Challenges of High-Grade Renal Trauma Management in a Resource-Limited Setting: A Case Report and Review of the Literature

Abstract

Caleb Brown*, Jennifer Osher, Ismael Kaitama, Gregory Shank and Andrew Trecartin

Ureteral injuries from blunt trauma are rare (<1% of urologic trauma) and even less common in children. In resource-limited settings such as rural Chad, limited diagnostics, absence of fluoroscopy, and delayed presentation complicate management. We present the case of a 13-year-old male who presented with fever, tachycardia and severe right-sided abdominal and flank pain four days after falling from a mango tree and striking his right flank. Bedside ultrasound showed severe right hydronephrosis and Foley catheterization yielded gross hematuria. A percutaneous nephrostomy was inserted under real-time ultrasound guidance. Additionally, a battery-powered flexible scope was utilized to place a double-J ureteral stent, as fluoroscopy is not available in this setting. The intervention proved to be lifesaving acutely and the patient was discharged with plans for delayed ureteral reconstruction. This case is unique considering that pediatric blunt ureteral injury is exceptionally rare and underrepresented in the literature. Falls from mango trees are a recognized cause of pediatric trauma in under-resourced agrarian regions. In the absence of Computed Tomography (CT) and fluoroscopy, portable ultrasound and endoscopic tools can facilitate safe urinary diversion. Redundancy in diversion methods may be beneficial when advanced imaging is unavailable and portable, battery-powered devices can enable life-saving interventions in austere environments and serve as a bridge to definitive surgical repair.