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Hoon Kwon, MD1
, Chang Ho Jeon, MD1, 2, Chang Won Kim, MD1
, Chang Ho Jeon, MD1, 2, Chang Won Kim, MD1
Abstract
Urinary tract injuries occur in up to 10% of patients with abdominal trauma, and the kidney is the most commonly injured structure of the urinary system. The kidney is the third most common abdominal organ to be injured by trauma, following the spleen and liver, in that order. The American Association for the Surgery of Trauma kidney injury scale is the most commonly used classification system for blunt renal injuries, which grades renal injury based on the size of laceration and its proximity to the renal hilum on CT. CT aids in delineating the most important features of urological injury that affect the diagnosis and management, including interventions. The major renal injuries are usually surgical emergencies. The current trend toward a more conservative management of renal trauma and advances in interventional radiology in the field of trauma may increase the use of interventional procedures for patients with renal injury. Urethral injuries can be anterior or posterior depending on the injury site, and interventional urethral realignment plays an important role in the treatment of urethral injury and surgical repair or endoscopic urethral realignment. Therefore, in this paper, we provide a literature review and discuss the efficacy and clinical significance of intervention for urologic trauma.
Figures and Tables
Fig. 1
A 57-year-old man showing a shattered kidney (The American Association for Surgery of Trauma V) after slipping.
A. CT scan shows a shattered kidney presenting as renal parenchyma completely separated from the renal capsule and contrast extravasation.
B. Left renal angiography confirms a shattered kidney. In addition, contrast leakage and pseudoaneurysm are demonstrated.
C. Selective embolization for the two feeders of contrast leakage and pseudoaneurysm using a mixture with 1:3 ratio of N-butyl-2-cyanoacrylate to lipiodol.
D. Follow-up CT after 2 months shows no perirenal fluid collection or urine leakage. The degree of enhancement is mildly reduced, but the remodeled kidney shows better renal perfusion on the coronal image.
Fig. 2
27-year-old man with main renal artery injury struck by an industrial robot.
A. CT scan shows discontinuation of the left renal artery (arrow) and almost no enhancement in the left kidney.
B. The left kidney is not visible on suprarenal abdominal aortography probably due to the transection or flow-limiting dissection of the left main renal artery.
C. The distal flow is faintly visible when contrast was injected through the 5-Fr catheter. However, the 0.035-inch hydrophilic coated guidewire could not pass beyond this point because of the acute vessel angle.
D. After changing the vessel angle using the 6-Fr angled guiding sheath (blue triple line), we succeeded in administering the 0.035-inch hydrophilic coated guidewire (red dotted line) up to the distal portion.
E. After the deployment of the 8-mm self-expandable metallic stent, completion renal angiography shows restoration of the parenchymal perfusion and venous drainage.
Fig. 3
Interventional realignment for posterior urethral disruption. A 32-year-old man with posterior urethral disruption after a motocycle accident.
A. Fluoroscopy reveals a complex pelvic fracture with contrast filling of the urinary bladder. The end (arrow) of the Foley catheter is not in the bladder.
B. Retrograde urethrogram shows posterior urethral disruption. The end of the disrupted membranous urethra has a beak appearance (arrow).
C. Supported by the 5-Fr catheter, a 0.035-inch hydrophilic coated guidewire (arrowhead) was located in the free space in the pelvic cavity without detecting the disrupted contralateral proximal urethra (retrograde approach). Another 0.035-inch hydrophilic coated guidewire (arrow), which was loaded in the 5-Fr catheter, was passed through the suprapubic cystostomy and navigated to pass through the site of the posterior urethral disruption so as to reach the external urethral orifice (antegrade approach).
D. A 16-Fr Foley catheter was inserted in the bladder over the guidewire (through-and-through technique) for posterior urethral realignment.
Fig. 4
Snare catheter being used for effectively grasping the guidewire with the retrograde approach.
Table 1
AAST Kidney Injury Scale, 2018 Revision (48)
Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Active bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that increases in size or attenuation in delayed phase. Vascular thrombosis can lead to organ infarction. Grade based on highest grade assessment made on imaging, at operation, or on pathologic specimen. More than one grade of kidney injury may be present and should be classified by the higher grade of injury. Advance one grade for bilateral injuries up to Grade III.
AAST = American Association for the Surgery of Trauma, AIS = abbreviated injury scale
Acknowledgments
This work was supported by clinical research grant from Pusan National University Hospital in 2018.
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