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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2015  |  Volume : 26  |  Issue : 4  |  Page : 797-799
Renal trauma in horse shoe kidney causing pseudoaneurysm of the right middle renal artery and large peri-nephric hematoma


Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India

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Date of Web Publication8-Jul-2015
 

How to cite this article:
Singh SK, Kapoor R. Renal trauma in horse shoe kidney causing pseudoaneurysm of the right middle renal artery and large peri-nephric hematoma. Saudi J Kidney Dis Transpl 2015;26:797-9

How to cite this URL:
Singh SK, Kapoor R. Renal trauma in horse shoe kidney causing pseudoaneurysm of the right middle renal artery and large peri-nephric hematoma. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 Dec 4];26:797-9. Available from: https://www.sjkdt.org/text.asp?2015/26/4/797/160220
To the Editor,

About 50% of all cases of genitourinary trauma are caused by injury to the kidneys and more than 50% of such cases are seen in patients under the age of 30 years. [1] About 90% of all renal injuries are caused by blunt trauma, while the remaining 10% are due to penetrating injuries. Motor vehicle accidents, falls, sports accidents and assaults are some of the common causes of blunt trauma. Penetrating injury to the kidney is usually caused by knife and bullet wounds, and in 85% of such instances organs other than the kidneys are also involved. [1]

We herewith report a 16-year-old male with no co-morbidity who presented with a history of blunt injury to the abdomen. He was having gross, painful hematuria associated with amorphous clots and right-sided flank pain. He was put on conservative treatment at a local hospital, to which he responded well. After 10 days, the hematuria recurred and, on ultrasound evaluation, there was irregularity in the renal pelvis, the cortico-medullary differentiation was lost and there was a peri-nephric blood collection around the right kidney. On contrast-enhanced computed tomography (CT) scan of the kidney, ureter and bladder region, there was a horse shoe kidney, a large right peri-nephric collection and pseudoaneurysm of the right mid-polar renal artery [Figure 1]A and B. His hemoglobin was 11.3 g/dL, serum creatinine was 1.1 mg/dL and urine culture was sterile. The patient was taken for angioembolization of the pseudoaneurysm. He responded well and was discharged in a stable condition. On follow-up CT scan, there was disappearance of the peri-nephric hematoma and no aneurysm [Figure 2].
Figure 1:

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Figure 2: Delayed computed tomography image showing no contrast excretion.

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Horseshoe kidney is the most common example of renal fusion. Its prevalence is one in 400 and the male to female ratio is 2:12. The kidneys lie parallel to the spine (instead of obliquely) and are joined at their lower poles (in 95%) by midline renal parenchymal tissue (the isthmus). Most patients with horseshoe kidneys remain asymptomatic; however, infection and calculi may develop and cause symptoms. Hemodynamic situation is the benchmark for deciding on the line of management in patients with blunt injury of the abdomen. Hemodynamically unstable patients require immediate laparotomy. However, if the patient is stable, a helical CT scan is the best option to stage the trauma. [2] More than 80% of blunt renal injuries are of minor grade (1-2) and do not require treatment; on the other hand, grade 5 lesions (except for renal thrombosis) require immediate treatment. The management of grades 3 and 4 injury is a subject of controversy (conservative vs. surgical management). The ultimate goal of treatment is preservation of renal function while minimizing morbidity. The consensus is that in a stable patient, all grades 3-4 renal injuries should be managed conservatively. [3] The same recommendation applies to the hemodynamically stable patient who is explored for associated injuries: A non-pulsatile, contained peri-nephric hematoma should be left alone .[3]

Successful selective renal artery embolization for managing hemorrhage in stable patients after blunt and penetrating renal trauma has been reported by several centers (REF). Primary angiographic management of renal vascular injuries has been advocated in stab wounds, with surgical exploration reserved for those in whom it fails. [3]

The success rate for embolization of isolated renal artery branch injuries is 70-80%, with post-embolization syndrome occurring in 10% of the patients. [4],[5] The risk of total renal loss may be lower with angio-embolization than with exploration of the kidney. [6] When grades 3-4 renal injuries (especially stab wounds) are managed without surgery, delayed or secondary renal bleeding may occur in up to 25% of the patients. [5] The mean (range) interval between the injury and the onset of secondary hemorrhage is 12 (2-36) days, and is most often caused by an arterio-venous fistula (AVF) or pseudo aneurysm. [5],[6]

When there is laceration of a large segmental branch of the renal artery, bleeding from the lacerated vessel is temporarily stopped by the tamponade effect of hematoma formation. With resolution of the hematoma, the artery re-bleeds into the resulting cavity, forming a pseudoaneurysm. [6]

Although small AVFs after renal biopsy resolve spontaneously in up to 70% of patients, most AVFs occurring after major renal trauma (especially stab wounds) do not heal spontaneously. Hypertension, bruit over the kidney and persistent hematuria are indications for arteriography, but renal scintigraphy may provide a non-invasive method to detect AVFs. A renal AVF or pseudoaneurysm can be managed successfully with selective angiographic embolization in up to 80% of cases. [5]

 
   References Top

1.
McGoldrick R, Carpinito R. Management of genitourinary trauma. In: Siroky MB, Edelstein RA, Krane RJ, eds. Manual of Urology, Diagnosis and Therapy. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 1999. p. 269-79.  Back to cited text no. 1
    
2.
Schreyer HH, Uggowitzer MM, RuppertKohlmayr A. Helical CT of the urinary organs. Eur Radiol 2002;12:575-91.  Back to cited text no. 2
    
3.
Santucci RA, Wessells H, Bartsch G, et al. Evaluation and management of renal injuries: Consensus statement of the renal trauma subcommittee. BJU Int 2004;93:937-54.  Back to cited text no. 3
    
4.
Haas CA, Spirnak JP. Traumatic renal artery occlusion: A review of the literature. Tech Urol 1998;4:1-11.  Back to cited text no. 4
    
5.
Heyns CF, Van Vollenhoven P. Selective surgical management of renal stab wounds. Br J Urol 1992;69:351-7.  Back to cited text no. 5
    
6.
Blankenship JC, Gavant ML, Cox CE, Chauhan RD, Gingrich JR. Importance of delayed imaging for blunt renal trauma. World J Surg 2001; 25:1561-4.  Back to cited text no. 6
    

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Correspondence Address:
Dr. Sanjeet Kumar Singh
Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.160220

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