Renal and Ureteral Injuries Flashcards
How to evaluate patient with Renal or Ureteral injury
CT scan with IV contrast three critical phases: arterial, nephrogram, and pyelogram.
Intraoperative cystoscopy with retrograde pyelograms
Single-shot intravenous pyelogram (IVP) , identify presence of contralateral kidney and an apparent ureteral injury
What sign on imaging pathognomonic for renal pelvis or ureteral injury ?
Contrast Extravasation on Delayed Phase image
What may Suggest ureteral injury on presentation
gross hematuria, urinoma, or hydronephrosis
Indications for Non Opertive management in renal injury
Hemodynamic stability
Grade of Injury
Initial Management :
-bed rest
-serial hemoglobin levels
-hemodynamic monitoring.
-active surveillance for blood transfusion with or without angioembolization.
-follow-up imaging for deep lacerations ( IV– V ) or clinical signs of complications
Patient on non operative management developed urinary extravasation with enlarging urinoma or fever
Consider Ureteral Stent or Percutanous Nephrostomy
Indications for IR management in renal injury
-can be utilized in hemodynamically unstable patients
-perirenal hematoma (> 4 cm)
-vascular contrast extravasation.
surgical intervention may be necessary for deep or complex renal lacerations (AAST III– V).
Absolute indications for operative management in Renal Injury
-Expanding/Pulsatile hematoma
-Renal Pedicle avulsion
-Persistent or Life threatening Shock or hemorrhage
-Ureteropelvic Junction Avusion/Disruption
Relative Indications for Operative management in Renal injury
-Urinary Extravasation wihtout viable tissue
-Concurrent colon/ pancreas/ trauma exploration with incomplete staging or grade III or greater concurrent renal injury
-Renovascular hypertension
-Failed embolization
Complications post renal repair or IR
-delayed bleed, AV fistula, or pseudoaneurysm
-If the collecting system was repaired :
delayed urine leak, leading to a urinoma or perirenal abscess.
MC Etiology for Ureteral injury
Penetrating Trauma
Pt with ureteral contusion without a urinary leak in undergoing exploratory laparotomy.
Ureteral Stent
when a delayed ureteral injury is recognized or when severe urinary extravasation
Nephrostomy drainage
Immediate repair vs Delayed Repair
Immediate :
trauma patient undergoing exploratory laparotomy.
ureteral repair may be performed if the injury is identified within 7 days
after 7 days, a delayed repair is attempted several weeks after the urinary leakage and acute inflammation have resolved.
describe the Coarse of the Ureter
-traverses the retroperitoneum beneath the gonadal vessels, on top of the psoas, over the iliac vessels near the iliac bifurcation
-The ureter blood supply varies by location; distally, the supply is lateral, then posterior as it travels over the iliac vessels, and then transitions to medially as the ureter travels to the renal hilum.
What suture for Ureteral repair used
4-0 or 5-0 absorbable interrupted
with a stent
Patient in extremis
damage control and bailout: tying off the ureter, temporary urinary drainage, and delayed repair.
Proximal Ureter Repair (Cephalad to Iliac Crest)
-A pyeloplasty may be required if a ureteropelvic junction (UPJ) is avulsed or severely injured.
-A ureteroureterostomy (UU) will be required if the injury is found more distal on the proximal ureter.
Midureter (Caudal to Iliac Crest, Cephalad to Sacroiliac)
-The UU is most often performed procedure in the midureter in an acute setting.
-On occasion, a trans-UU is required, passing the injured ureter retrosigmoid and performing an end-to-side anastomosis.
-contraindicated in patients with a history of urolithiasis
-psoas hitch can be performed with subsequent transverse incising of the bladder with cephalad mobilization (Boari flap).
Distal Ureter (Caudal to Sacroiliac)
-ureteral reimplant (ureteroneocystostomy).
-To maintain the reimplant off-tension, performing a psoas hitch is often required
When placing Suture for Psoas hitch
avoid nerve entrapment of either the genitofemoral or femoral nerve.
Options for Injury > 10 cm
-Bladder Flap
-Downward Nephropexy
-Ileal Ureter ( 15 cm from IC junction )
-Autotransplantation of the kidney
For bilateral repairs, a reverse seven ileal interposition
how to avoid complications post repair
nephrostomy tube, ureteral stent, and Foley catheter.
