Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel

Conservative management of high-grade renal trauma

INTRODUCTION

Renal trauma is the most common of urological trauma and accounts for up to 5% of all. The AAST scale is the most widely used to assess renal trauma. This study focuses on high-grade trauma, whose treatment has evolved towards a conservative approach, with techniques such as angioembolization. The aim is to describe the evolution in the management of high-grade renal trauma in all patients treated at La Paz University Hospital from 2001 to 2022.

METHODS

A descriptive retrospective study was conducted on patients treated at the hospital. The study was divided into two periods (2001-2010 and 2011-2022). A total of 285 patients with renal trauma were collected, of which 54 were high grade. The main variable is the type of management, conservative (embolization) or interventional through nephrectomy.

RESULTS

In the completed series, there was a decrease in radical nephrectomy in high-grade renal trauma from 50% to 13.8% over time, with an increase in embolization from 23,1% to 44,8%. In patients with isolated renal trauma, those treated with embolization increased from 28.6% to 69.2%, while those undergoing radical/partial nephrectomy decreased from 42.8% to 7.69%.

CONCLUSION

The management of renal trauma has evolved over the years in our center. The number of patients treated by embolization has increased, while the number of complications and nephrectomies has decreased.

Renal angioembolization vs. surgery for high-grade renal trauma: a nationwide comparative analysis

PURPOSE

Renal angioembolization (RAE) is widely employed in low-grade renal injuries and associated with improved patient outcomes, while surgery remains the mainstay for managing high-grade injuries. We compared the outcomes following surgery and RAE in high-grade renal trauma (HGRT).

METHODS

We used the ACS TQIP 2016-2020 to identify patients ≥ 16 years with HGRT who underwent RAE or surgery. Morbidity was the primary outcome, while mortality and lengths of stay were secondary outcomes. We accounted for clinically relevant characteristics using multilevel logistic regression analyses.

RESULTS

We included 591 patients, of whom 279 (47.2%) underwent RAE. After adjusting, there was no difference in morbidity, hospital LOS, or ICU LOS. The surgery cohort had increased odds of mortality (aOR 4.93; [95% CI] 1.53-15.82; p = 0.007) compared to RAE. In the penetrating injury subgroup, no associations between management and outcomes were observed. In the grade V injury subgroup, morbidity was significantly higher after surgery (aOR 4.64; [95% CI] 1.49-14.47; p = 0.008).

CONCLUSION

Overall, RAE did not significantly impact morbidity but was associated with improved mortality. RAE could safeguard renal function by augmenting the efficacy of concurrent non-operative interventions. Randomized studies are needed to further validate the utility of RAE in HGRT.

Future aspects of plant derived bioactive metabolites as therapeutics to combat benign prostatic hyperplasia

ETHNOPHARMACOLOGICAL RELEVANCE

Benign prostatic hyperplasia (BPH), characterized by prostate enlargement due to cell proliferation, is a common urinary disorder in men over 50, manifesting as lower urinary tract symptoms (LUTS). Currently, several therapeutic options are accessible for treating BPH, including medication therapy, surgery and watchful waiting. Conventional drugs such as finasteride and dutasteride are used as 5α-reductase inhibitors for the treatment of BPH. However long-term use of these drugs is restricted due to their unpleasant side effects. Despite the range of available medical therapies, the effective treatment against BPH is still inadequate. Certain therapeutic plants and their phytochemicals have the aforementioned goals and work by regulating this enzyme.

AIM OF THE STUDY

This review aims to provide a comprehensive insight to advancements in diagnosis of BPH, modern treatment methods and the significance of ethnobotanically relevant medicinal plants as alternative therapeutics for managing BPH.

MATERIAL AND METHODS

A thorough and systematic literature search was performed using electronic databases and search engines such as PubMed, Web of Science, NCBI and SciFinder till October 2023. Specific keywords such as "benign prostatic hyperplasia", "medicinal plants", "phytochemicals", "pharmacology", "synergy", "ethnobotany", "5-alpha reductase", "alpha blocker" and "toxicology". By include these keywords, a thorough investigation of pertinent papers was assured, and important data about the many facets of BPH could be retrieved.

RESULTS

After conducting the above investigation, 104 herbal remedies were found to inhibit Phosphodiesterase-5 (PDE-5) inhibition, alpha-blockers, or 5α -reductase inhibition effects which are supported by in vitro, in vivo and clinical trial studies evidence. Of these, 89 plants have ethnobotanical significance as alpha-blockers, alpha-reductase inhibition, or PDE-5 inhibition, and the other fifteen plants were chosen based on their ability to reduce BPH risk factors. Several phytocompounds, including, rutaecarpine, vaccarin, rutin, kaempferol, β-sitosterol, quercetin, dicaffeoylquinic acid, rutaevin, and phytosterol-F have been reported to be useful for the management of BPH. The use of combination therapy offers a strong approach to treating long-term conditions compare to single plant extract drugs. Furthermore, several botanical combinations such as lycopene and curcumin, pumpkin seed oil and saw palmetto oil, combinations of extracts from Funtumia africana (Benth.) Stapf and Abutilon mauritianum (Jacq.) Medik., and Hypselodelphys poggeana (K.Schum.) Milne-Redh. and Spermacoce radiata (DC.) Sieber ex Hiern are also supported through in vitro and in vivo studies for managing BPH through recuperation in patients with chronic long-term illnesses, as measured by the International Prostate Symptom Score.

CONCLUSION

The review proposes and endorses careful utilization of conventional medications that may be investigated further to discover possible PDE-5, 5 alpha-reductase, an alpha-blocker inhibitor for managing BPH. Even though most conventional formulations, such as 5 alpha-reductase, are readily available, systemic assessment of the effectiveness and mechanism of action of the herbal constituents is still necessary to identify novel chemical moieties that can be further developed for maximum efficacy. However, there exist abundant botanicals and medicinal plants across several regions of Africa, Asia, and the Americas, which can be further studied and developed for utilization as a potential phytotherapeutic for the management of BPH.

Urologic Trauma Management for Military Providers

INTRODUCTION

Genitourinary (GU) trauma resulting from combat and the treatment of these injuries is an inadequately explored subject. While historically accounting for 2 to 5% of combat-related injuries, GU-related injuries escalated considerably during U.S. involvements in Iraq and Afghanistan due to improvised explosive devices (IEDs). Advanced body armor increased survivability while altering injury patterns, with a shift toward bladder and external genitalia injuries. Forward-deployed surgeons and military medics manage treatment, with Role 2 facilities addressing damage control resuscitation and surgery, including GU-specific procedures. The review aims to provide an overview of GU trauma and enhance medical readiness for battlefield scenarios.

MATERIALS AND METHODS

This review examined urologic trauma management in combat, searching PubMed, Cochrane Central, Scopus, and Web of Science databases with search terms "wounds" OR "injuries" OR "hemorrhage" AND "trauma" AND "penile" OR "genital" AND "combat." Records were then screened for inclusion of combat-related urologic trauma in conflicts after 2001 and which were English-based publications. No limits based on year of publication, study design, or additional patient-specific demographics were implemented in this review.

RESULTS

Ultimately, 33 articles that met the inclusion criteria were included. Included texts were narrowed to focus on the management of renal injuries, ureteral trauma, bladder injuries, penile amputations, urethral injuries, testicular trauma, Central nervous system (CNS) injuries, and female GU injuries.

CONCLUSIONS

In modern conflicts, treatment of GU trauma at the point of injury should be secondary to Advanced Trauma Life Support (ATLS) care in addition to competing non-medical priorities. This review highlights the increasing severity of GU trauma due to explosive use, especially dismounted IEDs. Concealed morbidity and fertility issues underscore the importance of protection measures. Military medics play a crucial role in evaluating and managing GU injuries. Adherence to tactical guidelines and trained personnel is vital for effective management, and GU trauma's integration into broader polytrauma care is essential. Adequate preparation should address challenges for deploying health care providers, prioritizing lifesaving and quality-of-life care for casualties affected by GU injuries.

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Management of high-grade pediatric renal trauma in tertiary referral hospital in Indonesia: A case series and literature review

INTRODUCTION AND IMPORTANCE

Genitourinary tract injuries constitute 10 % of all traumas, with renal injuries being common in pediatric cases due to reduced perirenal fat and abdominal wall muscle development. However, very few reports of pediatric renal trauma in Indonesia have been reported. In this case series, We present a case series of high-grade renal injury and review the literature on pediatric renal trauma in Indonesia.

CASE PRESENTATION

We present four cases with renal trauma as the subjects of this case study. The 13-year-old boy, who was the initial patient, complained of hematuria and abdominal pain after falling from a tree. The second patient, the 13-year-old boy, presented with left lower back pain and hematuria after being elbowed in the left waist. The third patient, a 14-year-old boy, had been in a motorcycle accident and got grade 5 renal injury according to AAST classification. The final case involved a 4-year-old boy who experienced recurrent hematuria caused by a pseudoaneurysm following blunt renal trauma.

DISCUSSION

Trauma is the leading cause of morbidity and mortality in children, with approximately 3 % of children assessed in pediatric hospital trauma departments having had trauma. With appropriate management according to guidelines, mortality can be avoided.

CONCLUSION

The case series highlights the significance of treating pediatric renal trauma patients individually according to their hemodynamic state and degree of impairment.

Acute haemorrhage from a large renal epithelioid angiomyolipoma: diagnostic and management considerations in a teenage patient with a rare cancer

Acute renal haemorrhage is a life-threatening condition that is complicated in the context of renal malignancy. Here, we present the case of a teenage male presenting acutely with a large, bleeding renal epithelioid angiomyolipoma (EAML) of the kidney-a rare cancer, which is part of the perivascular epithelioid cell tumour family. The patient was managed acutely with prompt resuscitation, transfer to a centre of expertise and haemorrhagic control using radiologically guided endovascular techniques; this subsequently permitted an oncologically sound procedure (radical nephrectomy, inferior vena cava thrombectomy and lymphadenectomy) to be performed within 24 hours. The description and discussion around this unique case summarises the patient's clinical journey, while exploring the current literature surrounding diagnosis and outcomes of patients with renal EAMLs.

Surgical tactics in fire kidney injury and the first experience in performing laparoscopic nephrectomy at the II level of medical support (role II) in combat conditions: Case report

INTRODUCTION AND IMPORTANCE

According to the data from the American Urological Association (AUA) and the European Urological Association (EAU) (2020), kidney is the most frequently damaged organ of the genitourinary system. Kidney damage occurs in approximately 5 % of injured people and accounts for 24 % of traumatic injuries to abdominal organs. Surgical treatment remains the gold standard in unstable patients with gunshot and stab wounds. Minimally invasive surgical treatment of kidney injuries, which is usually performed after laparoscopic diagnosis, at the II level of medical care becomes possible in the first hours after injury.

CASE PRESENTATION

We performed two laparoscopic nephrectomies caused by gunshot shrapnel damage to the kidney in a military mobile hospital at the II level of medical support. The time since the injury was 64 ± 16 min. The wounded were extubated after the operations, activated on the first day. In one case, the drain was removed on the third day, in the other - on the fourth day. During the monitored period (30 days) after the operation, there were no complications in both wounded.

CLINICAL DISCUSSION

Laparoscopic nephrectomy in gunshot damage to the kidney was characterized by presence of a retroperitoneal tense hematoma. When opened, there were signs of bleeding from the kidney parenchyma, difficulty of anatomical visualization of anatomical structures - ureter, renal artery and vein.

CONCLUSION

It is possible to perform endovideosurgical operations - laparoscopic nephrectomy in combat kidney injury at a military mobile hospital with available high-tech equipment at the II level of medical support (Role II), thus bringing highly specialized care closer to the wounded. We noted a better cosmetic effect after the laparoscopic operations.

How a laparoscopy for ovarian cyst causes anuria?

Considering the proximity of the lower urinary tract to gynecologic organs, several iatrogenic injuries of the bladder or ureters can occur. We report the case of 25 year old woman who suffered from bilateral ureteral injury causing renal failure following a laparoscopic detorsion of the left ovarian cyst.Double J stents were placed for 2 months with a favorable post operative course.CTscan results after 2 months of urinary drainage showed normal kidneys with no ureteral dilatation nor contrast medium extravasation. Urinary tract injuries are rare in gynecologic laparoscopy but these lesions are associated with high morbidity.

Closed abdominal trauma in polytrauma. Part II: surgical tactics for the damages control

Closed abdominal trauma in polytrauma. Part II: surgical tactics for the damages control

Is endourological intervention a suitable treatment option in the management of iatrogenic thermal ureteral injury? A contemporary case series

BACKGROUND

Iatrogenic ureteral injury (IUI) is relatively rare, however, can cause sepsis, kidney failure, and death. Most cases of IUI are not recognized until the patient presents with symptoms following pelvic surgery or radiotherapy. Recently, minimally invasive approaches have been used more frequently in the treatment of IUI. This study evaluates urological intervention success rates and long-term clinical outcomes according to the type of IUI following hysterectomy.

METHODS

Twenty-seven patients who underwent surgery due to IUI in our clinic following hysterectomy were evaluated between January 2011 and April 2018. Patients were classified according to the time of diagnosis of IUI. The IUI cases diagnosed within the first 24 h following hysterectomy were designated as "immediate" IUI, while that diagnosed late period was considered 'delayed' IUI. The type of IUI was categorized as "cold transection" if it was due to surgical dissection or ligation without any thermal energy, and "thermal injury" if it was related to any energy-based surgical device. Patient information, laboratory and perioperative data, imaging studies, and complications were assessed retrospectively.

RESULTS

All cases of delayed diagnosis IUI were secondary to laparoscopic hysterectomy (P = 0.041). Patients with thermal injury to the ureter were mostly diagnosed late (delayed) (P = 0.029). While 31% of the patients who underwent endourological intervention were diagnosed immediately, 69% of them were diagnosed as delayed. These rates were roughly reversed for open reconstructive surgery: 73% and 27% (P = 0.041), respectively. We detected eight ureteral complications in our patient cohort following the urological intervention. In all these failed cases, the cause of IUI was a thermal injury (P = 0.046) and the patients had received endourological treatment (P = 0.005). No complications were detected in patients who undergo open urological reconstructive surgery. While one of the patients who developed urological complications had an immediate diagnosis, seven were in the delayed group (P = 0.016).

CONCLUSION

Endourological intervention is performed more frequently in delayed diagnosed IUI following hysterectomy, however, the treatment success rate is low if thermal damage has developed in the ureter. Surgical reconstruction is should be preferred in these thermal injury cases to avoid further ureter-related complications.

Salvation of a solitary kidney in a patient with grade IV renal trauma: a case report

There are many reasons for solitary kidney. Congenital causes include renal agenesis and dysplasia. Acquired causes include nephrectomy performed for reasons including traumatic kidney injury, disease (e.g., renal cell carcinoma), and donation for kidney transplantation. According to the European Association of Urology, the World Society of Emergency Surgery, and the American Association for the Surgery of Trauma guidelines, it is important to preserve the remaining renal function as much as possible when a solitary kidney patient has suffered a traumatic kidney injury. The authors present a case of kidney preservation in a solitary kidney patient with a traumatic grade IV renal injury through non-operative management involving superselective renal artery angioembolization.

Do we need repeated CT imaging in uncomplicated blunt renal injuries? Experiences of a high-volume urological trauma centre

Background

Current guidelines recommend repeat computed tomography (CT) imaging in high-grade blunt renal injury within 48–96 h, yet diagnostic value and clinical significance remain controversial. The aim of this work was to determine the possible gain of CT re-imaging in uncomplicated patients with blunt renal trauma at 48 h after injury, presenting one of the largest case series.

Methods

A retrospective database of patients admitted to our centre with isolated blunt renal trauma due to sporting injuries was analysed for a period of 20 years (2000–2020). We included only patients who underwent repeat imaging at 48 h after trauma irrespective of AAST renal injury grading (grade 1–5) and initial management. The primary outcome was intervention rates after CT imaging at 48 h in uncomplicated patients versus CT scan at the time of clinical symptoms.

Results

A total of 280 patients (mean age: 37.8 years; 244 (87.1%) male) with repeat CT after 48 h were included. 150 (53.6%) patients were classified as low-grade (grade 1–3) and 130 (46.4%) as high-grade (grade 4–5) trauma. Immediate intervention at trauma was necessary in 59 (21.1%) patients with high-grade injuries: minimally invasive therapy in 48 (81.4%) and open surgery in 11 (18.6%) patients, respectively. In only 16 (5.7%) cases, intervention was performed based on CT re-imaging at 48 h (low-grade vs. high-grade: 3.3% vs. 8.5%; p = 0.075). On the contrary, intervention rate due to clinical symptoms was 12.5% (n = 35). Onset of clinical progress was on average (range) 5.3 (1–17) days post trauma. High-grade trauma (odds ratio [OR]_{grade 4 vs. grade 3}, 14.62; p < 0.001; OR_{grade 5 vs. grade 3}, 22.88, p = 0.004) and intervention performed at the day of trauma (OR 3.22; p = 0.014) were powerful predictors of occurrence of clinical progress.

Conclusion

Our data suggest that routine CT imaging 48 h post trauma can be safely omitted for patients with low- and high-grade blunt renal injury as long as they remain clinically stable. Patients with high-grade renal injury have the highest risk for clinical progress; thus, close surveillance should be considered especially in this group.

Long-term renal functional outcomes following ureteroureterostomy performed during multi-organ resection for non-urothelial cancers

Objectives

To evaluate the long‐term renal function outcomes after ureteroureterostomy (UU) in patients undergoing multi‐organ resection for non‐urothelial cancers. The secondary aim was to examine the length of ureteric defect that can be successfully bridged with UU.

Patients and methods

We retrospectively reviewed the charts of patients who underwent UU between 1995 and 2012 at our institution. Renal imaging studies performed before and after UU were used to determine whether hydronephrosis was present. Renal function was assessed by comparing estimated glomerular filtration rate (eGFR) before and at the last follow‐up after UU.

Results

Nineteen patients underwent UU during multi‐organ resection for non‐urothelial cancers. Median follow‐up time was 62 months. Overall, UU had a high success rate, with one patient (5.2%) developing progressive hydronephrosis with a >20% drop in eGFR from baseline due to UU failure. Four additional patients developed progressive hydronephrosis due to cancer recurrence involving the UU. There were no statistically significant differences between pre‐ and post‐UU eGFR in these patient cohort. All patients with a ureteric defect of ≤5 cm underwent successful reconstruction.

Conclusions

UU maintains long‐term renal function in the majority of patients undergoing multi‐organ resection for non‐urothelial cancers and can be successfully utilized if the resected ureteric length is ≤5 cm.

Initial Experience with the Comprehensive Modified Laparoscopic Pyeloplasty Technique Based on Membrane Anatomy for Treating Ureteropelvic Junction Obstruction

OBJECTIVE

The aim of the objective was to present our initial experience and evaluate the feasibility of the novel comprehensive modified laparoscopic pyeloplasty (CMLP) technique based on membrane anatomy.

MATERIALS AND METHODS

Forty-eight patients underwent CMLP from February 2016 to October 2020. CMLP involves the following: dissection of the ureter was based on the fascia or fusion fascia formed by embryonic development. The ureter was separated from the ureteral sheath, and the pelvis and ureter were incised with incomplete amputation. The first stitch was placed between the lower point of the spatulated ureter and the lowest corner of the renal pelvis to ensure correct orientation of the anastomosis; anastomosis of the renal pelvis and ureter was performed using the touchless technique.

RESULTS

All CMLPs were completed successfully without conversion. The mean overall operating time was 230.96 min. The median estimated blood loss was 50.00 (interquartile range 20.00-57.50) mL. The average postoperative hospital stay was 9.31 days. The average follow-up time was 24.73 months. No major complications occurred. In 1 case, revision laparoscopic pyeloplasty was performed, but the obstruction persisted after double J stent removal, so ultimately, the double J stent required regular replacement. Another asymptomatic patient with hydronephrosis experienced failed treatment and is still under follow-up. The overall success rate was 95.83% (46/48). The success rate in patients with recurrent ureteropelvic junction obstruction (UPJO) was 87.5% (7/8).

CONCLUSIONS

CMLP is a practical and effective treatment option for UPJO with a high success rate. An advantage of CMLP is the clear surgical field.

The Impact of Obesity on Renal Trauma Outcome: An Analysis of the National Trauma Data Bank from 2013 to 2016

BACKGROUND

The obesity paradox has been recently demonstrated in trauma patients, where improved survival was associated with overweight and obese patients compared to patients with normal weight, despite increased morbidity. Little is known whether this effect is mediated by lower injury severity. We aim to explore the association between body mass index (BMI) and renal trauma injury grade, morbidity, and in-hospital mortality.

METHODS

A retrospective cohort of adults with renal trauma was conducted using 2013-2016 National Trauma Data Bank. Multiple regression analyses were used to assess outcomes of interest across BMI categories with normal weight as reference, while adjusting for relevant covariates including kidney injury grade.

RESULTS

We analyzed 15181 renal injuries. Increasing BMI above normal progressively decreased the risk of high-grade renal trauma (HGRT). Subgroup analysis showed that this relationship was maintained in blunt injury, but there was no association in penetrating injury. Overweight (OR 1.02, CI 0.83-1.25, p = 0.841), class I (OR 0.92, CI 0.71-1.19, p = 0.524), and class II (OR 1.38, CI 0.99-1.91, p = 0.053) obesity were not protective against mortality, whereas class III obesity (OR 1.46, CI 1.03-2.06, p = 0.034) increased mortality odds. Increasing BMI by category was associated with a stepwise increase in odds of acute kidney injury, cardiovascular events, total hospital length of stay (LOS), intensive care unit LOS, and ventilator days.

CONCLUSIONS

Increasing BMI was associated with decreased risk of HGRT in blunt trauma. Overweight and obesity were associated with increased morbidity but not with a protective effect on mortality. The obesity paradox does not exist in kidney trauma when injury grade is accounted for.

The role of angioembolization in the management of blunt renal injuries: a systematic review

Background

Recently, renal angioembolization (RAE) has gained an important role in the non-operative management (NOM) of moderate to high-grade blunt renal injuries (BRI), but its use remains heterogeneous. The aim of this review is to examine the current literature on indications and outcomes of angioembolization in BRI.

Methods

We conducted a search of MEDLINE, EMBASE, SCOPUS and Web of Science Databases up to February 2021 in accordance with PRISMA guidelines for studies on BRI treated with RAE. The methodological quality of eligible studies and their risk of bias was assessed using the Newcastle–Ottawa scale

Results

A total of 16 articles that investigated angioembolization of blunt renal injury were included in the study. Overall, 412 patients were included: 8 presented with grade II renal trauma (2%), 97 with grade III renal trauma (23%); 225 with grade IV (55%); and 82 with grade V (20%). RAE was successful in 92% of grade III–IV (294/322) and 76% of grade V (63/82). Regarding haemodynamic status, success rate was achieved in 90% (312/346) of stable patients, but only in 63% (42/66) of unstable patients. The most common indication for RAE was active contrast extravasation in hemodynamic stable patients with grade III or IV BRI.

Conclusions

This is the first review assessing outcomes and indication of angioembolization in blunt renal injuries. The results suggest that outcomes are excellent in hemodynamic stable, moderate to high-grade renal trauma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00873-w.

Trauma in pediatric urology

In pediatric trauma, the kidney is the most commonly injured organ of the urinary tract. Renal trauma occurs in 10% to 20% of all pediatric blunt abdominal trauma cases. The vast majority of renal injuries can be treated conservatively. However, cases associated with hemodynamic instability require operative interventions. Injuries to the ureter, bladder or urethra are almost exclusively encountered in polytraumatized children. The aim of this article is to give an overview on traumatic injuries to the pediatric urinary system.

Factors Predictive of Selective Angioembolization Failure for Moderate- to High-grade Renal Trauma: A French Multi-institutional Study

BACKGROUND

Angiography with selective angioembolization (SAE) is safe and effective in addressing bleeding in patients with renal trauma. However, there are no validated criteria to predict SAE efficacy.

OBJECTIVE

To evaluate factors predictive of SAE failure after moderate- to high-grade renal trauma.

DESIGN, SETTING, AND PARTICIPANTS

TRAUMAFUF was a retrospective multi-institutional study including all patients who underwent upfront SAE for renal trauma in 17 French hospitals between 2005 and 2015.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was SAE efficacy, defined as the absence of repeat SAE, salvage nephrectomy, and/or death for each patient.

RESULTS AND LIMITATIONS

Out of 1770 consecutive patients with renal trauma, 170 (9.6%) with moderate- to high-grade renal trauma underwent SAE. Overall upfront SAE was successful in 131 patients (77%) and failed in 39 patients: six patients died after the embolization, ten underwent repeat SAE, 22 underwent open nephrectomy, and one underwent open surgical exploration. In multivariate logistic regression analysis, gross hematuria (odds ratio [OR] 3.16, 95% confidence interval [CI] 1.29-8.49; p=0.015), hemodynamic instability (OR 3.29, 95% CI 1.37-8.22; p=0.009), grade V trauma (OR 2.86, 95% CI 1.06-7.72; p=0.036), and urinary extravasation (OR 3.49, 95% CI 1.42-8.83; p=0.007) were predictors of SAE failure. The success rate was 64.7% (22/34) for patients with grade V trauma and 59.6% (31/52) for those with hemodynamic instability. The study was limited by its retrospective design and the lack of a control group managed with either surgery or surveillance.

CONCLUSIONS

We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure. However, success rates in these subgroups remained relatively high, suggesting that SAE might be appropriate for those patients as well.

PATIENT SUMMARY

Selective angioembolization (SAE) is a useful alternative to nephrectomy to address bleeding in patients with renal trauma. Currently, there are no validated criteria to predict SAE efficacy. We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure.

Does Timing of Diagnosis and Management of Iatrogenic Ureter Injuries Affect Outcomes? Experience From a Tertiary Center

OBJECTIVE

To report urologic outcomes from a series of IUIs, sustained during nonurologic procedures, with regards to timing of diagnosis and management of the injury. Iatrogenic ureteral injury (IUI) is the most common mechanism of ureteral trauma. Injuries can be intraoperatively diagnosed (IOD) or postoperatively diagnosed (POD).

METHODS

This was a retrospective chart review of adult patients at a single institution who sustained an IUI from a non-urologic procedure between 2008 and 2019. Primary outcome was tube-dependence (ureter stent or nephrostomy tube) and nephrectomy rates at last follow-up. Secondary outcome was the number of additional urologic procedures required to manage subsequent complications of IUI.

RESULTS

There were 30 patients with IOD and 57 patients with POD. In the IOD group, at mean follow up of 6.3 months, 4 patients (14.3%) were tube dependent. In the POD group, at mean follow up of 13.1 months, 5 patients (10%) were tube dependent (P = .570). Rate of nephrectomy was higher in POD group compared to IOD, but the difference was not statistically significant (12.3% vs 6% respectively, P = .414). Additionally, in the POD group, 56% and 19.3% required a secondary and tertiary procedure to manage IUI complications, respectively. These rates were 16.7% (P < .001) and 3.3% (P = .002) in the IOD group.

CONCLUSION

Delayed diagnosis of IUI was significantly associated with increased number of procedures needed to manage the injury. The rate of nephrectomy and tube dependence in this group was higher but not statistically significant. Delayed diagnosis of IUI is associated with higher treatment burden.

Impact of trauma center designation in pediatric renal trauma: National Trauma Data Bank analysis

INTRODUCTION

The pediatric kidney is the most common urinary tract organ injured in blunt abdominal trauma. Trauma care in the United States has been established into a hierarchical system verified by the American College of Surgeons (ACS). Literature evaluating management of pediatric renal trauma across trauma tier designations is scarce.

OBJECTIVE

To examine the differences in the management and outcomes of renal trauma in the pediatric population based on trauma level designation across the United States.

STUDY DESIGN

We performed a review of the ACS - National Trauma Data Bank database. Pediatric patients (age 0-18 years) who were treated for renal injury between years 2011-2016 were identified. Our primary outcome was the difference in any complication rate amongst Level I versus Non-Level I trauma centers. Management strategies were evaluated as secondary outcomes. Propensity score matching (PSM) was utilized to adjust for baseline differences between cohorts. Multivariable regression analysis was performed to determine the independent effects of individual factors on complications, operative intervention, minimally invasive procedure, and blood transfusions.

RESULTS

Overall, 12,097 pediatric patients were diagnosed with renal trauma between 2011 and 2016 using target ICD-9 and AAST codes. After PSM, there was a total of 1623 subjects withing each group. No difference was identified between groups for occurrence on any complication [105 (6.5%) vs 114 (7.0%), p = 0.576. There were no differences in the rate of minimally invasive interventions [67 (4.1%) vs 48 (3.0%), p = 0.087], operative intervention [58 (3.6%) vs 68 (4.2%), p = 0.413], or nephrectomy [42 (2.6%) vs 47 (2.9%), p = 0.667] between Level I and Non-Level I trauma designations, respectively. Length of stay was longer in the Level I cohort compared to Non-Level I (days (SD)) [6.9 (8.8) vs 6.2 (7.9), p = 0.024. When specifically looking at risk factors associated with operative intervention, higher renal injury grade and injury severity score were highly correlated, whereas, trauma level designation was not found to be predictive for more aggressive management.

DISCUSSION & CONCLUSION

Our results corroborate with previous literature that renal injury grade and injury severity score are strong predictors of morbidity, invasive management, and complications. Pediatric renal trauma was managed similarly across trauma center designations, with the rate of complication and intervention more prevalent in patients with high grade renal injuries and concomitant injuries. Further studies are necessary to identify patients who will benefit most from transfer to a level I center.

Traumatic renal artery dissection: from imaging to management

Injury to the renal artery following blunt trauma is detected increasingly due to widespread and early use of multidetector computed tomography (CT), but optimal treatment remains controversial as no guidelines are available. This review illustrates the spectrum of imaging findings of traumatic renal artery dissection based on our experience, with the aim of understanding the physiopathology of ischaemic damage to the kidney, and the process of choosing the best therapeutic strategy (conservative, endovascular, surgical). Five main patterns of traumatic renal artery dissection are described: avulsion of renal hilum; dissection of the segmental renal branches; preocclusive main renal artery dissection; renal artery stenosis without flow limitation; thrombogenic renal artery intimal tear. In the polytrauma patient, management depends on various factors (haemodynamic status, associated lesions, time of diagnosis) rather than on the degree of renal artery stenosis. Non-operative management (NOM) is the preferred option in case of non-flow-limiting dissection of the renal artery and angio-embolisation is an important adjunct to NOM in cases of active bleeding. Embolisation of the renal artery stump may be the best option in cases of occlusive dissection, as catheter manipulation carries a high risk of vessel rupture. The therapeutic window for kidney revascularisation in cases of flow-limiting dissection of main renal artery may be variable. Endovascular stenting >4 h after trauma should be performed only if residual flow with preserved parenchymal perfusion is detected at angiography. Antiplatelet therapy administration is recommended in cases of stenting, but conditioned by the bleeding risk of the patient.

Selective nonoperative management of renal gunshot wounds

BACKGROUND

Selective nonoperative management (SNOM) of blunt kidney injuries has been the standard of care for decades. However, the role of SNOM after renal gunshot wounds (GSWs) remains unclear. The purpose of this study was to assess the safety and outcomes of SNOM of renal GSWs at a national level.

METHODS

The National Trauma Data Bank was queried for patients who sustained a GSW to the kidney (January 2007 to December 2014). Patients with emergency department death, transfer, nonsurvivable (Abbreviated Injury Scale score = 6) injuries, absent vitals on arrival, associated hollow viscus or major abdominal vascular injury, or missing procedure/discharge data were excluded. Study groups were defined according to management strategy, with operative management (OM) defined as laparotomy 4 hours or less from admission and SNOM defined by the lack of laparotomy 4 hours or less from admission. Demographics, injury data, and outcomes (mortality, complications, need for nephrectomy, failure of SNOM [defined as laparotomy 5-72 hours after admission], and hospital length of stay [LOS]) were collected. Logistic regression compared outcomes between SNOM and OM.

RESULTS

Over the study period, 1,329 patients met inclusion and exclusion criteria. Of these, 459 (34.5%) underwent SNOM (38.6% of American Association for the Surgery of Trauma kidney injury grades I-II, 39.4% of grade III, 24.0% of grade IV, and 5.2% of grade V). SNOM was associated with significantly shorter hospital LOS (6 days vs. 9 days, p < 0.001). Failure of SNOM occurred in 10.2%. Logistic regression showed no association between SNOM and mortality (odds ratio [OR], 0.614, p = 0.244). However, SNOM was independently associated with fewer complications (OR, 0.711; p = 0.008) and a reduction in need for nephrectomy (OR, 0.056; p < 0.001).

CONCLUSION

SNOM of GSWs to the kidney has become a common practice in the United States. It is safe and has a high success rate, even in severe kidney injuries. It decreases hospital LOS and is independently associated with fewer complications and reduced need for nephrectomy.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level IV.

Kidney and uro-trauma: WSES-AAST guidelines

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

Nationwide Procedural Trends for Renal Trauma Management

OBJECTIVE

To characterize national trends in procedural management of renal trauma.

BACKGROUND

Management of renal trauma has evolved to favor a more conservative approach. For patients requiring intervention, there is a paucity of information to characterize the nature of procedural therapy administered.

METHODS

A retrospective cross-sectional analysis was performed using data contained within the National Trauma Data Bank. The National Trauma Data Bank is a voluntary data repository managed by the American College of Surgeons, containing data regarding trauma admissions at 747 level I to V trauma centers throughout the United States and Canada. Participants included any patient with renal trauma requiring intervention from 2002 to 2012. They were identified according to International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, with codes 866.00 through 866.03 for blunt renal trauma, and codes 866.10 through 866.13 for penetrating trauma. Cases were separated into those requiring nephrectomy, renorrhaphy, or endovascular repair based on ICD-9 procedure code. The number of cases performed each year and yearly trends as measured by linear regression.

RESULTS

A total of 4296 cases were reported during the study period. Of these cases, 2635 involved blunt trauma and 1661 involved penetrating injury. There was a significant increase in the percentage of cases managed by endovascular means for both blunt and penetrating trauma (R = 0.92, P < 0.01; and R = 0.86, P < 0.01, respectively). This was primarily at the expense of nephrectomy, with cases showing significant decline in both groups.

CONCLUSIONS

National trends for procedural management of renal trauma are toward less invasive interventions. These trends suggest favorable change towards renal preservation and decreased morbidity, potentially facilitated, in part, by improved radiographic staging and endovascular techniques, and also increased provider awareness of the safety and value of conservative management.

Traumatic renal injury in a UK major trauma centre - current management strategies and the role of early re-imaging

OBJECTIVES

To analyse the contemporary management of renal injuries in a UK major trauma centre and to evaluate the utility and value of re-imaging.

PATIENTS AND METHODS

The prospectively maintained 'Trauma Audit and Research Network' database was interrogated to identify patients with urinary tract injuries between January 2014 and December 2017. Patients' records and imaging were reviewed to identify injury grades, interventions, outcomes, and follow-up.

RESULTS

Renal injury was identified in 90 patients (79 males and 11 females). The mean (sd; range) age was 35.5 (17.4; 1.5-94) years. Most of the renal traumas were caused by blunt mechanisms (74%). The overall severity of injuries was: 18 (20%) Grade I, 19 (21%) Grade II, 27 (30%) Grade III, 22 (24%) Grade IV, and four (4%) Grade V. Most patients (84%) were managed conservatively. Early intervention (<24 h) was performed in 14 patients (16%) for renal injuries. Most of these patients were managed by interventional radiology techniques (nine of 14). Only two patients required an emergency nephrectomy, both of whom died from extensive polytrauma. In all, 19 patients underwent laparotomy for other injuries and did not require renal exploration. The overall 30-day mortality was 13%. Re-imaging was performed in 66% of patients at an average time of 3.4 days from initial scan. The majority of re-imaging was planned (49 patients) and 12% of these scans demonstrated a relevant finding (urinoma, pseudoaneurysm) that altered management in three of the 49 patients (6.1%).

CONCLUSION

Non-operative management is the mainstay for all grades of injury. Haemodynamic instability and persistent urine leak are primary indications for intervention. Open surgical management is uncommon. Repeat imaging after injury is advocated for stable patients with high-grade renal injuries (Grade III-V), although more research is needed to determine the optimal timing.

Imaging Modalities in Genitourinary Emergencies

Emergency physicians rely on a multitude of different imaging modalities in the diagnosis of genitourinary emergencies. There are many considerations to be taken into account when deciding which imaging modality should be used first, as oftentimes several diagnostic tools can be used for the same pathologic condition. These factors include radiation exposure, sensitivity, specificity, age of patient, availability of resources, cost, and timeliness of completion. In this review, the strengths and weaknesses of different imaging tools in the evaluation of genitourinary emergencies are discussed.

[Advances in surgical repair of ureteral injury]

Ureteral injury can be classified as iatrogenic or traumatic, which represents a rare but challenging field of reconstructive urology. Due to their close proximity to vital abdominal and pelvic organs, the ureters are highly susceptible to iatrogenic injury, while ureteral injury caused by external trauma is relatively rare. The signs of ureteric injury are difficult to identify initially and often present after a delay. The treatment of ureteral injury, which is depended on the type, location, and degree of injury, the time of diagnosis and the patient's overall clinical condition, ranges from simple endoscopic management to complex surgical reconstruction. And long defect of the ureter presents much greater challenges to urologists. Ureterotomy under endoscopy using laser or cold-knife is available for the treatment of 2-3 cm benign ureteral injuries or strictures. Pyeloplasty is an effective treatment for ureteropelvic junction obstruction and some improved methods showed the possibility of repairing long-segment (10-15 cm) stenosis. Proximal and mid-ureteral injuries or strictures of 2-3 cm long can often be managed by primary ureteroureterostomy. When not feasible due to ureteral defects of longer segment, mobilization of the kidney should be considered, and transureteroureterostomy is alternative if the proximal ureter is of sufficient length. And autotransplantation or nephrectomy is regarded as the last resorts. Most of the injuries or strictures are observed in the distal ureter, below the pelvic brim, and are usually treated with ureteroneocystostomy. A non-refluxing technique together with a ureteral nipple or submucosal tunnel method, is preferable as it minimizes vesico-ureteral reflux and the risk of infection. In order to cover a longer distance, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) is often adopted. Among various ureteral replacement procedures, only intestinal ureteral substitution, which includes ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance when urothelial tissue is insufficient. Ileal ureter can be used to replace the ureter of >15 cm defect and even to replace the entire unbilateral ureter or bilateral ureter. Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction and adopted with encouraging results.

The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections

PURPOSE

'Prophylactic' ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk-benefit equation of this practice, and we aimed to assess the evidence base.

METHODS

A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms 'ureteric/ureteral/JJ/Double J stent' or 'ureteric/ureteral catheter' and 'colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury'. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates.

RESULTS

We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%).

CONCLUSIONS

Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.

Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society

BACKGROUND

Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma.

METHODS

Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded.

RESULTS

When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%.

CONCLUSION

Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma.

LEVEL OF EVIDENCE

Guidelines study, level III.

Our experience in emergency treatment of renal haemorrhage

INTRODUCTION

Renal haemorrhage is a potentially life-threatening event requiring emergency surgery. Endovascular therapy is currently the first-line treatment option.

OBJECTIVES

Review patients with renal haemorrhage who required emergency endovascular therapy at our center. Evaluate the causes of the bleeding, the treatment performed and the clinical outcomes.

MATERIAL AND METHODS

We performed a retrospective analysis of consecutive patients with renal bleeding who underwent endovascular therapy from June 2012 to June 2017 at Hospital Universitari Joan XXIII (Tarragona, Spain). Demographic data (age, gender and comorbidity) and other related variables were collected (mechanism of injury, haemodynamic stability and anticoagulant therapy). We also studied the CT angiography findings, time from diagnosis to surgery, endovascular technique and materials used, extent of tissue embolised and outcomes.

RESULTS

Twenty-two (22) patients were included with a mean age of 63 (range 19-85). The aetiology of injuries included: renal biopsy (n=7, 31.8%), bleeding from malignant kidney tumour (n=5, 22.7%), trauma (n=4, 18.2%), angiomyolipoma (n=2, 9.1%), spontaneous bleeding (n=2, 9.1%) and surgical complications (n=2, 9.1%). The endovascular therapy technique was embolisation in all cases. The following materials were used: spheres (9.1%); coils (63.6%); spheres + coils (18.2%); and spheres + plug (9.1%). In 17 cases (77.3%), selective embolisation was performed and in five cases (22.7%), embolisation of the whole kidney. Clinical and technical success rates of 100% were recorded. The 30-day mortality rate was 9.1%.

CONCLUSION

We believe that endovascular therapy is an effective modality for the management of renal bleeding which, in many cases, enables a large part of the renal tissue to be preserved.

[Management of ureteral injuries]

Ureteral injuries account for less than 3% of genitourinary injuries. Most of them are caused iatrogenically during abdominal surgery. The symptoms are often non-specific and do not aid in diagnosis. The later the injury is detected, the more often complications occur. Therefore, in such situations it is important to consider the possibility of ureteral injury and initiate further diagnostic steps as soon as possible. A variety of diagnostic tests are available. In addition to the direct inspection of the ureters and retrograde ureteropyelography, computed tomography (CT) urography is routinely used. Based on the time of diagnosis as well as the extent and the localization of the injury, the further procedure can be determined. For minor injuries, the insertion of a ureteral splint is usually the treatment of choice. In the case of higher grade damage, operative reconstruction by one of several possible surgical procedures is indicated.

Renal trauma: a 3-year audit from a Gold Coast trauma centre

BACKGROUND

Limited data Exists ? on the Australian epidemiology of renal trauma, with very few studies published in the literature. The authors aim to detail the trends of renal trauma in the coastal city of the Gold Coast.

METHODS

Retrospective data collection yielded 81 patients who sustained renal trauma from our 3-year period. Data included information on demographics, mechanism, American Association for the Surgery of Trauma (AAST) grade, presence of haematuria, associated injuries, management, and complications.

RESULTS

Male patients accounted for 83% (n = 67) of cases, and the average age of all injuries was 36 years. Low-grade AAST Grade I-III injuries comprised of 76% (n = 62) of injuries, AAST Grade IV contributed to 20% (n = 16) and 4% (n = 3) of injuries were AAST Grade V. The most common mechanism of injury was road accidents accounting for 35% (n = 28) followed by fall-related injuries (26%, n = 21). Other mechanisms included sport-related (13.5%, n = 11), non-motorized bicycle injuries (8.5%, n = 7), alleged assault (8.5%, n = 7), pedestrian injuries (5%, n = 4) and horse-related injuries (2%, n = 2). Ninety-six percent (n = 78) of kidney injuries were managed conservatively. Of the patients requiring intervention, all were AAST Grade V kidney injuries.

CONCLUSION

Males accounted for the majority of renal trauma cases, similar to the 3:1 ratio of male-to-female injuries found in other studies. In line with other studies, renal trauma reviewed on the Gold Coast also revealed road trauma as the leading cause, closely followed by falls. The majority of high-grade renal trauma was managed conservatively.

Multiple Injuries to the Lower Urinary Tract: Two Cases and Comparison with the EAU Guidelines

Blunt trauma to the lower urinary tract is usually associated with pelvic fractures. The European Association of Urology (EAU) provides guidelines to diagnose and treat these injuries. The guidelines summarise the available evidence and provide recommendations on diagnosis and treatment of these patients. Therefore, these guidelines are important adjuncts to the urologist and emergency physician in the clinical decision-making. However, strict adherence to the guidelines is not always easy or possible because of concomitant injuries obscuring the clinical picture. This is illustrated by two case reports of concomitant injuries of the lower urinary tract (bladder with urethral injury). The clinical decisions will be discussed point by point and should serve as a practical teaching moment for the reader.

Autosomal dominant polycystic kidney disease and minimal trauma: medical review and case report

Background

Blunt abdominal trauma in the setting of polycystic kidney disease is still scantly described in the literature and management guidelines of such patients are not well-established.

Case presentation

The authors herein present a case of hypovolemic shock secondary to segmental renal artery bleed in a 75-year-old man with polycystic kidney disease after minimal blunt abdominal trauma, who underwent successful selective arterial embolization, and provide a thorough review of similar cases in the literature, while shedding the light on important considerations when dealing with such patients.

Conclusions

It is important to suspect renal injury in patients with pre-existing renal lesions irrespective of the mechanism of injury; and, vice-versa to suspect an underlying abnormality in patients with a clinical deterioration that’s out of proportion to the mechanism of injury.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0192-3) contains supplementary material, which is available to authorized users.

Subcapsular renal hematoma after retrograde ureterorenoscopic lithotripsy: our experience

BACKGROUND

Ureterorenoscopy is the current standard treatment for ureteral and kidney stones, also stones greater than 2 cm can be removed. Complications linked to infectious processes or ureteral damage are the most frequently reported. Subcapsular renal hematoma is an extremely rare complication following this procedure.

METHODS

We report the retrospective experience of two urological referral units for stones disease by analyzing incidence, risk factors and management of subcapsular renal hematoma.

RESULTS

Between May 2011 and December 2017, 2497 consecutive ureteroscopies for urolithiasis were performed by 8 skilled endourologists. A subcapsular renal hematoma was diagnosed in four cases (0.12%). Symptoms appeared few hours after intervention in two patients and after 14 postoperative days in the remaining two. In all cases CT scan revealed a subcapsular renal hematoma without signs of active bleeding. Conservative treatment was successful. Two patients required blood transfusion. One patient developed renal hypotrophy.

CONCLUSIONS

Subcapsular renal hematoma represents a rare but potentially serious complication after ureterorenoscopic lithotripsy. Its real incidence and etiology still need to be clarified. The elevated intrarenal pressures play an important role. Persistent hematuria, flank pain and hemoglobin drop should guide prompt investigation to reach an early diagnosis. In most cases a conservative management is sufficient.

Renal trauma: the current best practice

The kidneys are the most vulnerable genitourinary organ in trauma, as they are involved in up to 3.25% of trauma patients. The most common mechanism for renal injury is blunt trauma (predominantly by motor vehicle accidents and falls), while penetrating trauma (mainly caused by firearms and stab wound) comprise the rest. High-velocity weapons impose specifically problematic damage because of the high energy and collateral effect. The mainstay of renal trauma diagnosis is based on contrast-enhanced computed tomography (CT), which is indicated in all stable patients with gross hematuria and in patients presenting with microscopic hematuria and hypotension. Additionally, CT should be performed when the mechanism of injury or physical examination findings are suggestive of renal injury (e.g. rapid deceleration, rib fractures, flank ecchymosis, and every penetrating injury of the abdomen, flank or lower chest). Renal trauma management has evolved during the last decades, with a distinct evolution toward a nonoperative approach. The lion's share of renal trauma patients are managed nonoperatively with careful monitoring, reimaging when there is any deterioration, and the use of minimally invasive procedures. These procedures include angioembolization in cases of active bleeding and endourological stenting in cases of urine extravasation.

Approach and Management of Traumatic Retroperitoneal Injuries

Traumatic retroperitoneal injuries constitute a challenge for trauma surgeons. They usually occur in the context of a trauma patient with multiple associated injuries, in whom invasive procedures have an important role in the diagnosis of these injuries. The retroperitoneum is the anatomical region with the highest mortality rates, therefore early diagnosis and treatment of these lesions acquire special relevance. The aim of this study is to present current published scientific evidence regarding incidence, mechanism of injury, diagnostic methods and treatment through a review of the international literature from the last 70 years. In conclusion, this systematic review showed an increasing trend towards non-surgical management of retroperitoneal injuries.

Safety and efficacy of transcatheter embolization with Glubran®2 cyanoacrylate glue for acute arterial bleeding: a single-center experience with 104 patients

PURPOSE

To assess the efficacy and the safety of Glubran^®2 n-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) transcatheter arterial embolization (TAE) for acute arterial bleeding from varied anatomic sites and to evaluate the predictive factors associated with clinical success and 30-day mortality.

METHODS

A retrospective review of consecutive patients who underwent emergent NBCA-MS Glubran^®2 TAE between July 2014 and August 2016 was conducted. Variables including age, sex, underlying malignancy, cardiovascular comorbidities, coagulation data, systolic blood pressure, and number of red blood cells units (RBC) transfused before TAE were collected. Clinical success, 30-day mortality, and complication rates were evaluated. Prognostic factors were evaluated by uni- and multivariate logistic regression analyses for clinical success, and by uni- and bivariate analyses after adjustment by bleeding sites for 30-day mortality.

RESULTS

104 patients underwent technically successful embolization with bleeding located in muscles (n = 34, 32.7%), digestive tract (n = 28, 26.9%), and viscera (n = 42, 40.4%). Clinical success rate was 76% (n = 79) and 30-day mortality rate was 21.2% (n = 22). Clinical failure was significantly associated with mortality (p < 0.0001). A number of RBC units transfused greater than or equal to 3 were associated with poorer clinical success (p = 0.025) and higher mortality (p = 0.03). Complications (n = 4, 3.8%) requiring surgery occurred only at puncture site. No ischemic complications requiring further invasive treatment occurred. Mean TAE treatment time was 4.55 min.

CONCLUSIONS

NBCA-MS Glubran^®2 TAE is a fast, effective, and safe treatment for acute arterial bleeding whatever the bleeding site.

Adult iatrogenic ureteral injury and stricture-incidence and treatment strategies

Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment. Left untreated they are associated with severe short- and long-term complications such as urinoma, septic state, renal failure, and loss of a renal unit. Treatment depends on timing of diagnosis, as well as extent of injury, and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts. While recent advances in ureteral tissue engineering are promising the topic is still underreported. Historically a domain of open surgery, laparoscopic and robotic-assisted approaches have proven their feasibility in small case series, and are increasingly being utilized as means of reconstructive surgery. This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances.