11. Injuries to the kidney and ureter; Endourological interventions

Question 1

Types of kidney injury

Answer 1

1. Minor renal trauma: Renal contusion with a subcapsular hematoma. Rarely
   require surgery.
2. Major renal trauma: Deep corticomedullary laceration that may extend into the collecting system, resulting in extravasation of urine into the perirenal space.
   - Large retroperitoneal and perinephric hematomas often accompany these deep lacerations.
3. Vascular injury: Detachment of the renal artery and vein or segmental branches of these vessels.
   Stretch without detachment can cause renal artery thrombosis

Injury is graded from 1-5 depending on the number and depth of lacerations and the degree of peri-renal bleeding.

Question 2

Symptoms of kidney injury

Answer 2

Pain on the injured side or general abdominal pain.

Nausea, Vomiting.

Hypotension and hemorrhagic shock.

Large retroperitoneal hematoma may cause a palpable abdominal mass, ileus.

Hematuria.

When shock is present with microscopic hematuria, the incidence of significant renal injury increases.

Question 3

Diagnosing kidney injury

Answer 3

History, symptoms

Ultrasound can demonstrate the hematoma but not parenchymal damage or lacerations.

Best method is contrast enhanced CT. Also visualizes other abdominal organs that may be damaged.

Lesions are seen by extravasation of contrast.
Lack of contrast uptake indicates arterial damage.

Follow up by an arteriography.

Question 4

Chronic compolications following kidney injury

Answer 4

Complications:

• Perinephric abscess
• Perinephric fibrosis
• Perihilar fibrosis, which can constrict renal artery and cause renovascular HTN.

Question 5

Treating kidney injury

Answer 5

Treatment: Minor injuries are treated conservatively with close monitoring.

Urinary extravasation can be managed with a double J catheter.

Evidence or persistent renal bleeding and expanding perirenal hematoma, or arterial injury are absolute indications of surgical exploration.

The procedure of renal reconstruction includes complete renal exposure, debridement of non-viable tissue, hemostasis by suture ligations, watertight closure of the collecting system, and coverage or approximation of parenchymal defect.

Total nephrectomy is indicated in extensive renal injuries when the patient’s life would
be threatened by attempted repair.

Question 6

Injury to the ureter, causes

Answer 6

Most commonly iatrogenic.
Hysterectomies - runs under the uterine artery
Endoscopic urinary stone removal.

Penetrating trauma or blunt trauma.

Question 7

Ureter injury symptoms.

Answer 7

• Urine extravasation will form a urinoma
• If the urinoma is infected, abscess and sepsis may follow
• Ureterovaginal or ureterocutaneous fistula may develop
• Acute peritonitis can occur if there is urinary extravasation

Question 8

Ureter injury diagnosis

Answer 8

To diagnose start with US and for more accurate diagnosis do a contrast enhanced CT or retrograde ureterography.

Question 9

Ureter injury treatment.

Answer 9

Partial injuries - placement of ureteric stents.

Complete rupture of the ureter requires open or laprascopic reconstruction.

First perform a percutaneous nephrostomy for decompression and urinary deviation.

Then one of the following:
• Ureteroureterostomy
• Transureteroureterostomy: Anastomosis with ureter on contralateral side.
• Ureteroimplantation: Re-implantation into kidney.
• Replacement with bowel segment if there is extensive loss of the ureter
• Pyeloplasty

Question 10

Endourological interventions

Answer 10

Endourology is the branch of urology that deals with the closed manipulation of the urinary tract. It includes all minimally invasive surgical procedures. Endourology is performed using small cameras and instruments inserted into the urinary tract.

Transurethral surgery has been the cornerstone of endoneurology, seeing as most of the urinary tract can be reached via the urethra.

• Antegrade pyelography: Percutaneous puncture of the renal collecting system.
Performed for diagnostic purposes or establishing an access route for therapeutic interventions (catheter placement and endoscopic procedures).

Done by the help of US guidance and fluoroscopy.

o Whitaker test: Percutaneous pressure/perfusion study to assess pyoloureteral resistance. High pressure suggests obstruction.

o Perfusion-chemolysis of renal stones: Nephrostomy catheters may be used for perfusion of the collecting system with chemolytic agents for stone dissolution. Adjuvant therapy of residual stones after surgery.

o Aspiration biopsy: Can be combined therapeutic drainage of fluid filled spaces.

• Retrograde endourology: Used to identify lesions and take biopsy or do therapeutic procedures.
o Urethroscopy
o Cystourethroscopy
o Transurethral ultrasound
o Transurethral surgery
o Ureterorenoscopy
o Retrograde pyelography