4
2
1
21 28
4 1 1 2 16
0 1 3 12
13
3
2
9 0 58
19 3 0
!5
0
0
0
0 2
3 2
61 8* 0 0
Normal (69)
Hematuria Not present 4-8 RBCYHPF 8-30 30-50 Gross Present-degree not known Diagnosis made by Renal exploration Immediate Delayed IVP alone Retrograde pyelogram Arteriogram Autopsy Type renal injury Contusion Laceration Rupture Pedicle injuq
Delayed Visualization (7)
Nonfunction (27)
1 1
5
*Gunshot 6, knife 2. tone patient pedicle + laceration. fOne patient bilateral renal iniuries (pedicle $One patient pedicle + UPJ rupture.
Not Done (22)
Total pts. (158)
0 0 2 3
12 0 1 2 6
20 2 8 31 69
8
1
1
28
18 2 4
5 0 0
10 0 0
66 5 63
1 1 0
0 2 0
0
1 0
4 6 5
0 5 2
8 13 2
4 3 0
12t
0
+ contralateral
laceration).
Results
Cause of trauma Traffic accidents were the cause in 104 patients (66 % ), falls in 5 (3 % ), a blow or crush in 7 (4 % ), and a sports injury in 12 (8 %). Penetrating injuries were caused by gunshot in 22 (14%) and a knife in 8 (5%).
Type of renal injury and perirenal hematoma A renal contusion was found in 83 patients (52.5 %), laceration in 45 (28.5%), rupture in 9 (6 % ), and pedicle injury in 21 (13 %). One patient had bilateral renal injuries-pedicle injury on one side and laceration on the contralatera1 side. Two patients with pedicle injuries had a second ipsilateral renal injury-a laceration in 1 patient and a ruptured ureteropelvic junction in the other. At the time of renal exploration, small perirenal hematomas were usually found with
Incomplete Filling (26)
0 1
3$
0
1
0 12
7 16
6 10 0 6’
83 (52.5%) 45 (28.5%) 9 (6%) 21 (13%)
renal contusion and renal artery thrombosis, and large perirenal hematomas were often found with deep renal laceration or rupture of the renal vein, renal artery, polar artery, or branch of the renal artery.
Diagnosis
of renal injury
(Table Z)
The degree of hematuria present on admission and the initial IVP findings compared with the diagnosis of renal injury are listed in Table I. The degree of hematuria did not help in diagnosing the type of renal injury. No hematuria was present in 12 of 22 patients with renal pedicle injuries. The only correlation between an IVP finding and a type of renal injury was found with a normal IVP and a renal contusion due to blunt trauma.
Associated
injuries
Associated injuries were present in 156 of 158 patients (99%) with a perirenal hematoma and averaged 2.6lpatient with a renal contusion,
TABLE
Associated Injury
Contusion
# Pts. with assoc. injury Ruptured diaphragm Ruptured spleen Ruptured liver Ruptured bowel Ruptured abd. vessels, pancreas, uterus, etc. Severe head injury Fractured ribs Fractured skull Fractured spine Fractured pelvis Fractured extremities
TABLE
III.
Associated injuries
II.
Laceration
Rupture
Pedicle Injury
Total
83 5 54 35 13
43 4 25 19 9
9 0 5 2 3
21 1 11 10 11
156 10 95 66 36
14 7 26 9 6 15 28
7 4 15 7 2 3 8
1 1 5 1 1 0 3
3 2 5 3 2 1 5
25 14 51 20 11 19 44
Treatment of renal injury with perirenal hematoma
Treatment
Contusion
Immediate surgery Nephrectomy Partial nephrectomy Suture Exploration
0
TOTALS
Rupture
Pedicle Injury 7”
Total
9*
4t 13 lO$ 4
7 0 0 0
9
31
7
13
60
69 0
10 0
0
2
3 2
82 4
0
1
0
1
69
11
2
5 83
4
0 9
0 0
Subtotal Conservative treatment and delayed surgery Nonsurgical Delayed nephrectomy Delayed partial nephrectomy Subtotal Died on admission/ O.R. table
Laceration
-
0 5” 1’
0
-
5# 3 21
18 13 15 14
87 12 159* *
(454;t+sT) *Initial IVP normal 2, nonfunction 2, incomplete filling 3, delayed visualization 2. tSplit kidney midportion 2. renal vein torn during dissection 1. poor general condition 1, *Secondary nephrectomy 1 patient. ‘Renal artery 1 all branches renal arterv 1, renal vein 4. renal artery + renal vein 1 (2 patients double renal injuiy-pedicle + laceration 1, pedicle + UPJ rupture 1). ‘Renal artery 2, branch renal artery 1, renal vein 2. “Branch renal artery 1, #Renal artery 4, branch renal artery 1. **Contralateral laceration with bilateral perirenal hematoma 1 patient (treatment partial nephrectomy).
2.4lpatient with a renal laceration, 2.4lpatient with a renal rupture, and 2.6 with a renal pedicle injury (Table II).
Treatment The treatment of the found during laparotomy
548
perirenal depended
hematoma on the de-
gree of the underlying renal injury and not on the size or extent of the hematoma (Table III). Immediate surgical management was used in 60 renal injuries with a perirenal hematoma found at laparotomy. The renal loss rate was 5 of 31 lacerations (16%), 7 of 7 ruptures (lOO%), and 7 of 13 pedicle injuries (54%). One patient with a laceration that was sutured
UROLOGY
/ DECEMBER
1985
i
VOLUME
XXVI. NUMBER
6
required nephrectomy as a secondary renal operation. Conservative management was used in 18 of the more severe renal injuries (laceration, rupture, pedicle injury) with perirenal hematoma found at laparotomy. The renal loss rate was 0 of 11 lacerations (0 %), 2 of 2 ruptures (100 %), and all 5 renal pedicle injuries with perirenal hematoma found at laparotomy. Delayed renal surgery during the postoperative period was required in 5 of the 18 patients (28%). Comment A small perirenal hematoma was often found with a renal contusion or with a renal artery thrombosis. In a renal contusion the hematoma was subcapsular and limited in size. In renal artery thrombosis from external trauma the intima of the renal artery is ruptured with a secondary occluding thrombosis while the outer muscular layers are intact with local bruising of the wall and no perirenal hematoma. A large perirenal hematoma was usually found with a deep renal laceration, renal ruptures, or renal pedicle injuries involving rupture of the renal vein, polar artery, or renal artery or one of its branches. The large perirenal hematoma resulted from disruption of the renal parenchyma and capsule or a renal vessel and the hematoma filled the Gerota space. The degree of the underlying renal injury should be determined as soon as possible. An IVP or arteriogram will establish the diagnosis in most cases. Renal exploration during laparotomy will establish the diagnosis if the IVP or arteriogram give indeterminate findings. A preoperative computed tomography (CT) scan gives a more accurate diagnosis of the renal injury.
UROLOGY
’ DECEMBER
1985
! VOLUME
Renal contusions should be managed conservatively. Small renal lacerations will heal with conservative management, but not all large renal lacerations (deep laceration, ruptured pole, split kidney) will heal spontaneously and the kidney return to normal with conservative management. A ruptured kidney and a renal pedicle injury require immediate surgical management. In summary, the medical records of 158 patients with a perirenal hematoma found during a laparotomy for intra-abdominal injury after external trauma were evaluated. A small perirenal hematoma was present with renal contusion and a renal artery thrombosis while a large perirenal hematoma was usually present with renal laceration, renal rupture, and renal pedicle injuries involving rupture of the renal vein, renal artery, a polar artery, or a branch of the renal artery. The treatment of the perirenal hematoma was that of the underlying renal injury and not related to the size of the perirenal hematoma.
XXVI. NUMBER
St. Paul-Ramsey Medical Center 640 Jackson Street St. Paul, Minnesota 55101 (DR. CASS) References 1. Cass AS, et al: Modification of an operating room table for immediate radiographic evaluation of the urinary tract in the acute severe trauma patient, J Urol 105: 569 (1971). 2. Cass AS. and Ireland GW: Comparison of the conservative and surgical management of the more severe degrees of renal trauma in multiule iniured oatients. ibid 109:8 (1973). 3. Stables DP,&et oI:‘Traumatic renal artery occlusion: 21 cases. ibid 115: 229 (1976). 4. Sullivan M, Smalley R, and Banowsky LH: Renal artery occlusion secondary to blunt abdominal trauma, J Trauma 12: 509 (1972).
6
549
OF PERIRENAL
HEMATOMA
FOUND DURING LAPAROTOMY
IN PATIENT
WITH MULTIPLE
INJURIES
A. S. CASS, M.B.B.S. M. LUXENBERG P GLEICH,
M.D.
J. HOLLANDER, C. SMITH,
M.D.
M.D.
From the Department of Urology, St. Paul, and Division of Urology, Minneapolis, Minnesota
St. Paul-Ramsey Medical Center, Hennepin County Medical Center,
ABSTRACTThe medical records of 158 patients with perirenal hematoma found during laparotomy for intra-abdominal injury from external trauma were analyzed. Small perirenal hematomas were usually associated with renal contusions and renal artery thrombosis, while large perirenal hematomas often were present with large renal lacerations, renal ruptures, and renal pedicle injuries with rupture of the renal vein, renal artery, polar artery, or branch of the renal artery. The management of the perirenal hematoma found during laparotomy depends on the degree of the underlying renal injury and not on the size or extent of the perirenal hematoma.
During laparotomy in a patient with multiple injuries from external trauma, conservative management of a perirenal hematoma can be time-saving and appealing, but may increase morbidity during the postoperative course and lead to loss of renal tissue. The signs, radiologic evaluation, and management of 158 patients with a perirenal hematoma found during a laparotomy for intra-abdominal injury from external trauma were evaluated. Material
and Methods
From 1959 to 1983, 1,522 patients were admitted with renal injury, and 513 had a laparotomy for associated intra-abdominal injury. During laparotomy, a perirenal hematoma was found in 158 patients, with 1 patient having bilateral perirenal hematomas. Patients with a retroperitoneal hematoma from other retro-
546
peritoneal structures, such as pancreas, duodenum, adrenal, and vessels were excluded. Also patients with ureteropelvic disruptions were not included in this study. Before 1969, the initial excretory urogram (IVP) was performed after the laparotomy was completed; but since 1969 the IVP was performed during laparotomy.’ With preliminary renal pedicle control, immediate surgical exploration of the perirenal hematoma found during laparotomy was started in 1969 when the initial IVP showed extravasation, nonfunction, incomplete filling, and delayed visualization.2 There were 66 patients (42 % ) under twenty years of age, 67 (42%) between twenty and thirty-nine years, 19 (12%) between forty and fifty-nine, and 6 (4%) over sixty years. One hundred twenty-five patients (79 %) were males.
UROLOGY
/
DECEMBER
1985
i
VOLUXIE
XXVI,
NUMBER
6
TABLE I.
type of renal injury
Initial IVP finding, degree of hematuria, and diagnosis of in 158 patients with a perirenal hematoma found at laparotomy Initial IVP Finding
Data
Extravasation (7) 0 0 0 1 4
2
1
21 28
4 1 1 2 16
0 1 3 12
13
3
2
9 0 58
19 3 0
!5
0
0
0
0 2
3 2
61 8* 0 0
Normal (69)
Hematuria Not present 4-8 RBCYHPF 8-30 30-50 Gross Present-degree not known Diagnosis made by Renal exploration Immediate Delayed IVP alone Retrograde pyelogram Arteriogram Autopsy Type renal injury Contusion Laceration Rupture Pedicle injuq
Delayed Visualization (7)
Nonfunction (27)
1 1
5
*Gunshot 6, knife 2. tone patient pedicle + laceration. fOne patient bilateral renal iniuries (pedicle $One patient pedicle + UPJ rupture.
Not Done (22)
Total pts. (158)
0 0 2 3
12 0 1 2 6
20 2 8 31 69
8
1
1
28
18 2 4
5 0 0
10 0 0
66 5 63
1 1 0
0 2 0
0
1 0
4 6 5
0 5 2
8 13 2
4 3 0
12t
0
+ contralateral
laceration).
Results
Cause of trauma Traffic accidents were the cause in 104 patients (66 % ), falls in 5 (3 % ), a blow or crush in 7 (4 % ), and a sports injury in 12 (8 %). Penetrating injuries were caused by gunshot in 22 (14%) and a knife in 8 (5%).
Type of renal injury and perirenal hematoma A renal contusion was found in 83 patients (52.5 %), laceration in 45 (28.5%), rupture in 9 (6 % ), and pedicle injury in 21 (13 %). One patient had bilateral renal injuries-pedicle injury on one side and laceration on the contralatera1 side. Two patients with pedicle injuries had a second ipsilateral renal injury-a laceration in 1 patient and a ruptured ureteropelvic junction in the other. At the time of renal exploration, small perirenal hematomas were usually found with
Incomplete Filling (26)
0 1
3$
0
1
0 12
7 16
6 10 0 6’
83 (52.5%) 45 (28.5%) 9 (6%) 21 (13%)
renal contusion and renal artery thrombosis, and large perirenal hematomas were often found with deep renal laceration or rupture of the renal vein, renal artery, polar artery, or branch of the renal artery.
Diagnosis
of renal injury
(Table Z)
The degree of hematuria present on admission and the initial IVP findings compared with the diagnosis of renal injury are listed in Table I. The degree of hematuria did not help in diagnosing the type of renal injury. No hematuria was present in 12 of 22 patients with renal pedicle injuries. The only correlation between an IVP finding and a type of renal injury was found with a normal IVP and a renal contusion due to blunt trauma.
Associated
injuries
Associated injuries were present in 156 of 158 patients (99%) with a perirenal hematoma and averaged 2.6lpatient with a renal contusion,
TABLE
Associated Injury
Contusion
# Pts. with assoc. injury Ruptured diaphragm Ruptured spleen Ruptured liver Ruptured bowel Ruptured abd. vessels, pancreas, uterus, etc. Severe head injury Fractured ribs Fractured skull Fractured spine Fractured pelvis Fractured extremities
TABLE
III.
Associated injuries
II.
Laceration
Rupture
Pedicle Injury
Total
83 5 54 35 13
43 4 25 19 9
9 0 5 2 3
21 1 11 10 11
156 10 95 66 36
14 7 26 9 6 15 28
7 4 15 7 2 3 8
1 1 5 1 1 0 3
3 2 5 3 2 1 5
25 14 51 20 11 19 44
Treatment of renal injury with perirenal hematoma
Treatment
Contusion
Immediate surgery Nephrectomy Partial nephrectomy Suture Exploration
0
TOTALS
Rupture
Pedicle Injury 7”
Total
9*
4t 13 lO$ 4
7 0 0 0
9
31
7
13
60
69 0
10 0
0
2
3 2
82 4
0
1
0
1
69
11
2
5 83
4
0 9
0 0
Subtotal Conservative treatment and delayed surgery Nonsurgical Delayed nephrectomy Delayed partial nephrectomy Subtotal Died on admission/ O.R. table
Laceration
-
0 5” 1’
0
-
5# 3 21
18 13 15 14
87 12 159* *
(454;t+sT) *Initial IVP normal 2, nonfunction 2, incomplete filling 3, delayed visualization 2. tSplit kidney midportion 2. renal vein torn during dissection 1. poor general condition 1, *Secondary nephrectomy 1 patient. ‘Renal artery 1 all branches renal arterv 1, renal vein 4. renal artery + renal vein 1 (2 patients double renal injuiy-pedicle + laceration 1, pedicle + UPJ rupture 1). ‘Renal artery 2, branch renal artery 1, renal vein 2. “Branch renal artery 1, #Renal artery 4, branch renal artery 1. **Contralateral laceration with bilateral perirenal hematoma 1 patient (treatment partial nephrectomy).
2.4lpatient with a renal laceration, 2.4lpatient with a renal rupture, and 2.6 with a renal pedicle injury (Table II).
Treatment The treatment of the found during laparotomy
548
perirenal depended
hematoma on the de-
gree of the underlying renal injury and not on the size or extent of the hematoma (Table III). Immediate surgical management was used in 60 renal injuries with a perirenal hematoma found at laparotomy. The renal loss rate was 5 of 31 lacerations (16%), 7 of 7 ruptures (lOO%), and 7 of 13 pedicle injuries (54%). One patient with a laceration that was sutured
UROLOGY
/ DECEMBER
1985
i
VOLUME
XXVI. NUMBER
6
required nephrectomy as a secondary renal operation. Conservative management was used in 18 of the more severe renal injuries (laceration, rupture, pedicle injury) with perirenal hematoma found at laparotomy. The renal loss rate was 0 of 11 lacerations (0 %), 2 of 2 ruptures (100 %), and all 5 renal pedicle injuries with perirenal hematoma found at laparotomy. Delayed renal surgery during the postoperative period was required in 5 of the 18 patients (28%). Comment A small perirenal hematoma was often found with a renal contusion or with a renal artery thrombosis. In a renal contusion the hematoma was subcapsular and limited in size. In renal artery thrombosis from external trauma the intima of the renal artery is ruptured with a secondary occluding thrombosis while the outer muscular layers are intact with local bruising of the wall and no perirenal hematoma. A large perirenal hematoma was usually found with a deep renal laceration, renal ruptures, or renal pedicle injuries involving rupture of the renal vein, polar artery, or renal artery or one of its branches. The large perirenal hematoma resulted from disruption of the renal parenchyma and capsule or a renal vessel and the hematoma filled the Gerota space. The degree of the underlying renal injury should be determined as soon as possible. An IVP or arteriogram will establish the diagnosis in most cases. Renal exploration during laparotomy will establish the diagnosis if the IVP or arteriogram give indeterminate findings. A preoperative computed tomography (CT) scan gives a more accurate diagnosis of the renal injury.
UROLOGY
’ DECEMBER
1985
! VOLUME
Renal contusions should be managed conservatively. Small renal lacerations will heal with conservative management, but not all large renal lacerations (deep laceration, ruptured pole, split kidney) will heal spontaneously and the kidney return to normal with conservative management. A ruptured kidney and a renal pedicle injury require immediate surgical management. In summary, the medical records of 158 patients with a perirenal hematoma found during a laparotomy for intra-abdominal injury after external trauma were evaluated. A small perirenal hematoma was present with renal contusion and a renal artery thrombosis while a large perirenal hematoma was usually present with renal laceration, renal rupture, and renal pedicle injuries involving rupture of the renal vein, renal artery, a polar artery, or a branch of the renal artery. The treatment of the perirenal hematoma was that of the underlying renal injury and not related to the size of the perirenal hematoma.
XXVI. NUMBER
St. Paul-Ramsey Medical Center 640 Jackson Street St. Paul, Minnesota 55101 (DR. CASS) References 1. Cass AS, et al: Modification of an operating room table for immediate radiographic evaluation of the urinary tract in the acute severe trauma patient, J Urol 105: 569 (1971). 2. Cass AS. and Ireland GW: Comparison of the conservative and surgical management of the more severe degrees of renal trauma in multiule iniured oatients. ibid 109:8 (1973). 3. Stables DP,&et oI:‘Traumatic renal artery occlusion: 21 cases. ibid 115: 229 (1976). 4. Sullivan M, Smalley R, and Banowsky LH: Renal artery occlusion secondary to blunt abdominal trauma, J Trauma 12: 509 (1972).
6
549