TRAUMA GINJAL

SUB BAGIAN UROLOGI

BAGIAN/SMF BEDAH
FK UNS/RSUD Dr. MOEWARDI

PENDAHULUAN
trauma abdomen trauma traktus
urogenitalis
Trauma urogenitalis trauma ginjal >>>
5% trauma abdomen
Dewasa muda sekitar 74%, usia tua 15%,
dan anak-anak 9%
Sering bersama trauma organ lain
(multiorgan trauma).
AS : trauma ginjal bersama hepar (40%),
lien (5-7%), pankreas (13%), kolon (7%) dan
usus halus / gaster (3%)
10%

ETIOLOGI
Trauma tumpul (Blunt Injury) 80-85%
Mekanisme trauma tumpul ginjal :
1. Trauma langsung pinggang kosta 11 &
12 fraktur melukai ginjal
2. Trauma tumpul bagian depan abdomen
3. Jatuh terduduk dari ketinggian

AAST Renal Injury Grading Scale

Grade*
1

Description of Injury
Contusion or non-expanding subcapsular haematoma
No laceration

Non-expanding peri-renal haematoma

Cortical laceration < 1 cm deep without extravasation

Cortical laceration < 1 cm without urinary extravasation

Laceration: through corticomedullary junction into collecting system

Or
Vasculary: segmental renal artery or vein injury with contained
haematoma, or partial vassel laceration, or vessel thrombosis

Laceration: shattered kidney

Or
Vascular: renal pedicle or avulsion

ETIOLOGI
Trauma tembus (penetrating
injury)
1. luka tusuk (stab wound)
2. luka tembak (gun shot)
. 80% luka tembus ginjal
trauma visera intraabdomen
. intervensi operatif

KLASIFIKASI

DIAGNOSIS
1.
2.
3.
4.
5.

Riwayat trauma
Hematuria (95%)
Hematoma di regio flank
Fraktur costa bawah
Hemodinamik tidak stabil
(hipotensi)

History and Physical Examination

Recommendations

GR

Haemodynamic stability should be decided upon admission

History should be taken from conscious patient, witnesses and

rescue team personnel with regard to the time and setting of
the incident

Past renal surgery, and known pre-existing renal abnormalities

(ureteropelvic junction obstruction, large cysts, lithiasis)
should be recorded

A though examination should be made of the thorax, abdomen,

flanks and back for penetrating wounds

Findings on physical examination such as haematuria, flank

pain, flank absasions and ecchymoses, fractured ribs,
abdominal tenderness, distension or mass, could indicate
possible renal involvement

Laboratory Evaluation
Recommendations

GR

Urine from a patient with suspected renal injury should be

inspected grossly and then by dipstick analysis

Serial haematocrit measurement indicates blood loss.

However, until evaluation is complete. It not be clean
whether it is due to renal trauma and or associated injuries.

Creatinine measurement could highlight patient who had

impaired renal function prior to injury

PEMERIKSAAN IMEJING GINJAL

Dahulu: IVP skg: CT Scan kontras
Jk fasilitas CT Scan (-) pakai IVP
Indikasi:
1. Trauma tembus regio flank /
abdomen tdk lihat derajat
hematuria
2. Trauma tumpul dewasa dg gross
hematuria /mikrohematuria + shock
(sistolik < 90 mmHg)
3. Trauma deselerasi
4. Trauma mayor berhubungan trauma
intra-abdominal & mikrohematuria
5. Trauma abdomen / flank penderita
anak dengan hematuria

Imaging
Recommendation

GR

Blunt trauma patients with macroscopic or microscopic haematurial (at least 5rbc/hpf) with
hypotention (systolic blood preassure <90mmHg) should undergo radiographic evaluation

Radiographic evaluation is also recommended for all patients with a history of rapid declaration
injury and/or significant associated injuries.

All patients with any degree of haematuria after penetrating abdominal or thoracic injury
require urgent renal imaging

Ultrasonograpy can be informative during the primary evaluation o polytrauma patients and for
the follow-up of recuperating patients, although more data is required to suggest this modality
university

A CT scan with enchancement of intravenous contrast material is the best imaging study for
the diagnosis and staging of renal injuries in haemodynamically stable patients

Unstable patients who require emergency surgical exploration should undergo a one-shot IVP
with bolus intravenous unjection of 2mL/kg contrast

Formal IVP/, MRI and radiographic scintigraphy are acceptable second-line alternative for
imaging renal trauma when CT is not availabel

Angiography can be used for diagnosis and simultaneous selective embolisation of bleeding
vessels

PENGELOLAAN NONOPERATIF
98% trauma tumpul renal
Penderita hemodinamik stabil

& staging

(+) & CT Scan (+)

Trauma tembus luka tembak / tusuk
staging hati-hati dg CT Scan monitor
ketat
55% trauma tusuk & 24% trauma luka
tembak nonoperatif
Trauma derajat III & IV monitor ketat
(serial hematokrit & CT Scan)
perdarahan persisten angiografi
embolisasi

Non-operative Management of Renal Injuries

Recommendations

GR

Following grade 1-4 blunt renal trauma, stable patients should be

manage conservatively with bed-rest, prophylactics antibiotic and
continuous of vital signs until haematurial resolves

Following grade 1-3 stab and low-velocity gunshot wounds, stable

patients, after complete staging, should be selected expectant
management

Indicated for surgical management include

Haemodynamic instability
Exploration for associated injuries
Expanding or pulsatile peri-renal haematoma identified during
laparotomy
Grade 5 injury
Incidental finding of pre-existing renal pathology requiring surgical
therapy

Renal reconstructing should be attempted in cases with where the

primary goal of controlling haemorrhage is achieved and sufficient
amount of renal parenchyma is viable

EKSPLORASI GINJAL
INDIKASI ABSOLUT
1. perdarahan ginjal yang
persisten hematoma
meluas, denyut, hematom
retroperitoneal
2. trauma renal derajat V

EKSPLORASI GINJAL

1.

2.
3.

4.

INDIKASI RELATIF
Trauma tumpul & tembus ginjal
komplikasi: ekstravasasi urin persisten,
abses perinefrik, urinoma terinfeksi, &
perdarahan
trauma derajat III & IV dg jar non-vital
luas & trauma organ intraperitoneal
trauma grade IV dg laserasi pelvis
renalis, parenkim ginjal & sistem
kolektivus & avulsi UPJ
trauma tumpul dg hematom
retroperitoneal & kelainan pd single
shot IVP

Algoritma Pengelolaan Trauma Ginjal

(a)
(a) IVP
IVP pada
pada trauma
trauma tumpul
tumpul ginjal
ginjal dengan
dengan trauma
trauma pada
pada pelvis
pelvis
ditunjukkan
ekstravasasi
kontras
ditunjukkan ekstravasasi kontras
(b)
(b) Tomogram
Tomogram yang
yang menunjukkan
menunjukkan trauma
trauma ginjal
ginjal mengenai
mengenai kaliks
kaliks

renalis
renalis yang
yang
pole
pole bawah
bawah

TRAUMA VASKULAR
Trauma vaskular renal (50%) syok (+)
mortalitas 10-50%
Trauma arteri renalis sulit utk diselamatkan &
rekonstruksi
Pembedahan rekonstruksi < 12 jam >>>
diselamatkan keberhasilan revaskularisasi 1030%, fs ginjal

CT Scan ginjal menunjukkan absen

komplit kontras pada ginjal kiri oleh
karena adanya avulsi komplit pedikel
renal

TROMBOSIS ARTERI RENALIS

NEFREKTOMI

CT Scan ginjal kiri dengan trombosis arteri renalis, menunjukkan kurangnya perfusi kontras
ke ginjal (kiri); Arteriografi menunjukkan oklusi komplit arteri renalis kiri sekunder akibat
trombus

Pergerakan ginjal ok deselerasi

peregangan arteri renalis ruptur
intima trombus

EKSPLORASI & REKONSTRUKSI GINJAL

Insisi

midline transabdominal dr proc xiphoideus - simfisis

pubis
Kolon transversum rongga dada (bungkus kasa lembab)
Identifikasi cab a. mesenterika pd usus halus
Angkat usus keatas dan ke kanan retroperitoneum
tampak
Insisi vertikal di atas aorta superior dr a. mesenterika
superior smp retroperitoneum perluas keatas dr lig Treitz
V. mesenterika inf petunjuk insisi diseksi hingga ant
perm aorta
Diseksi smp sup hingga v. renalis sin tanda identifikasi
pd renalis tegel dipasang
Kontrol perdrhan dg kompresi manual parenkim ginjal jk
perdarahan (+) klem vena waktu iskemik < 30

EKSPLORASI & REKONSTRUKSI GINJAL

Kontrol PD
Insisi fasia

(+) evakuasi hematom retroperitoneal

Gerota di lateral ginjal terpapar
evaluasi pelvis renalis, parenkim & pd
Rekonstruksi debridement adekuat: jar mati
dibuang preservasi kapsula renalis utk penutupan
ginjal
Ligasi PD parenkim kromik 4/0
Laserasi sistem kolektivus dijahit scr kedap air
(watertight fashion) kromik 4/0.
Inj metilen blue ke pelvis renalis identifikasi trauma
lain & penutupan sistem kolektivus
Tutup kapsula renalis reaproksimasi tepi parenkim
jahitan interrupted Vicryl 3/0
Jk defek ginjal luas packing dg agen hemostasis
(Avitene, Tissel, lemak perinefrik)

EKSPLORASI & REKONSTRUKSI GINJAL

Segmen

pole ginjal tidak vital (+) parsial

nefrektomi (amputasi & penutupan sistem
kolektivus) pakai omentum utk tutup defek
pole ginjal jk kapsula renalis (-)
Pasang Penrose drain (drainase retroperitoneum)
Suction drain tidak boleh

EKSPLORASI & REKONSTRUKSI GINJAL

EKSPLORASI & REKONSTRUKSI GINJAL

EKSPLORASI & REKONSTRUKSI GINJAL

EKSPLORASI & REKONSTRUKSI GINJAL

EKSPLORASI & REKONSTRUKSI GINJAL

DAMAGE CONTROL
Coburn

(2002): keuntungan
penyelamatan ginjal
packing dg laparotomy pads
kontrol perdrhn & dibuka kembali
dalam 24 jam eksplorasi &
evaluasi luas trauma
mencegah nefrektomi total

NEFREKTOMI
Indikasi :
Trauma ginjal ekstensif, hemodinamik
tidak stabil, suhu tubuh rendah, &
koagulasi buruk renal repair tdk
mgkn (fs ginjal kontralateral N)
Nash dkk (1995) 77% nefrektomi
(+) ok perdrhn parenkim luas,
vaskular & kombinasi, 23% ok
hemodinamik tdk stabil dg ginjal dpt
direkonstruksi.

Complication
Recommendations

GR

Complication following renal trauma require a thorough

radiographic evaluation

Medical management and minimally invasive technique should

be the first choice for the management of complications

Renal salvage should be the surgeons aim for patients in

whom surgical intervention is necessary

KOMPLIKASI
Ekstravasasi

urin persisten
urinoma, infeksi perinefrik &
kehilangan ginjal
Obs ketat & AB tepat
Perdarahan ginjal tertunda (21 hari)
bedrest, hidrasi, angiografi &
embolisasi
hipertensi arterial

Post Operative Care and Follow-Up

Recommendations

GR

Repeat imaging is recommended for all hospitalized patients

within 2-4 days of significant renal trauma (although no
specific data exists). Repeat imaging is always recommended in
cases of fever, flank pain, or falling haematrocrit

Nuclear scintigraphy before discharge from the hospital is

useful for documenting functional recovery

Within 3 month of major renal injury, patients follow-up should

involve:
1. Physical examination
2. Urinalysis
3. Individualized radiological investigation
4. Serial blood pressure measurement
5. Serum determination of renal function

Long-term follow-up should be dedicated on a case-by-case

basis but should at the very last involve monitoring for
renovascular hypertension

Paediatric Renal Trauma

Recommendations

GR

Indications for radiography evaluation of children suspect of

renal trauma include:
1. Blund and penetrating trauma patients with any level of
haematuria
2. Patient with associated abdominal injury regardless of the
findings of urinalysis
3. Patient with normal urinaluses who sustained a rapid
deceleration event, direct flank trauma, or all a fall from a
height

Ultrasonography is the considered a reliable method of

screening and monitoring blunt renal injuries by some
researchers, but is not universally accepted

CT scanning is the imaging study of choice for staging renal

injuries

Haemodynamic instability and a diagnoses grade 5 injury are

absolute indications for surgical exploration

Renal Injury in The Polytrauma Patient

Recommendations

GR

Polytrauma patients with associated renal injuries should be

evaluated on the basic of the most threatening injury

In case where surgical intervention is chosen, all associated

injuries be evaluated simultaneously

The decision for conservative management should consider all

injuries independently

Percutaneous Renal Procedures

Recommendations

GR

Latrogenic rupture of the main renal artery should be treated

with balloon tamponade, and, in case of failure, with a stent
graft

Surgical venous injuries should be managed with venorrhaphy

or patch agioplasty

The transoanted kidney should be evaluated on the basis of

renal function, type of injury and the patients conditions

Hyperselective embolisation may control arterial bleeding

during percutaneous procedures

Algorithm for The Management of

Paediatric Renal Trauma
Paediatric renal trauma

Blunt

Penetrating

UA

UA
>50 rbc/hpf
or
deceleration

UA

<50 rbc/hpf or
haemodynamicall
y stable

>5 rbc/hpf

Stable
Stable

Unstable

Unstable
CT Scan
Abdominal
exploration

CT Scan

Observes
Observes

Abdominal
exploration

Renal
exploration

NL
Observes

Renal
exploration

IVP

IVP

NL

ABNL

ABNL
Renal
exploration

Observes

Renal
exploration

Evaluation of Bunt Renal Trauma in Adults

Suspected adult blunt Renal trauma
Determine haemodynamic stability

Stable

Unstable
Microscopic
haematueria

Gross haematueria

Renal Imaging

Grade 1-2

Grade 3-4

Emergency
laparotomy Oneshot IVP

Rapid deceleraton
Injury or Major
associated injuries

Observation

Normal IVP

Stable

Retroperitoneal
haematoma

Grade 5

Observation,
bed rest. Serial
Ht, antibiotics

Associated
injuries requiring
laparotomy

Renal
exploration

Pulsatile or
expanding
Abnormal IVP

Evaluation of Penetrating Renal Trauma in Adults

Suspected adult blunt Renal trauma

Determine haemodynamic stability

Stable

Unstable

Emergency
laparotomy Oneshot IVP

Renal Imaging

Grade 3

Grade 4-5

Grade 1-2

Observation

Normal IVP

Stable

Retroperitoneal
haematoma

Pulsatile or
expanding
Observation,
bed rest. Serial
Ht, antibiotics

Associated
injuries requiring
laparotomy

Renal
exploration

Abnormal IVP

Terima kasih