Injuries and kidney damage

Kidneys in connection with their anatomical position to a certain extent are protected from external influence. However, they are often damaged in cases of abdominal, lumbar and abdominal injuries, and up to 70-80% of their injuries are combined with damage to other organs and systems. In urology, mainly isolated trauma and kidney damage.

Victims with combined injuries are more often referred to general surgical departments.

[1], [2], [3],

Epidemiology of kidney trauma

Gunshot injuries (injuries) of the kidneys are found mainly in wartime. According to the experience of the Great Patriotic War, they accounted for 12.1% of all injuries to the genitourinary organs. In subsequent military conflicts, there was an increase in the number of injuries of the kidneys by 2-3 times, which, apparently, is associated with a change in the nature of firearms. The main feature of modern gunshot lesions is the formation of the cavity along the wound channel, considerably exceeding the diameter of the wounding projectile with an extensive zone of destruction and necrosis, and the frequency of combined damages exceeds 90%.

Among patients with urological peacetime hospitals, the share of patients with closed renal damage is 0.2-0.3%.

[4], [5], [6], [7], [8], [9],

What causes kidney trauma?

Closed kidney damage

The mechanism of kidney damage can be different. The strength and direction of the impact, the place of its application, the anatomical location of the kidney and its topographic relationship with the XI and XII ribs, the spine, the physical properties of the kidney, the development of the musculature, the subcutaneous fat layer and paranephric fiber, the degree of intestinal filling, the magnitude of intraperitoneal and retroperitoneal pressure and etc. Kidney rupture occurs either as a result of direct trauma (a low back injury, falling on a hard object, squeezing the body), or from indirect impact (fall from height, bruises of the whole body, jumps). Interaction of these factors can cause compression of the kidney between the ribs and the transverse processes of the lumbar vertebrae, as well as hydrodynamic effects due to increased fluid pressure (blood, urine) in the kidney.

In the presence of previous trauma pathological changes in the kidney (hydro- and pionephrosis, anomalies of kidney development) organ damage occurs with a minor impact on the force - the so-called spontaneous rupture of the kidney, most often it is caused by a trauma to the abdomen or lumbar region.

A special type of closed renal damage is random damage during instrumental examinations of the upper urinary tract: perforation of the renal pelvis, cups with penetration of the ureteral catheter, loops and other instruments into the kidney parenchyma, perennial cellular tissue: tearing of the mucous membrane of the calyx in the area of the forearms due to insertion into the pelvis excess fluid of the floor with high pressure during the execution of retrograde pyelourethrography.

The development and introduction of new technologies into clinical urological practice led to the appearance of a special type of closed renal damage, to which the shock-wave radiotherapy is a part.

The mechanism of injury is due to a short-term exposure to the kidney of a high positive (above 1000 atm.) And low negative (-50 atm.) Pressure. Depending on the initial state of the kidney (acute pyelonephritis, shriveled kidney, decreased kidney function and other features), organ damage can occur even at low shock wave energies. When high energy is used, the severity of damage is directly proportional to the amount of shock wave impulses on the kidney. When using the optimal parameters of DLT, it can be equated with the severity of the injury to the injury of the kidney without damaging the capsule and the cellular structures of the kidney. At the same time, under certain conditions (defocusing of electrodes at 1 focus, shriveled kidney, acute pyelonephritis and others), intracranial anesthesia may occur. Subcapsular and paranephalic hematomas. Which indicates a severe traumatic injury. Pathological anatomy

Anatomical changes in the damaged kidney can be from minor hemorrhages in the parenchyma until its complete destruction. When the fibrous capsule breaks, the blood is poured into the pericardial tissue, gobbling it, and then forming a hematoma. In those cases where ruptures and fissures of the renal parenchyma reach the calyx and pelvis, urohematoma is formed. It also develops when the parenchyma and fibrous capsule are damaged without damaging the calyx of the kidneys or pelvis.

The division of kidney damage into the above groups does not exhaust all possible variants of them.

In practice, relatively easy damage is observed. Rare crushing of the kidney is rare; damage to the vascular pedicle of the kidney with closed trauma is an extremely rare clinical observation. Isolated trauma of the kidney, according to NG. Zaitseva (1966). 77.6% of the victims were affected. The rest noted a combination of damage to the kidney with damage to other organs: ribs, transverse processes of the vertebrae, abdominal organs and chest.

Traumatic damage to the kidney can be without a clear violation of the integrity of the body. In these cases, histological examination reveals morphological signs of circulatory disorders and dystrophic changes in the parenchyma. Functional disorders with such a damage to the kidney can be expressed even more than with obvious bursts.

Open renal damage

The causes and conditions for the onset of open renal damage are different. Particularly severe injuries of the kidneys are observed when they are wounded with modern firearms. This is due to the complex structure of the wound channel, the vastness of the tissue lesion zone near the wound canal, the frequent combined lesions of several adjacent areas, and often the multiplicity of lesions (up to 90%). Such wounds are often complicated by traumatic shock (about 60%) and massive blood loss. The increased kinetic energy of wounded shells, especially from mine explosive weapons, has led to an increase in the frequency of indirect damage to the kidneys in the wounding of nearby organs.

In studying the damage to the kidneys in military conflicts using modern firearms, the frequency of various types of wounds was determined: through wounds - 31.8%, crushing of the kidney - 27%, bruising - 23% of the wound of the vascular pedicle - 9.5%, tangential injuries - 16, 8%, blind wounds - 0.8%

Pathological anatomy. With gunshot wounds of the kidney with a modern weapon around the wound channel, the width of which considerably exceeds the diameter of the projectile, a zone of hemorrhages, small cracks and extensive necrosis form. The cavity of the wound channel is filled with wound detritus, blood clots and foreign bodies. Most gunshot wounds of the kidneys with good reason can be attributed to severe. Quite often (27%) there is a complete crushing of the organ or severe bruising of the kidneys (23%). Particularly severe are wounds from a shotgun. If the calyceal system is damaged, blood and urine flow through the wound channel into the surrounding tissues, the abdominal and (rarely) chest cavity, and also outward. Detachment of the kidney from the vascular pedicle does not always lead to fatal bleeding, because the inner shell of the artery is screwed into the lumen of the vessel.

Knife wounds are often linear cuts, which can be located both radially and transversely with respect to the kidney vessels. The latter circumstance has a definite value for the choice of the scope and nature of the surgical intervention. The closer the wound to the renal peduncle, the greater the risk of damage to large vessels and the larger the infarction zone, followed by its suppuration and melting. If the pelvis, calyx, ureter is damaged, if urinary incontinence fails, urinary infiltration occurs with the development of phlegmon retroperitoneal tissue, and with wounds penetrating the abdominal cavity, peritonitis occurs. In a favorable course, especially after a timely operation, within the next 4-5 days, the delineation of necrosis areas is already clearly visible, the proliferation of mesenchymal cells occurs and a young connective tissue develops. Maturation of the latter leads to the formation of a fibrous scar. In some cases, the urinary fistula is formed, which, in the absence of obstacles to the outflow of urine, can naturally close with time.

Symptoms of a kidney injury

Closed kidney damage - Symptoms

For damage to the urinary organs is characterized by a serious condition of the victims, heavy bleeding, severe pain, often urine in the surrounding tissue, urination disorder and impaired internal organs, which often contributes to the development of both early and late complications.

Clinical manifestations of kidney damage are diverse and depend on the type and severity. To damage the kidney is characterized by a triad of clinical symptoms: pain in the lumbar region, its swelling, hematuria.

Pain in the lumbar region is noted by 95% of patients with isolated lesions and all those who suffered from combined trauma. Pain occurs as a result of damage to tissues and organs surrounding the kidney, stretching of the fibrous capsule of the kidney, ischemia of its parenchyma, pressure on the parietal peritoneum with accruing hematoma, blockage of the ureter by blood clots. By the nature of the pain can be blunt, sharp, crooked with irradiation into the groin. Nausea, vomiting, bloating, symptoms of irritation of the peritoneum, a rise in body temperature often causes a diagnostic error.

Swelling in the lumbar or subcostal area is due to the accumulation of blood (hematoma) or blood together with urine (urogematoma) in the perineal or retroperitoneal tissue. It is usually observed in no more than 10% of the affected. At the same time, some clinicians note the presence of swelling in the lumbar region in 43.3% of the patients observed. Large hematomas or urogematomas can spread from the diaphragm to the pelvis along the retroperitonean tissue, and after 2-3 weeks they can be determined even in the scrotum and thigh.

The most significant, characteristic and frequent sign of kidney damage is hematuria.

Major hematuria was recorded with closed kidney damage during the Great Patriotic War in 50-80% of cases, in modern military conflicts hematuria occurred in 74% of cases. The microhematuria is detected by mail in all patients: it can be absent with mild injuries and, conversely, with extremely severe, in particular, kidneys from the vessels and ureter. The duration of hematuria and its intensity may be different. Usually it lasts 4-5 days, and in some cases up to 2-3 weeks or more. Secondary hematuria, observed in 2-3% of patients and appearing after 1-2 weeks or more after trauma, is caused by purulent melting of blood clots and rejection of myocardial infarcts.

In addition to these symptoms, if the kidney is damaged, it is possible to observe atypical signs that are important for the diagnosis: dysuria up to complete urinary retention due to tamponade of the bladder with blood clots, abdominal pain, irritation symptoms of the peritoneum, abnormalities of the gastrointestinal tract, signs of internal bleeding, fever in the development of posttraumatic pyelonephritis and suppuration of urogematomes.

The intensity of clinical manifestations of closed renal injuries allows them to be divided into 3 degrees of severity, which is important for drawing up the right plan for examination and treatment.

The severity of morpho-functional disorders in the kidney parenchyma after closed injuries and gunshot wounds is determined by external conditions at the time of their receipt (the nature of combat operations, natural conditions), the type and energy of the injuring shell, the timing and volume of medical care. The degree of disturbance of the function of the damaged kidney corresponds to the severity of morphological changes throughout the post-traumatic period. Morpho-functional changes in the kidneys are completed after 4-6 months of the post-traumatic period. With lesions of mild degree, the damaged kidney structures are restored with a loss of 1-15% of the functioning parenchyma. Damage to the kidney of moderate severity results in a loss of up to 30% of the functionally active parenchyma. Damage to the kidney of a severe degree is accompanied by irreversible degenerative-dystrophic changes up to 65% of the parenchyma.

Mild damage to the kidney should be attributed to when the general condition of the victim is not sufficiently disturbed, moderate pain in the lower back, short-term minor macro or microhematuria, peri-circular hematoma is absent, there are no signs of irritation of the peritoneum. This kind of damage is denoted as a kidney injury.

It is more difficult to clinically isolate damage to the kidney of moderate severity. In patients with an average severity of severity, the general condition of the satisfactory relatively quickly turns into a state of moderate severity.

In this case, the pulse becomes more frequent, blood pressure decreases, the hematuria is expressed and continues to increase. The accumulation of blood clots in the bladder can disrupt the act of urinating, until its acute delay.

Under the skin in places of abrasions, a part of the patients clearly has a hematoma. The pain in the site of the injury is negligible, most of the victims irradiate to the lower abdomen, the groin, the genitals. Obturation of the ureter with blood clots can cause renal colic on the side of the lesion. Damage to the abdomen and kidney, near-bypass hematoma (urogematoma) cause protective muscle tension in the anterior abdominal wall, signs of irritation of the peritoneum, intestinal flatulence, signs.

In the next 1-3 days a clear picture of the development of the disease appears in the direction of improvement, deterioration or relatively stable course. For improvement, a change in the general state of moderate severity to a satisfactory one is characteristic. Restoration of a stable pulse and arterial pressure, progressive reduction of hematuria, circumferential hematoma does not increase in size, bloating of the intestine and signs of irritation of the peritoneum disappear. If the clinical course worsens, symptoms that are characteristic of damage to the kidneys of a severe degree occur.

In case of severe injuries, collapse and shock appear to be in the foreground, severe pains in the lower back, profuse and prolonged macromembria are observed; urohematoma in the lumbar region and symptoms of internal bleeding tend to increase, it is not uncommon to combine kidney damage with the abdominal and thoracic cavity organs, the skeleton (fractures of the ribs, spine, pelvis).

[10], [11], [12]

Open Renal Damage - Symptoms

Open injuries (injuries) of the kidneys due to clinical manifestations, the principles of diagnosis and treatment are similar in many respects to closed ones. The main symptoms of injuries of the kidneys are pain in the wound area, hematuria, urogematoma, wound localization and the direction of the wound canal, urinary outflow from the wound. The last symptom, although the most reliable one, is rare in the early stages after injury (in 2.2% of cases). If you suspect a kidney injury, you can use the Nessler reagent technique to determine the urine in the bloody discharge from the wound. Urohematom with injuries of the kidneys are observed less often, because with combined wounds blood and urine enter the abdominal and pleural cavities.

Pain in the lumbar region is of different intensity and depends on the condition of the wounded and the degree of damage not only to the kidney, but also to other organs. The pain determines the protective tension of the abdominal muscles, and the earlier it appears and the more pronounced, the more reason to suspect a simultaneous damage to the abdominal organs.

Hematuria, as well as with closed injuries, is the leading and most frequent symptom of a kidney injury. It is observed, according to different authors. In 78,6-94,0% of cases. Blood in the urine appears fairly quickly after being injured; already with the first urination or with the urinary bladder catheterization in the urine contains a large number of blood clots, which can lead to bladder tamponade and urinary retention. By the degree of hematuria, one can not judge the type and volume of destruction of a wounded kidney. Conversely, the heaviest wounds of the kidney gate area may not be accompanied at all by the appearance of blood in the urine due to rupture of the vessels of the renal peduncle, and small tears of the renal parenchyma sometimes lead to profuse hematuria.

Extensive destruction of organs, significant blood loss lead to severe (31%) and extremely severe (38%) injured people with development of shock (81.4%).

The distribution of the wounded according to the degree of severity of the lesions is different than with closed renal injuries: the severe and moderate severity of kidney damage is about 90%.

Complications of various kidney damage

Clinical manifestations depend on the severity of the damage and the nature of the complications that are observed, which are observed in half of the patients in this group.

All complications of kidney damage are divided into early and late, the time interval between which is 1 month

To early complications include shock, internal bleeding, including secondary, retroperitoneal hematoma, urinary leakage, perineal abscess and other infectious processes, peritonitis (primary or early), pneumonia, sepsis, urinary fistula, arterial hypertension, urine.

Urinary swabs are formed with closed renal damage, when retroperitoneal space communicates with the urinary tract. In places where the integrity of the upper urinary tract is compromised, urine, along with blood (urogematoma), penetrates into the pericardial or near-cellular fatty tissue and accumulates in these places, forming cavities of various sizes. If the bowel-tubular system and the kidney tissues are damaged, the peri-kidney urogematoma can form relatively quickly, reaching a considerable size. Minor vascular damage leads to profuse impregnation of the blood of the perineal adipose tissue and the formation of hematomas. Impregnated with urine and blood, retroperitoneal fatty tissue in the subsequent often becomes inflamed, which leads to the development of isolated purulent foci (rarely) or with significant necrosis and melting fatty tissue - to urinary phlegmon, peritonitis (secondary), urosepsis (more often).

Among late complications, infections, secondary bleeding, the formation of arteriovenous fistulas, hydronephrosis, arterial hypertension, traumatic pyelonephros and paranephritis, urinary renal fistulas, urinary tract stones, ureteral compression, traumatic kidney cysts and pionephrosis deserve attention.

Renal failure is a formidable complication of kidney damage, it can develop both in the early and late periods after trauma. It can be caused by damage not only to both kidneys, but also to one (including a single) kidney, obstruction or compression from the outside of the ureters, acute bilateral pyelonephritis, as well as unilateral pyelonephritis complicated by bacteriemic shock, deep and extensive purulent inflammatory processes in the retroperitoneal cellulose .

The probability of occurrence of urological complications at various degrees of severity of kidney damage is as follows: light degree - 0-15%, average -38-43% and heavy-100%.

The incidence of arterial hypertension after kidney damage is 5-12%. In the early stages of hypertension is due to the perineal hematoma, which compresses the renal parenchyma. Usually, arterial hypertension develops 2-3 days after trauma and independently passes for 7-50 days (on average 29 days). In the event that after a few months the hypertension does not pass, then its cause, apparently, is the presence of a persistently ischemic parenchyma site

In later terms, the cause of hypertension may be arteriovenous fistula. Secondary renal bleeding is usually observed within 21 days after trauma.

[13], [14], [15], [16]

Classification of kidney trauma

The results of treatment of injuries of the urinary organs largely determine the effectiveness of early diagnosis and the right treatment methods. When rendering assistance to victims with injuries of the kidneys, it is important to have a unified understanding of the essence of the pathological process that emerged, a common tactic in choosing the method of treatment and ways to implement it. In many ways, the realization of this unity is helped by the classification of kidney damage.

Mechanical damage to the kidneys by their type is divided into two groups: closed (blunt or subcutaneous) and open (penetrating or injured). Among the latter, there are bullet, fragmentation, piercing, cutting, etc. Depending on the nature of the damage, they can be isolated or combined, and from the number of damage - single or multiple. The kidney is a paired organ, so when trauma occurs, it is necessary to distinguish the side of the lesion: left-sided, right-sided and bilateral. It is also necessary to indicate the area of kidney damage, the upper or lower segment, the body, the vascular pedicle. Damage, depending on the severity, can be mild, moderate or severe, with complications and without them.

By the type of injury to the kidney, closed injuries are divided into bruises without breaking the fibrous capsule; ruptures of the parenchyma of the kidney, not reaching the cups and the renal pelvis; ruptures of the parenchyma of the kidney, penetrating into the calyx and renal pelvis; crushing of the kidney; damage to the vascular pedicle or kidney from the vessels and ureter.

Among doctors, the classification of HA Lopatkin (1986) is most common. Closed kidney damage, he divides into 7 groups, depending on the nature and the existing traumatic changes in the kidney and surrounding paranephrine.

The first group includes a special type of damage, which occurs quite often - a kidney injury, in which multiple hemorrhages in the renal parenchyma are noted in the absence of a macroscopic rupture and subcapsular hematoma.

The second group is characterized by damage to the surrounding kidney of fatty tissue and ruptures of the fibrous capsule, which can be accompanied by small tears of the kidney cortex. In paranephral tissue, a hematoma is found in the form of blood imbibition.

The third group of lesions include the subcapsular rupture of the parenchyma, which does not penetrate the pelvis and calyx. Usually there is a large subcapsular hematoma. Near the place of rupture in the parenchyma, multiple hemorrhages and microinfarctions are revealed.

The fourth group consists of more severe injuries, which are characterized by ruptures of the fibrous capsule and parenchyma of the kidney with spreading to the pelvis or calyx. Such massive damage leads to hemorrhage and sweating of urine into the paranephric fiber with the formation of urohematemata. Clinically, such lesions are characterized by profuse hematuria.

The fifth group of kidney lesions are extremely serious injuries, characterized by a crushing of the organ, in which other organs, in particular the abdominal organs, are often damaged.

The sixth group includes kidney detachment from the renal pedicle, as well as isolated damage to the renal vessels with preservation of the integrity of the kidney itself, which is accompanied by intensive bleeding and can lead to the death of the victim.

The seventh group consists of contusions of the kidney, arising from EBT and other types of injuries.

[17], [18], [19]

Classification of open lesions (wounds)

• By the type of wounding projectile:
  • gunshot (bullet, fragmentation, kidney damage in case of mine explosion injury);
  • non-fire-resistant.
• In the course of the wound channel:
  • blind:
  • cross-cutting;
  • tangents.
• By the nature of the damage:
  • injury;
  • wound;
  • crushing of the kidney;
  • wound of the vascular pedicle.

The Committee for the Classification of Body Damage of the American Association of Trauma Surgery in 1993 proposed a classification of kidney damage, according to which injuries are divided into 5 degrees.

This classification is based on CT or direct examination of the organ during surgery. In foreign researches and publications of recent years, this classification is taken as the basis. Its advantage is the ability to more accurately determine the need for surgical intervention (nephrectomy or reconstruction).

Classification of kidney damage by the American Association of Trauma Surgery

Power	Type of damage	Description of pathological changes
I	Shake	Microscopic or severe hematuria, normal urological examination data
	Hematoma	Subcapsular, not increasing, there is no rupture of the parenchyma
II	Hematoma	Restricted to retroperitoneal space
	Gap	The rupture of the cortical layer of the parenchyma is less than 1 cm without extravasation of urine
III	Gap	Rupture without communication with the collecting system of the kidney and / or rupture> 1 cm without extravasation of urine
IV	Gap	Corticomedular rupture of the parenchyma, communication with the collecting system
	Vascular	Segmental artery or vein rupture with limited hematoma, renal vascular thrombosis rupture
V	Gap	Fully smashed kidney
	Vascular	Detachment of the renal pedicle or kidney deevascularization

It is necessary to find out the presence of premorbid diseases (hydronephrosis nephrolithiasis, cystic and tumor kidney diseases), in which damage to the kidney occurs more easily and is more difficult. Well-known experiment, when they took a cadaveric kidney and threw it from a height of 1.5 m and nothing happened to it. If the pelvis was filled with liquid, the ureter was bandaged and the kidney was thrown from the same height - multiple parenchyma ruptures were observed. This experiment clearly shows a greater susceptibility to damage to the hydroschemically altered kidney.

[20], [21]

Diagnosis of kidney trauma

Laboratory tests should include the definition of hematocrit and general urine analysis. Because hematuria does not correlate with the severity of kidney damage, CT scans with contrast enhancement are often used to determine the extent of kidney damage and to identify concomitant intra-abdominal trauma and complications, including retroperitoneal hematoma and urinary leakage. With blunt trauma, patients with microhematuria may have kidney bruises or minimal ruptures, but they almost never require visualization and surgical treatment. Execution of CT is mandatory in the following cases:

• falling from height;
• auto-trauma;
• macrohematuria;
• microhematuria with arterial hypotension;
• hematoma of the lateral abdomen.

In case of penetrating trauma, CT is shown to all patients with hematuria, regardless of its degree. In some cases, angiography is indicated for assessing persistent or prolonged bleeding with, if necessary, selective arterial embolization.

[22], [23], [24], [25], [26], [27], [28]

Closed kidney damage - Diagnosis

Based on patient complaints, anamnesis and clinical signs, the fact of kidney damage is usually established. At the same time, the definition of the type and nature of the damage often presents known difficulties and is possible only after a detailed urological examination. In each case, different methods of examining the patient are used depending on the indications and the specific capabilities of the medical institution.

[29], [30],

Open renal damage - Diagnosis

The general principles of examining a patient with suspected injury to the kidney are the same as for closed injuries of this organ.

It is only necessary to bear in mind that the severity of the wounded does not allow the use of many diagnostic methods: intravenous urography in all its variants, chromoscystoscopy. Radioisotope methods are poorly informative in the wounded in a state of shock. Any transurethral diagnosis is contraindicated in such a state.

Clinical diagnosis of kidney trauma

As with all other traumatic injuries, it is first necessary to determine hemodynamic parameters. In cases where hemodynamics is unstable. Operative intervention is shown. With stable hemodynamic parameters, a complete examination of the patient is possible.

Gematuria (macroscopic or microscopic), low back pain, side abdomen and lower chest, swelling (classical triad) and hemorrhages, as well as tension of abdominal muscles, fractures of the ribs, combined injuries of the abdominal cavity organs, presence of gunshot or stab wounds in the lower part of the chest, upper abdomen or lower back, fractures of the spinous processes of the vertebrae.

[31], [32], [33], [34], [35], [36]

Laboratory diagnosis of kidney trauma

With damage to the kidney of moderate severity, hematuria is detected in 98% of cases. However, even with severe injuries in 4% of cases, it may be absent, and in 25% - hematuria may be microscopic. Therefore, in the absence of visible hematuria, it is necessary to perform microscopic or rapid urine analysis to detect microhematuria (the presence of 5 or more red blood cells in the field of view at high magnification).

Determining the serum level of creatinine in the first hours after injury does not give any information about the presence of damage, but its elevated level may indicate the presence of premorbid kidney diseases.

Control of hematocrit indices in dynamics allows to detect latent bleeding. When reducing the hematocrit, it is necessary to exclude other sources of blood loss, especially if there is a suspicion of a combined trauma.

After EBRT, when traumatic shock wave impact on skeletal muscles and liver is possible, an increase in bilirubin, lactate dehydrogenase, serum glutamyl transaminase and creatinine phosphokinase levels is possible during the first 24 hours after the procedure. Reduction of these parameters is observed after 3-7 days, and complete normalization - after 3 months. Instrumental methods

All patients with closed abdominal, lumbar or thoracic injuries that have macrogematuria or microhematuria in combination with hypotension are indicated by radiation diagnostics. In adult patients with microhematuria without hypotension, the probability of having moderate and severe kidney damage is negligible (0.2%), and therefore the use of radiotherapy methods is impractical.

This statement is not applicable to children of childhood, with penetrating injuries, as well as with suspected co-trauma. In these cases, the survey is conducted using ray methods. In case of damage. Received as a result of a fall from the height, if we consider only the presence of macrohematuria or shock as an indication for the examination by radiation methods, it is possible to miss up to 29% of damage to the kidneys of medium and severe degree. This is why, in such cases, the presence of microhematuria and / or hemorrhage in the lumbar region is an additional reason for such studies.

Excretory urography

Special studies usually begin with an overview X-ray of the kidney area and excretory urography with indications - in high-dosage and infusion modifications. In addition to the usual X-ray images, after 7, 15 and 25 minutes after the contrast medium is injected into the vein, it is also useful to do delayed shots in the absence of the function of the damaged kidney (after 1,3,6 hours or more).

At present, the opinion of researchers about the use of excretory urography for the purpose of diagnosing kidney damage sharply diverge. Diagnosis of kidney damage implies a precise definition of the severity of injury according to the classification of the American Association for Trauma Surgery, which is best seen with CT with contrast, which is feasible in patients with stable hemodynamics. Excretory urography often does not provide an opportunity to determine the degree of damage and information about their combinations. Excretory urography can give a false picture of the absence of kidney function ("mute kidney"), even if there is no damage to the kidney vessels. It takes a lot of time to perform excretory urography. There is an opinion that excretory urography is more informative in the diagnosis of severe injuries. However, there are also data that say that. That with penetrating lesions this study in 20% of cases can give false positive information, and in 80% - it does not allow to establish the correct diagnosis. It is for this reason that excretory urography can not be considered a full diagnostic method, and it does not really matter when deciding on the need for surgery.

Absolutely other information in excretory urography with a bolus injection of contrast medium in the amount of 2 ml / kg. Which is used in patients with unstable hemodynamics or during surgical intervention for other injuries. One shot IVP is being performed. In the majority of victims, this makes it possible to identify "large" damage to the kidneys, especially when injuries in the projection of the kidney and / or macrohematuria. In severe renal damage, excretory urography can detect changes in 90% of cases.

[37], [38], [39], [40], [41], [42], [43]

Ultrasound diagnosis of kidney trauma

Currently, most clinicians examine the patient with suspected kidney damage starting with ultrasound and highly evaluate the results, a number of authors do not consider ultrasound a full diagnostic method for assessing kidney damage, since normal ultrasound data does not exclude the presence of lesions. For this reason, ultrasound should be supplemented by other methods of investigation. Usually ultrasound is used for the initial examination of patients with multiple trauma, which makes it possible to identify fluid in the abdominal cavity or in the retroperitoneal space, subcapsular hematoma of the kidney. Ultrasound is more effective for diagnosing moderate to severe lesions, in which changes are detected in 60% of cases, ultrasound is also used in convalescent patients for the purpose of dynamic observation. Sonographically detectable hematomas after a DLT session are observed in 0.6% of cases.

In some cases, and especially for the diagnosis of traumatic aneurysms and incomplete injuries of the main vessels, a Doppler study with color mapping is useful.

Despite the above facts, there is evidence in the literature that ultrasound can establish a correct diagnosis in 80%. Excretory urography - in 72% of cases, and with their joint application the correct diagnosis is possible with 98% sensitivity and 99% specificity. Therefore, if there is a suspicion of a kidney damage, ultrasound is the primary screening test, which is supplemented with excretory urography with hematuria.

If these studies do not help in diagnosis, chromocystoscopy is used. According to the indications resort to radioisotope renography or dynamic nephroscintnography, CT, MRI, if necessary - to renal angiography as the most informative method.

CT scan

At present, for diagnosis of kidney damage in patients with stable hemodynamic parameters, CT is a recognized "gold standard". It must be performed with contrast enhancement in both the nephrographic and urographic phases. To detect a swallow of urine, an intravenous injection of 100 ml of contrast medium with a rate of 2 ml / ok is recommended. Scanning is performed 60 seconds after the introduction of contrast. CT scan makes it possible to determine the severity of the lesion in 95.6-100% of cases.

With the help of CT angio-stroke you can detect vascular lesions with a frequency of up to 93. Magnetic resonance imaging. MRI is an alternative CT scan method. Compared to CT, it is more sensitive to detecting a kidney rupture, its non-viable fragment, and also a hematoma of different locations, but it is not suitable for detecting extravasation of urine.

[44], [45], [46]

MRI-diagnosis of kidney trauma

MRI is used as a back-up study if CT is impossible or if there is hypersensitivity to contrast agents. Immediately after a session of DLT in the kidney and in the surrounding tissue, hemorrhages and edema can develop. When using first-generation lithotriptors, various forms of kidney damage in MRI and radionuclide scanning were detected in 63-85% of cases.

Angiography

Applied for the diagnosis of damage to segmental or major vessels, if based on other studies, this suspicion arose. Angiography makes it possible to identify, at the same time, temporary selective or superselective embolization of the damaged arterial branch of the bleeding vessel at the same time to stop bleeding, and with incomplete rupture of the main vessel, endovascular stenting. If CT with contrasting shows no contrast of the kidney, then angiography is shown to clarify the presence of vascular damage. This is especially important if the damage is caused by the "sudden braking" mechanism and / or there is a hematoma in the kidney gates. Angiography is also indicated when a pulsatile hematoma is detected when Doppler ultrasound is detected.

The catheterization of the ureters retains its diagnostic value with the retrograde pyeloureterography. This method is used most often at the final stage of diagnosis and with severe injuries immediately before surgery.

Thus, if the nature of the kidney damage after performing ultrasound and excretory urography is unclear, preference should be given to CT MRT by radioisotope methods of investigation, and in some cases also by angiography. With long non-healing postoperative renal fistulas, fistulography is shown.

The most characteristic X-ray signs of kidney damage are: on the survey radiographs and tomograms, a shadow with a fuzzy border and a lack of a contour of the lumbar muscle on the prospective side of the lesion, a curvature of the spine due to a defensive contraction of the muscles; on intravenous urograms, a weak and delayed filling of the renal pelvis and ureter with contrast agent, subcapsular and extrarenal stains of contrast medium, in case of severe injuries, the absence of the function of the affected kidney. The same signs are more clearly revealed with high-volume or infusion urography, as well as retrograde pyeloureterograms.

If there is a suspicion of iatrogenic damage to the kidney, the time of instrumental manipulations of the introduction of a contrast agent along the ureteral catheter, stent or loop catheter reveals the localization of damage and spreading of the feces, which facilitates timely diagnosis of such injuries and proper provision of adequate care.

All instrumental studies are performed against the background of antibiotic therapy. Antibiotics can be administered both parenterally and together with a contrast agent.

The elucidation of the circumstances and the mechanism of trauma, the assessment of the patient's condition, the results of the physical, laboratory, instrumental, radiologic and other types of examinations make it possible to establish with certainty the side of damage, the nature and localization of damage to the kidney or ureter, the functional capacity of the kidneys, the nature of the urinary fistula and the causes that support them, then draw up a plan for treating the patient.

[47], [48], [49]

Open damage

The severity of the general condition of the wounded and the need for urgent surgical interventions minimize the number of studies necessary to establish an accurate diagnosis. However, always before the operation follows, having estimated the volume of blood loss, to perform, if possible, an overview X-ray and excretory urogram of the kidneys (preferably in several projections) with the purpose of simultaneous detection of bone injuries, detection of foreign bodies and their localization. Clarification of the type of kidney damage is carried out already on the operating table.

If the condition of the wounded allows, it is necessary to perform ultrasound and a radioisotope study, in some cases - renal arteriography. Renal selective angiography is considered to be the best method of diagnosis for kidney damage, even in patients who are in shock, when other methods of research are poorly informative. Embolization of damaged arteries, following angiography, ensures the stopping of bleeding, allows more successfully to deal with shock, to conduct a more detailed examination of the wounded and to begin the operation under optimal conditions.

Treatment of kidney trauma

The patient is hospitalized in the nearest surgical department of the medical institution. Without the extreme need to translate it into a urological hospital should not be to ensure peace and eliminate the danger of prolonged transportation. For consultation or participation in the operation, it is advisable to invite a urologist.

[50], [51], [52], [53], [54], [55]

Conservative treatment of kidney trauma

Closed kidney damage

Most urologists adhere to the conservative method of treating closed renal injuries, which can generally be performed in 87% of cases.

With isolated closed renal lesions of mild and moderate severity, if there are stable hemodynamic parameters and there are no other indications for surgical treatment, one can confine oneself to dynamic observation or conservative therapy, and with mild trauma of the kidney, treatment can often amount only to monitoring the victim.

In particular, conservative treatment of isolated renal injuries is performed when the overall condition of the victim is satisfactory, there is no profuse hematuria, symptoms of internal bleeding, signs of increasing hematoma and urinary infiltration. It implies the appointment of strict bed rest for 10-15 days, control of hemodynamics and hematocrit, preventive parenteral administration of antibiotics and uroantiseptics. Application of painkillers, hemostatic, preventing the development of gross scars and adhesions of preparations | hyaluronidase (lidase), glucocorticoids]. Such treatment is carried out until the disappearance of hematuria; it is successful in 98% of patients.

Continuous medical supervision allows you to monitor the course of treatment so that, if necessary, you can immediately conduct an open surgical procedure. It is necessary to remember the possibility of "two-phase" rupture of the kidney.

At the same time, over the past decade, there has been a trend towards operational activity with simultaneous expansion of indications for organ-preserving operations. With combined kidney damage, all urologists are unanimous in the opinion that ,. As a rule, surgical treatment is indicated.

With closed damage to the kidneys that occur with instrumental manipulation, first conduct conservative treatment. In perforation, the walls of the pelvis and / or calyx stop further examination of the patient, the antibiotic solution is injected through the catheter and the catheter is removed. The patient is assigned bed rest, hemostatic drugs, antibiotics, cold on the lumbar region or on the abdomen along the ureter, and in the following days - heat. In the case of a rapid increase in hematoma (urogematoma) in the lumbar region or abdomen on the side of the lesion with intensive macrohematuria, with deterioration in the general condition of the patient, a lumbotomy with revision of the damaged kidney or other operations to expose the retroperitoneal space is shown.

Studies show that with isolated damage to the kidney of moderate severity, initially conservative treatment leads to lower rates of organ loss and the need for blood transfusions than surgical treatment. The likelihood of developing posttraumatic hypertension is the same in both cases.

The perirenal accumulation of fluid (blood) detected during CT scan associated with remote shock wave lithotripsy can self-resolve for several days and weeks, and subcapsular hematomas from 6 weeks to 6 months. Temporary decrease in renal function is observed in 30% of cases after lithotripsy, which can be prevented by the use of nifedipine and allopurinol.

Open renal damage

Conservative treatment is only permissible in isolated cases: with isolated wounds with cold weapons, without significant destruction of tissues, with moderate and short-term hematuria and a satisfactory condition of the wounded. Treatment of these victims is carried out according to the same plan as with closed renal damage.

[56], [57]

Operative treatment of a trauma of kidneys

Minimally invasive interventions

Percutaneous drainage of pararenal hematoma or urohematemia is performed under strict indications and is performed under the supervision of ultrasound or CT.

The purpose of this manipulation is the evacuation of the hematoma, a reduction in the duration of treatment, and a reduction in the risk of early and late complications.

Endoscopic drainage of the kidney with the help of an internal stent is performed with lesions of moderate severity, its purpose is to reduce urinary extravasation and / or eliminate the outflow of urine. Usually the stent is removed after 4 weeks. In patients with stable hemodynamics, if the segmental artery is damaged and / or when intensive hematuria continues, embolization of the bleeding vessel can be performed under angiographic control. The best results were obtained using this technique in patients with penetrating wounds caused by cold weapons (82%). Cases of intravascular stenting with partial renal artery damage are described.

Absolute indications for surgical treatment for closed and open kidney lesions:

• unstable hemodynamic parameters;
• increasing or pulsating hematoma.

Relative indications:

• Indistinctly defined degree of injury;
• extravasation of urine in large quantities;
• the presence of a large area of nonviable kidney tissue;
• severe damage (degree V);
• Combined injuries requiring surgical treatment;
• premorbid or incidental diseases of the damaged kidney;
• the unsatisfactory effect of conservative treatment or minimally invasive intervention.

Closed kidney damage

Operative treatment is conducted to prevent complications and / or their elimination. Operative treatment of kidney damage is performed in about 7.7% of cases. The frequency of surgical treatment for kidney damage of varying severity is as follows: mild - 0-15%. The average is 76-78%. Heavy -93%. With closed damages, this figure is 2.4%. With penetrating wounds with the use of cold weapons - 45% and gunshot wounds - 76%.

Clinical practice convinces. That in some cases, with closed renal injuries, operative treatment should be used as an emergency. The main indications are an increase in the symptoms of internal bleeding, a rapid increase in perineal urogematoma, intensive and prolonged hematuria with worsening of the general condition of the victim, as well as signs of a combination of damage to the kidney and other internal organs.

Before the operation, with pronounced anemization, blood transfusion (erythrocyte mass) or infusion of blood substitution solutions is indicated. Continuing during the operation, and often in the postoperative period. Very important are massive blood transfusions with combined injuries of the kidneys, internal organs and pelvic bones, when the victim loses a significant amount of blood poured into the abdominal cavity, retroperitoneal space and pelvic cellular tissue. Operate patients without stopping active anti-shock therapy. Anesthesia is preferably general.

At operations in occasion of traumatic damages of kidneys various accesses are possible. Most urologists with kidney damage with suspected simultaneous damage to the abdominal organs produce a laparotomy, usually a median one, i.e. Prefer transabdominal access. It makes it possible to simultaneously audit the organs of the abdominal cavity, since the probability of combining their injuries with damage to the kidney is high. At the same time, first cut the peritoneal leaf of the peritoneum towards the aorta slightly medial to the mesenterica. After the evacuation of the hematoma, it becomes possible to isolate the kidney vessels and take them to the rubber turnstiles for the purpose of squeezing, if necessary. After reaching the control of the vessels, an additional cut of the peritoneum and fascia of the Gerota lateral to the large intestine is performed to expose the kidneys. With this tactic, the level of nephrectomy decreases from 56% to 18%. Despite the data given, not all authors consider preliminary vascular monitoring a necessary measure. There is even an opinion that such a tactic only increases the time of the operation and increases the likelihood of the need for a transfusion of blood or its components.

With an isolated rupture of the kidney, a lumbar extraperitoneal incision is often used, preferably with a resection of XII, and if necessary, an XI rib, or in the XI or X intercostal space. Such access makes it possible to expand the scope of intervention with indications before thoracolumbolarparotomy. Having examined the damaged kidney, the urologist determines the extent and nature of the intervention on it.

In carrying out surgery, the possibility of restoring the integrity of the kidney, even with severe damage, is 88.7%.
Restoration of the kidney implies its mobilization, removal of nonviable tissues, hemostasis, hermetic suturing of the collecting system and elimination of the parenchyma defect by bringing the edges of the wound closer. If restoration of a rupture of the kidney is impossible, then resection is performed. Defect of the parenchyma can be covered with a flap of an epiploon on the stem or with special preparations containing a hemostatic sponge.

It should be noted that after an operative recovery of the kidneys suffer insignificantly. At a scintigraphy in the remote postoperative period they on the average make 36%. With operative treatment of kidney damage, the overall complication rate is approximately 9.9%. What. However, is not accompanied by a loss of body.

After trauma in the place of kidney tissue develops benign dystrophy.

Surgical treatment of vascular kidney damage involves nephrectomy or vascular repair. The operative restoration of the damaged renal vein in 25% of cases allows to save the kidney. However, with the restoration of the renal artery, early or late complications often occur. The worst prognosis is also closed severe kidney damage. Late diagnosis (more than 4 hours after the injury) and large size of the ischemic tissue also worsen the prognosis. The following data on the frequency of treatment of vascular kidney damage by various methods are presented in the literature: nephrectomy - 32%, revascularization - 11%, conservative treatment - 57%, and after conservative treatment the incidence of hypertension was 6%. For lesions of moderate severity with rupture of branches of renal vessels after revascularization in a scintigraphic examination, impairment of kidney functions averages 20%. Quite a frequent complication of such kidney damage is a "mute kidney" without hypertension. Given the above facts, some authors consider it inappropriate to preserve the kidney with significant damage to the renal artery, if there is a complete contralateral kidney.

Indications for early nephrectomy: multiple deep kidney ruptures that can not be restored; non-viability of the greater part of the parenchyma, crushing of the kidney; damage to its vascular pedicle is the general severe condition of the patient and the presence of significant combined injuries which pose an immediate danger to the life of the patient. With lesions of an easy degree, nephrectomy is usually not performed, with an average of 3-16.6%. At a heavy - 86-90,8% of cases. In 77% of cases, nephrectomy is performed for unresponsive parenchymal or vascular lesions, and in 23% - based on life indications, although there is a potential possibility of kidney restoration. The level of nephrectomy is high in gunshot wounds, especially in military conditions. The total nephrectomy score for operative treatment of kidney damage is 11.3-35.0%.

Indication for organ-preserving operations: ruptures or detachments of one of the ends of the kidney; single cracks and ruptures of the kidney, as well as its fibrous capsule; damage to a single kidney; damage to one of the kidneys with another pathologically altered one; simultaneous damage to both kidneys.

Restrained treatment of organ-preserving operations by urologists explains the fear of repeated bleeding and development of purulent processes in the damaged kidney and surrounding tissue.

The most commonly used are the following organ-preserving operations: tamponade and suturing of the kidney wounds, resection of the upper or lower segments with superposition of pyelo- or nephrostomy. To perform such operations on the kidney is especially important the problem of hemostasis. In recent years, urologists have more often tampon the wound of the kidney with autotransplant (muscle, fatty tissue, omentum) or preparations from the blood (hemostatic sponge, fibrin film). Stitches on the wounds of the kidneys are imposed with observance of certain rules: pierced ligature is laid with paranephric fiber, fascia or aponeurosis; seams are applied tactilely with a catgut or synthetic absorbable thread deep enough (with the capture of the cortical or medullary layer) without tightening tight threads to avoid strong compression of the parenchyma, which subsequently causes necrosis of its Sections and the occurrence of secondary bleeding. With shallow wounds of the kidney. Not penetrating into the pelvis and calyx, after suturing the wound from the superposition of pyelonephros and nephrostomy, one can abstain.

The ruptures of the pelvis, revealed during the operation, are stitched with nodular catgut or synthetic absorbable sutures. Operation on the kidney is completed by the application of nephro- or pyelostoma.

At the end of the operation on the kidney, the wound in the lumbar region, regardless of the nature of the surgery, is carefully drained and sutured. If surgical intervention on the damaged kidney was performed through the abdominal cavity, a fairly wide contrapperture is applied in the lumbar region, the back of the peritoneum over the operated kidney is sutured, and the abdominal cavity is sewn tightly. In the postoperative period, the whole complex of conservative measures aimed at preventing complications continues.

Open renal damage

In cases where the "fate" of a damaged kidney should be solved in the absence of ultrasound, instrumental and radiographic research, it should be remembered that it is rare (in 0.1%) to injure a single or horseshoe-shaped kidney. Therefore, before you remove the kidney, you need to make sure of the availability and functional usefulness of the other.

The first medical aid in the field of war in case of kidney damage involves pain relief with trimeperiline (promedol) or its analogue from a syringe tube, giving inside a broad spectrum of antibiotics, immobilization in case of suspicion of a fracture of the spine or pelvic bones, with injuries - the application of an aseptic dressing.

The first medical aid consists in repeated use of analgesics to eliminate the disadvantages of transport immobilization, in case of injuries, control of the bandage with the hemming, and with indications for stopping the external bleeding (clamping, dressing in the wound), the introduction of tetanus toxoid.

According to the vital indications of patients with penetrating cavitary wounds, as well as those who have signs of continuing internal bleeding, operate.

Urgent operations of the first stage include the surgical treatment of wounds contaminated with radioactive and poisonous substances or abundantly polluted by earth. The same group includes injuries and injuries of the kidneys with stopped bleeding.

Access to surgical treatment of wounds and kidney interventions is better to use typical, regardless of the direction of the wound channel. In isolated wounds, one of the varieties of lumbar incisions is used, with combined ones - access is determined by the nature of damage to the abdominal, thoracic and pelvic organs, but at the same time they tend to use typical thoraco-, lumbo- and laparotomy in their various combinations. Most urologists with combined injuries of the kidneys and abdominal organs prefer to use a median laparotomy. When interventions on wounded organs are recommended to observe a certain order: first take all measures to stop severe bleeding, the source of which is most often parenchymal organs and vessels of the mesentery: then perform interventions on hollow organs (stomach, small and large intestine), the last to process wounds urinary tract (ureter, bladder).

If the source of bleeding is a kidney, then regardless of access, the area of its vascular pedicle is first checked and a soft vascular clamp applied to it. There is an opinion that the clamping of the kidney vessels to 20 minutes, and according to other researchers, and up to 40 minutes does not cause the kidney much harm. Having dried the pericardial space from the bleeding blood, determine the degree of anatomical destruction of the organ and continue to do the same. As with closed renal damage. Nephrectomy is the most frequent (62.8%) type of intervention with open injuries of the kidney. Indications for early nephrectomy in the presence of another functioning kidney: massive crushing of the renal parenchyma; multiple and deep ruptures and wounds of the kidney's body reaching the organ gates; damage to the main kidney vessels. In other cases, it is recommended to perform organ-preserving operations, the main ones of which are suturing the kidney wounds and tamponade with autotransplant, resection of the upper or lower segment of the kidney with pyelone or nephrostomy, a pelvis suture, ureterocutaneo or ureterocystoneostomy, and others. When a sufficiently deep wound of the kidney is detected, the nephro- or pyelostoma is superimposed, and it is advisable to remove the tube not through the wound of the kidney, but next to it, using a thin layer of parenchyma over one of the middle or lower calyces, and only after this, the kidney wounds and the tamponade of the kidneys are made.

An obligatory element of the operative allowance for open (especially gunshot) wounds is the surgical treatment of the wound (wound), including, in addition to stopping the bleeding, excision of nonviable tissues, dissection of the wound channel, removal of foreign bodies, cleaning the wound from dirt, inserting antibiotics into and around it .

After the intervention on the damaged kidney and surgical treatment, wounds (wounds) provide reliable drainage of the circumcostal or near-cellular space, including by superimposing contra-images.

In providing specialized urological care, further treatment of wounds is performed according to generally accepted principles in urology, repeated surgical procedures are performed, with indications - nephrectomy or intervention on the kidney with elements of restorative surgery.

[58], [59]

Combined injury of the kidneys

With closed damages of the kidney, combined injuries occur with a frequency of 10.3%, with penetrating wounds - 61-94%. In cases of moderate damage, the level of occurrence of combined lesions is approximately 80%.

Expectant tactics for damage to the kidney, combined with damage to the abdominal organs and a non-viable fragment of the kidney tissue, leads to a significant increase in mortality among these patients compared with primary surgical treatment (respectively, 85 and 23%). During surgical intervention for combined injuries and unstable hemodynamic parameters, priority is given to the damage most threatening the patient's life.

Combined injuries of the parenchymal organs of the abdominal cavity can be treated simultaneously without increasing the risk of mortality. Combined injuries of the colon and pancreas can not be considered a reason for refusing to restore the kidney.

[60], [61], [62]

Preceding or Incidental Diseases

Previous diseases of the damaged kidney are infrequent (3.5-19%). The combination of kidney damage with congenital malformations is observed in 3.5%, with urolithiasis in 8.4%. With large cysts of the kidney - in 0.35%, tumors - in 0.15%, with anomalies of LMS - in 5.5% of cases. Combined damage is associated with a higher risk of complications. In this case, organ damage occurs with less intense effects than usual.

In the presence of premorbid diseases, conservative treatment can be performed only with minor damage to the kidney, and surgical treatment should be aimed at preserving the kidney.

Despite the fact that with damage to the kidneys of severe severity with stable hemodynamic parameters, some authors describe cases of conservative treatment with a safe outcome, the method of choice for the treatment of such lesions is operational.

The presence of a large non-viable segment of the kidney

As studies show, with kidney damage, the presence of nonviable tissue can lead to complications and the need for delayed surgery, especially with concomitant vascular injuries. The purpose of surgical intervention is the removal of non-viable tissue and the restoration of a damaged kidney.

Treatment of complications of kidney trauma

Conservative and / or minimally invasive treatments for post-traumatic complications are preferred. Secondary bleeding, arterio-venous fistulas and false aneurysms can be successfully eliminated by the method of endovascular embolization. Elimination of extravasation of urine and urinomas is often carried out by establishing an internal stent and percutaneous drainage of the lobule space, which can also be used to treat a peripoint abscess. If the conservative and minimally invasive measures are ineffective, surgical treatment is indicated. The primary goal of the operation is to preserve the kidney. The likelihood of developing persistent arterial hypertension after damage to the kidneys is small, is 2.3-3.8%, but with its development requires serious, often surgical treatment (reconstruction of the vessel, nephrectomy).

A very important factor in the rehabilitation of patients is postoperative treatment and observation for a certain time.

Further management

A re-examination is shown to all hospitalized patients with significant kidney trauma after 2 4 days after receiving an injury. It is also recommended in the development of fever, the appearance of pain in the lumbar region or with a decrease in hematocrit.

Before discharge (10-12 days after injury), a radionuclide study is recommended to assess the kidney function.

After a significant kidney injury, follow-up includes:

• physical examination;
• Analysis of urine;
• personalized radiation research;
• control of blood pressure;
• control of creatinine in the blood.

Long-term observation is established individually; at least it is necessary to control blood pressure.

Prognosis of kidney trauma

The prognosis for closed kidney lesions of mild and moderate degree without developed complications is favorable. Severe injuries and serious complications may require the performance of nephrectomy and lead to disability.

The prognosis for open renal injuries depends on the severity of the injury. The nature and type of damage to these organs, the presence of complications, injuries to other organs when combined wounds, the timeliness and volume of care provided.

In patients who have suffered renal damage, regardless of the treatment methods used (conservative or operative), there is a high risk of late complications. Even when the damaged kidney is removed, half of the patients in the contralateral kidney develop different diseases after a certain period (chronic pyelonephritis, stones, tuberculosis). All this dictates the need for a long-term follow-up of patients who have suffered a kidney injury.

Summarizing the above, the following points can be singled out.

• At present, there is no uniform classification of kidney damage in the world. In European countries, the most widely used classification by the American Association of Trauma Surgery is universally accepted, urologists use the Lopatkin HA classification.
• It is recognized advisable that the diagnosis of traumatic injuries of the kidney should be based on KT data, and in some cases (vascular lesions) supplemented with angiography. In urgent situations and / or patients with unstable hemodynamic parameters, one-shot infusion excretory urography (one shat lVP) should be performed.
• Determining the severity of the damage is crucial in the choice of treatment tactics. The correct diagnosis makes it possible in most cases to successfully perform a conservative treatment even with lesions of high severity.
• Minimally invasive methods of treatment should find more frequent use in kidney damage.
• It is necessary to take great care in the treatment of penetrating wounds with the use of firearms with high speed bullets, combined and vascular lesions, the presence of a large non-viable segment of the kidney, premorbid diseases and injuries with an inaccurately established degree of severity.
• It should be borne in mind that the above circumstances, as well as post-traumatic complications that have arisen, can not by themselves be an indication for nephrectomy, and the desire of the urologist should always be the preservation of the organ.