British Journal of Urology (1976), 41, 711-720 0
The Role of Angiography in Diagnosis and Management of Blunt Renal Trauma H. LIPSKY, P. PETRITSCH
and
H. SCHREYER
Department of Urology and Department of Radiology, University of Grar, Austria
Renal injury is suspected when trauma is followed by pain, tenderness over the kidney and haematuria. The most important investigation for the diagnosis is the intravenous pyelogram (IVP), preferably done with a high dose or infusion technique. Renal angiography has been recommended as an important complementary investigation by some authors (Olsson and Lunderquist, 1963; Vogler and Bergmann, 1963; Elkin, Chien-Hsing and Paredes 1966; Lang et al., 1971 ; Vermillion, McLaughlin and Pfister, 1971). Our experience with closed renal injuries is based on 223 patients who were treated in the period 1956-1973. Angiography was used as an additional investigation in 40 patients. Patients and Methods The patients were divided into 2 groups: those with mild and those with severe injuries (Table I). An injury was considered mild when there was no sign of shock or loin haematoma and the IVP did not show gross pathological changes. Patients with shock, loin haematoma, loss of function or gross changes such as extravasation of urine or rupture of parenchyma were considered to have a severe injury. In 23 cases there were other associated intra-abdominal injuries. The most important investigation for diagnosis was the IVP. Retrograde pyelography and cystoscopy were used in the first years of this series. Table I Classification of 223 Patients with Blunt Renal Injuries Mild
168
Severe
55
All managed conservatively Primary operated Conservatively managed
30 25
Angiography was done in 40 patients. At the beginning, it was performed ‘on all consecutive patients but later, only in selected cases. Though it was done sometimes only a few hours after injury it proved to be a safe procedure and no complications were observed. In most cases angiography was done on the second or third day after the injury. Technique Angiography was done under local anaesthesia via the femoral artery. The dye was injected into the aorta and the vascular architecture of the kidneys visualised. Main stream injection has the advantage of showing accessory vessels as well as the main artery. 40 ml Urografin (76 %) was 47/ 7 - ~
71 1
712
BRITISH JOURNAL OF UROLOGY
Fig. 1. Blunt injury to right kidney. Conservative management. (a), Urography: good excretion by intact collecting system. Flat indentation of lateral contour and separation of the calyces and of renal pelvis indicate a rupture of the kidney and an intrarenal haematoma. (b), Arteriography : kidney ,supplied by 3 arteries. Displacement of intrarenal arteries upper half of kidney caused by an intrarenal haematoma. (c), Arteriography (nephrogrdphic phase): complete rupture of upper half.
ANGIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF BLUNT RENAL TRAUMA
713
Fig. 2. Blunt injury to left kidney. Conservative management. (a), Urography showing normal excretion. Some deformity of upper calyces. Extravasation of dye from upper pole; (b), Arteriography: lack of opacification of vessels and parenchyma in upper and middle part of the kidney (necrotic parenchyma). Medial displacement of arteries at the border of this region is caused by oedema and haematoma.
given at a flow rate of 25 ml per sec. Selective renal angiography was only rarely done. It was possible to detect all vascular lesions accurately with aortography : in the nephrographic phase the parenchyma was more intensively visualised than with the IVP and ruptures were more precisely demonstrated (Figs. 1 to 4). However, in comparing the results of the IVP with the angiogram it was found that in most cases where there was an abnormality in the IVP, the angiogram also showed pathological changes. In 3 cases angiography was normal but there were pathological findings in the IVP such as delayed excretion, extravasation of urine or filling defects in the renal pelvis. The angiographic diagnosis and the management of these patients is shown in Table 11.
Management In the group with mild injuries an operation was never considered. In 1 patient from this group a nephrectomy was necessary because a renal carcinoma was revealed on the IVP and in 2 further patients a congenital hydronephrosis was found, requiring a pyeloplasty at a later date. In the group of patients with severe injuries 30 out of 55 were explored within the first days. Because of life endangering haemorrhage 5 nephrectomies were carried out within the first hours of admission. No angiograms were done in these 5 patients. Angiograms were carried out in the 15 patients who subsequently required a partial nephrectomy. These angiograms showed either occlusion of branches of the renal artery or complete avulsion of a pole. In all but 1 of these cases major areas of parenchyma had either a diminished or no blood supply. All operations were carried out 2 to 5 days after the injury. There were no problems with bleeding and the
714
BRITISH JOURNAL OF UROLOGY
Table II
Table 111
Angiographic Diagnosis and Management in 40 Cases Management of 55 Patients with Severe Blunt Renal Injuries Rupture with ischaemia of 15 major part of parenchyma Rupture with intact vascular architecture Intrarenal haematoma Normal
Partial nephrectomy Nephrectomy
14 1
Partial nephrectomy Repair and drainage Conservative
1 2
6
Conservative
6
10
Conservative
10
9
6
Primary operated
Primary conservative management
30
25
Nephrectomy Partial nephrectomy Repair and drainage Nephrectomy (abscess) Nephrectomy (haemorrhage) Partial nephrectomy (haemorrhage)
Table IV Follow-up of 50 Patients with Blunt Renal Injury Mild injuries All conservatively managed Severe injuries Conservatively managed
Operated
19
Hypertensive (not renal origin)
3
21 8
13
Hypertensive Stricture of p-ujunction Parenchymal shrinkage Calcification
6
Hypertensive Parenchymal shrinkage
4
1 6 I 1
necrotic parenchyma was easily identified and resected. In 1 patient in which the angiogram showed 2 deep lacerations a post-traumatic arterial thrombosis of the main artery had developed, which required nephrectomy. 10 patients required repair of a deep laceration and drainage of the perirenal haematoma; in 2 it was decided to operate after angiography, in the other 8 the decision was made on clinical signs. The other 25 patients with severe injuries were at first managed conservatively. 2 patients were explored at 5 and 7 days after their injury because of severe haemorrhage. In 1 case a nephrectomy became necessary, in the other the haemorrhage was controlled by partial nephrectomy. A perinephric abscess due to urine extravasation occurred in 2 patients in this group and a nephrectomy was necessary in both (Table 111). Angiography influenced the management in 5 patients in this group: though the IVP showed gross changes, a normal blood supply to the whole parenchyma was seen by angiography and the patients were therefore managed conservatively.
There were difficulties in following our patients and only 50 patients were examined 1 to 17 years after the injuries. IVP, urinalysis and blood pressures were checked. Angiography was carried out in 4 cases (Table IV). All patients with mild injuries who were treated conservatively, had a normal IVP. 3 patients
5
15 10 2 1
I
ANGIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF BLUNT RENAL TRAUMA
715
Fig. 3. Blunt injury to right kidney. Partial nephrectomy. (a), Urography: normal excretion of dye, No visualisation of the calyces of lower pole. Extravasation from lower pole. (b), Arteriography : kidney supplied by 2 arteries. Complete disruption of lower pole. Artery sup lying lower pole intact. Some visualisatlon of parenchyma o f lower pole indicated that the circulation was maintainel
had an elevated blood pressure and in 2 of them the hypertension was attributed to their age. The mild hypertension in a third, younger patient may have had another aetiology. The highest incidence of complications was observed in the group of patients with severe injuries who had been managed conservatively. Parenchymal shrinkage was present in 6 and in 1 case a stricture of the pelvi-uretericjunction due to perinephric adhesions was found. 1 patient had calcification of the upper pole, 6 patients in this group were hypertensive: all were under the age of 30. Shrinkage of the parenchyma was found in 5 and in 3 the follow-up angiogram showed diminished vascularisation of the shrunken parenchyma. In the contracted parts of the kidneys the transport of dye was delayed. Serial angiography demonstrated this phenomenon distinctly by comparing the shrunken and the normal part of the kidney (Fig. 5). In 1 case histological examination of the removed kidney showed hypertrophy of the j uxta-glomerular apparatus. In 2 the hypertension was cured by nephrectomy and in a 3rd, nephrectomy is proposed but has not yet been done. 3 hypertensive patients are not yet fully assessed. Complications were also observed in the early operation group. The follow-up IVP showed parenchymal shrinkage in 2 cases and 4 patients had hypertension. All these hypertensive patients were young. In 1 treated by primary repair of a laceration and drainage of a haematoma, the follow-up angiogram showed diminished vascularisation at the site of the repair. Since the renin level in this patient is abnormally high a nephrectomy is planned. The 3 other patients have not yet been fully assessed.
716
BRITISH JOURNAL OF UROLOGY
Fig. 4. Blunt injury to left kidney. Partial nephrectomy. (a), Urography showing normal excretion. Large extravasationfrom lower pole. (b) and (c), Arteriography :complete avulsion of the lower pole. No visualisation of lower pole artery and parenchyma.
Discussion If a renal injury is suspected, an IVP should be performed as soon as the shock has been corrected and the blood pressure is normal. This investigation confirms the extent of the injury with an accuracy of almost 90 % (Scott et al., 1963; Morrow and Mendez, 1970; Lucey, Smith and Koontz, 1972) and demonstrates a normally functioning contralateral kidney. Comparisons of the IVP and angiogram show good agreement as far as the simple diagnosis of an injury is concerned. In mild injuries angiography can detect lesions which have escaped the IVP but the angiogram can show normal vascular architecture when there are pathological changes on the IVP. This has been reported by others (Elkin et al., 1966; Morrow and Mendez, 1970). Angiography is the best method for demonstrating pedicle injuries, aneurysms, a-v shunts, intraparenchymal vascular disruptions and infarctions. When should angiography be done? There is no indication for angiography in any cases of mild injury and in injuries with life endangering haemorrhage. We would recommend angiography in the severe injury which can be managed expectantly and especi'ally if there is absence of function, large perirenal haematoma, perirenal urinary extravasation or the suspicion of a severe injury with dislocation of kidney fragments on the IVP. In the absence of renal function it should be done as soon as possible to exclude post-traumatic thrombosis of the renal artery. When the artery is stretched during trauma, an intimal tear can occur, while the elastic media and adventitia remain intact. The intimal tear is followed by thrombosis and thrombectomy has been advocated for this complication (Ross, Ackermann and Pierce, 1970; Caponegro and Leadbetter, 1973; Fay et al., 1974). If there is function of the kidney on the IVP angiography can be performed some days after the injury. By that time any initial traumatic arterial spasm has subsided. Our indications for performing arteriography agree with those of Pryor and Williams (1975), who recommended
ANGIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF BLUNT RENAL TRAUMA
717
that renal arteriography is indicated immediately if visualisation is either absent or incomplete on the IVP; an early indication is prolonged haematuria or poor visualisation on the IVP and uncertain pathology. Angiography is only justifiable if therapeutic decisions are made from the results. The management of renal injuries is still a point of controversy. Some authors have excellent results with strictly conservative management (Slade, 1971; Ceccarelli, 1972), while others find that early surgical intervention shortens the stay in hospital and avoids post-traumatic complications (Bandhauer, 1967; Cass and Ireland, 1973). The true incidence of post-traumatic hypertension and ureteric stricture, the most dangerous complications, is difficult to evaluate because of the difficulties with long-term follow-up-a problem shared by most other authors. We were surprised to find a.relatively high incidence of hypertension in our series. Angiography should always be done in post-traumatic hypertension. If there is a post-traumatic thrombosis of a minor accessory artery the IVP can show a normal kidney while angiography clearly shows the diminished vascularisation of the parenchyma. For further assessment the renal vein renin estimation should be performed. In 4 cases of malignant hypertension the renal aetiology was well established by angiography and renal vein renin estimation. Most other series report some cases of renal hypertension (Braasch and Strom, 1943; Dowse and Kihn, 1963; Bandhauer, 1967). Lang et al. (1971) reported in their series that in 5 out of 13 patients who developed hypertension the arteriogram showed either a segmental infarct or a large cortical infarct without collateral supply by a capsular artery or a large perirenal haematoma. In our experience the development of hypertension could not be predicted from the angiogram. Hypertension occurred in 4 patients who had been explored: 2 of them had had a partial nephrectomy and 2 a repair of a severe laceration. However, hypertension occurs not infrequently after partial nephrectomy for other reasons (Rauchenwald, Henning and Urlesberger, 1973). Hypertension might be explained either by insufficient resection of the damaged parenchyma leaving behind parts with diminished blood supply or by thrombosis of arteries after operation. In a period of 17 years the attitude towards the management of these cases has changed. In the first years the management was based mainly on clinical observation. Since angiography has been available we have relied on this investigation as well. Early surgical intervention can lead to nephrectomy because of uncontrolled haemorrhage (Cass and Ireland, 1973). If early surgery becomes necessary a transperitoneal approach allows good control of the renal pedicle and helps to avoid unnecessary nephrectomy. Our nephrectomy rate for all types of injuries is 4%. This i s a small figure compared to other series in which the nephrectomy rate has varied from 3 to 19 % (Dowse and Kihn, 1963; Bandhauer, 1967; Slade, 1971; Vermillion et al., 1971; Lucey et al., 1972; Pryor and Williams, 1975). We attribute our low rate to an expectant attitude of surgical treatment and the use of angiography. However, because of angiography we have performed relatively more partial nephrectomies. Although the numbers were small the highest incidence of complications occurred in that group of patients with severe injuries who were managed conservatively. We feel that there is a definite place for conservative surgery in severe renal injuries but if angiography shows an insufficient blood supply to a major part of the parenchyma we recommend removal of the necrotic tissue. Lang et al. (1971) have shown that a minor infarction can be managed conservatively if there is a good blood supply via the capsular arteries. Deep lacerations need not be explored if the vascular architecture of the fragments is intact. Exceptions are lacerations in which the renal pelvis is ruptured and urinary extravasation has occurred. Small intrarenal extravasations of urine and intrarenal haematomas can be managed conservatively, but one must be aware that a thrombosis of a smaller artery might ensue, leading to hypertension as in 4 cases in this series. Conclusion We strongly recommend an expectant attitude toward all types of blunt renal injuries and particularly, an evaluation of the extent of severe injuries by means of angiography.
718
BRITISH JOURNAL OF UROLOGY
Fig. 5. Blunt injury to right kidney 7 years ago. Conservatively managed. Hypertension. Cured by nephrectomy. (a), Urography: shrinkage of lower pole. Normal excretion. (b) and (c), Arteriography : normal upper half. Decreased volume of lower pole. Reduction of smaller vessels and delayed perfusion showing regionally impaired circulation.
ANGIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF BLUNT RENAL TRAUMA
719
Summary In a series of 223 patients with blunt renal injury, 40 patients underwent angiography. From this experience the following conclusions have been drawn : If a renal injury is suspected the IVP must be done as soon as possible. In most cases the diagnosis can be confirmed. Mild injuries should be managed conservatively and therefore need no angiography. In life endangering injury there is no time for angiography. The operation should be done preferably by a transperitoneal approach to allow good control of the renal pedicle. Patients with severe injuries should undergo angiography. If there is no function on the IVP, angiography should be done immediately to diagnose possible arterial thrombosis. In most cases angiography can be carried out some days after the trauma. This investigation provides an exact diagnosis and helps in deciding about further treatment. If a major part of the kidney has no blood supply, or there is a rupture with a large perirenal extravasation of urine, we recommend conservative surgery to avoid early and late complications. All operations should be done some days after the trauma. All patients with renal injuries, either operated or conservatively managed, should be carefully followed up. Angiography should be done in all cases of post-traumatic hypertension.
References BANDHAUER, K. (1967). Die organerhaltende Friihoperation bei Nierenverletzungen. Urologe, 6, 337-340. BRAASCH, W. F. and STROM, G. W. (1943). Renal trauma and its relation to hypertension. Journal of Urology, 50, 543-549. CAPONEGRO, P. J. and LEADBETTER, G. W. (1973). Traumatic rena artery thrombosis. Journal of Uro/ogy, 109, 769-771. CECCARELLI, F. E. (1972). Expectant treatment in the management of blunt renal trauma. In Current Controversies in Urologic Management, ed. by R. Scott. Philadelphia: Saunders, pp. 112-126. CASS,A. S . and IRELAND, G. W. (1973). Comparison of the conservative and surgical management of the more severe degrees of renal trauma in multiple injured patients. Journal of Urology, 109, 8-10. DOWSE,J. L. A. and KIHN,R. B. (1963). Renal injuries. Diagnosis, management and sequelae in 67 cases. British Journal of Surgery, 50, 353-361. ELKIN,M., CHIEN-HSING MENGand PAREDES, R. G . (1966). Correlation of intravenous urography and renal angiography in kidney injury. Radiology, 86, 496-498. FAY,R., BROSMAN, S., LINDSTROM, R. and COHEN, A. (1974). Renal artery thrombosis: a successful revascularization by autotransplantation. Journal of Urology, 111, 512-577. D. R. and SCOTT,W. W. (1951). Renal trauma: a study of 71 cases. Journalof Urology, HODGES, C. V., GILBERT, 66, 627-637. LANG,E. K., TRICHEL, B. E., TURNER, W. E., FONTENOT, R. A., JOHNSON, B. and St MARTIN, E. C. (1971). Arteriographic assessment of injury resulting from renal trauma. An analysis of 74 patients. Journal of Urology, 106, 1-14. LUCEY,D. T., SMITH,M. J. V. and KOONTZ, W. W. (1972). Modern trends in the management of urologic trauma. Journal of Urology, 107, 641-646. MORROW, J. W. and MENDEZ, R. (1970). Renal trauma. Journalof Urology, 104,649-653. OLSSON,0. and LUNDERQUIST, A. (1963). Angiography in renal trauma. Acta Radiologica, I, 1-21. PRYOR,J. P. and WILLIAMS, J. P. (1975). A study of 137 cases of renal trauma. British Journal of Urology, 47, 45-49. RAUCHENWALD, K., HENNING, K. and URLESBERGER, H. (1973). Nierenresektion-Operationstechnik und Spatergebnisse. Aktuelle Urologie, 4, 169-1 79. Ross, R., ACKERMAN, E. and PIERCE, J. M. (1970). Traumatic subintimal haemorrhage of the renal artery. Journal of Urology, 104, 11-15. SCOTT,R., CARLTON, C. E., ASHMORE, A. J. and DUKE,H. H. (1963). Initial management of non-penetrating renal injuries: clinical review of 111 cases. Journal of Urology, 90, 535-540. SLADE,N. (1971). Management of closed renal injuries. Brirish Journal of Urology, 43, 639-645.
720
BRITISH JOURNAL OF UROLOGY
VERMILUON, C. D., MCLAUGHLIN, A. P. and PFISTER, R. C. (1971). Management of blunt renal trauma. Journal of Urology, 106,478-484. VOGLER,E. and BERGMANN, M. (1963). Angiographie bei stumpfen Nierentraumen. Fortschritte auf dem Gebiefe der R6ntgenstrahlen und Nuklearmedizin, 98, 675-685.
The Authors H. Lipsky, MD, Univ. Doz. for Urology. P. Petritsch. MD, Senior Registrar in Urology. H. Schreyer, MD, Professor of Radiology.
The Role of Angiography in Diagnosis and Management of Blunt Renal Trauma H. LIPSKY, P. PETRITSCH
and
H. SCHREYER
Department of Urology and Department of Radiology, University of Grar, Austria
Renal injury is suspected when trauma is followed by pain, tenderness over the kidney and haematuria. The most important investigation for the diagnosis is the intravenous pyelogram (IVP), preferably done with a high dose or infusion technique. Renal angiography has been recommended as an important complementary investigation by some authors (Olsson and Lunderquist, 1963; Vogler and Bergmann, 1963; Elkin, Chien-Hsing and Paredes 1966; Lang et al., 1971 ; Vermillion, McLaughlin and Pfister, 1971). Our experience with closed renal injuries is based on 223 patients who were treated in the period 1956-1973. Angiography was used as an additional investigation in 40 patients. Patients and Methods The patients were divided into 2 groups: those with mild and those with severe injuries (Table I). An injury was considered mild when there was no sign of shock or loin haematoma and the IVP did not show gross pathological changes. Patients with shock, loin haematoma, loss of function or gross changes such as extravasation of urine or rupture of parenchyma were considered to have a severe injury. In 23 cases there were other associated intra-abdominal injuries. The most important investigation for diagnosis was the IVP. Retrograde pyelography and cystoscopy were used in the first years of this series. Table I Classification of 223 Patients with Blunt Renal Injuries Mild
168
Severe
55
All managed conservatively Primary operated Conservatively managed
30 25
Angiography was done in 40 patients. At the beginning, it was performed ‘on all consecutive patients but later, only in selected cases. Though it was done sometimes only a few hours after injury it proved to be a safe procedure and no complications were observed. In most cases angiography was done on the second or third day after the injury. Technique Angiography was done under local anaesthesia via the femoral artery. The dye was injected into the aorta and the vascular architecture of the kidneys visualised. Main stream injection has the advantage of showing accessory vessels as well as the main artery. 40 ml Urografin (76 %) was 47/ 7 - ~
71 1
712
BRITISH JOURNAL OF UROLOGY
Fig. 1. Blunt injury to right kidney. Conservative management. (a), Urography: good excretion by intact collecting system. Flat indentation of lateral contour and separation of the calyces and of renal pelvis indicate a rupture of the kidney and an intrarenal haematoma. (b), Arteriography : kidney ,supplied by 3 arteries. Displacement of intrarenal arteries upper half of kidney caused by an intrarenal haematoma. (c), Arteriography (nephrogrdphic phase): complete rupture of upper half.
ANGIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF BLUNT RENAL TRAUMA
713
Fig. 2. Blunt injury to left kidney. Conservative management. (a), Urography showing normal excretion. Some deformity of upper calyces. Extravasation of dye from upper pole; (b), Arteriography: lack of opacification of vessels and parenchyma in upper and middle part of the kidney (necrotic parenchyma). Medial displacement of arteries at the border of this region is caused by oedema and haematoma.
given at a flow rate of 25 ml per sec. Selective renal angiography was only rarely done. It was possible to detect all vascular lesions accurately with aortography : in the nephrographic phase the parenchyma was more intensively visualised than with the IVP and ruptures were more precisely demonstrated (Figs. 1 to 4). However, in comparing the results of the IVP with the angiogram it was found that in most cases where there was an abnormality in the IVP, the angiogram also showed pathological changes. In 3 cases angiography was normal but there were pathological findings in the IVP such as delayed excretion, extravasation of urine or filling defects in the renal pelvis. The angiographic diagnosis and the management of these patients is shown in Table 11.
Management In the group with mild injuries an operation was never considered. In 1 patient from this group a nephrectomy was necessary because a renal carcinoma was revealed on the IVP and in 2 further patients a congenital hydronephrosis was found, requiring a pyeloplasty at a later date. In the group of patients with severe injuries 30 out of 55 were explored within the first days. Because of life endangering haemorrhage 5 nephrectomies were carried out within the first hours of admission. No angiograms were done in these 5 patients. Angiograms were carried out in the 15 patients who subsequently required a partial nephrectomy. These angiograms showed either occlusion of branches of the renal artery or complete avulsion of a pole. In all but 1 of these cases major areas of parenchyma had either a diminished or no blood supply. All operations were carried out 2 to 5 days after the injury. There were no problems with bleeding and the
714
BRITISH JOURNAL OF UROLOGY
Table II
Table 111
Angiographic Diagnosis and Management in 40 Cases Management of 55 Patients with Severe Blunt Renal Injuries Rupture with ischaemia of 15 major part of parenchyma Rupture with intact vascular architecture Intrarenal haematoma Normal
Partial nephrectomy Nephrectomy
14 1
Partial nephrectomy Repair and drainage Conservative
1 2
6
Conservative
6
10
Conservative
10
9
6
Primary operated
Primary conservative management
30
25
Nephrectomy Partial nephrectomy Repair and drainage Nephrectomy (abscess) Nephrectomy (haemorrhage) Partial nephrectomy (haemorrhage)
Table IV Follow-up of 50 Patients with Blunt Renal Injury Mild injuries All conservatively managed Severe injuries Conservatively managed
Operated
19
Hypertensive (not renal origin)
3
21 8
13
Hypertensive Stricture of p-ujunction Parenchymal shrinkage Calcification
6
Hypertensive Parenchymal shrinkage
4
1 6 I 1
necrotic parenchyma was easily identified and resected. In 1 patient in which the angiogram showed 2 deep lacerations a post-traumatic arterial thrombosis of the main artery had developed, which required nephrectomy. 10 patients required repair of a deep laceration and drainage of the perirenal haematoma; in 2 it was decided to operate after angiography, in the other 8 the decision was made on clinical signs. The other 25 patients with severe injuries were at first managed conservatively. 2 patients were explored at 5 and 7 days after their injury because of severe haemorrhage. In 1 case a nephrectomy became necessary, in the other the haemorrhage was controlled by partial nephrectomy. A perinephric abscess due to urine extravasation occurred in 2 patients in this group and a nephrectomy was necessary in both (Table 111). Angiography influenced the management in 5 patients in this group: though the IVP showed gross changes, a normal blood supply to the whole parenchyma was seen by angiography and the patients were therefore managed conservatively.
There were difficulties in following our patients and only 50 patients were examined 1 to 17 years after the injuries. IVP, urinalysis and blood pressures were checked. Angiography was carried out in 4 cases (Table IV). All patients with mild injuries who were treated conservatively, had a normal IVP. 3 patients
5
15 10 2 1
I
ANGIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF BLUNT RENAL TRAUMA
715
Fig. 3. Blunt injury to right kidney. Partial nephrectomy. (a), Urography: normal excretion of dye, No visualisation of the calyces of lower pole. Extravasation from lower pole. (b), Arteriography : kidney supplied by 2 arteries. Complete disruption of lower pole. Artery sup lying lower pole intact. Some visualisatlon of parenchyma o f lower pole indicated that the circulation was maintainel
had an elevated blood pressure and in 2 of them the hypertension was attributed to their age. The mild hypertension in a third, younger patient may have had another aetiology. The highest incidence of complications was observed in the group of patients with severe injuries who had been managed conservatively. Parenchymal shrinkage was present in 6 and in 1 case a stricture of the pelvi-uretericjunction due to perinephric adhesions was found. 1 patient had calcification of the upper pole, 6 patients in this group were hypertensive: all were under the age of 30. Shrinkage of the parenchyma was found in 5 and in 3 the follow-up angiogram showed diminished vascularisation of the shrunken parenchyma. In the contracted parts of the kidneys the transport of dye was delayed. Serial angiography demonstrated this phenomenon distinctly by comparing the shrunken and the normal part of the kidney (Fig. 5). In 1 case histological examination of the removed kidney showed hypertrophy of the j uxta-glomerular apparatus. In 2 the hypertension was cured by nephrectomy and in a 3rd, nephrectomy is proposed but has not yet been done. 3 hypertensive patients are not yet fully assessed. Complications were also observed in the early operation group. The follow-up IVP showed parenchymal shrinkage in 2 cases and 4 patients had hypertension. All these hypertensive patients were young. In 1 treated by primary repair of a laceration and drainage of a haematoma, the follow-up angiogram showed diminished vascularisation at the site of the repair. Since the renin level in this patient is abnormally high a nephrectomy is planned. The 3 other patients have not yet been fully assessed.
716
BRITISH JOURNAL OF UROLOGY
Fig. 4. Blunt injury to left kidney. Partial nephrectomy. (a), Urography showing normal excretion. Large extravasationfrom lower pole. (b) and (c), Arteriography :complete avulsion of the lower pole. No visualisation of lower pole artery and parenchyma.
Discussion If a renal injury is suspected, an IVP should be performed as soon as the shock has been corrected and the blood pressure is normal. This investigation confirms the extent of the injury with an accuracy of almost 90 % (Scott et al., 1963; Morrow and Mendez, 1970; Lucey, Smith and Koontz, 1972) and demonstrates a normally functioning contralateral kidney. Comparisons of the IVP and angiogram show good agreement as far as the simple diagnosis of an injury is concerned. In mild injuries angiography can detect lesions which have escaped the IVP but the angiogram can show normal vascular architecture when there are pathological changes on the IVP. This has been reported by others (Elkin et al., 1966; Morrow and Mendez, 1970). Angiography is the best method for demonstrating pedicle injuries, aneurysms, a-v shunts, intraparenchymal vascular disruptions and infarctions. When should angiography be done? There is no indication for angiography in any cases of mild injury and in injuries with life endangering haemorrhage. We would recommend angiography in the severe injury which can be managed expectantly and especi'ally if there is absence of function, large perirenal haematoma, perirenal urinary extravasation or the suspicion of a severe injury with dislocation of kidney fragments on the IVP. In the absence of renal function it should be done as soon as possible to exclude post-traumatic thrombosis of the renal artery. When the artery is stretched during trauma, an intimal tear can occur, while the elastic media and adventitia remain intact. The intimal tear is followed by thrombosis and thrombectomy has been advocated for this complication (Ross, Ackermann and Pierce, 1970; Caponegro and Leadbetter, 1973; Fay et al., 1974). If there is function of the kidney on the IVP angiography can be performed some days after the injury. By that time any initial traumatic arterial spasm has subsided. Our indications for performing arteriography agree with those of Pryor and Williams (1975), who recommended
ANGIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF BLUNT RENAL TRAUMA
717
that renal arteriography is indicated immediately if visualisation is either absent or incomplete on the IVP; an early indication is prolonged haematuria or poor visualisation on the IVP and uncertain pathology. Angiography is only justifiable if therapeutic decisions are made from the results. The management of renal injuries is still a point of controversy. Some authors have excellent results with strictly conservative management (Slade, 1971; Ceccarelli, 1972), while others find that early surgical intervention shortens the stay in hospital and avoids post-traumatic complications (Bandhauer, 1967; Cass and Ireland, 1973). The true incidence of post-traumatic hypertension and ureteric stricture, the most dangerous complications, is difficult to evaluate because of the difficulties with long-term follow-up-a problem shared by most other authors. We were surprised to find a.relatively high incidence of hypertension in our series. Angiography should always be done in post-traumatic hypertension. If there is a post-traumatic thrombosis of a minor accessory artery the IVP can show a normal kidney while angiography clearly shows the diminished vascularisation of the parenchyma. For further assessment the renal vein renin estimation should be performed. In 4 cases of malignant hypertension the renal aetiology was well established by angiography and renal vein renin estimation. Most other series report some cases of renal hypertension (Braasch and Strom, 1943; Dowse and Kihn, 1963; Bandhauer, 1967). Lang et al. (1971) reported in their series that in 5 out of 13 patients who developed hypertension the arteriogram showed either a segmental infarct or a large cortical infarct without collateral supply by a capsular artery or a large perirenal haematoma. In our experience the development of hypertension could not be predicted from the angiogram. Hypertension occurred in 4 patients who had been explored: 2 of them had had a partial nephrectomy and 2 a repair of a severe laceration. However, hypertension occurs not infrequently after partial nephrectomy for other reasons (Rauchenwald, Henning and Urlesberger, 1973). Hypertension might be explained either by insufficient resection of the damaged parenchyma leaving behind parts with diminished blood supply or by thrombosis of arteries after operation. In a period of 17 years the attitude towards the management of these cases has changed. In the first years the management was based mainly on clinical observation. Since angiography has been available we have relied on this investigation as well. Early surgical intervention can lead to nephrectomy because of uncontrolled haemorrhage (Cass and Ireland, 1973). If early surgery becomes necessary a transperitoneal approach allows good control of the renal pedicle and helps to avoid unnecessary nephrectomy. Our nephrectomy rate for all types of injuries is 4%. This i s a small figure compared to other series in which the nephrectomy rate has varied from 3 to 19 % (Dowse and Kihn, 1963; Bandhauer, 1967; Slade, 1971; Vermillion et al., 1971; Lucey et al., 1972; Pryor and Williams, 1975). We attribute our low rate to an expectant attitude of surgical treatment and the use of angiography. However, because of angiography we have performed relatively more partial nephrectomies. Although the numbers were small the highest incidence of complications occurred in that group of patients with severe injuries who were managed conservatively. We feel that there is a definite place for conservative surgery in severe renal injuries but if angiography shows an insufficient blood supply to a major part of the parenchyma we recommend removal of the necrotic tissue. Lang et al. (1971) have shown that a minor infarction can be managed conservatively if there is a good blood supply via the capsular arteries. Deep lacerations need not be explored if the vascular architecture of the fragments is intact. Exceptions are lacerations in which the renal pelvis is ruptured and urinary extravasation has occurred. Small intrarenal extravasations of urine and intrarenal haematomas can be managed conservatively, but one must be aware that a thrombosis of a smaller artery might ensue, leading to hypertension as in 4 cases in this series. Conclusion We strongly recommend an expectant attitude toward all types of blunt renal injuries and particularly, an evaluation of the extent of severe injuries by means of angiography.
718
BRITISH JOURNAL OF UROLOGY
Fig. 5. Blunt injury to right kidney 7 years ago. Conservatively managed. Hypertension. Cured by nephrectomy. (a), Urography: shrinkage of lower pole. Normal excretion. (b) and (c), Arteriography : normal upper half. Decreased volume of lower pole. Reduction of smaller vessels and delayed perfusion showing regionally impaired circulation.
ANGIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF BLUNT RENAL TRAUMA
719
Summary In a series of 223 patients with blunt renal injury, 40 patients underwent angiography. From this experience the following conclusions have been drawn : If a renal injury is suspected the IVP must be done as soon as possible. In most cases the diagnosis can be confirmed. Mild injuries should be managed conservatively and therefore need no angiography. In life endangering injury there is no time for angiography. The operation should be done preferably by a transperitoneal approach to allow good control of the renal pedicle. Patients with severe injuries should undergo angiography. If there is no function on the IVP, angiography should be done immediately to diagnose possible arterial thrombosis. In most cases angiography can be carried out some days after the trauma. This investigation provides an exact diagnosis and helps in deciding about further treatment. If a major part of the kidney has no blood supply, or there is a rupture with a large perirenal extravasation of urine, we recommend conservative surgery to avoid early and late complications. All operations should be done some days after the trauma. All patients with renal injuries, either operated or conservatively managed, should be carefully followed up. Angiography should be done in all cases of post-traumatic hypertension.
References BANDHAUER, K. (1967). Die organerhaltende Friihoperation bei Nierenverletzungen. Urologe, 6, 337-340. BRAASCH, W. F. and STROM, G. W. (1943). Renal trauma and its relation to hypertension. Journal of Urology, 50, 543-549. CAPONEGRO, P. J. and LEADBETTER, G. W. (1973). Traumatic rena artery thrombosis. Journal of Uro/ogy, 109, 769-771. CECCARELLI, F. E. (1972). Expectant treatment in the management of blunt renal trauma. In Current Controversies in Urologic Management, ed. by R. Scott. Philadelphia: Saunders, pp. 112-126. CASS,A. S . and IRELAND, G. W. (1973). Comparison of the conservative and surgical management of the more severe degrees of renal trauma in multiple injured patients. Journal of Urology, 109, 8-10. DOWSE,J. L. A. and KIHN,R. B. (1963). Renal injuries. Diagnosis, management and sequelae in 67 cases. British Journal of Surgery, 50, 353-361. ELKIN,M., CHIEN-HSING MENGand PAREDES, R. G . (1966). Correlation of intravenous urography and renal angiography in kidney injury. Radiology, 86, 496-498. FAY,R., BROSMAN, S., LINDSTROM, R. and COHEN, A. (1974). Renal artery thrombosis: a successful revascularization by autotransplantation. Journal of Urology, 111, 512-577. D. R. and SCOTT,W. W. (1951). Renal trauma: a study of 71 cases. Journalof Urology, HODGES, C. V., GILBERT, 66, 627-637. LANG,E. K., TRICHEL, B. E., TURNER, W. E., FONTENOT, R. A., JOHNSON, B. and St MARTIN, E. C. (1971). Arteriographic assessment of injury resulting from renal trauma. An analysis of 74 patients. Journal of Urology, 106, 1-14. LUCEY,D. T., SMITH,M. J. V. and KOONTZ, W. W. (1972). Modern trends in the management of urologic trauma. Journal of Urology, 107, 641-646. MORROW, J. W. and MENDEZ, R. (1970). Renal trauma. Journalof Urology, 104,649-653. OLSSON,0. and LUNDERQUIST, A. (1963). Angiography in renal trauma. Acta Radiologica, I, 1-21. PRYOR,J. P. and WILLIAMS, J. P. (1975). A study of 137 cases of renal trauma. British Journal of Urology, 47, 45-49. RAUCHENWALD, K., HENNING, K. and URLESBERGER, H. (1973). Nierenresektion-Operationstechnik und Spatergebnisse. Aktuelle Urologie, 4, 169-1 79. Ross, R., ACKERMAN, E. and PIERCE, J. M. (1970). Traumatic subintimal haemorrhage of the renal artery. Journal of Urology, 104, 11-15. SCOTT,R., CARLTON, C. E., ASHMORE, A. J. and DUKE,H. H. (1963). Initial management of non-penetrating renal injuries: clinical review of 111 cases. Journal of Urology, 90, 535-540. SLADE,N. (1971). Management of closed renal injuries. Brirish Journal of Urology, 43, 639-645.
720
BRITISH JOURNAL OF UROLOGY
VERMILUON, C. D., MCLAUGHLIN, A. P. and PFISTER, R. C. (1971). Management of blunt renal trauma. Journal of Urology, 106,478-484. VOGLER,E. and BERGMANN, M. (1963). Angiographie bei stumpfen Nierentraumen. Fortschritte auf dem Gebiefe der R6ntgenstrahlen und Nuklearmedizin, 98, 675-685.
The Authors H. Lipsky, MD, Univ. Doz. for Urology. P. Petritsch. MD, Senior Registrar in Urology. H. Schreyer, MD, Professor of Radiology.
