What is the approach to managing retroperitoneal injuries?

Management of Retroperitoneal Injuries

The approach to retroperitoneal injuries should be guided by hemodynamic status, with hemodynamically unstable patients requiring immediate operative management, while stable patients can be managed non-operatively with appropriate imaging and monitoring.

Initial Assessment and Classification

• Retroperitoneal injuries should be classified by anatomical zones to guide management decisions 1:

  • Zone 1 (central): From esophageal hiatus to sacral promontory
  • Zone 2 (lateral): From lateral diaphragm to iliac crest
  • Zone 3 (pelvic): Confined to retroperitoneal space of the pelvic bowl 2

• Hemodynamic status is the key factor in determining management strategy for all retroperitoneal injuries 1

• CT scan with IV contrast enhancement including delayed imaging is the gold standard for evaluating retroperitoneal injuries in hemodynamically stable patients 1

Management Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Hemodynamically unstable patients with retroperitoneal injuries should undergo immediate operative management (OM) 1, 3

• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be used as a bridge to definitive procedures for hemorrhage control in unstable patients 1

• In patients with pelvic fractures and retroperitoneal bleeding:

  • Pre-peritoneal pelvic packing (PPP) should be performed along with external fixation 1
  • PPP is a quick procedure (under 20 minutes in experienced hands) that effectively controls venous bleeding, which accounts for 80-90% of retroperitoneal hemorrhage in pelvic fractures 1

• Uncontrollable life-threatening hemorrhage, avulsion of renal pedicle, and pulsating/expanding retroperitoneal hematoma are absolute indications for operative management 1

• Damage control principles should be applied with rapid control of hemorrhage as the primary goal 3

Hemodynamically Stable Patients

• Non-operative management (NOM) is appropriate for hemodynamically stable patients with retroperitoneal injuries 1, 4

• Serial physical examinations by experienced clinicians are reliable in detecting significant injuries after penetrating trauma to the abdomen 1

• When CT scanning is not available, other imaging modalities such as intravenous pyelography, plain radiography, or ultrasound may be used, though they are less effective 1

• Angiography with super-selective angioembolization is indicated in stable patients with:

  • Arterial contrast extravasation
  • Pseudoaneurysms
  • Arteriovenous fistula
  • Non-self-limiting gross hematuria 1

Management Based on Specific Retroperitoneal Organs

Renal Injuries

• Management of traumatic renal injuries has shifted from operative exploration to non-operative management in most cases 1

• Percutaneous angioembolization is increasingly accepted for treating ongoing bleeding without surgical exploration 1

• The presence of non-viable tissue (devascularized kidney) is not an indication for immediate operative management in the absence of other indications for laparotomy 1

Ureteral Injuries

• Ureteral injuries are rare (1% of urologic injuries) and often iatrogenic 1

• Treatment may include placement of a ureteral stent or surgical repair, depending on severity and location 1

Bladder Injuries

• Bladder injuries occur in approximately 1.6% of blunt abdominal trauma victims, mostly associated with pelvic fractures 1

• Retrograde cystography (CT or conventional) is essential for diagnosis 1

• Management differs based on type:

  • Extraperitoneal ruptures (60% of cases): Non-operative management with catheter drainage
  • Intraperitoneal ruptures (30% of cases): Surgical repair 1

Urethral Injuries

• Posterior urethral injuries are associated with pelvic fractures 1

• Blood at the urethral meatus is the most common finding 1

• Securing catheter drainage of the bladder is the immediate goal of treatment 1

Common Pitfalls and Caveats

• Isolated retroperitoneal injuries from blunt trauma without major hemorrhage or gross hematuria are often difficult to diagnose, leading to delayed treatment 5

• Penetrating injuries associated with retroperitoneal hematoma should be explored, especially if entering the peritoneal cavity 1

• Retroperitoneal hematoma discovered during laparotomy requires exploration if pulsatile or if it is the only cause of hemodynamic instability 1

• The presence of retroperitoneal injuries generally worsens prognosis in trauma patients and requires more attention in both diagnosis and treatment 6

• There is an increasing trend toward non-surgical management of retroperitoneal injuries when possible, but this requires careful patient selection and monitoring 4