Campbell GU Trauma 2021

Question 1

Most important information to obtain in blunt renal injury: ___

Answer 1

Mechanism of injury

** Deceleration? Speed of car or height of fall;

** Kidney is vulnerable to decelration injury: tear at points of fixation: hilum or UPJ

Question 2

Penetrating trauma:
Anterior axillary line damages: ___

Posterior axillary line: ___

Ipsilateral rib fracture increases incidence of renal trauma ___-fold

Answer 2

AAL: renal hilum and pedicle

PAL: parenchyma

Three-fold

Question 3

Best indicators of significant GU injury: ___

Answer 3

Gross hematuria
Microhematuria (>5 RBCs/high-power field)

** Esp. when hypotensive (<90 mmHg), penetrating trauma

** Degree of hematuria does not correlate with injury severity

Question 4

Grade I renal injury

Answer 4

Contusion
Microscopic or gross hematuria, urologic studies normal
Hematoma
Subcapsular, nonexpanding without parenchymal laceration

Question 5

Grade II renal injury

Answer 5

Hematoma
Nonexpanding perirenal hematoma confined to renal retroperitoneum
Laceration
<1 cm parenchymal depth of renal cortex without urinary extravasation

Question 6

Grade III renal injury

Answer 6

Laceration

>1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation

Question 7

Grade IV

Answer 7

Laceration
Parenchymal laceration extending through renal cortex, medulla, and collecting system
Vascular
Main renal artery or vein injury with contained hemorrhage

Question 8

Grade V

Answer 8

Laceration
Completely shattered kidney
Vascular
Avulsion of renal hilum, devascularizing the kidney

Question 9

Indications for renal imaging

Answer 9

1. Penetrating trauma with a likelihood of renal injury (abdomen, flank, ipsilateral rib fracture, significant flank ecchymosis, or low chest entry/exit wound) who are hemodynamically stable enough to have a CT (instead of going directly to the operating room or angiography suite)
2. Blunt trauma with significant acceleration/ deceleration mechanism of injury, specifically rapid deceleration as would occur in a high-speed motor vehicle accident or a fall from heights
3. Blunt trauma and gross hematuria
4. Blunt trauma with microhematuria and hypotension (<90 mm
   Hg systolic at any time during evaluation and resuscitation)
5. Pediatric patients greater than 5 RBCs/HPF

Question 10

Pediatric patients have higher risk for renal trauma because of the ff: ___

Answer 10

Larger comparative kidney size
Less perirenal fat
Non-ossified bones
Less relative rib coverage over the kidneys in children

Question 11

Children do not become hypotensive with major blood loss due to:

Answer 11

High catecholamine output after trauma, which maintains blood pressure until approximately 50% of blood volume has been lost.

Question 12

Best method for GU imaging in trauma

Answer 12

Contrast-enhanced CT with immediate and delayed images

Question 13

Findings on CT suspicious for MAJOR injury:

Answer 13

(1) medial hematoma, suggesting vascular injury; (2) medial urinary extravasation, suggesting renal pelvis or ureteropelvic junction avulsion injury; (3) global lack of contrast enhancement of the parenchyma, suggesting renal artery occlusion; and (4) the combination of two or more of the following: large hematoma greater than 3.5 cm, medial renal laceration, and vascular contrast extravasation (suggesting brisk active bleeding), which constitute an AAST grade IVb injury

Question 14

Main purpose of the one-shot IVP:____

How to do the one-shot IVP: ___

Answer 14

Assess the presence of a functioning contralateral kidney.

Only a single film is taken 10 minutes after IV injection (IV push) of 2 mL/kg of contrast material.

Question 15

Non-operative management is the STANDARD OF CARE in: ___

Answer 15

Hemodynamically stable, well-staged patients AAST grades I-IVa, regardless of mechanism

Question 16

Routine follow-up CT imaging for NOM of Grade IV-V renal injuries is prudent at ___ post-injury to evaluate for: ___

Answer 16

48-72 hours
Urinoma
Hematoma

** Significant complications almost always present with symptoms (fever, flank pain, decreasing hematocrit, hematuria)

Question 17

Absolute indications for operative management (4): ___

Answer 17

(1) hemodynamic instability with no or transient response to resuscitation,
(2) expanding/pulsatile renal hematoma (usually indicating renal artery laceration),
(3) suspected renal vascular pedicle avulsion, and
(4) ureteropelvic junction avulsion

Question 18

Relative indications for operative management (4): ___

Answer 18

(1) urinary extravasation with significant renal parenchymal devascularization (older data suggested a higher complication rate than average if watched, but these also can be closely observed)
(2) renal injury together with colon/pancreatic injury (these patients have a higher complication rate if their renal injury is not repaired at the time of colon/ pancreatic injury, but the renal injury may be closely observed after repair of the enteric injury)
(3) arterial thrombosis
(4) urinary extravasation from parenchymal injury

Question 19

Surgical exploration is best by ___ approach, allows inspection of: ___

Answer 19

Transabdominal approach

Intra-abdominal organs and bowel

Question 20

Principles of renal reconstruction after traumaL ___

Answer 20

Complete renal exposure
Measures for temporary vascular control
Limited debridement of nonviable tissue
Hemostasis by individual suture ligation of bleeding vessels
Watertight closure of the collecting system if necessary/possible, re-approximation of the parenchymal defect
Coverage with nearby fascio-adipose flaps (Gerota fascia or omentum) if feasible
Liberal use of drains

Question 21

For unilateral arterial thrombosis:

For bilateral arterial thrombosis:

Answer 21

UNILATERAL: revascularization rarely results in a successful salvage or a viable kidney. As long as the contra-lateral kidney is normal, observation is often the best management.

BILATERAL: revascularization should be attempted, as up to 56% of patients can potentially avoid dialysis by prompt intervention

Question 22

Basic mechanisms for arterial hypertension as a complication of trauma:

Answer 22

(1) renal vascular injury, leading to stenosis or occlusion of the main renal artery or one of its branches (Goldblatt kidney)
(2) compression of the renal parenchyma with extravasated blood or urine (Page kidney)
(3) post-trauma arteriovenous fistula.

Question 23

Best imaging study for detecting ureteral injuries

Answer 23

CT urography with delayed images

Question 24

CT findings suggestive of ureteral injury

Answer 24

Contrast extravasation
Delayed ipsilateral nephrogram
Ipsilateral hydronephrosis, Lack of contrast in the distal ureter
Periureteral urinoma

Question 25

Most sensitive radiographic test for ureteral injury

Answer 25

Retrograde ureterogram
(RGP)

** BUT it is time-consuming and cumbersome

Question 26

Management options for ureteral injuries:

UPPER:

MIDDLE:

LOWER:

Answer 26

Upper: direct ureteroureterostomy
Transureteroureterostomy

Middle:
Direct ureteroureterostomy
Transureteroureterostomy

Lower:
Reimplantation
Psoas hitch

Question 27

Repair of the injured ureter should be performed: ___

Answer 27

At the SAME time as the initial laparotomy, in a stable patient

Question 28

Principles of management of injured ureter:

Answer 28

1. Mobilize the injured ureter carefully, sparing the adventitia widely.
2. Debride the ureter minimally but judiciously until edges bleed
3. Repair ureters with spatulated, tension-free, stented watertight anastomosis, using fine absorbable sutures and retroperitoneal drainage afterward.
4. Retroperitonealize the ureteral repair by closing peritoneum
5. DO NOT tunnel ureteroneocystostomies but rather create a widely spatulated nontunneled anastomosis.
6. With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition to isolate the repair when possible.
7. If immediate repair is not possible, or the patient hemodynamically unstable, one management option is to ligate the ureter with long silk or polypropylene suture, and plan to repair it later,

Question 29

Management:
Intact contused ureters: ___
Large areas of contusion that appear non-viable: ___

Answer 29

Intact: ureteral stenting (cystoscopy or cystotomy); maintain for 6 weeks

Large/non-viable: excision of damaged area and U-U or ureteroneocystosytomy

Question 30

If ureter is ligated (tied but not cut): ___

Answer 30

Remove ligature and observe for viability

If viability questionable = ureteroureterostomy or ureteral reimplantation

Question 31

Ureteral perforation during URS: ___

Answer 31

Treated by ureteral stenting