BERKELEY, CA (UroToday.com) - Now that the world has largely embraced expectant management of most renal injuries, the issue becomes just who might require surgery or other intervention after an initially non-operative approach.
Among adult patients with Grade IV renal injury, some initial features on CT seem to be associated with a higher rate of subsequent surgery or endoscopic/percutaneous procedures.[1] They include the size of the hematoma > 3.5 cm, medical contrast extravasation indicating possible renal pelvis injury, and intravascular contrast extravasation indicating the potential for brisk ongoing bleeding. Our paper is one of the first to attempt to validate these findings in a pediatric renal trauma population. We found that 75% of patients with medial extravasation required endoscopic drainage with ureteral stent, percutaneous nephrostomy, or both. This treatment failed 50% of the time, requiring open repair and even nephrectomy.
In general, the available data seems to indicate that children with significant renal injury do as well, or even better, than adults with similar injuries. In our series we found the following:
- The overall rate of intervention in a pediatric population with renal injury was 7%. The rate for those with Grade IV injury was as high as 30%.
- The only patients who required intervention in this cohort of 61 renal injury patients were the medial extravasation group and a single Grade V injury requiring speedy nephrectomy.
- Delayed treatment of medial extravasation was commonly seen (as most patients were transferred to us from other institutions) but should be avoided when possible.
Best practices in the non-operative care of renal trauma patients have some caveats that are worth mentioning:
- Always treat patients who are exsanguinating from the kidney quickly and definitively with either renal exploration or angioembolization.
- Concomitant renal pelvis or ureteral injuries most always require treatment.
- Angioembolization may be an appropriate first treatment for renal trauma bleeding only in centers with sufficient experience, and where the procedure is rapidly available.
- Children have a higher risk of significant underlying renal pathology, such as congenital hydronephrosis or Wilms' tumor, which may either cause more significant injury (direct blow to hydronephrotic kidney) or require definitive nephrectomy (Wilms tumor).
Reference:
- Dugi DD 3rd, Morey AF, Gupta A, Nuss GR, Sheu GL, Pruitt JH. American Association for the Surgery of Trauma grade 4 renal injury substratification into grades 4a (low risk) and 4b (high risk). J Urol. 2010 Feb;183(2):592-7. doi: 10.1016/j.juro.2009.10.015. Epub 2009 Dec 16.
Written by:
Richard A. Santucci, MD, FACS as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Specialist-in-Chief, Urology
The Detroit Medical Center
Detroit, MI 48070 USA
More Information about Beyond the Abstract