Urological Emergencies in Clinical Practice стр.45

Renal ultrasonography can be used in the evaluation of renal injuries. However, all of the studies upon which our current management of renal injuries are based, have used CT. It remains to be established whether, at least in some cases, ultrasonography can stage such injuries accurately enough to allow CT to be dispensed with. Ultrasound can certainly establish the presence of two kidneys and the presence of a retroperitoneal haematoma and with power Doppler can identify the presence of blood flow in the renal vessels. However, it cannot accurately identify parenchymal tears, collecting system injuries, or extravasation of urine until a later stage when a urine collection has had time to accumulate.

Contrast-enhanced CT allows the following questions to be answered:

■ How deep is the parenchymal laceration?

■ Does the parenchyma enhance, i.e., is it perfused?

■ Is there extravasation of urine?

■ How big and where is the retroperitoneal haematoma?

■ Are other organs injured (bowel, spleen, liver, pancreas, etc.)?

Major injuries to either the collecting system or to the renal vessels is suggested by finding the following on CT:

■ Absence of enhancement of the parenchyma suggests a renal artery injury.

■ A haematoma medial to the kidney suggests a vascular injury.

■ Medial extravasation of contrast suggests disruption of the PUJ or renal pelvis.

58 J. REYNARD

Staging (Grading)

Using CT, renal injuries can be staged (graded) according to the American Association for the Surgery of Trauma Organ Injury Severity Scale (Fig. 5.2):

Grade

Description

I

Contusion (normal CT) or subcapsular haematoma with no

 

parenchymal laceration

II

<1 cm deep parenchymal laceration of cortex, no

 

extravasation of urine (i.e., collecting system intact)

III

>1 cm deep parenchymal laceration of cortex, no

 

extravasation of urine (i.e., collecting system intact)

IV

Parenchymal laceration involving cortex, medulla, and

 

collecting system, or renal artery or renal vein injury

 

with contained haemorrhage

V

Completely shattered kidney or avulsion of renal hilum

Intravenous Urography for Renal Imaging


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