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Diagnosis and management of urinary extravasation after high-grade renal trauma

Nature Reviews Urology volume 16, pages 54–64 (2019)Cite this article

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Abstract

Renal trauma research has historically focused on parenchymal injuries and the risk of bleeding. However, much less is known about the diagnosis and optimal management of urinary extravasation, which complicates ~30% of high-grade renal injuries. Immediate or delayed ureteral stenting is the most common procedure used to treat collecting system injuries when intervention is needed. However, the lack of evidence-based guidelines leaves the diagnosis and management of urinary extravasation largely dependent upon physicians’ experience, initial and follow-up imaging protocols, and the definitions used for grading the injuries. The knowledge gaps in the management of urinary extravasation that need to be addressed include the timing of excretory-phase CT imaging, patterns of clinically significant urinary extravasation, predictors of complications when urinary extravasation occurs, protocols for obtaining and interpreting follow-up imaging, and the role of ureteral stenting and other interventions in management. To improve the management of urinary extravasation after high-grade renal trauma, large, multi-institutional prospective trails assessing different diagnostic and therapeutic protocols are needed.

Key points

  • Urinary extravasation occurs in at least 30% of patients with high-grade renal trauma.

  • Excretory-phase CT with appropriate delay (8–10 minutes after contrast bolus) is needed to accurately diagnose urinary extravasation.

  • In most patients, urinary extravasation heals spontaneously with expectant management.

  • Ureteral stenting is the most common procedure performed to treat urinary extravasation.

  • Indications for intervention and use of prophylactic antibiotics are not well defined.

  • Prospective and multi-institutional studies are needed to improve the management of renal trauma and urinary extravasation.

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Fig. 1: Urinary extravasation after renal trauma.
Fig. 2: Delayed excretory-phase CT for diagnosis of urinary extravasation.
Fig. 3: Asymmetric extravasation of contrast material by the injured kidney.
Fig. 4: Blood clots in the renal collecting system.
Fig. 5: Excretory-phase CT scan in the hydronephrotic kidney.
Fig. 6: Vascular contrast extravasation versus urinary extravasation.

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Acknowledgments

The authors thank M. M. McFarland (Eccles Health Sciences Library, University of Utah) and M. Fiander (Department of Pharmacotherapy, University of Utah) for their kind contribution to the literature search.

Authors contributions

S.K. and R.E.A. researched data for the article. S.K. and J.B.M. wrote the manuscript. S.K., J.M.H and J.B.M. made substantial contributions to discussion of content. All the authors reviewed and/or edited the article before submission.

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Nature Reviews Urology thanks F. Burks, J. Broghammer, and N. Corcoran for their contribution to the peer review of this work.

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  1. Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA

    Sorena Keihani, Ross E. Anderson, James M. Hotaling & Jeremy B. Myers

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Keihani, S., Anderson, R.E., Hotaling, J.M. et al. Diagnosis and management of urinary extravasation after high-grade renal trauma. Nat Rev Urol 16, 54–64 (2019). https://doi.org/10.1038/s41585-018-0122-x

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