Trauma and injuries to the kidneys

The kidneys, due to their anatomical position, are protected to a certain extent from external influences. However, they are often damaged by abdominal, lumbar and peritoneal injuries, and up to 70-80% of their injuries are combined with injuries to other organs and systems. In urology, isolated injuries and damage to the kidneys are mainly encountered.

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

[ 1 ], [ 2 ], [ 3 ]

Epidemiology of renal injury

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

Among patients in urological hospitals in peacetime, the proportion of patients with closed kidney injuries accounts for 0.2-0.3%.

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

What causes kidney injury?

Closed kidney injuries

The mechanism of kidney injury may vary. The force and direction of the blow, the place of its application, the anatomical location of the kidney and its topographic relationship with the 11th and 12th ribs, the spine, the physical properties of the kidney, the development of the muscles, subcutaneous fat layer and paranephric tissue, the degree of intestinal filling, the magnitude of intra-abdominal and retroperitoneal pressure, etc. are important. Kidney rupture occurs either as a result of direct trauma (lumbar contusion, falling on a hard object, compression of the body) or from indirect impact (falling from a height, bruises of the whole body, jumping). The interaction of these factors can cause compression of the kidney between the ribs and transverse processes of the lumbar vertebrae, as well as hydrodynamic impact due to increased fluid pressure (blood, urine) in the kidney.

In the presence of pathological changes in the kidney preceding the injury (hydro- and pyonephrosis, anomalies in the development of the kidneys), damage to the organ occurs with minor blows - the so-called spontaneous rupture of the kidney, most often caused by trauma to the abdomen or lumbar region.

A special type of closed kidney injury includes accidental damage during instrumental examinations of the upper urinary tract: perforation of the renal pelvis, calyx with penetration of the ureteral catheter, loop and other instruments into the renal parenchyma, perirenal tissue: ruptures of the mucous membrane of the calyx in the area of the fornices due to the introduction of an excess amount of fluid into the pelvis under high pressure during retrograde pyelourethrography.

The development and implementation of new technologies in clinical urological practice have led to the emergence of a special type of closed kidney injury, which includes shock wave EBRT.

The mechanism of injury is caused by short-term exposure of the kidney to high positive (over 1000 atm.) and low negative (-50 atm.) pressure. Depending on the initial condition of the kidney (acute pyelonephritis, shrunken kidney, decreased renal function, and other features), organ damage can occur even with low shock wave energies. When using high energies, the severity of damage is directly proportional to the number of shock wave impulses on the kidney. When using optimal DLT parameters, it can be equated in severity of injury to a kidney contusion without damage to the capsule and cellular structures of the kidney. At the same time, under certain conditions (defocusing of electrodes in 1 focus, shrunken kidney, acute pyelonephritis, etc.), intrarenal, subcapsular and paranephric hematomas may occur. which indicates severe traumatic injury. Pathological anatomy

Anatomical changes in the damaged kidney can range from minor hemorrhages in the parenchyma to its complete destruction. When the fibrous capsule ruptures, blood spills into the perirenal tissue, imbibing it with subsequent formation of a hematoma. In cases where ruptures and cracks in the renal parenchyma reach the calyces and pelvis, a urohematoma is formed. It also develops when the parenchyma and fibrous capsule are damaged without damage to the renal calyces or pelvis.

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

In practice, relatively mild injuries are most often observed. Complete crushing of the kidney is rare; damage to the vascular pedicle of the kidney in a closed injury is an extremely rare clinical observation. Isolated kidney injury, according to N.G. Zaitsev (1966), occurred in 77.6% of victims. The rest had a combination of kidney injury with injuries to other organs: ribs, transverse processes of the vertebrae, abdominal organs and chest.

Traumatic damage to the kidney may also occur without obvious damage to the integrity of the organ. In these cases, histological examination reveals morphological signs of circulatory disorders and dystrophic changes in the parenchyma. Functional disorders with such damage to the kidney may be expressed to an even greater extent than with obvious ruptures.

Open kidney injuries

The causes and conditions of open kidney injuries vary. Particularly severe kidney injuries are observed when they are injured by modern firearms. This is due to the complex structure of the wound channel, the vastness of the tissue damage zone near the wound channel, frequent combined damage to several adjacent areas, and often multiple injuries (up to 90%). Such injuries are often complicated by traumatic shock (about 60%) and massive blood loss. The increased kinetic energy of wounding projectiles, especially from mine-explosive weapons, has led to an increase in the frequency of indirect kidney injuries when nearby organs are injured.

When studying kidney injuries in military conflicts using modern firearms, the frequency of different types of wounds was determined: penetrating wounds - 31.8%, crushing of the kidney - 27%, contusion - 23%, vascular pedicle wounds - 9.5%, tangential wounds - 16.8%, blind wounds - 0.8%.

Pathological anatomy. In gunshot wounds to the kidney with modern weapons, a zone of hemorrhages, small cracks and extensive necrosis is formed around the wound channel, the width of which significantly exceeds the diameter of the projectile. The cavity of the wound channel is filled with wound detritus, blood clots and foreign bodies. Most gunshot wounds to the kidneys can rightfully be classified as severe. Quite often (27%) there is complete crushing of the organ or severe contusions of the kidneys (23%). Wounds from a shotgun are especially severe. When the calyceal-pelvic system is damaged, blood and urine flow through the wound channel into the surrounding tissues, the abdominal and (less often) chest cavity, and also outward. Detachment of the kidney from the vascular pedicle does not always lead to fatal bleeding, since the inner lining of the artery is twisted into the lumen of the vessel.

Knife wounds often have the form of linear incisions, which can be located both radially and transversely in relation to the renal vessels. The latter circumstance has a certain significance for the choice of the volume and nature of surgical intervention. The closer the wound to the renal pedicle, the greater the risk of damage to large vessels and the larger the infarction zone with subsequent suppuration and melting. In case of damage to the pelvis, cups, ureter, if surgical intervention is not performed, urinary infiltration occurs with the development of phlegmon of the retroperitoneal tissue, and in case of wounds penetrating the abdominal cavity - peritonitis. With a favorable course, especially after a timely operation, within the next 4-5 days, the delimitation of necrosis areas is already clearly visible, proliferation of mesenchymal cells occurs and young connective tissue develops. The maturation of the latter leads to the formation of a fibrous scar. In some cases, a urinary fistula is formed, which, in the absence of obstacles to the outflow of urine naturally, can close on its own over time.

Symptoms of Kidney Injury

Closed Kidney Injuries - Symptoms

Damage to the urinary organs is characterized by a severe condition of the victims, profuse bleeding, severe pain, frequent release of urine into the surrounding tissues, urinary disorders and dysfunction of the internal organs, which often contributes to the development of both early and late complications.

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

Pain in the lumbar region is noted by 95% of patients with isolated injuries and by all victims with 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 by an increasing hematoma, blockage of the ureter by blood clots. The nature of the pain can be dull, sharp, colicky with irradiation to the groin area. Nausea, vomiting, bloating, symptoms of peritoneal irritation, and an increase in body temperature often cause a diagnostic error.

Swelling in the lumbar or subcostal region is caused by the accumulation of blood (hematoma) or blood with urine (urohematoma) in the perirenal or retroperitoneal tissue. It is usually observed in no more than 10% of victims. However, some clinicians note the presence of swelling in the lumbar region in 43.3% of observed patients. Large hematomas or urohematomas can spread from the diaphragm to the pelvis along the retroperitoneal tissue, and after 2-3 weeks they can even be detected in the scrotum and thigh.

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

Major hematuria was recorded in 50-80% of cases of closed kidney injuries during the Great Patriotic War, in modern military conflicts hematuria occurred in 74% of cases. Microhematuria is detected in almost all patients: it may be absent in mild injuries and, conversely, in extremely severe ones, in particular, when the kidney is torn from the vessels and ureter. The duration of hematuria and its intensity may vary. 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 1-2 weeks or more after the injury, is caused by purulent melting of thrombi and rejection of renal infarctions.

In addition to the listed symptoms, when a kidney is damaged, one can also observe atypical signs that are important for diagnosis: dysuria up to complete urinary retention due to tamponade of the bladder by blood clots, pain in the lower abdomen, symptoms of peritoneal irritation, gastrointestinal dysfunction, signs of internal bleeding, fever as a result of the development of post-traumatic pyelonephritis and suppuration of urohematoma.

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

The severity of morpho-functional disorders in the renal parenchyma after closed injuries and gunshot wounds is determined by the external conditions at the time of their receipt (the nature of military actions, natural conditions), the type and energy of the wounding projectile, the timing and scope of medical care. The degree of dysfunction 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. In case of mild injuries, the damaged structures of the kidney are restored with the loss of 1-15% of the functioning parenchyma. Moderate kidney injury entails the loss of up to 30% of the functionally active parenchyma. Severe kidney injury is accompanied by irreversible degenerative-dystrophic changes in up to 65% of the parenchyma.

Mild damage to the kidney is considered to be when the general condition of the victim is slightly impaired, there is moderate pain in the lower back, short-term minor macro- or microhematuria, there is no perirenal hematoma, and there are no signs of peritoneal irritation. This type of damage is referred to as a kidney contusion.

It is more difficult to clinically distinguish moderate kidney damage. In victims with moderate severity, the general condition changes from satisfactory to moderate relatively quickly.

At the same time, the pulse quickens, arterial pressure decreases, hematuria is pronounced and continues to increase. The accumulation of blood clots in the bladder can disrupt the act of urination, up to acute retention.

In some patients, a hematoma is clearly visible under the skin at the site of abrasions. Pain at the site of injury is insignificant, in most victims it radiates to the lower abdomen, groin area, and genitals. Obstruction of the ureter by blood clots can cause renal colic on the side of the injury. Injuries to the abdomen and kidney, perirenal hematoma (urohematoma) cause protective tension of the muscles of the anterior abdominal wall, signs of peritoneal irritation, intestinal flatulence, and signs of.

In the next 1-3 days, a clear picture of the disease development emerges in the direction of improvement, deterioration, or a relatively stable course. Improvement is characterized by a change in the general condition from moderate to satisfactory. restoration of a stable pulse and blood pressure, progressive reduction of hematuria, the perirenal hematoma does not increase in size, intestinal distension and signs of peritoneal irritation disappear. With deterioration of the clinical course, symptoms characteristic of severe kidney damage occur.

In severe injuries, collapse and shock come to the fore, severe pain in the lower back, profuse and prolonged macrohematuria are observed; urohematoma in the lumbar region and symptoms of internal bleeding tend to increase, and combinations of kidney damage with abdominal and thoracic organs, and skeletal damage (rib, spine, and pelvic fractures) are common.

[ 10 ], [ 11 ], [ 12 ]

Open Kidney Injuries - Symptoms

Open kidney injuries (wounds) are similar to closed ones in many ways in their clinical manifestations, diagnostic and treatment principles. The main symptoms of kidney injuries are pain in the wound area, hematuria, urohematoma, wound localization and direction of the wound channel, and urine leakage from the wound. The last symptom, although the most reliable, is rarely encountered in the early stages after injury (in 2.2% of cases). If a kidney injury is suspected, the Nessler reagent technique can be used to determine urine in bloody discharge from the wound. Urohematoma is observed less frequently in kidney injuries, since in combined injuries, blood and urine enter the abdominal and pleural cavities.

Pain in the lumbar region can be of varying intensity and depends on the condition of the injured person and the degree of damage not only to the kidney, but also to other organs. Pain causes protective tension in the abdominal muscles, and the earlier it appears and the more pronounced it is, the more grounds there are to suspect simultaneous damage to the abdominal organs.

Hematuria, as with closed injuries, is the leading and most common symptom of kidney injury. According to various authors, it is observed in 78.6-94.0% of cases. Blood in the urine appears quite quickly after injury; already during the first urination or during catheterization of the bladder, the urine contains a large number of blood clots, which can lead to tamponade of the bladder and urinary retention. The degree of hematuria cannot be used to judge the type and extent of destruction of the injured kidney. On the contrary, the most severe injuries to the renal hilum area may not be accompanied by the appearance of blood in the urine at all due to rupture of the vessels of the renal pedicle, and small tears of the renal parenchyma sometimes lead to profuse hematuria.

Extensive destruction of organs and significant blood loss lead to severe (31%) and extremely severe (38%) conditions of the wounded with the development of shock (81.4%).

The distribution of the wounded by the severity of injuries is different than in the case of closed kidney injuries: severe and moderate kidney injuries account for about 90%.

Complications of various kidney injuries

Clinical manifestations depend on the severity of the injury and the nature of the accompanying complications, 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.

Early complications include shock, internal bleeding, including secondary, retroperitoneal hematoma, urinary leaks, perirenal abscess and other infectious processes, peritonitis (primary or early), pneumonia, sepsis, urinary fistula, arterial hypertension, urinoma.

Urine leaks occur with closed kidney injuries, when the retroperitoneal space communicates with the urinary tract. In places where the integrity of the upper urinary tract is compromised, urine together with blood (urohematoma) penetrates into the perirenal or periureteral fatty tissue and accumulates in these places, forming cavities of various sizes. With damage to the calyceal-pelvic system and kidney tissue, a perirenal urohematoma can form relatively quickly, reaching significant sizes. Minor vascular damage leads to abundant blood saturation of the perirenal fatty tissue and the formation of hematomas. Retroperitoneal fatty tissue soaked in urine and blood often subsequently becomes purulent, which leads to the development of isolated purulent foci (rare) or, with significant necrosis and melting of fatty tissue, to urinary phlegmon, peritonitis (secondary), urosepsis (more often).

Among the late complications, noteworthy are infections, secondary bleeding, formation of arteriovenous fistulas, hydronephrosis, arterial hypertension, traumatic pyelo- and paranephritis, urinary renal fistulas, urinary tract stones, ureteral compression, traumatic renal cysts and pyonephrosis.

Renal failure is a serious complication of kidney damage, it can develop both early and late after the injury. It can be caused by damage to not only both kidneys, but also one (including the only) kidney, blockage or external compression of the ureters, acute bilateral pyelonephritis, as well as unilateral pyelonephritis complicated by bacteremic shock, deep and extensive purulent-inflammatory processes in the retroperitoneal tissue.

The probability of occurrence of urological complications with different degrees of severity of kidney damage is as follows: mild - 0-15%, moderate - 38-43% and severe - 100%.

The incidence of arterial hypertension after kidney injury is 5-12%. In the early stages, hypertension is caused by a perirenal hematoma, which compresses the renal parenchyma. Arterial hypertension usually develops 2-3 days after injury and goes away on its own within 7-50 days (on average 29 days). If hypertension does not go away after several months, then its cause is most likely the presence of a persistently ischemic area of the parenchyma.

In later stages, hypertension may be caused by arteriovenous fistulas. Secondary renal hemorrhage is usually observed within 21 days after injury.

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

Classification of kidney injury

The results of treatment of urinary organ injuries are largely determined by the effectiveness of early diagnostics and correctly selected treatment methods. When providing assistance to victims with kidney injuries, it is important to have a unified understanding of the nature of the pathological process that has arisen, a unified tactic in choosing a treatment method and ways of implementing it. In many ways, the implementation of this unity is facilitated by the classification of kidney injuries.

Mechanical damage to the kidneys is divided into two groups by type: closed (blunt or subcutaneous) and open (penetrating or wounds). Among the latter are bullet, shrapnel, stabbing, cutting, etc. Depending on the nature of the damage, they can be isolated or combined, and depending on the number of injuries - single or multiple. The kidney is a paired organ, so in case of injury it is necessary to highlight the side of the injury: left-sided, right-sided and bilateral. It is also necessary to indicate the area of kidney damage - the upper or lower segment, body, vascular pedicle. Damage, depending on the severity, can be mild, moderate or severe, with or without complications.

Based on the type of kidney injury, closed injuries are divided into contusions without disruption of the fibrous capsule; ruptures of the renal parenchyma that do not reach the calyces and renal pelvis; ruptures of the renal parenchyma that penetrate the calyces and renal pelvis; crushing of the kidney; damage to the vascular pedicle or detachment of the kidney from the vessels and ureter.

Among doctors, the most common classification is that of N. A. Lopatkin (1986). He divides closed kidney injuries into 7 groups depending on the nature and existing traumatic changes in the kidney and surrounding paranephric tissue.

The first group includes a special type of injury that occurs quite frequently: kidney contusion, in which multiple hemorrhages are observed in the renal parenchyma in the absence of a macroscopic rupture and subcapsular hematoma.

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

The third group of injuries includes subcapsular parenchyma rupture that does not penetrate the renal pelvis and calyces. A large subcapsular hematoma is usually present. Multiple hemorrhages and microinfarctions are detected in the parenchyma near the rupture site.

The fourth group consists of more severe injuries, which are characterized by ruptures of the fibrous capsule and renal parenchyma with spread to the pelvis or calyces. Such massive damage leads to hemorrhage and urine leakage into the paranephric tissue with the formation of urohematoma. Clinically, such injuries are characterized by profuse hematuria.

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

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

The seventh group consists of kidney contusions that occur during DLT and other types of injuries.

[ 17 ], [ 18 ], [ 19 ]

Classification of open injuries (wounds)

• By type of projectile:
  • gunshot (bullet, shrapnel, kidney damage due to mine-explosive trauma);
  • non-firearms.
• Along the wound channel:
  • blind:
  • through;
  • tangents.
• By the nature of damage:
  • injury;
  • wound;
  • crushed kidney;
  • injury to the vascular pedicle.

In 1993, the Organ Injury Classification Committee of the American Association for the Surgery of Trauma proposed a classification of kidney injuries, according to which injuries are divided into 5 degrees.

This classification is based on CT data or direct examination of the organ during surgery. Foreign studies and publications of recent years use this classification as a basis. Its advantage is the ability to more accurately determine the need for surgical intervention (nephrectomy or reconstruction).

American Association for the Surgery of Trauma Classification of Renal Injuries

Degree	Damage type	Description of pathological changes
I	Shake	Microscopic or gross hematuria, urologic examination findings are normal
	Hematoma	Subcapsular, non-proliferative, no parenchymal rupture
II	Hematoma	Limited to the retroperitoneal space
	Breakup	Rupture of the cortical parenchyma layer less than 1 cm without urine extravasation
III	Breakup	Rupture without communication with the renal collecting system and/or rupture >1 cm without urine extravasation
IV	Breakup	Corticomedullary parenchymal rupture, communication with the collecting system
	Vascular	Rupture of a segmental artery or vein with a limited hematoma, renal rupture, vascular thrombosis
V	Breakup	Completely crushed kidney
	Vascular	Renal pedicle avulsion or renal devascularization

It is necessary to determine the presence of premorbid diseases (hydronephrosis, nephrolithiasis, cystic and tumor diseases of the kidneys), in which kidney damage occurs more easily and is more severe. A well-known experiment was when a cadaveric kidney was taken and thrown from a height of 1.5 m and nothing happened to it. If the renal pelvis was filled with liquid, the ureter was tied and the kidney was thrown from the same height, multiple ruptures of the parenchyma were observed. This experiment clearly shows the greater susceptibility of a hydronephrotic kidney to damage.

[ 20 ], [ 21 ]

Diagnosis of kidney injury

Laboratory studies should include hematocrit and urinalysis. Because the severity of hematuria does not correlate with the severity of renal injury, contrast-enhanced CT is often used to determine the extent of renal injury and to identify concomitant intra-abdominal trauma and complications, including retroperitoneal hematoma and urinary leaks. Patients with microscopic hematuria may have renal contusions or minor lacerations with blunt trauma, but these almost never require imaging and surgical treatment. CT is mandatory in the following situations:

• fall from a height;
• car accident;
• macrohematuria;
• microhematuria with arterial hypotension;
• hematoma of the lateral abdomen.

In penetrating trauma, CT is indicated in all patients with hematuria, regardless of its severity. In selected cases, angiography is indicated to evaluate persistent or prolonged bleeding, with selective arterial embolization performed if necessary.

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

Closed Kidney Injuries - Diagnosis

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

[ 29 ], [ 30 ]

Open Kidney Injuries - Diagnosis

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

It is only necessary to keep in mind that the severity of the wounded person's condition does not allow the use of many diagnostic methods: intravenous urography in all its variants, chromocystoscopy. Radioisotope methods are of little information in wounded people in a state of shock. Any transurethral diagnostics are generally contraindicated for a wounded person in such a state.

Clinical diagnostics of kidney injuries

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

The presence of kidney damage may be indicated by hematuria (macroscopic or microscopic), pain in the lower back, in the lateral abdomen and lower chest, swelling (classic triad) and hemorrhage, as well as abdominal muscle tension, rib fractures, combined injuries to the abdominal organs, the presence of gunshot or stab wounds in the lower chest, upper abdomen or lower back, fractures of the spinous processes of the vertebrae.

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

Laboratory diagnostics of kidney injuries

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

Determination of serum creatinine levels in the first hours after injury does not provide any information about the presence of damage, but its elevated level may indicate the presence of premorbid kidney disease.

Monitoring hematocrit values dynamically allows detecting hidden bleeding. If hematocrit decreases, it is necessary to exclude other sources of blood loss, especially if there is a suspicion of combined trauma.

After DLT, when the traumatic impact of the shock wave on the skeletal muscles and liver is possible, during the first 24 hours after the procedure, the levels of bilirubin, lactate dehydrogenase, serum glutamyl transaminase and creatinine phosphokinase may increase. A decrease in 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 who have macrohematuria or microhematuria with hypotension are recommended to undergo imaging studies. In adult patients with microhematuria without hypotension, the probability of moderate to severe renal injury is negligible (0.2%), making the use of imaging studies inappropriate.

This statement does not apply to pediatric patients, penetrating injuries, or suspected combined trauma. In these cases, radiological examination is indicated. In injuries resulting from a fall from a height, if we consider only the presence of macrohematuria or shock as an indication for radiological examination, we can miss up to 29% of moderate and severe kidney injuries. That is why in such cases, the presence of microhematuria and/or hemorrhage in the lumbar region are additional grounds for conducting such studies.

Excretory urography

Special studies usually begin with a general radiograph of the kidney area and excretory urography when indicated - in high-dose and infusion modifications. In addition to conventional radiographs, 7, 15 and 25 minutes after the introduction of a contrast agent into the vein, it is useful in the case of the absence of function of the damaged kidney to make delayed images (after 1, 3, 6 hours or more).

Currently, the opinions of researchers on the use of excretory urography for the diagnosis of kidney injury differ sharply. Diagnosis of kidney injury involves an accurate determination of the severity of the injury according to the classification of the American Association for the Surgery of Trauma, which is best revealed by CT with contrast, which is feasible in patients with stable hemodynamics. Excretory urography often does not provide an opportunity to determine the extent of damage and information about their combinations. Excretory urography can give a false picture of the absence of kidney function ("silent kidney"), even if there is no damage to the renal vessels. Excretory urography requires a lot of time. There is an opinion that excretory urography is more informative in the diagnosis of severe injuries. However, there is also data indicating that in penetrating injuries this study can give false positive information in 20% of cases, and in 80% it does not provide an opportunity to establish the correct diagnosis. It is for this reason that excretory urography cannot be considered a full-fledged diagnostic method, and it is not of great importance when deciding on the need for surgical intervention.

Excretory urography with a bolus injection of a contrast agent in the amount of 2 ml/kg has a completely different information content. It is used in patients with unstable hemodynamics or during surgery for other injuries. One single image is taken (one shot IVP). In most victims, this makes it possible to identify "large" kidney damage, especially with injuries in the projection of the kidney and/or macrohematuria. In severe kidney damage, excretory urography can detect changes in 90% of cases.

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

Ultrasound diagnostics of kidney injuries

Currently, most clinicians begin examination of a patient with suspected kidney injury with ultrasound and highly value the results obtained, a number of authors do not consider ultrasound a full-fledged diagnostic method for assessing kidney injury, since normal ultrasound data do not exclude the presence of damage. For this reason, ultrasound should be supplemented with other research methods. Usually, ultrasound is used for the primary examination of patients with multiple injuries, which makes it possible to detect fluid in the abdominal cavity or in the retroperitoneal space, subcapsular hematoma of the kidney. Ultrasound is more effective for diagnosing moderate and severe injuries, in which changes are detected in 60% of cases. Ultrasound is also used in recovering patients for the purpose of dynamic observation. Sonographically detected 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, Doppler examination with color mapping is useful.

Despite the stated facts, there is data in the literature that ultrasound allows establishing the correct diagnosis in 80% of cases, excretory urography - in 72% of cases, and when they are used together, the correct diagnosis is possible with 98% sensitivity and 99% specificity. Therefore, if kidney damage is suspected, ultrasound is the primary screening study, which in case of hematuria is supplemented by excretory urography.

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

Computer tomography

Currently, CT is the recognized "gold standard" for diagnosing kidney damage in patients with stable hemodynamic parameters. It should be performed with contrast enhancement in both the nephrographic and urographic phases. To detect urine leakage, intravenous administration of 100 ml of contrast agent at a rate of 2 ml/ca. Scanning is performed 60 s after the contrast administration. CT makes it possible to determine the severity of damage in 95.6-100% of cases.

CT angiotraphy can detect vascular damage with a frequency of up to 93. Magnetic resonance imaging. MRI is an alternative to CT. Compared to CT, it is more sensitive for detecting kidney rupture, its non-viable fragment, and hematomas of various locations, but is not suitable for detecting urine extravasation.

[ 44 ], [ 45 ], [ 46 ]

MRI diagnostics of kidney injuries

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

Angiography

Used to diagnose damage to segmental or main vessels if other studies have raised such a suspicion. Angiography makes it possible, when such damage is detected, to simultaneously perform temporary selective or superselective embolization of the damaged arterial branch of the bleeding vessel to stop the bleeding, and in case of an incomplete rupture of the main vessel - endovascular stenting. If CT with contrast shows no contrast in the kidney, angiography is indicated to clarify the presence of vascular damage. This is especially important if the damage occurred by the mechanism of "sharp braking" and/or there is a hematoma in the renal hilum. Angiography is also indicated when a pulsating hematoma is detected by Doppler ultrasound.

Ureteral catheterization with retrograde pyeloureterography retains its diagnostic value. This method is most often used at the final stage of diagnostics and in cases of severe injuries immediately before surgery.

Thus, if the nature of kidney damage is unclear after performing ultrasound and excretory urography, preference should be given to CT MRI radioisotope methods of examination, and in some cases, angiography. In case of long-term non-healing postoperative renal fistulas, fistulography is indicated.

The most typical radiographic signs of kidney damage are: on plain radiographs and tomograms - a homogeneous shadow with fuzzy borders and the absence of the contour of the lumbar muscle on the supposed side of the injury, curvature of the spine due to protective muscle contraction; on intravenous urograms - weak and delayed filling of the renal pelvis and ureter with contrast agent, subcapsular and extrarenal leaks of contrast agent, in severe injuries - the absence of function of the affected kidney. These same signs are more clearly revealed by high-volume or infusion urography, as well as by retrograde pyeloureterograms.

If iatrogenic kidney injury is suspected, the time of instrumental manipulations to introduce a contrast agent through a ureteral catheter, stent or loop catheter reveals the location of the damage and the spread of leaks, which facilitates the timely diagnosis of such damage and the correct provision of adequate care.

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

Clarification of the circumstances and mechanism of injury, assessment of the patient's condition, results of physical, laboratory, instrumental, radiological and other types of examinations allows us to reliably establish the side of injury, the nature and localization of damage to the kidney or ureter, the functional capacity of the kidneys, the nature of urinary fistulas and the causes supporting them, and then draw up a treatment plan for the patient.

[ 47 ], [ 48 ], [ 49 ]

Open injuries

The severity of the general condition of the injured person and the need for urgent surgical interventions reduce to a minimum the number of studies required to establish an accurate diagnosis. However, before the operation, it is always necessary, having assessed the volume of blood loss, to perform, if possible, a general radiograph and an excretory urogram of the kidneys (preferably in several projections) in order to simultaneously identify bone damage, detect foreign bodies and their localization. The type of kidney damage is clarified already on the operating table.

If the patient's condition allows, an ultrasound and radioisotope examination should be performed, and in some cases, renal arteriography. Renal selective angiography is considered the best diagnostic method for kidney damage, even in patients in shock, when other methods of examination are uninformative. Embolization of damaged arteries following angiography ensures bleeding cessation, allows for more successful treatment of shock, a more detailed examination of the patient, and the commencement of surgery under optimal conditions.

Treatment of kidney injury

The patient is hospitalized in the nearest surgical department of the medical institution. Unless absolutely necessary, he should not be transferred to a urological hospital in order to ensure peace and eliminate the danger of long-term transportation. It is advisable to invite a urologist for consultation or participation in the operation.

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

Conservative treatment of kidney injury

Closed kidney injuries

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

In isolated closed kidney injuries of mild and moderate severity, if there are stable hemodynamic parameters and there are no other indications for surgical treatment, dynamic observation or conservative therapy may be sufficient, and in the case of mild kidney injury, treatment can often be limited to monitoring the victim.

In particular, conservative treatment of isolated kidney injuries is carried out when the general condition of the victim is satisfactory, there is no profuse hematuria, symptoms of internal bleeding, signs of increasing hematoma and urinary infiltration. It involves strict bed rest for 10-15 days, monitoring of hemodynamic parameters and hematocrit, prophylactic parenteral administration of antibiotics and uroantiseptics. The use of painkillers, hemostatic drugs, drugs that prevent the development of coarse scars and adhesions | hyaluronidase (lidase), glucocorticoids]. Such treatment is carried out until the disappearance of hematuria; it is successful in 98% of patients.

Constant medical supervision allows monitoring the course of treatment so that, if necessary, open surgery can be performed immediately. It is necessary to remember the possibility of "two-phase" kidney ruptures.

At the same time, in the last decade there has been a tendency towards surgical activity with a simultaneous expansion of indications for organ-preserving operations. In case of combined kidney injuries, all urologists are unanimous in their opinion that, as a rule, surgical treatment is indicated.

In case of closed kidney injuries caused by instrumental manipulations, conservative treatment is initially performed. In case of perforation of the wall of the pelvis and/or calyx, further examination of the patient is stopped, an antibiotic solution is administered through the catheter and the catheter is removed. The patient is prescribed bed rest, hemostatic drugs, antibiotics, cold on the lumbar region or on the abdomen along the ureter, and in the following days - heat. In case of rapid enlargement of the hematoma (urohematoma) in the lumbar region or in the abdomen on the side of the injury with intense macrohematuria, with deterioration of the general condition of the patient, lumbotomy with revision of the damaged kidney or other operations for the purpose of exposing the retroperitoneal space are indicated.

Studies show that in isolated moderate renal injury, initially conservative treatment results in lower rates of organ loss and need for blood transfusions than surgical treatment. The likelihood of developing post-traumatic hypertension is the same in both cases.

Perirenal fluid accumulation (blood) associated with extracorporeal shock wave lithotripsy, detected by CT, may resolve spontaneously within days to weeks, and subcapsular hematomas within 6 weeks to 6 months. A 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 kidney injuries

Conservative treatment is permissible only in individual cases: in isolated cold weapon wounds, without significant tissue destruction, with moderate and short-term hematuria and satisfactory condition of the wounded. Treatment of these victims is carried out according to the same plan as for closed kidney injuries.

[ 56 ], [ 57 ]

Surgical treatment of kidney injury

Minimally invasive interventions

Percutaneous drainage of pararenal hematoma or urohematoma is performed according to strict indications and is carried out under ultrasound or CT control.

The purpose of this manipulation is to evacuate the hematoma, reduce the treatment time, and reduce the risk of early and late complications.

Endoscopic drainage of the kidney using an internal stent is performed for moderate injuries; its purpose is to reduce urine extravasation and/or eliminate the obstruction of urine outflow. The stent is usually removed after 4 weeks. In patients with stable hemodynamics, with damage to a segmental artery and/or with ongoing intense hematuria, 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 for partial damage to the renal artery have been described.

Absolute indications for surgical treatment of closed and open kidney injuries:

• unstable hemodynamic parameters;
• growing or pulsating hematoma.

Relative indications:

• poorly defined degree of injury;
• extravasation of urine in large quantities;
• the presence of a large area of non-viable kidney tissue;
• severe injury (grade V);
• combined injuries requiring surgical treatment;
• premorbid or incidental diseases of the damaged kidney;
• unsatisfactory effect from conservative treatment or minimally invasive intervention.

Closed kidney injuries

Surgical treatment is performed to prevent complications and/or eliminate them. Surgical treatment of kidney injuries is performed in approximately 7.7% of cases. The frequency of surgical treatment for kidney injuries of varying severity is as follows: mild - 0-15%. moderate - 76-78%. severe -93%. In case of closed injuries, this figure is 2.4%. In case of penetrating wounds using bladed weapons - 45% and in case of gunshot wounds - 76%.

Clinical practice convinces us that in some cases of closed kidney injuries, surgical treatment must be used as an emergency aid. The main indications are the increase in symptoms of internal bleeding, rapid enlargement of the perirenal urohematoma, intense and prolonged hematuria with deterioration of the general condition of the victim, as well as signs of a combination of damage to the kidney and other internal organs.

Before surgery, in case of severe anemia, blood transfusion (erythrocyte mass) or infusion of blood-substituting solutions is indicated. This continues during surgery and often in the postoperative period. Massive blood transfusions are very important in case of combined damage to the kidneys, internal organs and pelvic bones, when the victim loses a significant amount of blood flowing into the abdominal cavity, retroperitoneal space and pelvic tissue. Patients are operated on without stopping active anti-shock therapy. General anesthesia is preferable.

In operations for traumatic kidney injuries, various approaches are possible. Most urologists perform laparotomy, usually median, in cases of kidney injury with suspected simultaneous damage to the abdominal organs, i.e. they prefer transabdominal access. It allows for simultaneous revision of the abdominal organs, since there is a high probability of their damage being combined with kidney injury. In this case, the parietal peritoneum is first excised in the direction of the aorta slightly medial to the mesenterica. After the hematoma has been evacuated, it becomes possible to isolate the renal vessels and take them on rubber tourniquets for clamping if necessary. After achieving control over the vessels, an additional incision of the peritoneum and Gerota's fascia is made lateral to the colon to expose the kidney. With this tactic, the nephrectomy rate decreases from 56% to 18%. Despite the data provided, not all authors consider preliminary vascular control a necessary measure. There is even an opinion that such tactics only increase the time of the operation and increase the likelihood of the need for a transfusion of blood or its components.

In isolated renal rupture, a lumbar extraperitoneal incision is more often used, preferably with resection of the 12th, and if necessary, the 11th rib, or in the 11th or 10th intercostal space. This approach allows for expanding the scope of intervention when indicated for thoracolumbolaparotomy. Having examined the damaged kidney, the urologist determines the scope and nature of the intervention on it.

During surgical intervention, the possibility of restoring the integrity of the kidney even with severe damage is 88.7%.
Restoration of the kidney involves its mobilization, removal of non-viable tissue, hemostasis, hermetic suturing of the collecting system and elimination of the parenchyma defect by bringing the edges of the wound together. If restoration of the kidney rupture is impossible, then its resection is performed. The parenchyma defect can be covered with a flap of omentum on a pedicle or special preparations containing a hemostatic sponge.

It should be noted that after surgical restoration of kidney function, they suffer insignificantly. In scintigraphy in the remote postoperative period, they average 36%. In surgical treatment of kidney damage, the overall complication rate is approximately 9.9%. which, however, is not accompanied by organ loss.

After injury, benign dystrophy develops at the site of the kidney tissue.

Surgical treatment of vascular injuries of the kidney involves nephrectomy or vascular restoration. Surgical restoration of the damaged renal vein in 25% of cases allows preserving the kidney. However, when restoring the renal artery, early or late complications quite often occur. Closed severe kidney injuries also have the worst prognosis. Late diagnosis (more than 4 hours after injury) and large size of ischemic tissue also worsen the prognosis. The literature presents the following data on the frequency of treatment of vascular injuries of the kidneys by various methods: nephrectomy - 32%, revascularization - 11%, conservative treatment - 57%, while after conservative treatment the frequency of hypertension was 6%. In moderate injuries with rupture of branches of the renal vessels after revascularization, scintigraphic examination shows an average deterioration in kidney function of 20%. A fairly common complication of such kidney injuries is a "silent kidney" without hypertension. Taking into account the above facts, some authors consider it inappropriate to preserve the kidney in case of significant damage to the renal artery if there is a fully functional contralateral kidney.

Indications for early nephrectomy: multiple deep ruptures of the kidney that cannot be restored; non-viability of the majority of the parenchyma, crushing of the kidney; damage to its vascular pedicle; general severe condition of the patient and the presence of significant combined injuries that pose an immediate threat to the patient's life. In case of mild injuries, nephrectomy is usually not performed; in case of moderate injuries, it is performed in 3-16.6% of cases; in case of severe injuries, it is performed in 86-90.8% of cases. In 77% of cases, nephrectomy is performed due to parenchymal or vascular injuries that cannot be restored, and in 23% - based on vital indications, although there is a potential possibility of kidney restoration. The rate of nephrectomy for gunshot wounds is high, especially in military conditions. The overall rate of nephrectomy in surgical treatment of kidney injuries is 11.3-35.0%.

Indications for organ-preserving operations: ruptures or tears of one end of the kidney; single cracks and ruptures of the body of the kidney, as well as its fibrous capsule; damage to a single kidney; damage to one kidney with a pathologically altered other; simultaneous damage to both kidneys.

The reserved attitude towards organ-preserving operations on the part of urologists explains the fear of repeated bleeding and the development of purulent processes in the damaged kidney and the surrounding tissue.

The most frequently used organ-preserving surgeries are: tamponade and suturing of kidney wounds, resection of the upper or lower segments with the application of a pyelo- or nephrostomy. The problem of hemostasis is especially important for performing such kidney surgeries. In recent years, urologists have been more often tamponing the kidney wound with autologous tissue (muscle, fatty tissue, omentum) or blood preparations (hemostatic sponge, fibrin film). Sutures are applied to kidney wounds in compliance with certain rules: paranephric tissue, fascia or aponeurosis are placed under the suturing ligature; sutures are applied tactilely with catgut or synthetic absorbable thread deep enough (capturing the cortex or medulla), without tightening the thread tightly to avoid strong compression of the parenchyma, which subsequently causes necrosis of its parts and the occurrence of secondary bleeding. For shallow kidney wounds. not penetrating the renal pelvis and calyces, after suturing the wound, one can refrain from applying pyelo- and nephrostomy.

The ruptures of the renal pelvis revealed during the operation are sutured with interrupted catgut or synthetic absorbable sutures. The operation on the kidney is completed by the application of a nephro- or pyelostomy.

At the end of the kidney operation, the wound in the lumbar region, regardless of the nature of the surgical intervention, is carefully drained and sutured. If the surgical intervention on the damaged kidney was performed through the abdominal cavity, a sufficiently wide counter-opening is applied in the lumbar region, the posterior leaf of the peritoneum over the operated kidney is sutured, and the abdominal cavity is sutured tightly. In the postoperative period, the entire complex of conservative measures aimed at preventing complications is continued.

Open kidney injuries

In cases where the "fate" of a damaged kidney must be decided in the absence of ultrasound, instrumental and X-ray examination data, it should be remembered that rarely (0.1%) a single or horseshoe kidney may be injured. Therefore, before removing a kidney, it is necessary to make sure that the other kidney is present and functionally adequate.

First aid in military field conditions for kidney damage includes pain relief with trimeperilin (promedol) or its analogue from a syringe-tube, oral administration of broad-spectrum antibiotics, immobilization if a fracture of the spine or pelvic bones is suspected, and in case of wounds - application of an aseptic bandage.

First aid consists of repeated use of analgesics, elimination of deficiencies in transport immobilization, in case of injuries - control of the dressing with bandaging, and, if indicated, stopping external bleeding (applying a clamp, ligating a vessel in a wound), and administering tetanus toxoid.

For vital indications, patients with penetrating cavity wounds, as well as those who have signs of ongoing internal bleeding, undergo surgery.

Urgent operations of the first order include surgical treatment of wounds contaminated with radioactive and toxic substances or heavily contaminated with soil. This group also includes damage and wounds to the kidneys with stopped bleeding.

It is better to use typical approaches for surgical treatment of wounds and interventions on the kidney, regardless of the direction of the wound channel. In case of isolated wounds, one of the types of lumbar incisions is used, in case of combined wounds, the approach is determined by the nature of the damage to the abdominal, chest and pelvic organs, but they try to use typical thoraco-, lumbo- and laparotomy in various combinations. Most urologists prefer to use midline laparotomy for combined wounds of the kidneys and abdominal organs. When intervening on injured organs, it is recommended to follow a certain sequence: first, take all measures to stop severe bleeding, the source of which is most often the parenchymatous organs and mesenteric vessels: then perform interventions on hollow organs (stomach, small and large intestine), and lastly, treat wounds of the urinary tract (ureter, bladder).

If the source of bleeding is the kidney, then regardless of the access, first the area of its vascular pedicle is revised and a soft vascular clamp is applied to it. It is believed that clamping the renal vessels for up to 20 minutes, and according to other researchers, up to 40 minutes does not cause much harm to the kidney. Having dried the perirenal space from the spilled blood, the degree of anatomical destruction of the organ is determined and then proceed in the same way as with closed kidney injuries. Nephrectomy is the most common (62.8%) type of intervention for open kidney wounds. 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 body of the kidney, reaching the gates of the organ; damage to the main vessels of the kidney. In other cases, organ-preserving operations are recommended, the main ones being suturing of kidney wounds and tamponade with autologous tissue, resection of the upper or lower segment of the kidney with pyelostomy or nephrostomy, renal pelvis suturing, ureterocutaneostomy or ureterocystoneostomy, and others. When sufficiently deep kidney wounds are detected, nephro- or pyelostomy is indicated, and it is desirable to bring the tube out not through the kidney wound, but next to it, using a thin layer of parenchyma over one of the middle or lower calyces, and only after that suturing and tamponade of the kidney wounds are performed.

A mandatory element of surgical care for open (especially gunshot) wounds is surgical treatment of the wound(s), which includes, in addition to stopping bleeding, excision of non-viable tissue, dissection of the wound channel, removal of foreign bodies, cleaning the wound from dirt, and the introduction of antibiotic solutions into and around it.

After intervention on the damaged kidney and surgical treatment of the wound(s), reliable drainage of the perirenal or periureteral space is ensured, including by applying counter-openings.

When providing specialized urological care, further wound treatment is carried out according to generally accepted principles in urology, repeated surgical treatments are performed, and, if indicated, nephrectomy or intervention on the kidney with elements of reconstructive surgery.

[ 58 ], [ 59 ]

Combined renal injury

In closed kidney injuries, combined injuries occur with a frequency of 10.3%, in penetrating wounds - 61-94%. In moderate injuries, the incidence of combined injuries is approximately 80%.

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

Combined injuries of parenchymatous abdominal organs can be treated simultaneously without increasing the risk of mortality. Combined injuries of the colon and pancreas cannot be considered a reason to refuse kidney restoration.

[ 60 ], [ 61 ], [ 62 ]

Pre-existing or incidental diseases

Previous diseases of the damaged kidney are rare (3.5-19%). The combination of kidney damage with congenital defects is observed in 3.5%, with urolithiasis - in 8.4%. with large kidney cysts - in 0.35%, tumors - in 0.15%, with anomalies of the ureteral junction - in 5.5% of cases. Combined damage is characterized by a higher risk of complications. In this case, organ damage occurs with less intense impacts than usual.

In the presence of premorbid diseases, conservative treatment can be carried out only in cases of minor kidney damage, and surgical treatment should be aimed at preserving the kidney.

Despite the fact that in cases of severe kidney damage with stable hemodynamic parameters, some authors describe cases of conservative treatment with a favorable outcome, the method of choice for treating such damage is surgical.

Presence of a large non-viable kidney segment

As studies show, in kidney damage, the presence of non-viable tissue can lead to complications and the need for delayed surgical intervention, especially in the case of concomitant vascular damage. The goal of surgical intervention is to remove non-viable tissue and restore the damaged kidney.

Treatment of complications of kidney injury

Conservative and/or minimally invasive methods of treating post-traumatic complications are preferable. Secondary bleeding, arteriovenous fistulas and false aneurysms can be successfully eliminated by endovascular embolization. Elimination of urine extravasation and urinoma is often carried out by installing an internal stent and percutaneous drainage of the perirenal space, which can also be used to treat perirenal abscess. If conservative and minimally invasive measures are ineffective, surgical treatment is indicated. The primary goal of surgery is to preserve the kidney. The probability of developing persistent arterial hypertension after kidney damage is low, 2.3-3.8%, but if it develops, serious, often surgical treatment (vessel reconstruction, nephrectomy) is required.

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

Further management

A repeat examination is indicated for all hospitalized patients with significant renal trauma 2–4 days after the injury. It is also recommended if fever develops, if lumbar pain occurs, or if the hematocrit decreases.

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

After significant kidney injury, monitoring includes:

• physical examination;
• urine analysis;
• personalized radiological examination;
• blood pressure control;
• control of creatinine levels in the blood.

Long-term monitoring is individualized; at a minimum, blood pressure monitoring is necessary.

Prognosis of kidney injury

The prognosis for mild to moderate closed kidney injuries without complications is favorable. Severe injuries and serious complications may require nephrectomy and lead to disability.

The prognosis for open kidney injuries depends on the severity of the injury, the nature and type of damage to these organs, the presence of complications, damage to other organs in combined injuries, and the timeliness and scope of care provided.

Patients who have suffered kidney injury, regardless of the treatment methods used (conservative or surgical), have a high risk of developing late complications. Even when the damaged kidney is removed, half of the patients develop various diseases in the contralateral kidney after a certain period of time (chronic pyelonephritis, stones, tuberculosis). All this dictates the need for long-term dispensary observation of people who have suffered kidney injury.

To summarize the above, the following points can be made.

• Currently, there is no unified classification of kidney injuries in the world. In European countries, the classification of the American Association for the Surgery of Trauma is generally recognized and most widely used, urologists use the classification of H. A. Lopatkin.
• It is considered appropriate that the diagnosis of traumatic renal injury should be based on CT data and in some cases (vascular injuries) supplemented by angiography. In urgent situations and/or patients with unstable hemodynamic parameters, infusion excretory urography in the single-shot mode (one shot LVP) should be performed.
• Determining the severity of the injury is crucial in choosing the treatment tactics. A correct diagnosis allows, in most cases, to successfully conduct conservative treatment even with high-severity injuries.
• Minimally invasive treatments should be used more frequently in kidney injuries.
• Great caution is required when treating penetrating wounds from high-velocity firearms, combined and vascular injuries, the presence of an extensive non-viable renal segment, premorbid diseases, and injuries of uncertain severity.
• It should be taken into account that the above circumstances, as well as the resulting post-traumatic complications, cannot in themselves be an indication for nephrectomy, and the urologist’s desire should always be to preserve the organ.