Page 13 - 63 craniocerebral-and-spinal-trauma30-35_opt

202 Urogenital and Perineal Trauma

reliable method for staging bladder injuries and can be used in place of Management of Renal Injuries
plain film cystography. Obtain CT images before contrast is given, at The management of renal injuries in a child depends on the stability
bladder capacity, and after the bladder is drained. of the child and the extent of injury sustained by the child. It is, how-
Renal scintigraphy ever, pertinent to define the goals of management of renal injuries in
children. These goals are to preserve renal tissue and function and to
Nuclear renography is not readily available in most centres across
minimise morbidity.
Africa because of the requirement for a radiation physicist and/or
Following careful imaging and stratification of the renal injury,
nuclear radiographic pharmacist. It has almost no role in the immedi-
children are either managed nonoperatively (i.e., expectantly) or
ate evaluation of patients with urinary trauma. Nevertheless, nuclear
operatively. Whichever management option is chosen, it is important to
scintigraphy can identify the presence or absence of a functional renal
bear in mind the goals of management stated above.
unit. Scanning a trauma patient is cumbersome and yields no addi-
tional anatomical details; therefore, CT scans are the preferred imaging Minor Injuries
modality in almost every case of acute trauma. In the chronic, posttrau- There is little controversy over the management of minor renal inju-
matic recovery phase, it may have a role to monitor differential renal ries. Most cases are managed nonoperatively with the expectation that
function or to assess the degree of obstruction if used with furosemide complete renal tissue will be preserved and full renal function will
(diuretic renography). return. Microscopic haematuria in a stable child with a renal contusion
Renal angiography and interventional radiography would not require hospitalisation of the child, but that child’s activ-
This imaging modality is limited to institutions where an interventional ity should be restricted until the haematuria clears. Gross haematuria
radiologist is present and where digital, multiplanar fluoroscopy is would, however, require strict bed rest in hospital. Ambulation starts
available. Most developing countries do not have access to this com- when the haematuria clears. If the haematuria persists, then IVU or
plex and expensive technology. However, where present, it is very contrast enhanced CT is done and bed rest continued. If the bleeding
useful to determine the extent of renal vascular injury and also provide is due to small-calibre renal vessels, angiography with embolisation is
an opportunity for the interventional radiologist to access actively done if facilities are available. In Africa, where interventional radiol-
bleeding sites within the kidney and embolise them. Arteriography is ogy facilities for embolisation are not routinely available, expectant
4
useful in nonoperative management of major renal trauma because up management is usually the preferred management. If bleeding persists,
to 25% of complex renal injuries may have delayed bleeding. Selective however, then open laparotomy with direct repair of bleeding sites is
embolisation is 80% effective in treating posttraumatic arteriovenous done. A follow-up ultrasound or CT scan is then done 6–8 weeks later.
malformations or pseudoaneurysms. Interventional radiologists can Renal scintigraphy, where available, or IVU in many centres in Africa,
also percutaneously access and drain an obstructed kidney or abdomi- is done to assess renal function. The blood pressure is monitored at each
nal/pelvic fluid collection. clinic follow-up.
Major Injuries
Retrograde pyelography
Children with major renal injuries pose a significant challenge to the
Retrograde pyelography is done during urethrocystoscopy, when the
surgeon in Africa. In children whose vital signs are stable, either imme-
ureteric orifices are catheterised and a soluble contrast injected. It is
diate or delayed surgery is employed, depending on the circumstances.
used to confirm ureteric injuries.
Early or immediate surgery
Kidney Trauma As a general rule, if the vital signs of the child with major renal injury
Renal injuries account for 30–70% of all urogenital tract injuries in are unstable, an expanding flank mass is present, and the haematocrit
1,2
children. There is a higher incidence of renal injuries in children is decreasing, then renal vascular injury is likely and immediate opera-
compared to adults because of several anatomical reasons. The kidney tive intervention should be carried out. The only absolute indication for
in the child is proportionately larger and more mobile than that of early surgery is haemodynamic instability. Because most complex renal
the adult; the abdominal wall and retroperitoneal fat in the child give injuries in children are associated with hypotension, bleeding, and other
little or no protection to the kidney; and foetal lobulation may initi- organ injury, almost all require exploration if the goals of management
ate cleavage planes after even minor trauma to the child’s abdomen. are to be achieved. Early operation may also decrease the incidence of
Certain conditions predispose children to renal injury, including con- morbidity such as abscesses, sepsis, and intestinal ileus. Early opera-
genital hydronephrosis, multicystic kidney, renal tumours (e.g., Wilms’ tion also reduces the duration (and cost) of the hospital stay, which is
tumour), duplication or fusion anomalies of the kidney, and compensa- important to practitioners in Africa, as a short hospital stay means there
tory hypertrophy (solitary kidney). would be bed space available for other patients. Early operation also
2
Blunt trauma is responsible for up to 80% of the injuries. Direct reduces the incidence of postoperative hypertension.
trauma crushes the kidneys against the lumbar spine or paravertebral McAninch has described a transabdominal approach to gain early
6
muscles. Indirect acceleration-deceleration injury, when applied to the access to the renal pedicle before mobilising the overlying colon
kidney, may disrupt the ureteropelvic junction. laterally and entering the Gerota’s fascia of the injured kidney. This
Renal injury may be classified as minor, major, or complex. method resulted in a higher renal salvage rate due to better vascular
1. Minor injuries account for 85% of renal injuries and include control and less bleeding. An incision is made through the posterior
contusions, subcapsular haematoma, and superficial lacerations. peritoneum and base of the mesentery immediately on top of the aorta;
There is parenchymal damage without capsular tears or pelvicalyceal the inferior mesenteric vein is used to guide the surgeon to the site
system involvement. of incision on the aorta. Through this more medial incision, the renal
2. Major injuries account for 10% of renal injuries. There is cortical vessels are readily identified (compared to a lateral approach through
laceration, deep parenchymal laceration involving the collecting the bed of the injured kidney) and secured with a temporary Rommel
system with limited extravasation. tourniquet or bulldog clamp. The colon can then be reflected and
Gerota’s fascia entered in a more controlled fashion.
3. Complex injuries account for 5% of renal injuries. They include
rupture of a solitary or malformed kidney, kidney fragmentation, Nonoperative or delayed management
significant renal vascular injury, or rupture of the renal pelvis or ureter. Proponents of nonoperative management of major renal injuries argue
that no controlled trials have conclusively shown a benefit of early