After A a young male presented with non pulsatile retroperitoneal hematoma. On table IVU was done. Right kidney not visualized. Left kidney showed immediate excretion of dye. What is next step in management:
Ans is 'd' i.e. Perform on table angiography "nonvisualization of the kidney requires immediate aeriography or CT scan to determine whether renal vascular injury exists."- Smith's Urology "Absence of kidney perfusion is an indication for renal aery angiography"- Sabiston The major causes of nonvisualization on an IVU are total pedicle avulsion, aerial thrombosis, severe contusion causing vascular spasm, and absence of the kidney. Aeriography would help identify major aerial and parenchymal injuries.Aerial thrombosis and avulsion of the renal pedicle are best diagnosed by aeriography. Also know: Best imaging study to detect and stage renal and retroperitoneal injuries is - computed tomography with contrast media. It can define the size and extent of the retroperitoneal hematoma, renal lacerations, urinary extravasation, and renal aerial and venous injuries; additionally, it can detect other intra-abdominal injuries. Management: Blunt injuries--Minor renal injuries from blunt trauma account for 85% of cases and do not usually require operation. Bleeding stops spontaneously with bed rest and hydration. Cases in which operation is indicated include those associated with persistent retroperitoneal bleeding, urinary extravasation, evidence of nonble renal parenchyma, and renal pedicle injuries (less than 5% of all renal injuries). Aggressive preoperative staging allows complete definition of injury before operation. Penetrating injuries--Penetrating injuries should be surgically explored. A rare exception to this rule is when staging has been complete and only minor parenchymal injury, with no urinary extravasation, is noted. In 80% of cases of penetrating injury, associated organ injury requires operation; thus, renal exploration is only an extension of this procedure. In the above question, the patient had non pulsatile hematoma. A pulsatile or expanding hematoma is an indication for surgical exploration.
Nephrectomy
Open Gerota's fascia and explore proximal renal vessels
Perform Retrograde pyelography
Perform on table angiography