A case of grade V renal trauma with total avulsion of renal artery and vein: Management strategies and outcomes

Abstract

Renal trauma is a serious condition that can result in significant morbidity and mortality, particularly in the case of Grade V injuries with complete avulsion of the renal artery and vein. We report a case of a 22-year-old male who sustained a Grade V renal injury in a motor vehicle accident resulting in total avulsion of the renal artery and vein. The patient underwent immediate surgical exploration with successful nephrectomy and ligation of the renal pedicle. This case reports aims to discuss the management strategies for severe renal injuries and the outcomes associated with this approach.

1. Introduction

Renal trauma is a significant health issue and can result from both blunt and penetrating mechanisms. The severity of renal injury is graded using the American Association for the Surgery of Trauma (AAST) renal injury scale, which ranges from Grade I to Grade V. Grade V injuries are the most severe, involving total avulsion of the renal pedicle, and are associated with a high risk of morbidity and mortality.¹ In this case report, we describe the management strategies and outcomes associated with a patient who sustained a Grade V renal injury with complete avulsion of the renal artery and vein.

2. Case presentation

A 22-year-old male was brought to the emergency department following a motorcycle accident. The patient was complaining of severe left flank pain and was found to have hematuria. He had no significant medical history prior to the accident. He was not taking any medications and had no known allergies. The patient was wearing a helmet at the time of the accident but was not wearing any other protective gear.

On physical examination, the patient was alert and oriented. He had left flank tenderness with no signs of external injury. The patient's vital signs were within normal limits. Laboratory tests showed hematuria and anemia, with a hemoglobin level of 9.1 g/dL. Computed tomography (CT) scan of the abdomen and pelvis showed a large hematoma in the left retroperitoneal space with total avulsion of the left renal artery and vein (Fig. 1). No other injuries were identified.

Fig. 1.

CT scan of the abdomen objectifying a Grade V left renal injury with total avulsion of the artery (red arrow) and vein (blue arrow) with a large perinephric hematoma (yellow arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

The patient was immediately taken to the operating room for surgical intervention. During the surgery, the hematoma in the left retroperitoneal space was evacuated, which resulted in significant bleeding from the site of the left renal artery and vein. Upon further examination, it was discovered that the artery and vein were completely avulsed. Due to the severity of the injury, it was necessary to ligate the left renal artery and vein to stop the bleeding. The left kidney was then removed which was severely lacerated (Fig. 2). The patient received a blood transfusion and remained stable throughout the procedure and was transferred to the intensive care unit for postoperative management.

Fig. 2.

Surgical specimen: lacerated left kidney with total avulsion of the renal artery and vein.

The patient had an uneventful recovery and was discharged home after a few days. He was advised to follow up with his primary care physician for further management of his renal function. The patient was referred to a physical therapist for rehabilitation and was advised to wear protective gear when operating a motorcycle in the future.

3. Discussion

Renal avulsion is a rare but serious form of renal trauma that can result in complete disruption of the renal artery and vein, leading to significant bleeding and potentially life-threatening hemorrhagic shock. In our case, the patient suffered a grade V renal trauma with total avulsion of the renal artery and vein, resulting in a gross perinephric hematoma.

The formation of a perinephric hematoma can provide a tamponade effect, which occurs when the pressure from the hematoma compresses the bleeding vessels, reducing the flow of blood and helping to control bleeding.² Intraoperatively, the presence of the perinephric hematoma provided a visual cue to the extent of the injury, and allowed for careful exploration and identification of the disrupted vessels. The hematoma was then evacuated, and the disrupted vessels were repaired, ultimately resulting in a successful outcome for the patient.

While the tamponade effect of the perinephric hematoma can help to control bleeding in cases of renal avulsion, surgical intervention is still necessary to repair the damaged vessels and prevent further bleeding.² The use of intraoperative ultrasound can also be helpful in identifying and repairing the disrupted vessels.³

The management of severe renal injuries is complex and requires a multidisciplinary approach, involving trauma surgeons, urologists, and interventional radiologists. Several management strategies have been proposed, including conservative management, selective embolization, and surgical intervention.⁴ The choice of management strategy depends on several factors, including the severity of the injury, the patient's hemodynamic stability, and the presence of associated injuries.

Conservative management may be considered in stable patients with minor renal injuries, such as Grade I and II injuries.⁵ Selective arterial embolization has been shown to be effective in controlling bleeding in patients with more severe renal injuries, such as Grade III and IV injuries.⁴ However, in cases of Grade V injuries with total avulsion of the renal artery and vein, surgical intervention is typically required to prevent severe hemorrhage. In our case, the patient underwent immediate surgical exploration with successful nephrectomy and ligation of the renal pedicle, resulting in a good outcome.

The management of severe renal injuries is associated with a high risk of morbidity and mortality, particularly in cases of Grade V injuries. However, advances in surgical techniques, critical care management, and interventional radiology have improved outcomes in these patients.

Postoperative management is also critical, particularly those requiring nephrectomy. These patients often require intensive care management, including close monitoring of fluid and electrolyte balance, blood pressure, and urine output. In addition, close monitoring for signs of infection and sepsis is essential, particularly in patients with associated injuries or prolonged hospital stays.

4. Conclusion

Severe renal injuries, particularly those involving total avulsion of the renal artery and vein, require prompt surgical intervention and a multidisciplinary approach. Nephrectomy is often necessary in these cases, with the goal of controlling hemorrhage and preventing sepsis. Advances in surgical techniques, critical care management, and interventional radiology have improved outcomes in these patients. However, these injuries are still associated with a high risk of morbidity and mortality, and close postoperative management is essential for optimal outcomes.