HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smith, M. Articles by Talner, L. Search for Related Content PubMed PubMed Citation Articles by Smith, M. Articles by Talner, L. Social Bookmarking                      What's this?

Rupture of a Ureteropelvic Junction—Obstructed Kidney in a 15-Year-Old Football Player

¹ Department of Radiology, Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
² Department Pediatrics, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104.
³ Department Urology, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104.

Received June 25, 2002; accepted after revision July 16, 2002.

 
This is another in the continuing series on radiology in trauma cases from the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee B. Talner.

Address correspondence to F. A. Mann.

A 15-year-old male football player developed flank pain immediately after a direct helmet blow to his left flank. Urinalysis revealed no hematuria. CT showed a ruptured left hydronephrotic kidney with a large urinoma (Figs. 1A and 1B). Retrograde urography showed a ureteropelvic junction stenosis with an intact renal pelvis. CT performed 9 days later showed resolution of the urinoma and prompt excretion of contrast material without extravasation (Fig. 1C). The patient underwent elective ureteropelvic junction repair.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —15-year-old male football player with rupture of preexisting hydronephrotic kidney. Contrast-enhanced CT scan obtained during excretion phase shows laceration through thinned parenchyma (arrow) of lower left kidney. Excreted contrast agent settles dependently into dilated calyces. Note urinoma anterior to kidney.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —15-year-old male football player with rupture of preexisting hydronephrotic kidney. Contrast-enhanced CT scan, obtained during same phase as A, at mid kidney shows slightly collapsed but intact left renal pelvis (arrowheads), large urinoma displacing intestines to right and surrounding main renal vein (arrow).

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —15-year-old male football player with rupture of preexisting hydronephrotic kidney. Contrast-enhanced CT scan obtained during excretion phase 9 days after placement of ureteral stent (arrow) shows resolution of urinoma, increased contrast excretion compared with A, and no extravasation.

Renal injury caused by blunt abdominal trauma is approximately twice as common in children as adults and is often more severe. Children have relatively larger and more lobulated kidneys, less perirenal fat, and decreased muscle and bony protection. A preexisting renal abnormality increases the risk for blunt renal injury and is two to five times more prevalent in children with renal injuries than in similarly affected adults [1]. The most common preexisting anomalies are cyst and tumor, horseshoe or ectopic kidney, and hydronephrosis.

Patients with preexisting renal abnormalities sustain higher grades of renal injury with lower energy trauma and are more likely to require surgery than those without a preexisting abnormality. A dilated, noncompressible renal pelvis, characteristic of ureteropelvic junction obstruction, is prone to rupture after a sudden increase in intraabdominal pressure. Parenchymal laceration from a direct impact may extend into the dilated intrarenal collecting system. In either case, urinoma is a likely complication.

CT is the appropriate radiologic examination in patients at risk for significant blunt renal injury and should always include a nephrographic phase. An arterial phase image will depict active bleeding. An excretion phase image obtained 10 min after contrast injection should be added to the examination if fluid around the kidney or ureter is present.

Although the degree of hematuria does not correlate with the grade of renal injury, gross hematuria suggests major injury in at least 25% of the patients [2], and this finding clearly warrants CT. Flank tenderness or ecchymosis and severe multi-system trauma are associated with significant renal injury and require imaging—even in the absence of hematuria [2]. Whether to image children with minor trauma and microhematuria remains controversial [2]. Hypotension with microhematuria is a predictor of significant renal injury in adults but not in children [3]. Hematuria may be absent in patients with an injured obstructed kidney or with a complete ureteral avulsion.

Urine extravasation from a parenchymal laceration involving the collecting system (grade IV injury) of a previously normal kidney often resolves with bed rest [4]. Intervention is warranted only for persistent bleeding or urine leakage. Grade IV injuries to kidneys with preexisting obstruction require retrograde urography for diagnosis, percutaneous nephrostomy or retrograde stenting for decompression, and subsequent endoscopic or open surgical reversal of obstruction. If quantitative radionuclide scintigraphy shows minimal function in the injured hydronephrotic kidney after 4-6 weeks of decompression, nephrectomy may be warranted.

References

Top References

 

1. Schmidlin FR, Iselin CE, Naimi A, et al. The higher risk of abnormal kidneys in blunt renal trauma. Scand J Urol Nephrol 1998;32:388 -392[Medline]
2. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol 1996;156:2014 -2018[Medline]
3. Stein JP, Kaji DM, Eastham J, Freeman JA, Esrig D, Hardy BE. Blunt renal trauma in the pediatric population: indications for radiographic evaluation. Urology 1994;44:406 -410[Medline]
4. Matthews LA, Smith EM, Spirnak JP. Nonoperative treatment of blunt renal lacerations with urinary extravasation. J Urol 1997;157:2056 -2058[Medline]

CiteULike

Complore

Connotea

Del.icio.us

Digg

Reddit

Technorati

This article has been cited by other articles:

				M. M. Grinsell, S. Showalter, K. A. Gordon, and V. F. Norwood Single Kidney and Sports Participation: Perception Versus Reality Pediatrics, September 1, 2006; 118(3): 1019 - 1027. [Abstract] [Full Text] [PDF]

				T. Geoghegan, W. Benfayed, and W. C. Torreggiani Rupture of Ureteropelvic Junction-Obstructed Kidney Am. J. Roentgenol., September 1, 2003; 181(3): 886 - 886. [Full Text] [PDF]

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smith, M. Articles by Talner, L. Search for Related Content PubMed PubMed Citation Articles by Smith, M. Articles by Talner, L. Social Bookmarking                      What's this?