Upper Tract Trauma (Chap 90 12th Ed Chapter Review)

Question 1

What is the relation of hematuria to the severity of GU injury?

Answer 1

The best indication of significant urinary system injury is gross
hematuria. However, the absence of hematuria does not exclude a
significant GU injury. The degree of hematuria and the severity of renal injury are not
consistently correlated.

Question 2

How is evaluation of urologic trauma in children different from adults?

Answer 2

Evaluation of urologic trauma in children differs from adults in that
children: (1) are at greater risk for renal trauma, (2) often do not
become hypotensive with major blood loss, and (3) have a higher
propensity for renal anomalies.

Question 3

Which areas are impacted by rapid deceleration?

Answer 3

Rapid deceleration from a fall from height or a high-velocity impact
may result in injuries at points of fixation such as the ureteral pelvic
junction and the renal hilum (renal artery intimal disruption).

Question 4

What are the criteria for radiologic imaging in trauma?

Answer 4

Criteria for radiologic imaging include (1) all penetrating trauma, (2)
high-impact rapid deceleration trauma, (3) all blunt trauma with
gross hematuria, (4) all blunt trauma with microhematuria and
hypotension, and (5) pediatric patients with hematuria.

Question 5

How do you manage adult microscopic hematuria without shock in trauma?

Answer 5

Adult patients with microscopic hematuria without shock may be
observed without imaging studies.

Question 6

What are the findings in CT suggestive of major renal injury?

Answer 6

Findings suggestive of a major renal injury on CT include medial
laceration, perinephric hematoma size, intravascular contrast
extravasation, medial urinary extravasation, and devitalized renal
fragments.

Question 7

Which adult patients with renal trauma can you treat non operatively?

Answer 7

Nonoperative management for renal injuries is preferred in the
hemodynamically stable patient, particularly with grades I to III
renal injuries.

Question 8

How do you manage low-velocity renal gunshot wounds?

Answer 8

Exploration of low-velocity renal gunshot wounds is not mandatory
in selected cases. Such patients with isolated renal parenchymal
lacerations with stable and contained hematomas who are
hemodynamically stable, with no intra-abdominal organ injury, may
be observed expectantly.

Question 9

What are the absolute indications for renal exploration in trauma?

Answer 9

Absolute indications for renal exploration are (1) hemodynamic
instability with shock, (2) expanding or pulsatile hematoma, (3)
suspected renal pedicle avulsion, and (4) uncontained retroperitoneal
hematoma.

Question 10

What are the relative indications for intervention in renal trauma?

Answer 10

For kidney trauma, perinephric hematoma size, intravascular contrast
extravasation, devitalized renal fragments, arterial thrombosis, and
collecting system contrast extravasation are relative indications for
intervention.

Question 11

What is damage control surgery in trauma?

Answer 11

“Damage control” is the management technique of immediate control
of bleeding, and fecal and urinary leak only, in the unstable patient.
Definitive reconstruction is deferred until the patient is stable and
fully resuscitated. For ureter injuries this entails ligation and
nephrostomy, externalizing, or stenting. At a staged/planned
laparotomy, the ureter is later repaired.

Question 12

What causes hypertension from renal parenchymal injury?

Answer 12

Hypertension from renal parenchymal injury is usually short lived.
Renal vascular injury or compression of the renal parenchyma by a
subcapsular hematoma (Page kidney) can also cause high blood
pressure

Question 13

How do you manage damaged ureteral tissue in repairing ureteral injuries?

Answer 13

When repairing ureteral injuries, the ureteral tissue should be
debrided back to a bleeding edge to remove all traumatized
microvascular damaged tissue.

Question 14

How can vascular graft aneurysms in the proximity of the ureter damage to it?

Answer 14

Placement of vascular graft aneurysms in proximity of the ureter may
cause a periureteral inflammatory reaction and ureteral
injury/stenosis.

Question 15

How do you manage ureteral injuries to the proximal and mid ureter?

Answer 15

Ureteral injuries to the proximal and mid ureter can often be
managed by uretroureterostomy. The gap being bridged is based on
ureter mobilization and its elasticity.

Question 16

How do you manage distal ureteral injuries?

Answer 16

In the stable trauma patient, distal ureteral injuries should be
reimplanted into the bladder. In select cases, a ureteroureterostomy
can be considered. If the gap is large, then psoas hitch or Boari
bladder flap is the better management.

Question 17

What is the best diagnostic radiograph test in delayed ureteral injury?

Answer 17

For delayed ureteral injury, the best diagnostic radiographic test (in
the stable patient) to confirm injury, is a retrograde urogram.

Question 18

When is the best time to repair ureteral transections?

Answer 18

Ureteral transections should be repaired within a week of the injury,
or the repair should be delayed for 6 or more weeks.

Question 19

If the ureter is injured along with other organs, what should you place to isolate it?

Answer 19

It is prudent to isolate the ureteral repair from other injured organs
(such as colon) with omentum or peritoneum.

Question 20

How do manage ureteral injury during ureteroscopy?

Answer 20

Ureteral injury noted during ureteroscopy should be managed by
ureteral stent placement. When a stent cannot be placed or
inadequately diverts the urine, then a percutaneous nephrostomy
should be placed.

Question 21

How do you repair ureteral injury during vascular surgery?

Answer 21

Ureteral injury occurring during vascular surgery should be repaired
and isolated from the graft with normal tissue such as omentum.