Renal and ureteric injury
Key points
Renal trauma
Commonest causes of blunt renal trauma:
1. Road traffic accidents
2. Falls
3. Sport/bicycles
Penetrating renal trauma is much less common than blunt trauma and has worse outcomes
Most common complication - urinoma
Horseshoe + hydronephrotic kidneys at particular risk
Management
Embolise if actively bleeding
Stent or drain insertion can aid non-operative management (NOM)
Grade 5 injuries can have NOM, however if laparotomy is required for other reasons, it should be removed
No evidence for standard practice
If vascular injury - can operate/IR stent to salvage if within a few hours of accident
Do renal USS at 48 hours to look for leak
Give antibiotics if leak
Follow up DMSA - low evidence, but can do for high grade injuries 3 months later to check if BP monitoring is needed/nephrectomy if non-functioning and hypertensivw
Ureteric trauma
Gunshot wounds most common
Contrast leak can be seen on CT Urogram
Management
Place catheter to keep bladder empty
If blunt contusion - stent if obstructed
If < 1week old injury - primary repair
If >1 week - nephrostomy + delayed repair
Missed injury - risk of urinoma, fistula, renal failure
Upper ureteral injuries can be repaired, and if additional length is required, the kidney can be mobilised
Middle ureter injuries can be repaired primarily or by connecting the undamaged portion of the injured ureter to the other ureter (transureteroureterostomy).
Lower ureter injuries can be associated with disruption of the blood supply from the iliac artery. In such cases, the distal end of the ureter can be connected directly to the bladder. A psoas hitch (fix bladder up to psoas) or Boari flap can be used if the ureteral length is insufficient for a neocystotomy
References
Holcomb and Ashcraft’s Pediatric Surgery, 7th edition, 2020, Chapter 16 Abdominal and Renal Trauma
Essentials of Pediatric Urology, 3rd edition, 2022, Chapter 23 Pediatric Genitorurinary trauma
Hirschl, Ron, et al., editors. "Ureter Repair for Trauma." Pediatric Surgery NaT, American Pediatric Surgical Association, 2016. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829223/all/Ureter_Repair_for_Trauma.