Abdominal contrast-enhanced CT scan, particularly the helical type, has a relatively high accuracy when used for the diagnosis of renovascular injuries [6]. Its advantages include its rapidity, noninvasiveness, and ability to diagnose associated injuries [3]. Renal artery occlusion manifests on CT as “lack of enhancement or excretion often in the presence of normal renal contour, rim enhancement, central hematoma, and abrupt cutoff of an enhancing renal artery” [3]. The findings in renal venous injuries are similar (central hematomas, renal enhancement, and intact renal contours) but typically show anterior displacement of the renal hilum and parenchyma [3].

Although angiography is invasive and time consuming compared to CT, it may be more specific for defining the exact location and degree of vascular injuries [20]. It is indicated when, in the absence of a CT scan, intravenous urography (IVU) shows no visualization of the kidneys, the common causes of nonvisualization being total avulsion of the renal vessels, renal artery thrombosis, and severe contusion causing major vascular spasm [20]. It is also indicated if pedicle injury is suspected and the findings on CT are equivocal [20].

Prior to the advent of CT, IVU was commonly the initial imaging modality for renal trauma, its major finding being nonfunction of the affected kidney [3, 20]. However, nonfunction is not peculiar to renovascular injuries – in one study, out of 53 % with unilateral renal nonvisualization, only 40 % had injury to the renal pedicle [3, 21]. Therefore, whenever CT is available, it should be the preferred diagnostic technique.

Renal scintigraphy can be used to evaluate the renal vasculature when CT is unavailable or if the patient is allergic to iodinated contrast material [20]. It provides a quantitative assessment of renal blood flow and renal function, although this is rarely used in the acute trauma discovery phase of care [7].

In the patient with renovascular trauma, urinalysis may show gross or microscopic hematuria. Although hematuria is neither sensitive nor specific for renovascular trauma, findings of gross hematuria or findings of microscopic hematuria in the presence of shock mandate interrogation of the genitourinary system to exclude injury [20].

For a trauma patient evaluated within 1 h of injury, the serum creatinine concentration obtained is a reflection of prior renal function, and an elevated level indicates pre-injury renal pathology [20]. Whatever the case, it is important to establish a baseline value, as serial measurement of creatinine will be required for patients with renovascular trauma.

In certain scenarios, observation can play a role in the management of renovascular injuries [23]. These scenarios include venous thrombosis with two kidneys present, segmental arterial injury, arterial thrombosis with two kidneys present, arterial intimal injury with two kidneys present (Fig. 21.1), or a delayed presentation with a nonfunctional kidney. Nephrectomy may be required in these cases, though it is rarely indicated acutely [23]. It may be necessary if the patient develops either subsequent infectious or hypertensive complications.

There are a few case series that have described the use of angiography with arterial embolization for treatment of renovascular injuries. This option is used when the primary problem is arterial bleeding in a hemodynamically normal patient. In one study, all five patients with renovascular injuries underwent superselective arterial embolization, bleeding was controlled without recurrence, and serum creatinine concentration returned to pre-injury values within 10 days [24]. Similar results were obtained in another series with six patients [25]. The small sample sizes in these and other studies make outcome of this treatment option uncertain, and further studies are needed to define the exact group of renovascular trauma patients that would benefit from this technique.

Vascular repair is one of the “renal preservation strategies” and is especially indicated if a patient has a solitary kidney or in cases of bilateral renal injuries [7, 26–31]. Repair can be done primarily or by use of a bypass graft. Outcomes following repair are described below subsequently. The majority of authors suggest that success of arterial reconstruction depends on the duration and degree of ischemia and presence or absence of accessory renal arteries providing collateral flow, with irreversible damage occurring when the warm renal ischemia time exceeds 2 h [2, 32]. A lack of relationship between outcome and time to definitive surgery is also reported, because the time of warm ischemia that is tolerated is so short [7]. This is the primary consideration when deciding whether to undertake an interventional or observational approach to renal injury.

Partial nephrectomy/parenchymal repair has both been used in the management of renovascular injuries [7]. The segmental vascular supply of the kidney makes this feasible, as one segment can be removed without compromising the functions of the other segments.

Immediate nephrectomy can be used as the primary treatment modality in severe renovascular injury of the grade IV/V variety. It is also indicated when there is failure of vascular repair with either infectious or hypertensive complications resulting from the nonfunctional kidney.

The operative approach to the vasculature of the right kidney usually requires a Cattell-Braasch maneuver (right medial visceral rotation) for exposure of the kidney, renal vessels, and associated right-sided retroperitoneal vascular structures. For the left kidney and vascular structures, a Mattox maneuver (left-sided medial visceral rotation) is usually undertaken. These approaches are used for addressing renal vascular injuries or when a partial nephrectomy is to be done. The primary technical consideration for total nephrectomy is whether vascular control is obtained prior to entering Gerota’s fascia and mobilizing the kidney. From a practical standpoint, this is usually dictated by the patient’s hemodynamic status. In patients with rapidly expanding hematomas, it is usually most expeditious to enter Gerota’s fascia, quickly mobilize the kidney, and control the bleeding with manual pressure or clamps once the kidney and renal vasculature are mobilized. If the patient’s hemodynamic status allows, the approach above to the renal vessels preserves the option of a partial nephrectomy.

These may include abdominal CT scan, angiography, or renal scintigraphy [7]. Renal scintigraphy provides a quantitative assessment of renal function, especially when attempts have been made to salvage the kidneys [7, 33]. The patient with renal dysfunction becomes symptomatic when renal function drops below 25 %. When renal function drops below 10–15 %, dialysis is required to sustain life [34].

Blood pressure monitoring helps to detect the onset of renovascular hypertension. If this occurs, it may be controlled with medication but ultimately often requires nephrectomy.

Serial measurement of serum creatinine and electrolytes is important to monitor renal function. However, if the patient has one normal kidney, the serum creatinine may not change even with no function of the contralateral kidney, so this must not be used as the sole measure to follow renal function.

The incidence of posttraumatic renovascular hypertension in the literature ranges from 3.2 to 50 %, with the true incidence reported to be close to about 5 % [7, 37–42]. Several explanations have been proposed to describe the mechanism of hypertension following renovascular trauma, including renal artery stenosis or occlusion resulting from thrombosis, compression, or an intimal flap, as well as the development of a restrictive fibrous capsule around the traumatized kidney that compresses the renal parenchyma and limits normal blood flow [35, 37, 43]. Both of these result in activation of the renin-angiotensin-aldosterone system, with subsequent salt and water retention and widespread vasoconstriction of arterioles. Intractable renovascular hypertension is amenable to nephrectomy, and surgery may be the optimal treatment option [7, 19, 44–47].

Renal dysfunction may be reversible or may progress to acute or chronic renal failure. Serial measurement of serum creatinine is extremely insensitive to changes in renal function of the injured kidney in the presence of a normal contralateral kidney.

Like renovascular injuries, injuries to the ureters are relatively rare. Injuries to the blood vessels that supply the ureters do not occur in isolation from ureteral injuries themselves. Therefore, a snapshot of ureteral trauma is provided, with specific highlights of vascular considerations as applicable. This chapter focuses on ureteral injury due to external trauma rather than iatrogenic injuries.

The incidence of ureteral injuries from external trauma is estimated to range from less than 1 % to about 2.6 % of all genitourinary injuries, with blunt trauma accounting for about 61.5 % of cases and penetrating trauma accounting for the remaining 38.5 % [49, 50]. Siram et al. reported mortality rates of 6 % for penetrating trauma and 9 % for blunt trauma, although these differences were not statistically significant [49]. In that study, penetrating trauma patients had a higher incidence of vascular injuries (38 %). In patients with penetrating trauma, the most commonly injured vessels were the iliac vein (18 %), iliac artery (10 %), and the inferior vena cava (7 %), whereas, in the blunt trauma subset, the iliac artery (6 %), renal artery (4 %), and renal vein (3 %) were the most commonly injured. Therefore, in the evaluation of any patient with ureteral trauma, a careful search for associated blood vessel injury should be carried out. Alternatively, and more commonly, the surgeon is operating for major vascular injury of the iliac or renal vessels, and after control of the vascular injuries, the surgeon is obliged to evaluate the ureter adjacent to the vascular injury.

The ureters are a pair of tubular structures composed largely of smooth muscles that convey urine from the kidneys to the bladder where it is stored prior to micturition. In the adult, the ureter is about 25 cm in length and has a diameter of about 3 mm [51]. The ureter is retroperitoneal, with the upper half located in the abdomen, where it exits the kidney from the renal pedicle, and the lower half located in the pelvis, where it enters the bladder at an oblique angle. The ureter receives multiple blood supplies. The abdominal part is supplied by branches from the renal artery, the abdominal aorta, and the gonadal artery, whereas the pelvic part is supplied by the common iliac artery, internal iliac artery, inferior vesical artery (in the male), or uterine artery (in the female) [51]. The veins draining the ureter generally correspond to the arteries. The peristaltic actions of the ureteral smooth muscles help to actively convey urine from the kidney to the bladder. Reflux in the opposite direction is normally prevented by the oblique angling of the ureter as it enters the bladder.