Methodological Instructions for Students
Theme: Injuries to the kidney and ureter.
Site: Classroom, hospital ward, X-Ray cabinet, operating room, casuality ward, hospital
ward, dressing room, cystoscopic room.
Aim: To study symptoms and principles of treatment injuries of kidneys and ureter.
Professional Motivation:
For the last time as a result of increasing of accidents and urbanization we have
augmentation of closed renal injuries. Indirect ("contrecoup")injury, caused by falling from a
height and landing on the feet or buttocks, is less common. On rare occasion, acute abdominal
muscle contraction have caused a hydronephrotic kidney to burst.
Basic Level:
1. Anatomy and physiology of urinary tract.
2. To take history and physical examination.
3. X-Ray, instrumental, laboratory, endoscopic methods in injuries of kidneys and ureter
diagnosis.
4. Conservative measures of etiologic, pathogenetic and symptomatic treatment; different
kinds of surgical treatment.
Students' Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. General clinical symptoms of the renal injury.
Gross hematuria following any injury means trauma to the urinary tract. Signs and
symptoms localized to one flank and the findings of impared function of the kidney are strongly
suggestive. Extravazation of opaque medium, as shown on x-ray films, is diagnostic. A history
or evidence of physical injury is usually present. Pain in the renal area may be obscured by the
severity of other injuries (e. g, fractures or injuty to the viscera). Gross hematuria, not necessarily
proportionate to the severity of the injury, is usually noted with the first voiding. It may be
intermittent or continuous. Nausea, vomiting, and abdominal distention due to intestinal ileus are
common in the presence of retroperitoneal bleeding. Urinary retention may occur from clots in
the bladder. There may be symptoms of injuries to the other organs. Shock or signs of
hemorrhage may be found with severe renal injury or in the presence of multiple injuries.
Ecchymosis may be noted over the flank or back. Local tenderness is present. A mass in the
flank may be caused by extravasation of blood of urine, but if the overlying peritoneum has been
these fluids may leak into the peritoneal cavity; hence, no flank mass develops. Rigidity of the
abdominal muscles on the effected side and rebound tenderness are common. Abdominal
distention and hypoperistalsis are to be expected. The ipsilateral testicle may be hypertensive
The possibility of injuries to organs of the chest or the abdomen should be explored. Fracture of
the pelvis should cause one to suspect injury to the bladder or urethra. Oliguria may accompany
the hypotensive phase of shock. The hematocrit, especially when followed serially, is of the
gratest importance; progressive anemia means progressive hemorrhage which may require
immediate surgical intervention. Hematuria is present in almost all cases. It is usually marked at
first. Infection may be found later if ureteral obstruction develops.
If the accident is not recognized at the time of surgery, the patient usually complains of
pain in the flank and lower abdominal quadrant. Vomiting may be severe. Paralytic ileus is often
marked. The patient will become quite ill if pyelonephritis or peritonitis complicates the picture.
Urine may suddenly begin to drain through the vagina, which may relieve all the foregoing
symptoms.
2. Classification of the injuries to kidney and ureter. There 2 main kinds of renal injuries:
opened and closed. The main types of the renal injuries are: simple bruising or ecchymosis,
haematoma, fissures, lacerations, rupture of the renal vascular pedicle, other pathologic lesions
associated with renal lacerations include peritoneal tears with intraperitoneal bleeding, other
visceral injuries, and fractures of the spine or ribs.
3. Diagnosis of the injuries to kidney.
Diagnostics of the isolated closed renal damage is not difficult in general. The anamnesis,
presence of trauma signs and hemorrhages, pain in lumbar region, positive Pasternatsky's
symptom testify probability of renal trauma. Chromocystoscopy, if possible, also helps to
establish the correct diagnosis. This method of research sometimes allows to find a location of
bleeding (that it is very important in case of combined trauma), to analyse functions of damaged
and opposite kidney, state of urinary bladder wall. However for a choice of method of treatment
it is necessary to know the character of damage and its localization. Chromocystoscopy for
children is very rarely performed, because narcosis is necessary for it. Without anesthesia this
test can be performed only for girls in age above 7 years. For diagnostics of kidney trauma of
children X-radiography is expedient, which begins from a observing radiography.
The method allows to find damage of bones, to suspect presence of retroperitoneal
hematoma (contours of kidney and lumbar muscles are absent). Excretory urography gives an
opportunity to define the side of damage, anatomical and function status of injured and opposite
kidney. X-ray signs of renal damage are weak and later spreading of X-ray contrast solution in
calyces-bowling systems, subcapsular and retrorenal spreading of X-ray contrast, deformation of
renal bowl and calyces. In angiogramms one can see violation of arterial and venous circulation
attached to marginal injuries, filling of pararenal tissue with X-ray contrast due to injuries of real
artery branches.
For diagnostics of closed trauma of kidney radionuclide and ultrasonic methods are used.
Radionuclide method is used to study function of damaged kidney. If it is saved up, during the
scintigraphies it is possible to establish localization of damage and even its degree. On scintiand scanogram one can see defect, which responds to the region of renal damage. On ultrasonic
scanogram the sites of violation of renal tissue are defined. Main role in diagnostics play
radionuclide methods, ultrasonic scanning.
4. Indications for the surgical treatment of closed renal injuries (nephrectomy, nephropexy)
and injuries to the ureter. Emergency measures of the treatment of the renal injuries are to treat
shock and hemorrhage. Surgical measures – since two-thirds of injured kidneys are merely
contused, bleeding will cease spontaneously. Even some of the ruptured organs will heal without
surgical care. 10 to 20% of cases may require early surgical intervention because of alarming
hemorrhage. Drainage of the perirenal space, suture of the renal laceration, or partial or total
nephrectomy may be necessary. Opiates for pain should be withheld until the completion of the
diagnostic steps; they may mask accompanying intraabdominal or pulmonary lesions. Bed rest is
indicated until hematuria has ceased and local signs of injury have largely subsided. Permephric
injection requires surgical drainage; late complications may require nephrectomy or repair of
secondary ureteral obstruction. In case of ureteral injury reparative surgery should be undertaken
as soon as as the injury is recognized. In simple perforation from a ureteral catheter or other
instrument, surgical drainage is usually not necessary. The ureteral wall will heal spontaneously.
Key words and phrases: injuries to the kidney and ureter, surgical treatment of closed
renal injuries and the injuries to the ureter.
Visual aids and material tools:
1. Slides:
1. 1 Rupture of the left kidney.
1. 2 Rupture or the right kidney.
2. Excretory urography – subcapsular kidney rupture.
II. Test and Assignments for Self-assesment:
Multiply choice. Choose the correct answer/statement:
1. In patient with closed renal rupture and shock the emergency measures are:
A. Nephrectomy.
B. Nephropyelostomy.
C. Treat shock and hemorrhage.
D. Infusion of the opiates.
E. Treatment of the secondery infection.
Real life situations to be solved.
A. The patient was brought to the hospital with multiple traumas. In the left lumbar region
hematoma was found. Hematuria. Pulse 94/min, blood pressure 105/70 mm Hg. What is the
initial diagnose? What methods of examination are necessary in this case?
Task 1. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination,
detects main clinical signs of the closed renal ruptures, forms diagnostic program, formulates
diagnosis.
Questions for the student:
1. What are the clinical symptoms of the closed renal ruptures?
2. What are the methods of examination of the patients with the closed renal ruptures?
3. What is the medical tactics in the patients with the closed renal ruptures?
Task 2. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination,
detects main clinical signs of the ruptures of ureter, forms diagnostic programme, formulates
diagnosis.
Questions for the student:
4. What are the clinical symptoms of the ruptures of ureter?
5. What are the methods of examination of the patients with the ruptures of ureter?
6. What is the medical tactics in the patients with the ruptures of ureter?
III. Answers to the SeIf-Assesment.
1.
С.
A- closed renal rupture; urography and excretory urography are useful.
Students Practical Activities:
Student must know:
1. Classification of the ruptures of kidneys.
2. Symptoms and clinical course of the ruptures of kidneys.
3. Diagnosis of the ruptures of kidneys.
4. Differential diagnosis of the renal ruptures.
5. Conservative treatment of the renal ruptures.
6. Surgical treatment of the ruptures of kidneys.
7. Symptoms and clinical course of the ruptures of ureter.
8. Diagnosis of the ruptures of ureter.
9. Differential diagnosis of the ruptures of ureter.
10. Principles of treatment of the renal ruptures.
Students should be able to:
1. Detect main clinical signs of the ruptures of kidney and ureter.
2. Define necessary quantity and sequence of patients examination: physical, laboratory,
roentgenological, endovesical.
3. Should be able to detect signs of the ruptures of kidney and ureter on excretory
urograms, retrograde ureteropyelograms etc.
4. Form diagnostic program for the patient with rupture kidney and ureter.
5. Prove and formulate clinical diagnosis.
6. Spend differential diagnosis.
7. Prove conservative treatment and indications for the surgical treatment.