The kidneys are vulnerable to blunt, penetrating, and deceleration injury ( Lang et al 1985; Federle 1990). Microscopic hematuria alone is a poor indicator of renal trauma, but heavier hematuria and the presence of hemodynamic disturbance warrants renal imaging. Ultrasound will demonstrate perirenal hematoma, urinoma, and the integrity of the renal artery and vein. However, dynamic CT, ideally in the spiral mode, is more informative and allows staging of injury ( Fig . 4). Staging is of importance as it can influence management. Renal arteriography may also be necessary and can be followed with embolization of any bleeding points.
Fig. 4 Photomontage of sequential CT cuts showing a bleeding left renal artery with contrast leakage. The associated renal infarction is seen as an area of non-enhancement in the posteromedial portion of the left kidney. This scan follows the normal layout of cross-sectional images and the left kidney is on the right side of each scan.
Renal arteriography showing transection of the lower half of the right kidney. Fistulas
Bilateral needle nephrostomies may need to be inserted to divert urine away from a lower-tract fistula. It is imperative that these catheters are made of a material that will not kink, and nephrostomies should be well sited in the collecting system. If necessary, a parallel balloon catheter may be inserted in the ureter to block flow to the fistula completely.
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