Pediatric Blunt Renal Trauma

Blunt Genitourinary Trauma Algorithm

 

Introduction

·         Trauma to the genitourinary (GU) tract is present in approximately 10% of all injuries.

·         Children are at increased risk of renal injury from blunt trauma due to decreased perirenal fat, weaker abdominal musculature, and less ossified thoracic cage.

 

 

Blunt Renal Trauma

·         The kidneys are the most commonly injured organs in the GU tract.

·         Gross hematuria mandates further workup of the GU tract – prompt surgical consultation is warranted.

·         If renal trauma suspected, CT abdomen and pelvis with IV contrast and delayed images (excretory phase) should be obtained.

·         Management depends on hemodynamic stability of the patient and grade of injury (see attached algorithm)

·         Most renal injuries do not require an operation in a stable patient with the exception of those who have evidence of urinary leak. 

·         Please refer to the attached algorithm for complete details.

 

AAST Kidney Injury Scoring Scale

Bladder Trauma

·         Extraperitoneal bladder rupture is most commonly associated with pelvic fracture.

·         Intraperitoneal bladder rupture is a result of blunt lower abdominal force on a full bladder.

·         Classic physical findings of bladder rupture include suprapubic pain, hematuria, and inability to void.

·         If bladder trauma suspected, CT cystogram should be obtained with contrast used to actively fill the bladder through the Foley catheter (rather than just clamping the Foley catheter and waiting)

·         Extraperitoneal bladder rupture is generally managed with Foley catheter drainage.

·         Intraperitoneal bladder rupture requires immediate surgical intervention.

·         Other considerations for operative management include:

o   If the patient is going to the operating room with another team (IE- ortho team for pelvis fracture)

o   Presence of bone or foreign body in the bladder

o   Bladder Neck injury

o   Concomitant vaginal or rectal injury

o   Extraperitoneal injury that hasn’t healed with Foley catheter drainage

·         It is acceptable to attempt Foley catheter placement x1 before calling urology team.

 

 

Urethral Trauma

·         Urethral injuries are usually due to blunt trauma and are associated with pelvic fracture or straddle-type injuries.

·         Injury of the bulbar urethra is most common.  Injuries of the female urethra are rare.  If present they require cystoscopy to rule out other injuries. 

·         Physical findings of blood at the meatus, perineal hematoma or extensive laceration, a high riding prostate, or a large hematoma found on rectal exam mandates a retrograde urethrogram prior to insertion of a Foley catheter.

·         Definitive diagnosis is via retrograde urethrogram (RUG)

·         Management requires OR (suprapubic diversion vs endoscopic placement of Foley)

 

 

References:

1.       Hagedorn JC, Fox N, Ellison JS, et al.  Pediatric Blunt Renal Trauma Practice management Guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society.  J Trauma Acute Care Surg  2019; 86: 916-25. doi: 10.1097/TA.0000000000002209

2.       Coccolini F, Moore EE, Kluger Y, et al.  Kidney and uro-trauma: WSES-AAST guidelines.  World J Emerg Surg. 2019;14:54. doi: 10.1186/s13017-019-0274-x

3.       Serafetinides E, Kitrey ND, Djakovic N, et al.  Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel.  Eur Urol. 2015;67:930-6. doi: 10.1016/j.eururo.2014.12.034.

4.       Coccolini, Federico & Moore, Ernest & Kluger, Yoram & Biffl, Walter & Leppäniemi, Ari & Matsumura, Yosuke & Kim, Fernando & Peitzman, Andrew & Fraga, Gustavo & Sartelli, Massimo & Ansaloni, Luca & Augustin, Goran & Kirkpatrick, Andrew & Abu-Zidan, Fikri & Wani, Imitiaz & Weber, Dieter & Pikoulis, Emmanouil & Larrea, Martha & Arvieux, Catherine & Catena, Fausto. (2019). Kidney and uro-trauma: WSES-AAST guidelines. World Journal of Emergency Surgery. 14. 10.1186/s13017-019-0274-x.

 

Disclaimer

These guidelines are not intended as a directive or to present a definitive statement of the applicable standard of patient care.  They are offered as an approach for quality assurance and risk management and are subject to (1) revision as warranted by the continuing evaluation of technology and practice; (2) the overall individual professional discretion and judgment of the treating provider in a given patient circumstance; and (3) the patient’s willingness to follow the recommended treatment.