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Renal Trauma
Vol. 118, November Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
Review Article RENAL TRAUMA ROBERT MENDEZ From the Department of Urology, Los Angeles County-University of Southern California Medical Center, Los Angeles, California
ABSTRACT
The pertinent literature on renal trauma for the last 25 years has been analyzed. An evolutionary pattern is seen in the development of diagnostic methods, while surgical and medical management of renal trauma has become much more precise for specific lesions. Various subareas of interest within the field have emerged, such as pediatric trauma, associated injuries and the subdivisions of blunt and penetrating trauma. Furthermore, therapy has been extended to include those severe vascular lesions that previously were considered untreatable. Various new and experimental concepts are described. Specific recommendations regarding the diagnosis and the therapeutic management are offered in an attempt to bring perspective to these new developments. Trauma affecting the kidneys has long stirred interest and controversy among urologists. During the last 25 years great advancements in diagnostic skills and surgical techniques have been applied to this field, creating an occasional diversity of opinion regarding their usefulness and effectiveness. An attempt is made herein to survey, analyze and bring perspective to these recent advancements in the field ofrenal trauma. Age, sex and incidence. Trauma most notably occurs in those individuals directly involved in violence and frequent activity. For the most part, these individuals are men in their 20s. In a review of all renal injuries at our medical center from 1934 to 1960 Scholl and Nation reported that 127 of 478 injuries occurred in individuals between 20 and 30 years old, while 102 of the 478 injuries were seen in the teenage group. 1 The third most common group comprised individuals in their 30s. This age and sex relationship also was noted subsequently in the same institution by Morrow and Mendez. 2 Other large series, such as those of Glenn and Harvard,3 and Peterson and Kiracofe,4 have revealed similar age and sex characteristics among their patients with renal injuries. The general incidence of blunt and penetrating renal trauma in a large metropolitan hospital has been reported by Campbell to represent 1 of 3,000 admissions. 5 Penetrating renal trauma is found 6 to 8 per cent of the time in patients admitted to the hospital with penetrating abdominal injuries. Tynberg and associates reported that 7.5 per cent of 2,121 patients with penetrating injuries entering their hospital had renal trauma, 6 while Scott and associates noted a 7.5 per cent incidence of renal injuries in 2,252 patients with penetrating abdominal wounds.7 No data are available with regard to the incidence of renal trauma owing to blunt injuries. Etiology. Traditionally, renal injuries are divided etiologically into those resulting from blunt trauma and those resulting from penetrating trauma. Blunt trauma is the more frequent, being the causative factor in 60 to 70 per cent of renal injuries. The majority of blunt trauma results from automobile and motorcycle accidents, with falls, athletic injuries, altercations and a sundry of crush injuries completing this etiologic group. Attempts to quantitate and calculate the direct force with which blunt trauma causes certain degrees of renal injuries have been done experimentally by Jaffe and
associates. 8 The mechanism of injury caused by blunt trauma may be direct or indirect. With direct injury the kidney may be crushed between the external force and vertebrae or back muscles. It also may occur with skeletal fractures, such as rib or vertebral fractures when the kidney is penetrated by these fractured bones. Indirect injury occurs because of a decelerating effect in which the kidney may be torn from its pedicle. Penetrating injuries are preponderantly gunshot wounds and stabbings. Gunshot wounds may be caused by a low or a high velocity missile. The former causes injury by its direct tissue penetration and the latter by direct tissue injury and blast effect to adjacent tissue. Stab wounds do not directly affect much parenchymal tissue but, rather, cause serious injuries by subsequent infections, arteriovenous fistulizations and vascular or collecting system damage. CLASSIFICATION OF RENAL INJURIES
The purpose of classifications has been to exact a more appropriate therapeutic regimen to the specific renal injury. Towards this end, many different schemes or types of classifications have emerged. Hodges and associates sought to classify injuries in a clinical sense as to those that would most likely require surgical intervention or medical management. 9 Injuries were classified as minor, major and critical. Minor injuries consisted of parenchymal damage without capsular rupture or extension of the defect to the pelves or calices, major injuries had parenchymal damage with capsular tears and extension into the collecting system, while critical injuries were defined as extensive pulpefaction of renal tissue and pedicle injuries. Recently, authors such as Banowsky, 10 Scott,7 Tynberg6 and Peters, 11 and their associates also have embraced this method of classification. Another method of classification has been by the etiology of the injury- blunt versus penetrating. Although of some minor benefit when used as a sole method of classification this method has little justification. Classification purely upon radiographic findings has been made but also has proved of less value. I prefer a similar classification patterned on that of Hodges and associates. 9 The lesion ultimately should be given a classification only upon complete analysis of all information
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RENAL TRAUMA
that is clinical assessment, etiologic identification, radiographic such. as infusion pyelograms, angiograpyelography and nuclear scans, and, at times, of the retroperitoneum. After a review of available information a classification separating parenchymal lesions into contusions, lacerations, severe fractures and is suggested. This 4-group classification rather than the similar 3-group classification previmentioned to more specifically determine which lesions surgical and which expectant management.
showed enough detail for interpretation and then 50 75 per cent of these actually correlated with the lesion encountered at the time of the operation or further definitive studies, such as angiography. Infusion IVP with tomography. As knowledge and ence accumulated infusion IVP with tomography ·was uuuJJvc,, to diagnostic use in renal trauma. 21 This technique enhancing qualities in the traumatized renal JJOH
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MENDEZ
soever regarding the exact nature of the lesion or if the lesion is secondary to a major stab wound (predisposing it to arteriovenous fistulization) then arteriography with selective renal angiography is obtained. Other studies, such as retrograde pyelography and/or renal scans, are then obtained when clarification of an injury could be obtained best by the use of these studies. ASSOCIATED INJURIES
Associated injuries occur in from 60 to 80 per cent of renal trauma cases. Their type, extent and management are of great importance to over-all clinical survival of the patient and management of the renal problem. There is usually a good correlation between the extent of trauma and the severity of the associated injuries. The type of associated injury varies somewhat with the etiology of injury. Blunt trauma patients have higher associated central nervous system and skeletal injuries, while those with penetrating trauma more often have associated visceral and, not infrequently, multiple genitourinary organ system involvement. Mortality rates in patients with renal trauma invariably are secondary to associated injuries. Of the penetrating renal trauma patients described by Scott and associates 80 per cent had major associated injuries. 7 Liver injury in 46 per cent was followed by other visceral organ damage to the spleen, stomach, colon, pancreas and small intestines in descending order of prevalence. Major vessel injuries were present in approximately 4 to 5 per cent of cases. Similar findings were noted by other investigators. 1' 2 ' 32 Diagnosis of the associated injuries usually is suspected by mode of injury and clinical presentation. Fourteen to 30 per cent of renal patients present in shock. This is invariably secondary to the associated injuries. Verification of the associated lesion is made by radiographic assessment or laparotomy. Because of suspected associated lesions, penetrating injuries usually will be explored by general surgeons and, thus, the primary decision for laparotomy rarely rests solely with the urologist. It is with respect to the exploration of the retroperitoneum that the urologist's opinion is usually requested. TREATMENT
While controversy on just what is considered optimal treatment has existed, with increased knowledge and sophisticated analysis of data most viewpoints have blended into a common view of management for all but a small number and type of renal injuries. Optimal treatment of renal injuries is now predicated upon cognizance of and consideration for 3 factors: 1) the clinical condition of the patient, 2) associated major injuries and 3) accurate diagnosis of the extent of renal injury. Of prime consideration to the urologist is the necessity to establish preoperatively as accurate a diagnosis as possible. For therapeutic purposes lesions are classified into 4 groups: 1) contusions, 2) lacerations, 3) fractured or pulpefacted kidneys and 4) pedicle injuries. A common approach to the management of groups 1, 3 and 4 now generally exists in the urologic community, while some controversy still exists in the laceration group of injuries. Contusions. As defined previously contusions account for a significant majority of renal lesions. Carlton and associates found 85 per cent of their blunt injuries to be of a minor variety (contusions and simple lacerations). 14 Scholl and Nation reported 256 of 478 injuries to be contusions only.' In 1960 Glenn and Harvard found an incidence of 64 per cent negligible or minimal renal injuries, 3 while Peterson and Kiracofe observed that 86 of 144 patients had minor injuries. 4 Mahoney and Persky found that 29 of 41 patients had contusions in a study recommending intravenous drip nephrotomography. 22 Cass and Ireland treated 4 of their 69 patients diagnosed as having contusions with an operation-3 had exploration of the kidney and 1 a nephrectomy for a massive congenital
hydronephrosis. rn The remammg 65 patients were treated medically. None required a further operation although some may have been included in their 6 patients requiring prolonged (more than 24 days) hospitalization until successful management was obtained. Most other larger series also advocate medical management of this group of lesions and report similar high success rates, 1. 7 • 11 , a3 Lacerations. These lesions include 1 or 2 parenchymal tears, with or without extravasation but with an intact kidney. Herein are the lesions whose management is most controversial. Although differences do exist as to form of treatment and outcome much of the apparent discrepancy is in the precise definition of the lesion, what is considered treatment and what is complication. Scott and associates, in a review of 54 minor penetrating injuries managed by an immediate operation, successfully treated 52, while 2 gunshot wounds in this minor category necessitated nephrectomy. 7 Four patients underwent exploration only, 20 patients had exploration and drainage only, while 29 patients underwent renography. In the major wound category, which included lacerations with extravasation and more severe injuries, 23 of 56 patients immediately explored underwent nephrectomy. Peterson and Kiracofe treated 32 minor penetrating and 54 minor blunt injuries. 4 Of the 32 penetrating injuries 7 were observed, 7 were explored and no treatment was deemed necessary, 16 had exploration and drainage only and 2 required a wedge resection repair. In the 54 cases of blunt mild injuries 47 were observed, 3 explored and no operation was deemed necessary, while 4 were explored and drained. Peterson and Kiracofe concluded retrospectively that 22 of 29 surgically explored and treated injuries could have been treated more appropriately by medical management. 4 In comparing conservative versus immediate surgical management of more severe degrees of renal trauma (lacerations, fractured kidneys, pedicle injuries) Cass and Ireland treated conservatively 18 patients with renal lacerations and did immediate operations on 22. 32 Of the total group of injuries treated conservatively 8 patients died of associated injuries, while 7 in the immediate surgically treated group also died of associated injuries. Of the remaining 16 patients in the conservative group, the bulk of whom had lacerations, only 1 underwent nephrectomy. Of the remaining 22 in the immediate surgically treated group, in which the majority also were lacerations, 15 underwent nephrectomy. Cass and Ireland state that 9 of the nephrectomies and 3 operations preserving kidney parenchyma were done before the introduction of preliminary vascular control procedures. 16 The conservative group had an average hospital stay of 29 days versus a 20-day average in the immediate surgically treated group of patients. Morrow and Mendez found 23 lacerations-21 patients were initially treated medically, while 2 underwent immediate operations to control bleeding. 2 In the non-operative group 5 patients eventually underwent nephrectomy for a 22 per cent nephrectomy rate. Many series tend to be supportive of the specific kinds of findings noted in the aforementioned series but precise comparison is impossible owing to the manner in which their data are presented. Several facts appear to emerge from the analysis of this specific type of injury. Renal lacerations can by and large successfully be treated medically as well as surgically. However, if immediate surgical intervention is the mode of therapy chosen prior vascular control must be obtained or nephrectomy rates tend to be inordinately high. The high rate of associated injuries tends to make exploration of penetrating injuries necessary. However, it does not make retroperitoneal and renal exploration necessary, especially if the renal diagnosis is reliably known preoperatively. If conservative management is chosen as therapy a far smaller nephrectomy rate can be anticipated, although hospitalization will be longer. In the final analysis, each case must be dealt with on an
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RENAL TRAUMA
with the clinical state of the patient being considerationo rn,r·nrrPn and palpable lesions As defined previously these lesions manifest numerous deep lacerations, major extravasation and non-visualization of the kidneyo Arteriogor scanning is necessary for an accurate diagnosiso The immediate exploration of these lesions is, indeed, mandatory if prolonged morbidity is to be circumventedo At times, partial nephrectomy can be aucul.°). Salvation of the kidney is rareo 70 3 &- 37 thrombosis usually results from a deceleration with the kidney rapidly hurdled away, causing the renal The effect usually occurs at the the aorta and renal artery, which is Intimal damage ensues followed by thrombosiso Skinner has reported the successful treatment of a patient who suffered renal artery thrombosis owing to a decelerating type an automobile accidento'38 Accurate diagnosis was by angiography, and a thrombectomy and excision the injured segment with end-to-end renal arterial anastomosis were accomplished 12 hours after the accidento the kidney underwent a prolonged acute tubular eventual function was demonstrated on IVPO Another cause of arterial thrombosis occur with fracture of a vertebral transverse process impingement upon the renaI artery managemento Once immediate surgical intervendeenied unnecessary the management becomes observant and mn,-,,-~,"'~ The is placed on bed rest and followed with determinations, such as vital w,uvuu,ucu palpation, serial hemoglobin and hematocrit and of urine that are at the side of the bed to follow degree of hematuriao The JS on bed rest until all clinical signs have been 3 and hematuria has cleared completely or amount (5 to 20 red blood cells per high rnicrohematuria existso The patient is then lateo monitoring of the kidney by serial infusion IVPs tomography and/or angiography as advocated by Rous27 is extremely helpful, especially in the face of extravasationo rebleeding with a decrease in HtJLHoLL•JU evidence a developing perinephric abscess, an expanding flank mass, persistent significant extravasation and a proloss of renal function are indications for surgical O
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I know of no published evidence that this expectant apto surgery will result in greater renal tissue loss than would occur normally if immediate surgical intervention were On the contrary, nephrectomy rates are and lower when this therapeutic approach is taken but is prolongedo As stated Whitney immediate nephrectomy is no great institution for the morbidity of a necessary delayed exploration with salvation of kidney tissue or even nephrectornyo 38 U~OLV-ULVH
Surgical treatmenio When an operation is deemed necessary after adequate evaluation and diagnosis the abdominal approach as outlined by Scott and Selzman is recommendedo 40 thorough laparotomy is performed through a midline incision with attention to associated injuries priority, Next the posterior peritoneum over the aorts incised, the left renal vein is retracted and a vascular clamp is applied to the appropriate renal artery Devascularized tissue is excised and any rent in the system is closed with a 4-zero running chromic suture possible; if not, interrupted sutures are usedo Various intertuo bular and interlobular vessels are and/ or ligated with 4-zero chromic sutureso A piece of fat or surgicel is then placed in the defect ,J.nd the margins of the laceration are approximated with of-eight 3-zero chromic catgut sutures the and parenchymao After the the observed for excessive bleedingo deemed the procedure of choice the capsule is dissected over the demarcated line to be excisedo A guillotine tion is doneo The collecting system is closed with zero chromic sutures and vessels are ligatedo The the amputated segment of kidney is then removed as intact as possible with the back side of the capsule is then used to cover the amputated surfaceo Debridement of devitalized tissue is ne>o~torrr1Prl on lacerations and then a running anastomosis is done 'c·-- obst:rnctim1 zero chromic sutureso With ureteropelvic " spatulation of the ends is accomplished with the anastomosis repair again made with 4-zero chromic sutures, Tbe anastomosis is stented with a Noo 5 ureteral catheter down into the bladder and brought out small opening of the renal pelviso If massive existed a nephrostomy tube is placedo renal vein lacerations usually are debrided and closed with 6-zero cardiovascular sutureso All other branch veins or accessm-y veins are simply ligatedo 410 42 Thrombectomy with a Noo 3 or 4 by excision of the damaged segment end-to-end arterial anastomosis may arterial thrombosis if an operation can be naodr.rn-,ocl 10 to 12 hours of injuryo hematoma rw.i,v11u,w. Of importance under these conditions of the presence of a normal functioning contralateral This confirmation can be accomplished under direct vision. An infusion IVP while the patient is on the table also is in most major medical centerso If this latter estab lishes a relative secure diagnosis treatment is done under the guide lines suggested previously. If an exact '°'""°S"vuw cannot be made the retroperitoneum is not if hematoma is small and seemingly stableo If there exists a large hernatoma, whether owing to penetrating or blunt trauma, and presence of a normal contralateral kidney has been established exploration of the is done previously described approacho Management of the renal injury surgically, of course, must take into account the associated intra-abdominal particular importance are concomitant pancreatic, ileal and colonic injurieso It is imperative that renal lesions with major extravasation be separated nnm,w" from. pancreatic or duodenal draining injurieso be the conservative treatment of choiceo 0
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PEDIATRIC TRAUMA
As a clinical entity trauma has special pediatrics, being the number 1 cause of death children between the ages of 1 and 14 yearso As for renal traurrw specifically, the pediatric patient is more vulnerable to renal trauma than the adulto Miller and associates have nn,rnPn
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MENDEZ
out that the "lack of strong muscles and a more rigid thoracic cage provide less protection for the retroperitoneal area". 43 It has been well documented that diseased and especially anomalous kidneys are much more prone to injury with trauma. 4 3--4 5 Blunt trauma accounts for a relatively higher percentage of pediatric renal injuries. In a study of 110 children by Javadpour and associates 70 per cent sustained blunt traumatic injuries, 46 while 90 per cent of the renal injuries reported by Cass and Ireland were a result of blunt trauma. 47 Children also tend to have a much higher incidence of associated head injuries with blunt trauma than do adults. Congenital anomalies. In a rather different and interesting approach to the assessment of trauma and anomalies, Miller and associates surveyed all children between O and 14 years old for 12 years with specific diagnoses, such as Wilms tumors, teratomas, hydronephrosis, and so forth, to determine what percentage were discovered because they sustained a traumatic injury. 43 Two classifications were given: those anomalous kidneys sustaining injury and those traumatized patients in whom trauma brought forth the discovery of congenital anomalous kidneys. They found that 17 per cent of hydronephrosis, 27 per cent of Wilms tumors and 25 per cent of hepatic tumors were discovered by trauma. Half of the hydronephrotic kidneys discovered had been aggravated by the trauma, while only a third of the tumors were affected by the trauma, two-thirds being found incidental to the trauma. Morse and associates also noted that 8 of 89 pediatric renal trauma patients had pre-existing congenital anomalies. 48 Cass and Ireland, in reviewing their 82 pediatric patients with renal injuries, found only 2 congenital anomalies-1 hydronephrosis and 1 bilateral hydroureter. 47 By and large, injuries in the pediatric group tended to be less severe than those encountered in the adult group. Additionally, although the ratio of male to female patients shows a male preponderance, it is not nearly as great as exists with adult patients. A classic example of trauma to an anomalous congenital kidney that also demonstrates the deceleration type of injury is related by Peters. 49 A white female infant presented to the emergency room with anuria. An IVP, which revealed nonvisualization, was followed by bilateral retrograde pyelography, which demonstrated bilateral ureteropelvic disruption of congenital ureteropelvic junction obstructions with hydronephrotic kidneys. The angiograms also revealed a subintimal tear of the left renal artery. Repair consisted of a right ureteropyeloplasty. An attempt at left renal artery repair proved unsuccessful and, thus, a left nephrectomy was performed. Subsequent followup IVPs have revealed a normal functioning right kidney. Diagnosis. Various subtle differences exist in the diagnostic approach of renal trauma in children. Unfortunately, all too often an inadequate evaluation is done because of a failure to elicit symptoms in a child, the reticence of parents to hospitalize their child with blunt injuries and the hesitation to use invasive techniques for further clarification, such as retrograde pyelography or renal angiography. Treatment. There is a much stronger tendency toward conservation in therapy of renal trauma in the pediatric patient. Reasons for this approach are several and include the greater life expectancy and the possible future susceptibility of pregnancy or athletic injuries. When surgical intervention is deemed necessary all attempts at maximal renal salvation are made. Salvation can be assured by thorough evaluation preoperatively. Morse and associates believe that the optimal time to operate, when intervention is needed, is between 2 and 7 days after injury, time enough for stabilization and evaluation, and prior to abscess or significant urinoma formation. 48 This type of approach has been quite successful in effecting a lower nephrectomy rate in children as compared to adults. 44 • 46 • 48 • 50
COMPLICATIONS
Precise evaluations of complications resulting from renal trauma have proved difficult to obtain in the past. Several factors appear to account for this. As Whitney and Peterson suggest, the transient nature of the patient population makes the accurate accumulation of data difficult. 39 However, perhaps as important is the problem of defining what is a complication, which evolves from the fact that those who manage renal injuries expectantly await adverse clinical changes prior to operative intervention. For the most part, this caution has been seen to dramatically lower nephrectomy rates. Interventionists who have initially opted for an operation and performed an initial nephrectomy do not see what they may consider a "complication", which has led to some of the expectant managed renal injuries necessitating operative intervention. Lastly, most data supporting the prevalence of high complication rates come from literature prior to 1952. 51 Much has changed in 25 years to enhance our knowledge, diagnosis and management of the traumatized patient and their associated injuries. However, when sufficient data exist to allow complications to be analyzed it is customary to divide them into early and late complications. As defined by Banowsky and associates immediate complications are "those which threaten the life or loss of the involved kidney within the first 6 weeks after injury". 10 With rare exception, early and late complications are the result of major renal injuries. The early complications seen most frequently are 1) hemorrhage with shock, 2) sepsis, 3) urinary extravasation, 4) perinephric abscess formation, 5) acute tubular necrosis with renal failure and 6) fistula formation (enteric or cutaneous). Included among late complications are 1) hypertension, 2) chronic infection (chronic pyelonephritis), 3) hydronephrosis, 4) chronic renal insufficiency, 5) calculus formation, 6) arteriovenous fistulas, 7) pseudocyst formation and 8) non-function. Hypertension. Hypertension, the most common of the delayed complications, may occur years after the internal injury, thereby making it essential that long-term followup of the trauma patient be pursued vigorously. Mitigated by parenchymal ischemia, the renal angiotensin system is responsible for the hypertension of renal trauma. The parenchymal ischemia may result from causes ranging from perinephric fibrosis to branch arterial occlusions, to inadequate partial nephrectomy or inadequate arterial repair. As noted by Cosgrove and associates arteriovenous fistulas causing hypertension may not be treated adequately by ligation, 52 thus nephrectomy is recommended for this sequelae of arteriovenous fistula formation. Ureteropelvic obstruction with hydronephrosis or infundibular stricture with partial hydronephrosis also may result in hypertension. Other late sequelae of renal trauma tend to be more symptomatic than hypertension and, therefore, usually are discovered within the first year of trauma. This is especially true with chronic infections, hydronephrosis and arteriovenous fistulas that present with hematuria. With increasing expertise in the management of renal trauma immediate and delayed complications assuredly will continue to diminish in the future. REFERENCES
1. Scholl, A. J. and Nation, E. F.: Injuries of the kidney. In:
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Urology, 3rd ed. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W.B. Saunders Co., vol. 1, chapt. 20, p. 785, 1970. Morrow, J. W. and Mendez, R.: Renal trauma. J. Urol., 104: 649, 1970. Glenn, J. F. and Harvard, B. M.: The injured kidney. J.A.M.A., 173: 1189, 1960. Peterson, N. E. and Kiracofe, L. H.: Renal trauma. When to operate. Urology, 3: 537, 1974. Campbell, M. F.: Injuries of the kidney. Surg. Clin. N. Amer.,
RENAL TRAUMA
21: 443, 1941.
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P., Hoch, W. H., Persky, L. and Zollinger, R. NI., Jr.: management of renal injuries coincident ,.vith penetrating wounds of the abdomen. J. Trauma, 13: 502, 1973. 7. Scott, R., Jr., Carlton, C. E., Jr. and Goldman, lVL: injuries of the kidney: an analysis of 181 patients.
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rn: 587, 1910. 11. Peters, P. and Bright, T. C , HI: Blunt renal injuries. Urol. Clin. N. Amer., 4: 17, 1977. 12. DeWeerd, J. H.: Management of renal injuries. J. Int. Coll. Surg., 29: 567, 1958. 13. Scholi, A. J. and Fen-ier, P. A.: Injuries of the Urology, 1st ed. Edited M. Campbell. Philadelphia: Saunders Co., vol. 2, p. 1954. 14. Carlton, C. E., ,fr., Scott, R., cir. and Goldman, M.: The management of penetrating injuries of the kidney. J. Trauma, 8: 1071, 1968. 15. Waterhouse, K. and Gross, M.: Trauma to the tract: a 5.. year experience with 251 cases. J. 1969. in 16. Cass, A. S. and Ireland, G. W.: Management of renal the severely injured patient. J·. Trauma, 12: · Diagnosis 17. Kazn:iin, M. H., Brosman, S. A. and Cockett, A. T. and management of renal trauma: a study of 120 patients. J. 101: 783, 1969. in the evaluation of renal 18. Morse, T. S.: Infusion in children. 693, 1966. 19. M., Meng, C.-H., and deParedes, R. G.: Roentgenologic uu,.w,wu of renal trauma with emphasis on renal angiograAmer. J. Roentgen., 98: 1, 1966. L. A.: Evaluation of the merits of ~vQt,w,•,ffrn and retro20. pyelography in the management trauma. J. 63: 9, 1950. 21. Schencker, B.: Drip infusion pyelography. Indications and appli·cations in urological. roentgen diagnosis. Radiology, 83: 12, 1964. 22. Mahoney, S. A. and Persky, L.: Intravenous drip nennr01;0:c,~D!2"the evaluation of
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Recent advances in the w,~!S'"v,ow and management of renal trauma. J. Urol., H3: 1975. V\Tooclruff, J. H., Jr., Cockett, A. T. K., Cannon,. R and Swanson, L. E.: Radiologic aspects of renal trauma on arteriography and renal isotope scanning. 184, 1967. Kazmin, M. H., Swanson, L. E. and Cockett, A. T. K.: Hemd scan: the test of choice in renal trauma. J. Urol., Betti, R., Palumbo, R., De Santis, M., Senin, U. and Biasirn, E.: Use of m,,w•rn•u_.?1 scintiscan in experimental trauma.. J. 1966. Cass, A. S. and lN.: Comparison of the and surgical management of the 1,;ore severe trauma in multiple injured patients. cl. U rol., Slade, N.: Management of closed renal injuries. 43: 639, 1971. Lucey, D. T., Smith, M. J·. and Koontz, W, W., A plea for the conservative treatment of renaI inju,ies. J. Traum2., 306, 1971. Fay, R., Brosman, S., Lindstrom., R. and Cohen, A.: artery thrombosis: a successful revascularization transplantation. J. Urol., Hl: 572, J.974. Rohl, L.: Vascular surgery in urology. Proc. Roy. Soc. J\/led.
589, 1971. 37. Evans, A. and Mogg, R. A.: Renal artery thrombosis closed trauma. J. Urol., 105: 330, 1971. 38. Skinner, D. G.: Traumatic renal artery thrombosis:
thrombectomy and revascularization. Ann. Surg., 1973. 39. Whitney, R. F. and Peterson, N. E.: Penetrating 7: 7, J.976.
, Jr. and Selzman, H. M.: tomy: review of 450 patients and a of the transperitoneal uu.rn,,u1. J. 41. Caplan, B. B., Halasz, and Bloomer, VV. B.: Resection and ligation of the suprarenal inferior vena cava.
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27. Rous, S. N.: The value of serial selective renal m the delayed management of renal trauma. J. 1972. 28, Cockett, A. T. K., Frank, I. N., Davis, R. S. and Linke, C. A.:
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THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
Review Article RENAL TRAUMA ROBERT MENDEZ From the Department of Urology, Los Angeles County-University of Southern California Medical Center, Los Angeles, California
ABSTRACT
The pertinent literature on renal trauma for the last 25 years has been analyzed. An evolutionary pattern is seen in the development of diagnostic methods, while surgical and medical management of renal trauma has become much more precise for specific lesions. Various subareas of interest within the field have emerged, such as pediatric trauma, associated injuries and the subdivisions of blunt and penetrating trauma. Furthermore, therapy has been extended to include those severe vascular lesions that previously were considered untreatable. Various new and experimental concepts are described. Specific recommendations regarding the diagnosis and the therapeutic management are offered in an attempt to bring perspective to these new developments. Trauma affecting the kidneys has long stirred interest and controversy among urologists. During the last 25 years great advancements in diagnostic skills and surgical techniques have been applied to this field, creating an occasional diversity of opinion regarding their usefulness and effectiveness. An attempt is made herein to survey, analyze and bring perspective to these recent advancements in the field ofrenal trauma. Age, sex and incidence. Trauma most notably occurs in those individuals directly involved in violence and frequent activity. For the most part, these individuals are men in their 20s. In a review of all renal injuries at our medical center from 1934 to 1960 Scholl and Nation reported that 127 of 478 injuries occurred in individuals between 20 and 30 years old, while 102 of the 478 injuries were seen in the teenage group. 1 The third most common group comprised individuals in their 30s. This age and sex relationship also was noted subsequently in the same institution by Morrow and Mendez. 2 Other large series, such as those of Glenn and Harvard,3 and Peterson and Kiracofe,4 have revealed similar age and sex characteristics among their patients with renal injuries. The general incidence of blunt and penetrating renal trauma in a large metropolitan hospital has been reported by Campbell to represent 1 of 3,000 admissions. 5 Penetrating renal trauma is found 6 to 8 per cent of the time in patients admitted to the hospital with penetrating abdominal injuries. Tynberg and associates reported that 7.5 per cent of 2,121 patients with penetrating injuries entering their hospital had renal trauma, 6 while Scott and associates noted a 7.5 per cent incidence of renal injuries in 2,252 patients with penetrating abdominal wounds.7 No data are available with regard to the incidence of renal trauma owing to blunt injuries. Etiology. Traditionally, renal injuries are divided etiologically into those resulting from blunt trauma and those resulting from penetrating trauma. Blunt trauma is the more frequent, being the causative factor in 60 to 70 per cent of renal injuries. The majority of blunt trauma results from automobile and motorcycle accidents, with falls, athletic injuries, altercations and a sundry of crush injuries completing this etiologic group. Attempts to quantitate and calculate the direct force with which blunt trauma causes certain degrees of renal injuries have been done experimentally by Jaffe and
associates. 8 The mechanism of injury caused by blunt trauma may be direct or indirect. With direct injury the kidney may be crushed between the external force and vertebrae or back muscles. It also may occur with skeletal fractures, such as rib or vertebral fractures when the kidney is penetrated by these fractured bones. Indirect injury occurs because of a decelerating effect in which the kidney may be torn from its pedicle. Penetrating injuries are preponderantly gunshot wounds and stabbings. Gunshot wounds may be caused by a low or a high velocity missile. The former causes injury by its direct tissue penetration and the latter by direct tissue injury and blast effect to adjacent tissue. Stab wounds do not directly affect much parenchymal tissue but, rather, cause serious injuries by subsequent infections, arteriovenous fistulizations and vascular or collecting system damage. CLASSIFICATION OF RENAL INJURIES
The purpose of classifications has been to exact a more appropriate therapeutic regimen to the specific renal injury. Towards this end, many different schemes or types of classifications have emerged. Hodges and associates sought to classify injuries in a clinical sense as to those that would most likely require surgical intervention or medical management. 9 Injuries were classified as minor, major and critical. Minor injuries consisted of parenchymal damage without capsular rupture or extension of the defect to the pelves or calices, major injuries had parenchymal damage with capsular tears and extension into the collecting system, while critical injuries were defined as extensive pulpefaction of renal tissue and pedicle injuries. Recently, authors such as Banowsky, 10 Scott,7 Tynberg6 and Peters, 11 and their associates also have embraced this method of classification. Another method of classification has been by the etiology of the injury- blunt versus penetrating. Although of some minor benefit when used as a sole method of classification this method has little justification. Classification purely upon radiographic findings has been made but also has proved of less value. I prefer a similar classification patterned on that of Hodges and associates. 9 The lesion ultimately should be given a classification only upon complete analysis of all information
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that is clinical assessment, etiologic identification, radiographic such. as infusion pyelograms, angiograpyelography and nuclear scans, and, at times, of the retroperitoneum. After a review of available information a classification separating parenchymal lesions into contusions, lacerations, severe fractures and is suggested. This 4-group classification rather than the similar 3-group classification previmentioned to more specifically determine which lesions surgical and which expectant management.
showed enough detail for interpretation and then 50 75 per cent of these actually correlated with the lesion encountered at the time of the operation or further definitive studies, such as angiography. Infusion IVP with tomography. As knowledge and ence accumulated infusion IVP with tomography ·was uuuJJvc,, to diagnostic use in renal trauma. 21 This technique enhancing qualities in the traumatized renal JJOH
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soever regarding the exact nature of the lesion or if the lesion is secondary to a major stab wound (predisposing it to arteriovenous fistulization) then arteriography with selective renal angiography is obtained. Other studies, such as retrograde pyelography and/or renal scans, are then obtained when clarification of an injury could be obtained best by the use of these studies. ASSOCIATED INJURIES
Associated injuries occur in from 60 to 80 per cent of renal trauma cases. Their type, extent and management are of great importance to over-all clinical survival of the patient and management of the renal problem. There is usually a good correlation between the extent of trauma and the severity of the associated injuries. The type of associated injury varies somewhat with the etiology of injury. Blunt trauma patients have higher associated central nervous system and skeletal injuries, while those with penetrating trauma more often have associated visceral and, not infrequently, multiple genitourinary organ system involvement. Mortality rates in patients with renal trauma invariably are secondary to associated injuries. Of the penetrating renal trauma patients described by Scott and associates 80 per cent had major associated injuries. 7 Liver injury in 46 per cent was followed by other visceral organ damage to the spleen, stomach, colon, pancreas and small intestines in descending order of prevalence. Major vessel injuries were present in approximately 4 to 5 per cent of cases. Similar findings were noted by other investigators. 1' 2 ' 32 Diagnosis of the associated injuries usually is suspected by mode of injury and clinical presentation. Fourteen to 30 per cent of renal patients present in shock. This is invariably secondary to the associated injuries. Verification of the associated lesion is made by radiographic assessment or laparotomy. Because of suspected associated lesions, penetrating injuries usually will be explored by general surgeons and, thus, the primary decision for laparotomy rarely rests solely with the urologist. It is with respect to the exploration of the retroperitoneum that the urologist's opinion is usually requested. TREATMENT
While controversy on just what is considered optimal treatment has existed, with increased knowledge and sophisticated analysis of data most viewpoints have blended into a common view of management for all but a small number and type of renal injuries. Optimal treatment of renal injuries is now predicated upon cognizance of and consideration for 3 factors: 1) the clinical condition of the patient, 2) associated major injuries and 3) accurate diagnosis of the extent of renal injury. Of prime consideration to the urologist is the necessity to establish preoperatively as accurate a diagnosis as possible. For therapeutic purposes lesions are classified into 4 groups: 1) contusions, 2) lacerations, 3) fractured or pulpefacted kidneys and 4) pedicle injuries. A common approach to the management of groups 1, 3 and 4 now generally exists in the urologic community, while some controversy still exists in the laceration group of injuries. Contusions. As defined previously contusions account for a significant majority of renal lesions. Carlton and associates found 85 per cent of their blunt injuries to be of a minor variety (contusions and simple lacerations). 14 Scholl and Nation reported 256 of 478 injuries to be contusions only.' In 1960 Glenn and Harvard found an incidence of 64 per cent negligible or minimal renal injuries, 3 while Peterson and Kiracofe observed that 86 of 144 patients had minor injuries. 4 Mahoney and Persky found that 29 of 41 patients had contusions in a study recommending intravenous drip nephrotomography. 22 Cass and Ireland treated 4 of their 69 patients diagnosed as having contusions with an operation-3 had exploration of the kidney and 1 a nephrectomy for a massive congenital
hydronephrosis. rn The remammg 65 patients were treated medically. None required a further operation although some may have been included in their 6 patients requiring prolonged (more than 24 days) hospitalization until successful management was obtained. Most other larger series also advocate medical management of this group of lesions and report similar high success rates, 1. 7 • 11 , a3 Lacerations. These lesions include 1 or 2 parenchymal tears, with or without extravasation but with an intact kidney. Herein are the lesions whose management is most controversial. Although differences do exist as to form of treatment and outcome much of the apparent discrepancy is in the precise definition of the lesion, what is considered treatment and what is complication. Scott and associates, in a review of 54 minor penetrating injuries managed by an immediate operation, successfully treated 52, while 2 gunshot wounds in this minor category necessitated nephrectomy. 7 Four patients underwent exploration only, 20 patients had exploration and drainage only, while 29 patients underwent renography. In the major wound category, which included lacerations with extravasation and more severe injuries, 23 of 56 patients immediately explored underwent nephrectomy. Peterson and Kiracofe treated 32 minor penetrating and 54 minor blunt injuries. 4 Of the 32 penetrating injuries 7 were observed, 7 were explored and no treatment was deemed necessary, 16 had exploration and drainage only and 2 required a wedge resection repair. In the 54 cases of blunt mild injuries 47 were observed, 3 explored and no operation was deemed necessary, while 4 were explored and drained. Peterson and Kiracofe concluded retrospectively that 22 of 29 surgically explored and treated injuries could have been treated more appropriately by medical management. 4 In comparing conservative versus immediate surgical management of more severe degrees of renal trauma (lacerations, fractured kidneys, pedicle injuries) Cass and Ireland treated conservatively 18 patients with renal lacerations and did immediate operations on 22. 32 Of the total group of injuries treated conservatively 8 patients died of associated injuries, while 7 in the immediate surgically treated group also died of associated injuries. Of the remaining 16 patients in the conservative group, the bulk of whom had lacerations, only 1 underwent nephrectomy. Of the remaining 22 in the immediate surgically treated group, in which the majority also were lacerations, 15 underwent nephrectomy. Cass and Ireland state that 9 of the nephrectomies and 3 operations preserving kidney parenchyma were done before the introduction of preliminary vascular control procedures. 16 The conservative group had an average hospital stay of 29 days versus a 20-day average in the immediate surgically treated group of patients. Morrow and Mendez found 23 lacerations-21 patients were initially treated medically, while 2 underwent immediate operations to control bleeding. 2 In the non-operative group 5 patients eventually underwent nephrectomy for a 22 per cent nephrectomy rate. Many series tend to be supportive of the specific kinds of findings noted in the aforementioned series but precise comparison is impossible owing to the manner in which their data are presented. Several facts appear to emerge from the analysis of this specific type of injury. Renal lacerations can by and large successfully be treated medically as well as surgically. However, if immediate surgical intervention is the mode of therapy chosen prior vascular control must be obtained or nephrectomy rates tend to be inordinately high. The high rate of associated injuries tends to make exploration of penetrating injuries necessary. However, it does not make retroperitoneal and renal exploration necessary, especially if the renal diagnosis is reliably known preoperatively. If conservative management is chosen as therapy a far smaller nephrectomy rate can be anticipated, although hospitalization will be longer. In the final analysis, each case must be dealt with on an
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with the clinical state of the patient being considerationo rn,r·nrrPn and palpable lesions As defined previously these lesions manifest numerous deep lacerations, major extravasation and non-visualization of the kidneyo Arteriogor scanning is necessary for an accurate diagnosiso The immediate exploration of these lesions is, indeed, mandatory if prolonged morbidity is to be circumventedo At times, partial nephrectomy can be aucu
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I know of no published evidence that this expectant apto surgery will result in greater renal tissue loss than would occur normally if immediate surgical intervention were On the contrary, nephrectomy rates are and lower when this therapeutic approach is taken but is prolongedo As stated Whitney immediate nephrectomy is no great institution for the morbidity of a necessary delayed exploration with salvation of kidney tissue or even nephrectornyo 38 U~OLV-ULVH
Surgical treatmenio When an operation is deemed necessary after adequate evaluation and diagnosis the abdominal approach as outlined by Scott and Selzman is recommendedo 40 thorough laparotomy is performed through a midline incision with attention to associated injuries priority, Next the posterior peritoneum over the aorts incised, the left renal vein is retracted and a vascular clamp is applied to the appropriate renal artery Devascularized tissue is excised and any rent in the system is closed with a 4-zero running chromic suture possible; if not, interrupted sutures are usedo Various intertuo bular and interlobular vessels are and/ or ligated with 4-zero chromic sutureso A piece of fat or surgicel is then placed in the defect ,J.nd the margins of the laceration are approximated with of-eight 3-zero chromic catgut sutures the and parenchymao After the the observed for excessive bleedingo deemed the procedure of choice the capsule is dissected over the demarcated line to be excisedo A guillotine tion is doneo The collecting system is closed with zero chromic sutures and vessels are ligatedo The the amputated segment of kidney is then removed as intact as possible with the back side of the capsule is then used to cover the amputated surfaceo Debridement of devitalized tissue is ne>o~torrr1Prl on lacerations and then a running anastomosis is done 'c·-- obst:rnctim1 zero chromic sutureso With ureteropelvic " spatulation of the ends is accomplished with the anastomosis repair again made with 4-zero chromic sutures, Tbe anastomosis is stented with a Noo 5 ureteral catheter down into the bladder and brought out small opening of the renal pelviso If massive existed a nephrostomy tube is placedo renal vein lacerations usually are debrided and closed with 6-zero cardiovascular sutureso All other branch veins or accessm-y veins are simply ligatedo 410 42 Thrombectomy with a Noo 3 or 4 by excision of the damaged segment end-to-end arterial anastomosis may arterial thrombosis if an operation can be naodr.rn-,ocl 10 to 12 hours of injuryo hematoma rw.i,v11u,w. Of importance under these conditions of the presence of a normal functioning contralateral This confirmation can be accomplished under direct vision. An infusion IVP while the patient is on the table also is in most major medical centerso If this latter estab lishes a relative secure diagnosis treatment is done under the guide lines suggested previously. If an exact '°'""°S"vuw cannot be made the retroperitoneum is not if hematoma is small and seemingly stableo If there exists a large hernatoma, whether owing to penetrating or blunt trauma, and presence of a normal contralateral kidney has been established exploration of the is done previously described approacho Management of the renal injury surgically, of course, must take into account the associated intra-abdominal particular importance are concomitant pancreatic, ileal and colonic injurieso It is imperative that renal lesions with major extravasation be separated nnm,w" from. pancreatic or duodenal draining injurieso be the conservative treatment of choiceo 0
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PEDIATRIC TRAUMA
As a clinical entity trauma has special pediatrics, being the number 1 cause of death children between the ages of 1 and 14 yearso As for renal traurrw specifically, the pediatric patient is more vulnerable to renal trauma than the adulto Miller and associates have nn,rnPn
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out that the "lack of strong muscles and a more rigid thoracic cage provide less protection for the retroperitoneal area". 43 It has been well documented that diseased and especially anomalous kidneys are much more prone to injury with trauma. 4 3--4 5 Blunt trauma accounts for a relatively higher percentage of pediatric renal injuries. In a study of 110 children by Javadpour and associates 70 per cent sustained blunt traumatic injuries, 46 while 90 per cent of the renal injuries reported by Cass and Ireland were a result of blunt trauma. 47 Children also tend to have a much higher incidence of associated head injuries with blunt trauma than do adults. Congenital anomalies. In a rather different and interesting approach to the assessment of trauma and anomalies, Miller and associates surveyed all children between O and 14 years old for 12 years with specific diagnoses, such as Wilms tumors, teratomas, hydronephrosis, and so forth, to determine what percentage were discovered because they sustained a traumatic injury. 43 Two classifications were given: those anomalous kidneys sustaining injury and those traumatized patients in whom trauma brought forth the discovery of congenital anomalous kidneys. They found that 17 per cent of hydronephrosis, 27 per cent of Wilms tumors and 25 per cent of hepatic tumors were discovered by trauma. Half of the hydronephrotic kidneys discovered had been aggravated by the trauma, while only a third of the tumors were affected by the trauma, two-thirds being found incidental to the trauma. Morse and associates also noted that 8 of 89 pediatric renal trauma patients had pre-existing congenital anomalies. 48 Cass and Ireland, in reviewing their 82 pediatric patients with renal injuries, found only 2 congenital anomalies-1 hydronephrosis and 1 bilateral hydroureter. 47 By and large, injuries in the pediatric group tended to be less severe than those encountered in the adult group. Additionally, although the ratio of male to female patients shows a male preponderance, it is not nearly as great as exists with adult patients. A classic example of trauma to an anomalous congenital kidney that also demonstrates the deceleration type of injury is related by Peters. 49 A white female infant presented to the emergency room with anuria. An IVP, which revealed nonvisualization, was followed by bilateral retrograde pyelography, which demonstrated bilateral ureteropelvic disruption of congenital ureteropelvic junction obstructions with hydronephrotic kidneys. The angiograms also revealed a subintimal tear of the left renal artery. Repair consisted of a right ureteropyeloplasty. An attempt at left renal artery repair proved unsuccessful and, thus, a left nephrectomy was performed. Subsequent followup IVPs have revealed a normal functioning right kidney. Diagnosis. Various subtle differences exist in the diagnostic approach of renal trauma in children. Unfortunately, all too often an inadequate evaluation is done because of a failure to elicit symptoms in a child, the reticence of parents to hospitalize their child with blunt injuries and the hesitation to use invasive techniques for further clarification, such as retrograde pyelography or renal angiography. Treatment. There is a much stronger tendency toward conservation in therapy of renal trauma in the pediatric patient. Reasons for this approach are several and include the greater life expectancy and the possible future susceptibility of pregnancy or athletic injuries. When surgical intervention is deemed necessary all attempts at maximal renal salvation are made. Salvation can be assured by thorough evaluation preoperatively. Morse and associates believe that the optimal time to operate, when intervention is needed, is between 2 and 7 days after injury, time enough for stabilization and evaluation, and prior to abscess or significant urinoma formation. 48 This type of approach has been quite successful in effecting a lower nephrectomy rate in children as compared to adults. 44 • 46 • 48 • 50
COMPLICATIONS
Precise evaluations of complications resulting from renal trauma have proved difficult to obtain in the past. Several factors appear to account for this. As Whitney and Peterson suggest, the transient nature of the patient population makes the accurate accumulation of data difficult. 39 However, perhaps as important is the problem of defining what is a complication, which evolves from the fact that those who manage renal injuries expectantly await adverse clinical changes prior to operative intervention. For the most part, this caution has been seen to dramatically lower nephrectomy rates. Interventionists who have initially opted for an operation and performed an initial nephrectomy do not see what they may consider a "complication", which has led to some of the expectant managed renal injuries necessitating operative intervention. Lastly, most data supporting the prevalence of high complication rates come from literature prior to 1952. 51 Much has changed in 25 years to enhance our knowledge, diagnosis and management of the traumatized patient and their associated injuries. However, when sufficient data exist to allow complications to be analyzed it is customary to divide them into early and late complications. As defined by Banowsky and associates immediate complications are "those which threaten the life or loss of the involved kidney within the first 6 weeks after injury". 10 With rare exception, early and late complications are the result of major renal injuries. The early complications seen most frequently are 1) hemorrhage with shock, 2) sepsis, 3) urinary extravasation, 4) perinephric abscess formation, 5) acute tubular necrosis with renal failure and 6) fistula formation (enteric or cutaneous). Included among late complications are 1) hypertension, 2) chronic infection (chronic pyelonephritis), 3) hydronephrosis, 4) chronic renal insufficiency, 5) calculus formation, 6) arteriovenous fistulas, 7) pseudocyst formation and 8) non-function. Hypertension. Hypertension, the most common of the delayed complications, may occur years after the internal injury, thereby making it essential that long-term followup of the trauma patient be pursued vigorously. Mitigated by parenchymal ischemia, the renal angiotensin system is responsible for the hypertension of renal trauma. The parenchymal ischemia may result from causes ranging from perinephric fibrosis to branch arterial occlusions, to inadequate partial nephrectomy or inadequate arterial repair. As noted by Cosgrove and associates arteriovenous fistulas causing hypertension may not be treated adequately by ligation, 52 thus nephrectomy is recommended for this sequelae of arteriovenous fistula formation. Ureteropelvic obstruction with hydronephrosis or infundibular stricture with partial hydronephrosis also may result in hypertension. Other late sequelae of renal trauma tend to be more symptomatic than hypertension and, therefore, usually are discovered within the first year of trauma. This is especially true with chronic infections, hydronephrosis and arteriovenous fistulas that present with hematuria. With increasing expertise in the management of renal trauma immediate and delayed complications assuredly will continue to diminish in the future. REFERENCES
1. Scholl, A. J. and Nation, E. F.: Injuries of the kidney. In:
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Urology, 3rd ed. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W.B. Saunders Co., vol. 1, chapt. 20, p. 785, 1970. Morrow, J. W. and Mendez, R.: Renal trauma. J. Urol., 104: 649, 1970. Glenn, J. F. and Harvard, B. M.: The injured kidney. J.A.M.A., 173: 1189, 1960. Peterson, N. E. and Kiracofe, L. H.: Renal trauma. When to operate. Urology, 3: 537, 1974. Campbell, M. F.: Injuries of the kidney. Surg. Clin. N. Amer.,
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589, 1971. 37. Evans, A. and Mogg, R. A.: Renal artery thrombosis closed trauma. J. Urol., 105: 330, 1971. 38. Skinner, D. G.: Traumatic renal artery thrombosis:
thrombectomy and revascularization. Ann. Surg., 1973. 39. Whitney, R. F. and Peterson, N. E.: Penetrating 7: 7, J.976.
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