Conservative treatment of stage III kidney injuries

OBJECTIVE: The aim of this study is to evaluate the safety and effectiveness of conservative management in stage III renal trauma. MATERIAL AND METHODS: We reviewed the records of 150 patients who presented in our institution with renal trauma between 1986 and 1995. RESULTS: Minor injuries (stage I and II: 100 cases) were treated with expectant management. Only 3 patients required nephrectomy in this group. Stage III injuries were seen in 40 patients. The great majority (85%) were treated conservatively with renal sparing procedures such as endourologic techniques (14 cases), nephrorraphy or partial nephrectomy (20 cases). Total nephrectomy was performed in 15% of the cases and only for severely injured kidney or major associated intraabdominal injuries. In this group, none of the patients suffered from hypertension at follow-up. All patients (10 cases) with pedicle injury (stage IV) required total nephrectomy. CONCLUSION: Stage III renal trauma with urinary extravasation can safely be treated conservatively.     

Conservative... and non conservative... treatment of renal blunt injuries

Whether patients with blunt renal trauma should be managed conservatively without surgery or undergo surgery is often hard to decide. We describe three clinical cases of blunt renal trauma, all involving the left kidney. All three patients had abdominal ultrasound studies and computerized tomographic (CT) scans. In the first case, an accidental fall led to severe injury of the renal hilus causing massive retroperitoneal extravasation. The patient underwent emergency nephrectomy and survived. The second case concerned a patient who was involved in a road accident, suffered injuries mainly affecting the spleen, and underwent splenectomy. A postoperative CT scan showed left renal vein thrombosis functionally excluding the inferior pole of the kidney. The patient received conservative non surgical treatment. A follow-up imaging study showed that although the thrombosis had resolved the renal pole had failed to regain normal function. In the third case, mild apparently unimportant trauma led to a massive hemorrhage responsible for a severe shock state. Despite prompt nephrectomy, renal failure and and pulmonary complications developed and one month after the injuries the patient died. The medical history referred to a "chronic hematoma" secondary to a childhood injury. In this case, the pre-existing hematoma probably led to a permanent communication with the vascular and excretory tree thus resulting in a kind of "silent" fistula that the relatively mild injury unexpectedly disrupted. For the two left nephrectomies we used a midline approach after isolating the renal Treitz vessels; special care was taken to mobilize the left colon. Although blunt renal trauma often responds to non surgical conservative treatment, some patients should undergo prompt surgery. All patients must be scheduled for long-term clinical and imaging follow-up.     

Renal transection conservatively treated three times by selectively transarterial embolization (TAE): a case report

A 12-year-old-man presented with left flank pain after a traffic accident on October 14, 2006. Computed tomography (CT) revealed major left renal hematoma and transection (IIIb). Selectively transarterial embolization (TAE) was performed to control upper transected renal bleeding on the same day, and again to do rebleeding two days later. Because CT revealed left perirenal urinoma caused by upper transected kidney on October 18, TAE was performed for the upper transected kidney not to function. Five months after left renal injury, CT demonstrated the left kidney successfully preserved without hydronephrosis, urinoma and hematoma. The patient was well and could be conservatively treated without hypertension and other complications. In previous reports, only a part of renal injury (III) cases with conservative treatment converted to nephrectomy, whereas approximately half of them with surgical treatment resulted in nephrectomy. Therefore, it is important to treat them as conservatively as possible and to preserve renal function, even in cases of major renal blunt injury.     

中重度肾损伤的诊治体会

目的 探讨中重度肾损伤的诊断和治疗。方法 回顾分析1980年至2000年116例肾损伤中的21例中重度肾损伤的病例资料。结果 21例中重度肾损伤者,根据B超、CT及手术探查结果,肾裂伤14例,肾碎裂伤6例、肾蒂伤1例。保守治疗11例(延迟手术2例),手术探查8例(肾切除4例,切肾率19.04％)。死亡2例,死亡率9.52％。结论 B超和CT是诊断肾损伤和判断肾损伤程度的重要依据。大多数的中度肾损伤可保守治疗,但应严密观察,肾碎裂伤及肾蒂伤者应紧急手术探查,手术中应尽早控制肾蒂。     

Use of hematoma size on computerized tomography and calculated average bleeding rate as indications for immediate surgical intervention in blunt renal trauma.

One of the most demanding situations for a urologist is to decide which blunt renal trauma patients need immediate surgical exploration. Although computerized tomography can offer a lot of invaluable information, clear guidelines for selection of surgical versus conservative treatment are still lacking. A retrospective study of 15 blunt renal trauma cases showed that the hematoma size measured from computerized tomography using the method of summation planimetry bears a much closer correlation with the clinical outcome of the patient than does the degree of kidney parenchymal defect. Moreover, the average bleeding rate, calculated by dividing the size of the hematoma by the time elapsed from injury to scanning, gives a more accurate prediction for the need for immediate surgical treatment.     

Nierentrauma

lsolated renal injuries are seldom. They mostly occur with coexisting abdominal injuries and polytrauma and vertebral fractures. Details of the traumatic event, external signs of injury and clinical symptoms may sustain the tentative diagnosis of renal injury. Ultrasound is used to ascertain the type and extent of the renal injury, and is adequate for rnonitoring provided that the patient’s condition is clinically stable. The diagnostic procedure of choice is the contrast-enhanced spiral CT to clear the situation in multiply injured patients. The classification of Miller and McAninch has become established for the catagorization of renal trauma. Conservative treatment is basicly applied for renal injuries of grades 1 and 2. But even in patients with higher grades of injury noninvasive management is recommended if the clinical parameters are stable. The only indication for immediate operative intervention actually is limited to cases showing an uncontrollable life threatening hemorrhagic shock definetely caused by the kidney trauma. The authors strongly advise against unforced exploration of the retroperitoneum. This often increases the risk of enhanced hemorrhage and mostly leads to a nephrectomy that was not primarily necessary.     

Renal vascular injuries

Fifteen patients with injuries to the renal arteries and/or veins have been treated in the past ten years. Nine injuries were the result of gunshot wounds, and six were from blunt trauma. Twelve patients presented to the emergency department in shock; two of these did not have a palpable blood pressure. Time from admission to time of operation averaged 6.4 hr for patients with blunt trauma and 1.25 hr for patients with penetrating trauma. Seven patients had ten associated abdominal vascular injuries, and two patients had injuries to both the right renal artery and left renal vein. Associated nonvascular abdominal injuries were found in all 15 patients. Efforts were made to repair renal vascular injuries with suture or grafting of the injured vessel in eight cases (53%). These efforts were successful in four patients, but in four the repair failed and a nephrectomy could not be avoided. Two patients died in the operating room or immediately postop in spite of successful repair of their renovascular injury. One injured left renal vein was ligated and nephrectomy was not necessary. In five patients, ligation of the injured renal artery and nephrectomy were necessary. There were five deaths (33%). Three of the deaths occurred in the operating room and two were postoperative deaths. Only one of the patients who died had a renal vessel injury without other major vessels involved. He did, however, have serious liver and kidney injuries. Multiple associated vascular, nonvascular, and head injuries were present in all four of the other deaths. We have continued to take an aggressive approach to exploration, isolation of the injury, and repair of the vessel whenever possible if a renal vessel injury is suspected.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis and treatment of renal trauma in 298 patients

OBJECTIVE: To investigate the diagnosis and treatment of renal trauma. METHODS: Retrospective analysis of 298 patients with renal trauma was carried out. Among them, 272 (91.3%) had blunt renal injuries and 26 (8.7%) had penetrating injuries; 123 (41.3%) had multiple complicated intraabdominal injuries and 56 (18.8%) had concomitant shock. Normal-dose-IVU examination was used in 39 patients and double-dose-IVU in 44 patients, ultrasonography in 109 patients, and CT in 45 patients. Conservative and supportive therapy was done in 193 patients (64.8%) and operation in 105 patients (35.2%). RESULTS: The positive rate was 48.7% by the normal-dose-I VU examination and 90.9% by double-dose-IVU, 78.8% by ultrasonography, and 95.6% by CT. One hundred and eighty-three patients were cured by conservative therapy and 101 by operation. Fourteen patients died. CONCLUSIONS: B-ultrasound can be conveniently used for primary assessment of renal injuries, while CT shows rapid, accurate and proper condition of a renal trauma patient. The treatment depends on the severity of the injury. The conservative therapy is employed in most cases which present slight or moderate injury and no evident massive bleeding. Severe injury requires surgical exploration. The operative approach is by using a transabdominal incision, which makes it relatively easy to explore intraabdominal organs and control the injured kidney. It is also very important to control shock and prevent other severe complications in the early stage of the treatment.     

Predictors of the need for nephrectomy after renal trauma

BACKGROUND: Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma. METHODS: This is a retrospective review of renal injuries admitted over a 12-year period to a Level I trauma center. RESULTS: Ninety-seven patients (73% male) sustained a kidney injury (mean age, 27 +/- 16; mean Injury Severity Score, 13 +/- 10). Of the 72 blunt trauma patients, 5 patients (7%) underwent urgent nephrectomy, 3 (4%) had repair and/or stenting, and 89% were observed despite a 29% laparotomy rate for associated intraabdominal injuries in this group. Twenty-five patients with penetrating trauma underwent eight nephrectomies (31%), one partial nephrectomy, and two renal repairs. Regardless of the mechanism of injury, patients requiring nephrectomy were in shock, had a higher 24-hour transfusion requirement, and were more likely to have a high-grade renal laceration (all p < 0.05). Bluntly injured patients requiring nephrectomy had more concurrent intraabdominal injuries (p < 0.0001). Overall, patients after penetrating trauma were more severely injured, had higher 24-hour transfusion requirements, and a higher nephrectomy rate (all p < 0.05). Despite a higher injury severity in the penetrating group, however, mortality was higher in the bluntly injured group (p < 0.0001). Univariate predictors for nephrectomy included: revised trauma score, injury severity score, Glasgow Coma Scale score, shock on presentation, renal injury grade, and 24-hour transfusion requirement. No patient with a mild or moderate renal injury required nephrectomy, whereas 6 of 12 (50%) grade 4 injuries and 7 of 8 (88%) grade 5 injuries required nephrectomy. Multiple logistic regression analysis confirmed penetrating injury, renal injury grade, and Glasgow Coma Scale score as predictive of nephrectomy. CONCLUSION: Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.     

Renal salvage in penetrating kidney injuries: a prospective analysis

BACKGROUND: Routine exploration of penetrating kidney injuries is not advised because of the fear of a higher nephrectomy rate. This study was conducted to assess the efficacy of renal salvage in patients who underwent routine exploration of the injured kidney and to document complications related to the procedure. METHODS: This was a prospective study over a 2-year period. RESULTS: Fifty patients (46 male and 4 female patients), median age 29 years (range, 16-69 years), were included. Mechanisms of injury were gunshot wound in 43 patients (86%) and stab wounds in 7 patients (14%). Mean Revised Trauma Score was 10.5. All patients underwent laparotomy. Three injuries were bilateral, for a total of 53 renal units. There were three deaths on the operating table (two nephrectomies and one bilateral repair). Management of the remaining 49 renal units was as follows: simple drainage in 13 (26.5%), renal repair in 17 (35%), partial nephrectomy in 6 (12%), and nephrectomy in 13 (26.5%). There were two minor complications directly related to the renal salvage: transient hypertension in one patient and a urine leak, which settled on conservative management. CONCLUSION: An overall renal salvage rate of 73.5% for penetrating trauma was achieved with routine exploration of the injured kidney.     

Indications for nonoperative management of renal stab wounds

PURPOSE: During the last 20 years 2,732 patients have presented to San Francisco General Hospital with renal trauma. Of these patients 198 sustained unilateral and 1 had bilateral stab wounds for a total of 200 renal injuries. We evaluated this subgroup of penetrating renal trauma cases to characterize the nature of the injuries and establish treatment guidelines for successful management. MATERIALS AND METHODS: Preoperative staging was performed in 143 cases (71.5%) with excretory urography or computerized tomography. Based on radiographic and clinical findings the injuries were graded according to the organ injury scaling system. There were 75 grade I (37.5%), 33 grade II (16.5%), 52 grade III (26%), 38 grade IV (19%) and 2 grade V (1%) injuries. Associated organ injuries in 122 patients (61%) involved primarily the liver, pleura, diaphragm and spleen. Mean injury severity score was 20.6 (range 4 to 50). RESULTS: Nonoperative treatment was selected in 108 patients (54%). In 3 patients initially treated nonoperatively delayed bleeding required surgical intervention. Of the 92 renal units explored 74 were reconstructed (80.4%) and 11 required nephrectomy (12%). The overall renal salvage rate was 94.5%. Complications included infection in 2 and hematoma in 2 patients each. Four patients died of nonurological complications. Followup imaging studies were obtained in 26 reconstructed kidneys (35.1%). None of the 107 patients who were followed demonstrated delayed sequelae of renal injuries or new onset of hypertension. CONCLUSIONS: Stab wounds are the most common penetrating trauma to the kidney. More than half of these injuries can be selectively treated nonoperatively. Management criteria are based on aggressive radiographic, laboratory, clinical and when indicated surgical staging. Meticulous attention to reconstructive techniques in renal exploration can ensure an excellent renal salvage rate.     

Renal reconstruction after injury

During an 11-year period 1,363 patients presented to our institution with renal trauma. Renal exploration was performed in 127 patients (133 renal units). Most patients had multiple organ injuries, as indicated by a mean blood loss of 4,160 ml. and a mean injury severity score of 25.8. Absolute indications for exploration were bleeding and pulsatile perirenal hematoma and relative indications included urinary extravasation, nonviable renal tissue and incomplete staging. Renal surgery was required in 2.4% of the blunt injuries, 45% of the stab wounds and 76% of the gunshot wounds. Salvage was successful in 88.7% of the kidneys explored and total nephrectomy was required in 11.3%. The success rate was based on early vascular control and reconstructive techniques of "renorrhaphy," partial nephrectomy, vascular repair and coverage with omental pedicle flaps. Complications occurred in 9.9% of the cases but none resulted in renal loss. When indicated, renal exploration after trauma is safe and in a high percentage of cases reconstruction will be successful.     

Features and outcomes of patients with grade IV renal injury

OBJECTIVE

To evaluate the clinical features and outcomes of patients who presented with grade IV renal trauma to our urban level I trauma hospital and to further refine the absolute indications for exploration and determine the outcomes of conservative management.

PATIENTS AND METHODS

In all, 77 patients with grade IV traumatic renal injuries presented to our emergency department between October 1997 and October 2006. A prospective trauma database including these patients was analysed to determine the patterns of injury, operative outcomes and complications.

RESULTS

A quarter of the patients had gunshot injuries, 9% had stab injuries, and 66% had blunt traumas. In all, 36% of patients required surgical exploration to treat associated non‐urological injuries. There was no or microscopic haematuria in 29% of the patients. Of the 32 patients who underwent renal exploration, 63% (20/32) underwent renorrhaphy and 37% (12/32) underwent nephrectomy. In multivariate analyses, only gunshot injury, surgery for non‐urological injury, and volume of blood transfused were significantly associated with the need for renal exploration (P = 0.015, P = 0.041, and P = 0.032, respectively). The renal complication rate was higher in patients managed conservatively vs those who underwent surgical exploration, but this was not statistically significantly different (28% vs 13%, P = 0.2). Hospital stay was longer after renal exploration than after conservative management at a median of 12 days vs 7 days (P = 0.01).

CONCLUSIONS

While almost all patients with penetrating injury require renal exploration, only 20% of those with blunt trauma do. Patients with no renal injuries and/or haemodynamic instability are more likely to require exploration. Finally, the rate of complications was not statistically different according to management type (conservative vs renal exploration).     

Urological trauma and severe associated injuries

Our experience with 212 cases of urinary tract injury in multiple trauma patients treated between 1972 and 1983 has been analysed and compared with data collected from 441 cases of isolated urinary tract injury during the same period. The following points are emphasised: (1) incidence and severity of urological trauma in multiple injured patients; (2) obstacles in diagnosis and the need for immediate radiographic assessment; (3) lower urinary tract injuries and the need for urinary diversion; (4) differences in therapeutic approach to renal injuries in multiple trauma patients. We paid special attention to the indication for surgical exploration in patients with a renal laceration and severe associated injuries.     

Renal failure and mortality after nephrectomy for severe trauma in multiply-injured patient: no inordinate risk

It was recently reported that renal loss by partial or total nephrectomy for renal trauma increases the rates of acute renal failure and death in the multiply-injured patient. Because our preference has been for immediate surgical intervention in such patients, a retrospective review was performed to ascertain the effect of partial or total nephrectomy. Eighty-eight patients met the criteria of multiple injuries including severe renal injuries (laceration, rupture, or pedicle injury) and availability of renal function data. Partial or total nephrectomy had been performed in 50 patients, renorrhaphy in 23, and 15 were managed without renal operation. In patients with renal lacerations, the numbers of associated injuries (including intra-abdominal injuries) were similar to those managed conservatively or by operation, and the rates of acute renal failure and mortality were the same with conservative management, renorrhaphy, or nephrectomy. Patients with renal pedicle injuries who had a nephrectomy did have a higher rate of acute renal failure than those managed conservatively (75% vs 0%; p less than 0.05), but they also had more associated injuries (2.8 vs. 1.6/patient; p less than 0.04) and they were older. These two factors, rather than the nephrectomy, probably accounted for the greater rates of acute renal failure and death.     

Clinical analysis of 35 patients with renal injury]

Because of the increase of abdominal trauma owing to traffic accident, the number of renal injury is increasing. Between May 1, 1986 and December 31, 1989, thirty-five cases with renal injury were treated in our hospital. The cases were classified as contusion, minor laceration, major laceration and vascular injury by the clinical findings and the radiographic evaluation. Contusion had 22 patients, who were treated conservatively except one with preexisting hydronephrosis. Four patients of minor laceration were all treated conservatively. In four cases of major laceration nephrectomy was performed, the other five cases were healed conservatively. There were two death cases caused by other organ injuries. The extent of associated injuries influenced the prognosis, rather than the degree of renal damage. Thirty-three cases except two survived with no complication. In cases of major injury same were managed conservatively, other required surgical treatment. Sometimes it is difficult to determine which treatment should be done. Indication for surgical treatment is discussed.     

The role of nephrectomy in the acutely injured

HYPOTHESIS: The high mortality in patients who undergo nephrectomy after trauma is not secondary to the nephrectomy itself but is the consequence of a more severe constellation of injuries associated with renal injuries that require operative intervention. DESIGN: A retrospective review of all patients identified using International Classification of Diseases, Ninth Revision codes as having sustained renal injuries over a 62-month period. PATIENTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. METHODS: All medical records were reviewed for patient management, definitive care, and outcome. Based on outcome, patients were assigned to either the survivor or nonsurvivor group. For patients who underwent nephrectomy, intraoperative core temperature changes, estimated blood loss, and operative time were also reviewed. RESULTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Twenty-nine patients underwent laparotomy with conservative management of the renal injury, of whom 5 (17.2%) died. Twelve patients had renal injuries repaired and all survived. Thirty-seven patients underwent nephrectomy, of whom 16 (43.2%) died. Compared with nephrectomy survivors, nephrectomy nonsurvivors had a significantly lower initial systolic blood pressure, higher Injury Severity Score, higher incidence of extra-abdominal injuries, shorter operative duration, and higher estimated operative blood loss. The nephrectomy survivors' core temperature increased a mean of 0.5 degrees C in the operating room, while the nephrectomy nonsurvivors' core temperature cooled a mean of 0.8 degrees C. CONCLUSIONS: Patients who undergo trauma nephrectomy tend to be severely injured and hemodynamically unstable and warrant nephrectomy as part of the damage control paradigm. That a high percentage of patients die after nephrectomy for trauma demonstrates the severity of the overall constellation of injury and is not a consequence of the nephrectomy itself.     

Expectant management of blunt renal trauma

Summary Forty-two patients with blunt renal injuries were treated between 1984 and 1994 at our institution. Twenty-nine patients revealed a contusion (grade I injury), 10 showed lacerations (grade II), 1 a severe fracture (grade III), and 2 presented pedicle injuries (grade IV). All 10 patients with incomplete renal injuries (grade II) were treated conservatively, i. e. without primary surgery. One of these 10 patients required surgical intervention 3 months after the trauma due to a urinary obstruction. Two of the ten patients with grade II injuries suffered late complications, namely a contracted kidney in one case and hypertension in the other. This means that of 10 patients with conservatively treated grade II renal trauma, a loss of the function of the affected kidney occurred in only one. In 9 patients complete function of the kidney could be preserved. In conclusion, conservative management of incomplete blunt renal injuries is an effective treatment option with few complications.      

Etiology, classification, and management of renal trauma

Management of blunt renal trauma demands an aggressive effort to define the extent and severity of the renal injury with imaging studies. In general, a conservative approach to treatment is recommended that may include an early surgical exploration when the risk of late hemorrhage is great and the kidney or a portion of the kidney has obviously already been lost. To treat all patients with surgery or with expectant treatment is illogical. If expectant treatment is elected and the patient has a significant renal injury, every effort should be made to follow the patient adequately with ultrasound or CT scans in order to identify at the earliest opportunity an expanding hematoma and prevent needless nephrectomy and shock. Of most importance is to avoid inadequate studies that fail to define the source of injury and lead in the long run to inadequate surgical management. A tongue-in-cheek representation of such a scheme of treatment is illustrated in Figure 5.     

Selective operative management of major blunt renal trauma

BACKGROUND: We reviewed the management and outcomes of patients at our Level I trauma center suffering major blunt renal trauma diagnosed and staged by CT scan. METHODS: We retrospectively reviewed the cases of 26 patients with blunt trauma at our institution who were initially hemodynamically stable and diagnosed with grade 4 or 5 renal injuries by CT scan. Patients were broken down into two groups based on whether they were managed conservatively or surgically. Patient characteristics and morbidity were analyzed. RESULTS: There were 14 patients managed conservatively and 12 patients managed surgically. There was no statistically significant difference in morbidity between the two groups. The only statistically significant predictor of failure of conservative management was a coexisting solid organ intra-abdominal injury. CONCLUSIONS: Conservative management of major blunt renal trauma is appropriate in hemodynamically stable patients.