Clinical indications for radiographic evaluation of blunt renal trauma

The evaluation of patients with blunt renal trauma has become controversial. We tested the hypothesis that renal contusion can be diagnosed clinically and that these patients do not require radiographic evaluation. To evaluate the association of microhematuria without shock and with renal contusion, we reviewed the medical records of 831 patients with hematuria following blunt renal trauma. Microscopic hematuria without shock was noted in 160 of 241 patients without and 334 of 590 with associated injuries. Of the former 160 patients 159 had renal contusion and 1 had a renal laceration, while of the latter 334 patients 329 had renal contusion, 3 had renal laceration, 1 had renal rupture and 1 had a pedicle injury. Most patients with microscopic hematuria and no shock after blunt renal trauma had a renal contusion, especially those with no associated injury. All of the patients with renal contusions experienced no complications from nonoperative management. However, avoiding a radiographic evaluation in patients with blunt renal trauma plus microhematuria and no shock would miss a few cases of severe renal injury.     

Radiologic Evaluation of Pediatric Blunt Renal Trauma in Patients with Microscopic Hematuria

As a result of the rapid increase in medical costs, the efficacy of diagnostic imaging is under examination, and efforts have been made to identify patients who may safely be spared radiographic imaging. We reviewed the records of children who presented to our institution with suspected blunt renal injuries to determine if radiographic evaluation is necessary in children with microscopic hematuria and blunt renal trauma. We retrospectively reviewed the medical records of 1200 children (ages less than 18 years) who sustained blunt abdominal trauma and who presented to our level I pediatric trauma center between 1995 and 1997. Urinalysis was performed in 299 patients (25%). Urinalysis results were correlated with findings on abdominal computed tomography (CT). All patients had more than three red blood cells per high power field (RBC/ hpf) or gross hematuria. Renal injuries were graded according to the injury scale defined by the American Association for the Surgery of Trauma. Sixty-five patients had microscopic hematuria. Thirty-five (54%) were evaluated with an abdominal CT scan. Three patients sustained significant renal injuries (grade II-V), and 32 patients had normal findings or renal contusions. Therefore only 3 of 65 patients (4.6%) sustained a significant renal injury. All three patients had other associated major organ injuries. Of the three patients with gross hematuria evaluated with abdominal CT, one (33%) sustained a significant renal injury and had no associated injuries. The degree of hematuria did not correlate with the grade of renal injury. Pediatric patients with blunt trauma, microscopic hematuria, and no associated injuries do not require radiologic evaluation, as significant renal injuries are unlikely. However, children who present with associated injuries and microscopic hematuria after blunt trauma may have significant renal injuries and should undergo radiologic evaluation.     

Indications for radiographic assessment in suspected renal trauma

We recommend that the criteria for radiographic assessment of suspected renal trauma be: (1) penetrating trauma to the flank or abdomen, regardless of the degree of hematuria; (2) blunt trauma and gross hematuria; or (3) blunt trauma associated with microhematuria and blood pressure below 90 mm Hg before or after emergency room admission. In hemodynamically stable patients in whom renal injury alone is suspected, we recommend intravenous urography, which will adequately stage 60 to 85 per cent of renal injuries. Computed tomography should be performed if the urography results are equivocal or as the primary study when multiple injuries are suspected. Arteriography can be reserved for patients with suspected renovascular injuries in whom CT scans are inconclusive.     

Radiographic assessment of renal trauma: a 10-year prospective study of patient selection

To develop criteria to determine which patients require radiographic assessment after blunt renal trauma, we studied prospectively 1,146 consecutive patients with either blunt (1,007) or penetrating (139) renal trauma between 1977 and 1987. Based on our preliminary results from 1977 to 1983, in which none of the 221 patients with blunt trauma and microscopic hematuria without shock had significant renal injuries, we designed a prospective study to determine if such patients could be managed safely without radiographic staging. During the last 10 years significant renal injuries were found in 44 patients (4.4 per cent) with blunt trauma and gross hematuria or microscopic hematuria associated with shock, and in 88 patients (63 per cent) with penetrating trauma. No significant injuries occurred in the 812 patients with blunt trauma and microscopic hematuria without shock, 404 of whom had complete radiographic assessment and 408 of whom did not. There were no delayed operations or significant sequelae related to the renal injury in these patients. We conclude that complete radiographic staging is mandatory in patients with penetrating trauma to the flank or abdomen and in patients with blunt trauma associated with either gross hematuria or microscopic hematuria and shock. However, patients with blunt trauma, microscopic hematuria and no shock who do not have associated major intra-abdominal injuries can be managed safely without excretory urography.     

Renal trauma: re-evaluation of the indications for radiographic assessment

We studied prospectively 359 consecutive patients with blunt (306) or penetrating (53) renal trauma to refine the indications for radiographic evaluation. Various factors, including the degree of hematuria, presence of shock and associated injuries easily assessable at the time of initial evaluation, were correlated with the severity of renal injury to determine whether any combination of parameters will separate patients with renal contusions from those with significant renal injuries (minor and major lacerations, and vascular injuries). We identified 3 groups: group 1-85 patients with gross hematuria or microscopic hematuria and shock after blunt trauma (including all 23 with significant renal injuries), group 2-221 patients with microscopic hematuria but no shock after blunt trauma (all with renal contusions) and group 3-53 patients with penetrating trauma. No combination of parameters was able to predict a severe injury in group 3. Our data support radiographic evaluation in groups 1 and 3. However, because all patients in group 2 had renal contusions and experienced no complications from nonoperative management we believe that excretory urography, which is time-consuming and costly, can be avoided in patients with microscopic hematuria but no shock after blunt renal trauma.     

Evaluation and treatment of blunt renal trauma

We examined retrospectively the records of 126 patients with blunt renal trauma to determine the criteria for radiological investigations and the imaging study of choice. Of the 3,993 patients admitted to our regional trauma unit during the last 13 years 126 (3.1%) had blunt renal trauma. Mean patient age was 32 years (range 13 to 87 years) and the male-to-female ratio was 3:1. Mean followup was 7 months (median 4 months). Of the patients 72% had a minor renal injury, 17% had a moderate injury and 11% had a major renal injury. Treatment was conservative in 114 patients, while 9 underwent a genitourinary operation. Results were excellent in 87% of the patients and good in 8%, while 5% failed treatment. All patients who had microscopic hematuria without shock had minor injuries. Excretory urograms (IVPs) were normal in 74% and 39% of the patients when performed for minor and moderate renal injuries, respectively. Computerized tomography (CT) was abnormal in all cases when performed, and was more sensitive and specific than an IVP. Therefore, the majority of patients with blunt renal trauma can be treated conservatively with an excellent result. Furthermore, radiological investigations are not needed in those with microscopic hematuria and no shock. When radiological investigations are indicated a CT scan is the imaging study of choice.     

Efficacy of Radiographic Imaging in Pediatric Blunt Renal Trauma

Purpose

We sought to determine whether radiographic imaging can effectively detect significant renal injuries in children with blunt trauma who do not have significant hematuria.

Materials and Methods

We reviewed the records of 180 children who presented to our hospital for suspected renal trauma between 1977 and 1995. Results of excretory urography or abdominal computerized tomography were correlated with urinalysis findings and clinical outcome.

Results

Of 147 patients with microscopic hematuria after blunt trauma 77 underwent imaging. Only 1 patient had a significant renal injury (grade 2 or greater) and 76 had normal findings or renal contusions only, including 11 with microscopic hematuria and shock. Of the 74 patients who did not undergo imaging a clinical diagnosis of renal contusion was made and followup was available for 57 (77 percent). All patients healed without adverse sequelae. Of 33 patients with gross hematuria significant renal injuries were found in 9, including 3 who required immediate surgical repair of a major renal laceration or vascular injury. Combining our results with those of other reported series revealed significant renal injuries in only 11 of 548 children (2 percent) with less than 50 red blood cells per high power field on presenting urinalysis after blunt abdominal trauma. These patients were likely to have multiple associated injuries.

Conclusions

Significant renal injuries are unlikely in pediatric patients with blunt renal trauma but no gross or substantial microscopic hematuria. Shock does not appear to be a clinically useful indicator.     

171例肾损伤的诊治体会

目的提高肾损伤的诊治效果。方法回顾性分析171例肾损伤患者的临床诊治资料。结果血尿147例(86.0%);B超检查132例,其中103例(78%)有异常表现;CT检查130例,阳性表现107例(82.3%);静脉肾盂造影(IVU)检查65例,其中肾穿透伤7例(占10.8%),肾钝挫伤2例(占3%)。本组患者手术治疗46例(26.9%),非手术治疗125例(73.1%)。死亡12例(7%),治愈159例(93%),93例(54.4%)随诊1～3年,尿常规及肾功能检查正常。结论尿液检查和B超检查快速安全,无损伤;对于有血尿的肾穿透伤患者,或虽无血尿,但高度怀疑肾损伤的患者,如生命体征平稳,IVU检查是必需的;CT检查明确率高,可同时了解其他脏器受损程度。如果损伤严重,尤其是合并腹腔内脏器受损者,宜适时探查肾脏,做出相应的外科处理。     

Renal artery and vein injury following blunt trauma.

Blunt injuries of the renal vascular pedicle occur infrequently. The experience with fourteen cases of blunt renal vascular trauma is presented. Most patients were injured in motor vehicle accidents. The diagnosis was made immediately after admission in 6 patients, delayed in 5, and at autopsy in 3. Most patients presented with gross or microscopic hematuria. The diagnosis of renal vascular injury was suggested by IVP in most instances. Surgical management was used in the 6 patients in whom the immediate diagnosis of renal pedicle injury was made; primary vascular repair was carried out in 4 patients and nephrectomy in two. Conservative management was used in 4 of the 5 patients with delayed diagnosis, and nephrectomy was required in the fifth. Three patients received no treatment as two were dead on arrival and one die during laparotomy. Seven patients died (50%). One of the 7 survivors has a functioning kidney following repair of a renal vein laceration. Three patients with devascularized kidneys have been followed long term and have not developed hypertension. An IVP should be mandatory following severe blunt trauma, especially when hematuria is present. Renal arteriography is indicated with distortion of calyces, extravasation or nonfunction seen on IVP and allows a definitive diagnosis of renal vessel injury to be made.     

Investigation and management of blunt renal injuries in children: a review of 11 years' experience

Over an 11-year period, 333 patients aged 6 months to 13 years were investigated for suspected blunt renal trauma. Ninety-one renal injuries were demonstrated. All patients who had preexisting pathology sustained major (ie, grade III or IV) injuries and all those who required surgery presented with 4+ or macroscopic hematuria with or without loin signs. Intravenous pyelography (IVP) showed no injury in 140 (89%) of 157 patients who had 0 to 3+ microscopic hematuria, and did not influence management in the remaining 17 patients. Seventy-eight (84%) patients were treated nonoperatively, with one death and few complications. Thirteen (14%) patients underwent early laparotomy, with a nephrectomy rate of 92%. No patient with a renal pedicle injury was considered suitable for vascular reconstruction. We conclude that (1) contrast studies are of little value in pediatric patients with asymptomatic microscopic hematuria after blunt trauma; (2) IVP remains the most cost-effective means of investigating renal injuries; and (3) laparotomy is only indicated for ongoing hemorrhage from the severely injured kidney and in a few selected patients with renal pedicle injuries.     

Intravenous pyelography in abdominal trauma

The present report is a retrospective review of 23 patients admitted to the University of Kentucky Medical Center during 1975 and 1976, selected because they had sustained renal trauma as ascertained by hematuria, intravenous pyelography (IVP), or operative intervention. The value of IVP was determined by the patients' eventual hospital course. Of five patients with penetrating injuries, all had hematuria and an intravenous pyelogram on admission. One of these patients did not require an operation. Among the 18 patients with blunt abdominal trauma, six of the 14 patients who had hematuria and an IVP on admission were spared operation. Four patients did not have hematuria, but all four had a renal lesion. Two of these patients required an operation: one for inspection of a traumatic left nephrectomy; the other for bilateral renal artery occlusion, successfully repaired after 16 hours. Whenever feasible all patients sustaining abdominal trauma should have an IVP regardless of whether or not hematuria is present.     

Blunt renal trauma-blessing in disguise?

Purpose: The purpose of this study was to quantify pathologic lesions of the kidney found incidentally during the workup of a blunt renal trauma. Methods: A retrospective review of the medical records of 103 patients ages 0 to 18 years with blunt renal injuries admitted to a level 1 pediatric trauma center between January 1, 1991 and December 31, 1999 was performed. All patients underwent ultrasonography and Doppler of their renal vessels. Additional investigations with computed tomography (CT) scan, cystography, or nuclear medicine functional studies were performed as indicated. Results: Coexisting urogenital lesions were identified in 13 of 103 (12.6%) patients reviewed, and 7 (54%) required surgical treatment. The majority of the patients (9 of 13, 69%) suffered minimal trauma. All patients presented with gross hematuria as their main symptom. Stenosis of the uretero-pelvic junction was the most frequent diagnosis (n = 7): 3 patients required uretero-pyeloplasty, and 3 required nephrectomy. Two heterogeneous renal masses were discovered in which the diagnosis of a malignant process could not be eliminated; elective resection and open biopsy were performed. The diagnoses of multicystic kidney and solitary cyst with complex hematoma, respectively, were confirmed on pathology. Grade III ureterovesical reflux with pyelonephritis (n = 1), polycystic kidney (n = 1), extrarenal pelvis without obstruction (n = 1), and horseshoe kidney (n = 1) were the other lesions discovered. Conclusions: Pathologic lesions of the urinary tract are uncommon; however, they may complicate an otherwise negligible renal trauma. The diagnostic and therapeutic approach to blunt renal trauma must be modified in these cases. A high index of suspicion must be maintained when a patient presents with gross hematuria with a minimal force blunt abdominal trauma.     

The use of ultrasonography as the initial diagnostic exploration in blunt renal trauma.

Fifty-four patients with blunt renal trauma underwent abdominal ultrasound as their initial diagnostic exploration if their hemodynamic status and associated injuries did not contraindicate unnecessary delays. Renal ultrasound allowed us to diagnose the injuries and to identify which patients required a more aggressive radiological exploration to obtain a diagnosis of certainty. At the same time we were able to certify that this technique is highly accurate in the diagnosis of lesions associated with gross hematuria. The noninvasiveness and low cost of this procedure makes it, in our experience, the technique of choice in the initial workup of blunt renal trauma.     

Urinoma following blunt renal trauma in a patient with anomalous solitary kidney: A case report

Introduction and importanceBlunt traumatic injury to the genitourinary system is uncommon. Urinoma formation may occur in patients with blunt trauma after high grade renal injuries. In such cases, the presence of solitary kidney must be ruled out as it may affect treatment decisions.Case presentationA 21 years old male presented to our facility with complaints of abdominal pain and frank hematuria following physical assault. Physical examination revealed tenderness at the right flank. Laboratory evaluation showed a decreased hemoglobin level and urinalysis showed proteinuria and marked hematuria. Imaging findings were consistent with AAST Grade IV right renal injury affecting the renal pelvis with urinoma formation and congenital megacalyces. Incidental finding of unilateral renal agenesis on the left side was also noted. Our patient underwent Ureteroscopy with double-J stenting. Subsequent ultrasonography after the procedure showed resolution of the perirenal collection.DiscussionThe presence of solitary kidney must be ruled out in cases of high grade renal trauma as operative procedures may lead to catastrophic consequences in such cases. Urinoma formation after renal trauma may occur if the renal pelvis is injured and should be managed preferably by urinary diversion in the form of ureteral stenting over other operative procedures, especially in patients with anomalous solitary kidney.ConclusionPresence of bilateral kidneys should be confirmed before subjecting patients with high grade renal injury to operative procedures. Early ureteric stenting appears to be an effective method of urinary diversion for management of symptomatic urinomas in patients with anomalous solitary kidney.     

肾损伤450例的诊断和治疗

目的　提高肾损伤的诊疗水平。方法　对450例肾损伤进行了回顾性分析。结果　闭合性损伤423例,开放性损伤27例, 合并伤227例。B超阳性率68.2%,双倍剂量IVU阳性率47.9%,CT阳性率100%。根据病情分别选择手术与保守治疗,非手 术治愈365例,超选择性肾动脉栓塞4例,手术治愈67例,死亡14例。结论　B超检查快捷安全,应作为肾损伤首选检查方法, 在诊断中主要起到筛选作用。CT扫描为肾损伤程度分类和选择治疗方案提供可靠依据,应作为重度肾损伤和术前常规检查方 法。治疗取决于伤情,保守治疗是重要的治疗方法,严格掌握手术和非手术治疗指征是处理肾损伤的关键。     

Microscopic hematuria after blunt trauma. Is pyelography necessary?

Hematuria after blunt abdominal trauma is common with multiple organ system injuries, and many trauma centers routinely perform intravenous pyelography (IVP) on all trauma patients having any degree of hematuria. However, it has been suggested that many IVPs could be avoided if more selective criteria were used. To help determine the need for an IVP, we reviewed the records of 102 consecutive patients undergoing IVP after blunt abdominal trauma over a 17-month period. Twenty-six (25%) patients had gross hematuria. Of these, seven (27%) had abnormal IVPs, and two (7.7%) of those required urologic surgery. Seventy-six (75%) patients had microscopic hematuria. Of these, one (1.3%) had an abnormal IVP but required no urologic surgery. Thus, if IVP had been performed only when gross hematuria was present, then all surgically significant urinary tract lesions would have been recognized, and 75 per cent of these 102 patients would have been spared IVPs. We agree with others that microscopic hematuria alone is not an indication for emergency IVP in these trauma patients. However, gross hematuria or other strong clinical evidence of renal injury still mandates IVP early during the assessment of patients who have suffered blunt abdominal trauma.     

Traumatische Aortenruptur mit begleitender Typ-B-Aortendissektion nach Skiunfall

The occurrence of aortic dissections after deceleration trauma is commonplace but aortic injuries after blunt trauma are extremely rare complications. We report a case of an acute aortic rupture accompanied by a type B dissection after a skiing accident with blunt thoracic trauma and renal contusion. The leading symptom was the onset of hematuria 12 h later. The computed tomography (CT) angiography permitted the exact diagnosis and the patient was transferred for acute thoracic endovascular aortic repair. This regimen resulted in the patient achieving a stable condition and potentially harmful complications could be avoided.     

Emergency intravenous pyelography in the trauma patient. A reexamination of the indications

Because of the high incidence of abnormal intravenous pyelograms (IVPs) in victims of blunt trauma undergoing resuscitation, a retrospective review of the Trauma Registry at the University of California, San Diego Medical Center, was undertaken to evaluate the indications for ordering this test. The charts of 216 patients were reviewed, all of whom had formal IVPs (four films) done as an emergency procedure at the time of admission. In this study, special attention was directed toward comparing both the degree of hematuria and the anatomic site of injury with the results of the IVP. A total of 20 renal injuries was detected by IVP. Of these injuries, all but one had hematuria that was greater than 50 red blood cells per high-power field. All but one of the abnormal IVPs were associated with obvious abdominal injuries. The results of the IVP influenced the clinical course of only one patient in the entire series. We conclude that the use of the formal IVP (four films) in the resuscitation phase of treating the multiply traumatized patient be reserved for those patients with penetrating abdominal injury or with hematuria consisting of greater than 50 red blood cells per high-power field. For any major blunt abdominal trauma without significant hematuria, a more simple and rapid study (one-shot IVP) to demonstrate bilateral nephrograms is probably adequate to rule out occult renal artery thrombosis.     

Hematuria as a predictor of abdominal injury after blunt trauma.

Among the 1,484 patients included in the Renal Trauma Project with evidence of blunt trauma and hematuria, 160 patients were found to have both hematuria and a significant intra-abdominal injury not related to the genitourinary system. The incidence of abdominal injury generally increased with the degree of hematuria, approaching 24% in patients with gross hematuria. For each category of degree of hematuria, patients with shock had a significantly higher incidence of abdominal injury (p < 0.05) than patients without shock. The incidence of abdominal injury in patients with microscopic hematuria and shock was 29%, and it was 65% for patients with both gross hematuria and shock. All patients with gross hematuria after blunt abdominal trauma and all patients with microscopic hematuria and a history of shock should be evaluated for both urologic and extra-renal abdominal injuries.     

Prospective study of computed tomography in initial management of blunt abdominal trauma

Physical examination is often unreliable in the evaluation of blunt abdominal trauma. The utility of computed tomography (CT) in the early management of abdominal trauma in the absence of definite signs is controversial. CT was prospectively evaluated as an adjunct to physical examination in the initial assessment of blunt abdominal trauma. Indications for emergency abdominal CT were a stable patient with an equivocal abdominal examination, closed head injury, spinal cord injury, hematuria, or pelvic fracture. One hundred twenty patients were studied. CT was accurate in 98.3% of these patients. With associated head injury, combining head and abdominal CT proved to be expeditious. Splenic, hepatic, and renal injuries were reliably detected with CT. Minor injuries which did not require laparotomy were reliably diagnosed. Patients with acute pancreatic injuries may have normal CT findings. Eighty-six per cent of laparotomies were therapeutic. In conjunction with close clinical monitoring, CT was reliable in evaluation of blunt abdominal trauma in a selected group of patients.