Pediatric Kidney Trauma.pptxxxxxxxxxxxxx

trauma renal

1. Pediatric Kidney Trauma Reza Amorga

2. Epidemiology 2 Trauma is the leading cause of morbidity and mortality in children and is responsible for more childhood deaths than the total of all other causes. In children, the kidney is the most commonly injured organ of the urinary system. Kidney trauma occurs in 10% to 20% of all pediatric blunt abdominal trauma cases. In Grimsby et al., reporting 2,213 cases of pediatric kidney injuries, >50% of the patients were adolescents aged 15-18 years and 6% of the patients aged < 5 years Singer, G., Arneitz , C., Tschauner , S., Castellani, C., & Till, H. (2021). Trauma in pediatric urology. Seminars in Pediatric Surgery, 30(4), 151085.. Grimsby GM, Voelzke B, Hotaling J, Sorensen MD, Koyle M, Jacobs MA. Demographics of pediatric renal trauma. J Urol. 2014;192:1498–1502.

3. Mechanism of Injury In children, the kidneys are low in the abdomen, less well protected by the lower ribs, more mobile, have less protective perirenal fat, and are proportionately larger in the abdomen In European studies up to 95% of renal injuries are caused by blunt trauma, and 5% caused by penetrating trauma. Pediatric renal injuries are usually caused by either rapid deceleration forces or direct blows to the flank due to falls, sports injuries, bicycle or motor vehicle accidents. 3 Singer, G., Arneitz , C., Tschauner , S., Castellani, C., & Till, H. (2021). Trauma in pediatric urology. Seminars in Pediatric Surgery, 30(4), 151085.

4. Renal Injury Classified according AAST 4 Buckley, J. C., & McAninch , J. W. (2004). Pediatric renal injuries: management guidelines from a 25-year experience. The Journal of urology, 172(2), 687–690 Radmyar , R., Bogaert, B., Burgu , B., Dogan, H.S., Nijman, J.M et al., 2022. EAU Guidelines on Paediatric Urology.

5. Diagnostic Evaluation

6. Clinical Examination Vital Sign : Blood Pressure, Respiratory Rate, Heart Rate, Temperature Flank pain Flank bruising Abdominal Distension Fracture lower ribs 6 Singer, G., Arneitz , C., Tschauner , S., Castellani, C., & Till, H. (2021). Trauma in pediatric urology. Seminars in Pediatric Surgery, 30(4), 151085.. Grimsby GM, Voelzke B, Hotaling J, Sorensen MD, Koyle M, Jacobs MA. Demographics of pediatric renal trauma. J Urol. 2014;192:1498–1502.

7. Laboratory Finding Urinalysis : Hematuria 65% suffer visible haematuria and 33% nonvisible, while only 2% have no haematuria at all Complete Blood Count, Renal Fuction Test, PPT, APTT 7 Buckley, J. C., & McAninch , J. W. (2004). Pediatric renal injuries: management guidelines from a 25-year experience. The Journal of urology, 172(2), 687–690 Radmyar , R., Bogaert, B., Burgu , B., Dogan, H.S., Nijman, J.M et al., 2022. EAU Guidelines on Paediatric Urology.

8. Imaging The Main Objective : Adequately stage the injury of the kidney, to reveal preexisting pathologies and to identify concomitant injuries to other organs. 8 Singer, G., Arneitz , C., Tschauner , S., Castellani, C., & Till, H. (2021). Trauma in pediatric urology. Seminars in Pediatric Surgery, 30(4), 151085..

9. USG In Acute Trauma, USG used as screening tool and for reliably following the course of renal injury, example parenchymal lesion, hematomas, and urinomas. Sensitivity 79-100% for detect gr III-V injuries, Negative Predictive Value 79-100% 9 Edwards A, Hammer M, Artunduaga M, Peters C, Jacobs M, Schlomer B. Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imaging. J Pediatr Urol. 2020;16:e551–e557.

10. Intravenous Pyelography (IVP) A good alternative imaging method if a CT scan is not available. One Shot IVP perform in patients undergoing immediate abdominal exploration. One-shot trauma IVU consists of 2 mL/kg of body weight of standard 60% ionic or nonionic contrast injected intravenously, followed by a single abdominal radiograph 10 minutes later. In children, 2-3 mL/kg of nonionic contrast is preferred. Sensitivity only 50% 10 Patel, V. G., & Walker, M. L. (1997). The role of "one-shot" intravenous pyelogram in evaluation of penetrating abdominal trauma.  The American surgeon ,  63 (4), 350–353. Singer, G., Arneitz , C., Tschauner , S., Castellani, C., & Till, H. (2021). Trauma in pediatric urology. Seminars in Pediatric Surgery, 30(4), 151085.. Morey, A. F., Mcaninch , J. W., Tiller, B. K., Duckett, C. P., & Carroll, P. R. (1999). Single Shot Intraoperative Excretory Urography For The Immediate Evaluation Of Renal Trauma. The Journal Of Urology, 161(4)

11. CT SCAN CT Scan with Contrast with a delayed urographic phase is considered the gold standart for grading renal injuries. CT recommended in pediatric patients high energy /penetrating/deceleration trauma and/or in cases of drop in hematocrit associated with any degree of hematuria 11 Singer, G., Arneitz , C., Tschauner , S., Castellani, C., & Till, H. (2021). Trauma in pediatric urology. Seminars in Pediatric Surgery, 30(4), 151085..

12. 12 Radmyar , R., Bogaert, B., Burgu , B., Dogan, H.S., Nijman, J.M et al., 2022. EAU Guidelines on Paediatric Urology

13. Management

14. EAU Guideline Conservative management with bed rest, fluids and monitoring has become the standard approach for treating blunt renal trauma with stable children. In stable patient with grade 2 or higher close follow up with CT/USG 48-72 hours after initial scan and CBC serial. Absolute indication for surgery : Persistent bleeding into an expanding or unconfined hematoma Relative indication for surgery : Massive urinary extravasation Extensive non-viable renal tissue 14 Radmyar , R., Bogaert, B., Burgu , B., Dogan, H.S., Nijman, J.M et al., 2022. EAU Guidelines on Paediatric Urology

15. Minimally Invansive Intervention Angio-embolization Stenting Percutaneus drainage 15 Radmyar , R., Bogaert, B., Burgu , B., Dogan, H.S., Nijman, J.M et al., 2022. EAU Guidelines on Paediatric Urology

16. 16 Radmyar , R., Bogaert, B., Burgu , B., Dogan, H.S., Nijman, J.M et al., 2022. EAU Guidelines on Paediatric Urology

17. Algorithm Management (AUA) 17 Buckley, J. C., & McAninch , J. W. (2004). Pediatric renal injuries: management guidelines from a 25-year experience. The Journal of urology, 172(2), 687–690

18. 18 Nonoperative management was significantly associated with reduced renal loss rates with an odds ratio (OR) of 0.05 (95% confidence interval [CI], 0.03–0.06).

19. 19 Nonoperative management had significantly less blood transfusion requirements with an OR 10.15 (95% CI,3.33-30.98) Hagedorn, J. C., Fox, N., Ellison, J. S., Russell, R., Witt, C. E., Zeller, K., Ferrada , P., & Draus , J. M., Jr (2019). Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. The journal of trauma and acute care surgery, 86(5), 916–925.

20. In Stable Patient, Renal Injury Gr III-V on going or delayed bleeding: Angioembolization vs Surgery ? 20 Angioembolization was significantly associated with reduced renal loss rates with an OR of 0.08 (95% CI 0.01, 0.82). Hagedorn, J. C., Fox, N., Ellison, J. S., Russell, R., Witt, C. E., Zeller, K., Ferrada , P., & Draus , J. M., Jr (2019). Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. The journal of trauma and acute care surgery, 86(5), 916–925.

21. In Stable Patient, Renal Injury Gr III-V on going or delayed bleeding: Angioembolization vs Surgery ? 21 There was no difference between the two groups (OR, 0.96; 95% CI, 0.08–11.91). Due to the small numbers reported, as well as the heterogeneity and variability in the reporting of complications (infection/urine leak) among all the studies Hagedorn, J. C., Fox, N., Ellison, J. S., Russell, R., Witt, C. E., Zeller, K., Ferrada , P., & Draus , J. M., Jr (2019). Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. The journal of trauma and acute care surgery, 86(5), 916–925.

22. In stable patient, Renal Injury Gr IV-V with symptomatic urinoma : Stenting/ Percutaneus Drain vs Open Exploration The definition of symptomatic urinoma was author dependent and included worsening flank pain, expanding urinoma on repeat imaging, and persistent urinary extravasation 20 days after the original injury. 22

23. In stable patient, Renal Injury Gr IV-V with symptomatic urinoma : Stenting/ Percutaneus Drain vs Open Exploration Internal ureteral stenting was the most successful single intervention , for pediatric patient populations, internal drainage is more cosmetically appealing and less of a social burden . Synchronous percutaneous drainage should be saved for individuals with very large urinomas that may lead to infection or abscess formation 23 Umbreit , E. C., Routh, J. C., & Husmann , D. A. (2009). Nonoperative Management of Nonvascular Grade IV Blunt Renal Trauma in Children: Meta-analysis and Systematic Review. Urology, 74(3), 579–582. 2 Major disadvantages of ureteral stenting in Pediatrics : both stent placement and removal require general anesthesia the ureteral stents used in pediatrics are typically of size 4-5 Fr, increased risk of occlusion by clot from any resolving hematoma and may allow the persistence of urinary extravasation and/or urinoma

24. Surgical Exploration

25. Mc Aninch Procedure Midline incision laparotomy The transverse colon is retracted anteriorly and superiorly, towards the patient’s chest. The small intestine is wrapped in a moist towel and retracted superiorly and to the right to expose the ligament of Treitz, the root of the mesentery, and the underlying great vessels . An incision is made in the posterior peritoneum , over the aorta , just above the inferior mesenteric vein . The dissection continues superiorly along the aorta until the left renal vein is identified, crossing over anteriorly. A vessel loop is placed around the vein for retraction. Once the left renal vein is mobilized and retracted, dissect out the left renal artery, which is located posterior to the renal vein 25 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

26. Mc Aninch Procedure After vascular control has been achieved, a medial visceral rotation is performed by mobilizing the left colon along the white line of Toldt and reflecting the colon medially . The kidney is then exposed by making an anterior vertical incision in Gerota’s fascia. 26 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

27. Exposure of the left kidney and the hilum after medial rotation of the left colon (artery in red , vein in blue and ureter in yellow loop). 27 Mc Aninch Procedure Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

28. The right renal vessels can be exposed through the same posterior peritoneal incision . The right renal artery originates from the right side of the aorta and courses under the inferior vena cava and behind the renal vein. Exposure of the right renal vessels through a midline retroperitoneal dissection. The left renal vein is identified as it crosses over the aorta and is retracted to expose the underlying right renal artery ( red loop ) 28 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

29. Renal Injury Repair After opening Gerota’s fascia and exposing the kidney, the extent of the injury is assessed . In cases with significant bleeding from the parenchyma, the renal vessels are clamped for bleeding control. Manual compression of the bleeding parenchyma is often adequate for temporary control of the hemorrhage. Any significant bleeders are controlled by suture ligation or by electrocautery . Once hemorrhage is controlled, any devitalized tissue is sharply excised . The collecting system is carefully examined and any injury is repaired watertight with a 4– 0 absorbable suture . 29 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

30. Pelviocalicoraphy Intraoperative evaluation of the integrity of the collecting system: insertion of a 22-gauge needle into the proximal ureter, with bulldog clamp applied distally, and injection of 2–3 mL of methylene blue into the renal pelvis. Extravasation of the methylene blue (circle) confirms injury to the collective system . If identified, close the leaks or repair the injury with figure-of- eight, 4–0 absorbable sutures . 30 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

31. Pelviocalicoraphy Repair of injury to the collecting system (circle), of the lower pole of the left kidney, with 4–0 absorbable suture. 31 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

32. Suture of Renal Capsule If possible, the renal capsule should be primarily closed , without tension, using pledgets Definitive, tension-free, repair of left kidney injury using pledgets . 32 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

33. Large Defect in the Renal Capsule If the defect in the capsule is large , an omental pedicle flap , fibrin sealant , or thrombin-soaked GelFoam bolsters can be used to fill the defect. The capsule should then be closed over the bolster or flap with pledgeted 4–0 polypropylene sutures If other intra-abdominal injuries are present, an omental interposition flap should be placed over the renal injury to separate the kidney from the other injuries. A retroperitoneal drain should be placed at the end of the operation. 33 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

34. Partial Nephrectomy 34 Extensive damage to the lower poles of the kidney is best managed with partial nephrectomy Partial lower pole nephrectomy with the raw surface covered with absorbable materials such as GelFoam , which can be sutured to the remaining renal capsule.

35. 35 Partial lower pole nephrectomy with preservation of the capsule: the capsule can close over the raw surface of the kidney Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

36. Nephrectomy If the injury to the kidney is too extensive for repair , a nephrectomy is warranted. If the patient is unstable, and the kidney is the source of hemorrhage, likewise nephrectomy is warranted. Ligate the artery and the vein, near the kidney hilum, with 0 silk ties. The ureter should be identified and ligated with a 2–0 silk tie. 36 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press

37. Complication

38. Early Complication Bleeding Hypertension Infection Perinephric Abscess Sepsis Urinary Fistula Urinary Extravasation Urinoma 38 Singer, G., Arneitz , C., Tschauner , S., Castellani, C., & Till, H. (2021). Trauma in pediatric urology. Seminars in Pediatric Surgery, 30(4), 151085.. Delayed Complication Persistent Bleeding Hydronephrosis Calculus Formation Chronic Pyelonephritis Hypertension Arteriovenous Fistula (AVF) Pseudoaneurysms

39. Follow up

40. Follow Up Serial Blood Pressure Measurement Physical Examination (Abdominal Circumference) Urinalisis Ureum / Creatinin Radiology Investigation (USG/CT) 40 Serafetinides , E., Kitrey , N. D., Djakovic , N., Kuehhas , F. E., Lumen, N., Sharma, D. M., & Summerton, D. J. (2015). Review of the Current Management of Upper Urinary Tract Injuries by the EAU Trauma Guidelines Panel. European Urology, 67(5), 930–936.

41. Cases in Saiful Anwar Hospital

42. Case 1 42 Demetriades , D., Inaba, K., & Velmahos , G. C. (2020). Atlas of surgical techniques in trauma . Cambridge University Press 12yo boy, Haematuria & Right flank pain after fell from tree w/ right flank did the primary contact Normal finding from physical exam w/ stable hemodynamic CT-Scan Abdomen -> D iscontinuity of right upper renal pole with good vascular pedicle and intact pelviocalyceal system, NOM was selected, 72 hrs CT-Scan Abdomen evaluation: I ntact vascular pedicle and Intact pelviocalyceal system CT-Scan Evaluation: Unabled (Personal problem). However from clinical evaluation patient overall condition was good and fully recovered with full conservative approach

43. 43

44. Case 2 6 yo boy, Haematuria & Right flank pain after MVA, Normal finding from physical exam w/ stable hemodynamic CT-Scan Abdomen: R ight kidney laceration involving the pelviocalyceal system, segmental artery injury with leakage of urine in perirenal space were found -> NOM was selected (Discharge w/ no complaint) Readmitted in 2 weeks due to large right flank lump & Fever -> CT-Scan Evaluation (Large urinoma) -> Drainage (Initial volume of 2000cc) CT-Scan Evaluation: R ight kidney laceration was found without any leakage of perirenal fluid was visible RPG: I ntact of renal parenchym without any extravasation of contrast were found 44

45. Case 3 14yo boy, Haematuria & Leftt flank pain after MVA, Normal finding from physical exam w/ stable hemodynamic CT-Scan Abdomen: Laceration of left kidney with formed of shattered kidney were found NOM was selected (Discharge w/ no complaint) Readmitted in 1 week due to large left flank lump & continous haematuria CT-Scan Evaluation ( Hematome ) Drainage (Initial volume of 180cc) Superselective embolization (No ongoing bleeding was found) CT-Scan Evaluation: No active bleeding and leakage of contrast were found RPG: No leakage of contrast were found 45 Initial 1-Week

46. 46 Superselective Embolization Follow-up CT-Scan RPG

47. Conclusion