0022-534 7/78/1192-0259$02. 00/0 The Journal of Urology Copyright © 1978 by The Williams & Wilkins Co.
Vol. 119, February
Printed in U.SA.
Case Reports PENETRATING RENAL TRAUMA IN THE NEONATE WILLIAM J. CROMIE, ROBLEY D. BATES
JOHN W. DUCKETT, JR.
From the Children's Hospital of Philadelphia, University of Pennsylvania Medical School, Philadelphia, Pennsylvania
For years the management of blunt and penetrating renal trauma has been the source of controversy in the literature. The indications for a specific therapeutic program vary with each individual case and with the complicating factors involved. An unusual form of penetrating renal trauma in the neonate is presented and the rationale for therapy is discussed. autologous clot was considered but was deemed impossible owing to the risk of occluding the entire renal artery. Failing this, 2 operative procedures were considered. First, the clot could be aspirated through a pyelotomy incision and an attempt could be made to identify the bleeding area. This would be followed by ligation of the specific segmental vessel supplying that portion of the kidney. If this were technically impossible an upper pole partial nephrectomy could be performed with preservation of the remaining parenchyma.
The patient was born by cesarean section at approximately 35 weeks of gestation. The mother was a gravida IV, para 3, 34-year-old black woman. Physical examination and ultrasound revealed an intrauterine growth retardation. The mother was hospitalized for a pitocin challenge that failed and, subsequently, she underwent amniocentesis, which yielded blood, presumed to be placental in origin. Approximately 1 hour later the fetal heart rate slowed and an emergency cesarean section was performed. The Apgar was 2 at 1 minute and 8 at 5 minutes with spontaneous respiration after 3 minutes of life. The newborn had gross hematuria upon delivery, with a hematocrit of 30 gm. per cent on the voided urine specimen. On transfer to the premature nursery he was pale with a significant tachycardia, a hemoglobin of 9.3, a platelet count of 154,000, and normal prothrombin and partial thromboplastin times. An emergency excretory urogram (IVP) revealed bilateral hydronephrosis with a normal renal contour on the left side (fig. 1, A). The right kidney was never delineated clearly but the renal pelvis and distal ureter revealed a large negative filling defect that represented a clot passing down the ureter. The bladder was filled with an extremely large collection of blood. On physical examination the bladder could be palpated just below the umbilicus and the newborn had a reflex penile erection. He received 95 cc packed red blood cells and 36 cc fresh frozen plasma, which stabilized him hemodynamically. An arteriogram, which was performed through an indwelling umbilical artery catheter, revealed a bleeding point in the right upper pole of the kidney that communicated with the dilated collecting system (fig. 1, B). The patient was then transferred to our hospital.
Fm. 1. A, IVP with clot in right collecting system and ureter (arrow). B, arteriogram shows bleeding site in right upper pole (arrow).
The newborn had stable vital signs and was in no distress. Initially, evacuation of the large intravesical clot was considered to relieve the ureteral obstruction. Even with a No. SF cystoscope endoscopic removal would not be without risk and might not be effective. Alternatively, direct suprapubic aspiration, using an infant laparoscope, was considered. However, during the next 2 hours of observation the newborn was able to pass small clots without difficulty and to void with an adequate stream, clearly indicating that he was not obstructed completely. Management of the renal bleeding also posed technical problems. Embolization of the upper renal segment with Accepted for publication September 16, 1977.
The patient's condition, however, remained stable. Blood pressure and hematologic status remained unchanged with no evidence of continued bleeding. During the ensuing hours it became apparent that direct surgical intervention was unnecessary. The large clot appeared to have compressed the bleeding site in the renal parenchyma without producing colic or complete obstruction of urine flow. The next day he continued to pass blood-tinged urine without difficulty and there was no evidence of further bleeding. The following day the bulk of the intravesical clot was passed per urethram and the urine cleared. An IVP, obtained 6 days post-injury, revealed marked resolution of the obstruction with minimal alteration of the right kidney (fig. 2). 259
CROMIE, BATES AND DUCKETT
Among the more serious fetal complications are subdural hematoma, 3 splenic laceration,4 pneumothorax, 5 cardiac laceration and tamponade, 6 arteriovenous fistula 7 and exsanguination from cord laceration. 8 Our case of penetrating renal trauma appears to be the first of its type reported in the literature. The size of our patient (2.2 gm.), the significant degree of hemorrhage and the considerable acute dilatation of the urinary tract owing to the large volume of clot within the system presented an interesting management problem. Our decision was not to evacuate the clot on the premise that it would provide effective tamponade at the bleeding point. This decision, coupled with careful monitoring of vital signs, hematocrit, urine output and repeat physical examinations, demonstrated that select cases of penetrating renal trauma can be managed non-operatively with a good result. In this instance there was no further bleeding, transfusion was not required and the newborn voided the intravesical clot spontaneously 2 days post-injury. He was discharged from the hospital 8 days after delivery with a normal urogram, hematocrit and blood pressure. REFERENCES
1. Hirschhorn, K.: The role and the hazards of amniocentesis.
Fm. 2. IVP 6 days post-injury. COMMENT
Amniocentesis is being performed more frequently to facilitate perinatal diagnosis of an increasing number of inherited and congenital disorders. 1 Although the potential benefits of this procedure are considerable complications do occur. 2
Ann. N.Y. Acad. Sci., 240: 117, 1975. 2. Ryan, G. T., Ivy, R., Jr. and Pearson, J. W.: Fetal bleeding as a major hazard of amniocentesis. Obst. Gynec., 40: 702, 1972. 3. Creasman, W. T., Lawrence, R. A. and Thiele, H. A.: Fetal complications of amniocentesis. J.A.M.A., 204: 949, 1968. 4. Egley, C. C.: Laceration of fetal spleen during amniocentesis. Amer. J. Obst. Gynec., 116: 582, 1973. 5. Cook, L. N., Shott, R. J. and Andrews, F. A.: Fetal complications of diagnostic amniocentesis: a review and report of a case with pneumothorax. Pediatrics, 53: 421, 1974. 6. Berner, H. W., Seisler, E. P. and Barlow, J.: Fetal cardiac tamponade: a complication of amniocentesis. Obst. Gynec., 40: 599, 1972. 7. Gottdiener, J. S., Ellison, R. C. and Lorenzo, R. L.: Arteriovenous fistula after fetal penetration at amniocentesis. New Engl. J. Med., 293: 1302, 1975. 8. Goodlin, R. C. and Clewell, W. H.: Sudden fetal death following diagnostic amniocentesis. Amer. J. Obst. Gynec., 118: 285, 1974.