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Ringen AH, Fatland A, Skaga NO, Gaarder C, Naess PA. Pediatric renal trauma: 17 years of experience at a major Scandinavian trauma center. Trauma Surg Acute Care Open 2023; 8:e001207. [PMID: 38020860 PMCID: PMC10649896 DOI: 10.1136/tsaco-2023-001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background Children are at increased risk of renal injuries from blunt trauma due to their anatomic constitution. The kidney is injured in 5-20% of pediatric patients with blunt abdominal trauma. During the last decades, the management of pediatric renal injuries has evolved toward non-operative management (NOM) unless the patient is hemodynamically compromised. The aim of the present study was to assess contemporary treatment strategies and evaluate outcomes in pediatric patients with renal injuries admitted to a major Scandinavian trauma center. Methods A retrospective cohort study of all trauma patients under 18 years admitted to our institution from January 1, 2003 to December 31, 2019 with main focus on patients with renal injury. Outcomes for two time periods were compared, 2003-2009 (Period 1; P1) and 2010-2019 (Period 2; P2), and the study cohort was also stratified into age groups, survivors and non-survivors and severity of renal injury. Results In total, there were 4230 pediatric patients included in Oslo University Hospital Trauma Registry during this 17-year period and of these 115 (2.7%) had a renal injury. Nephrectomy was performed in four (3.5%) of the patients, angiographic embolization five (4.3%) and ureteral stent placement was performed in six patients (5.2%) due to urinary extravasation. Seven patients died, implying a crude mortality of 6.1%, with one exception secondary to traffic-related incidents. None of the deaths were attributed to renal injury and mortality fell to 1.2% in P2. Discussion This study on contemporary pediatric renal trauma care is one of the largest from a single institution outside the USA. Our results clearly show that NOM, including minimally invasive procedures in selected cases, is achievable in more than 90% of cases with low mortality and morbidity. Level of evidence Level IV.
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Affiliation(s)
- Amund Hovengen Ringen
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - André Fatland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nils Oddvar Skaga
- Department of Anesthesia, Oslo University Hospital Ulleval, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Paal Aksel Naess
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
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Urine Leaks in Children Sustaining Blunt Renal Trauma. J Trauma Acute Care Surg 2022; 93:376-384. [PMID: 34991128 DOI: 10.1097/ta.0000000000003532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few consensus statements exist to guide the timely diagnosis and management of urine leaks in children sustaining BRT (blunt renal trauma). The aims of this study were to characterize kidney injuries among children who sustain BRT, evaluate risk factors for urine leaks, and describe the negative impact of urinoma on patient outcomes and resource consumption. METHODS A retrospective review was performed of 347 patients, aged <19 years, who presented with BRT to a single ACS-verified Level I Pediatric Trauma Center between 2005-2020. Frequency of and risk factors for urine leak after BRT were evaluated, and impact on patient outcomes and resource utilization were analyzed. RESULTS In total, forty-four (12.7%) patients developed urine leaks, which exclusively presented among injury grades 3 (n = 5; 11.4%), 4 (n = 27; 61.4%), and 5 (n = 12; 27.3%). A minority of urine leaks (n = 20; 45.5%) were discovered on presenting CT scan but all within 3 days. Kidney-specific operative procedures (nephrectomy, cystoscopy with J/ureteral stent, percutaneous nephrostomy) were more common among urine leak patients (n = 17; 38.6%) compared with patients without urine leaks (n = 3; 1.0%; p = 0.001). Patients with urine leak had more frequent febrile episodes during hospital stay (n = 24; 54.5%; p = 0.001) and showed increased overall 90-day readmission rates (n = 14; 33.3%; p < 0.001). Independent risk factors that associated with urine leak were higher grade (OR 7.9, 95% CI 2.6-24.3; p < 0.001), upper-lateral quadrant injuries (OR 2.9, 95% CI, 1.2-7.1; p = 0.02 and isolated BRT (OR 2.6, 95% CI, 1.0-6.5; p = 0.04). CONCLUSIONS In a large cohort of children sustaining BRT, urine leaks result in considerable morbidity, including more febrile episodes, greater 90-day readmission rates, and increased operative or image-guided procedures. This study is the first to examine the relationship between kidney quadrant injury and urine leaks. Higher grade (4-5) injury, upper lateral quadrant location, and isolated BRT were independently predictive of urine leaks. LEVEL OF EVIDENCE III. STUDY DESIGN Care Management.
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Zvizdic Z, Milisic E, Jonuzi A, Bukvic M, Vesnic S, Milisic L, Pasic IS, Vranic S. Successful minimally invasive management of nonvascular grade IV blunt renal trauma with complete transection in a 7-year-old girl. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Bird R, De Los Reyes T, Beno S, Siddiqui A. The characteristics, management and outcomes of high- and low-grade renal injuries in paediatric trauma patients at a major trauma centre. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086221076650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Children, given anatomical variations, are at increased risk of renal injury following trauma. The management of paediatric renal injuries has, similar to other solid organ injuries, largely shifted towards conservative management; however, hemodynamically unstable patients may still warrant surgical exploration or interventional techniques. The aim of this study is to describe the local incidence, demographics, morbidity and outcomes associated with high- and low-grade renal injury in a paediatric major trauma population. Method This was a 5-year retrospective review of trauma registry data and chart analysis of all paediatric renal injuries from major trauma at a North American level 1 paediatric trauma centre between January 2016–31 December 2020. Data was analysed using SPSS v27 with p < 0.05 considered significant. Results Of 1334 major trauma patients, 45 suffered a kidney injury (20 high-grade and 25 low-grade injuries), of which 93.3% underwent conservative management with no difference in outcomes between groups. 80% of patients had concurrent injuries (a quarter requiring surgery for these), with a trend towards higher rates of chest injuries in high-grade renal injury patients ( p = 0.08). Bicycle injuries were statistically more likely to cause high-grade renal injury ( p = 0.02). Angiography was utilized infrequently (3/45 patients, 6.6%), and no patients underwent embolization in our study population. Overall mortality (4.4%) and length of stay were unaffected by grade of injury. Conclusion Paediatric renal injury is an uncommon injury in major trauma patients (3.4%). Most cases can be managed conservatively regardless of the grade of injury. Renal injury patients are likely to have concurrent injuries, often requiring surgery. Further studies are needed to measure the success and utilization of interventional radiology techniques for management in children.
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Affiliation(s)
- Ruth Bird
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Thomas De Los Reyes
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Urology, Hospital for Sick Children, Toronto, Canada
| | - Suzanne Beno
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Emergency Medicine, Hospital for Sick Children, Toronto, Canada
| | - Asad Siddiqui
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
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5
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Routine repeat imaging may be avoidable for asymptomatic pediatric patients with renal trauma. J Pediatr Urol 2022; 18:76.e1-76.e8. [PMID: 34872844 DOI: 10.1016/j.jpurol.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 10/08/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION AUA Urotrauma guidelines for renal injury recommend initial nonoperative management followed by repeat CT imaging for stable patients with deep lacerations or clinical signs of complications. Particularly in pediatric patients where caution is taken to limit radiation exposure, it is not known whether routine repeat imaging affects clinical outcomes. OBJECTIVE Our objective was to determine whether routine repeat imaging is associated with urologic intervention or complications in nonoperatively managed pediatric renal trauma. METHODS We retrospectively analyzed 337 pediatric patients with blunt and penetrating renal trauma from a prospectively collected database from 2005 to 2019 at a Level I trauma center. Exclusion criteria included age >18 years old, death during admission (N = 39), immediate operative intervention (N = 28), and low-grade renal injury (AAST grades I-II, N = 91). Routine repeat imaging was defined as reimaging in asymptomatic patients within 72 h of initial injury. Patients were placed into three imaging groups consisting of: (A) those with routine repeat imaging, (B) those reimaged for symptoms, or (C) those not reimaged. Comparisons were made using logistic regression controlling for grade of renal injury. RESULTS Of the included 179 children, 44 (25%) underwent routine repeat imaging, 20 (11%) were reimaged for symptoms, and 115 patients (64%) were managed without reimaging. Compared to patients who were reimaged for symptoms, asymptomatic patients in the routine repeat imaging group and without reimaging group were significantly less likely to develop a complication (16% and 7% vs. 55%, p < 0.001) or require delayed urologic procedure (5% and 1% vs. 25%, p = 0.007). Comparing the routine repeat imaging group to those without reimaging, we found no difference in complications (p = 0.47), readmissions (p = 0.75), or urologic interventions (p = 0.50). CONCLUSION Despite suffering high-grade (III-IV) renal injuries, the majority of pediatric patients who remained asymptomatic during the first three days of hospitalization did not require a urologic intervention. Foregoing repeat imaging was not associated with a higher rate of complications or delayed procedures, supporting that routine repeat imaging may expose these children to unnecessary radiation and may be avoidable in the absence of signs or symptoms of concern.
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Edwards A, Passoni NM, Chen CJ, Schlomer BJ, Jacobs M. Renal artery angiography in pediatric trauma using a national data set. J Pediatr Urol 2020; 16:559.e1-559.e6. [PMID: 32611488 DOI: 10.1016/j.jpurol.2020.05.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 04/07/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking. OBJECTIVE This study uses the National Trauma Data Bank (NTDB), to evaluate renal outcomes after use of renal artery angiography. We hypothesized that patients undergoing renal artery angiography for renal trauma are unlikely to require additional surgical interventions. STUDY DESIGN All children ≤18 years old treated for traumatic renal injuries from 2012 to 2015 were identified by the Abbreviated Injury Scaled Score (AISS) codes in the NTDB. AISS codes were converted to American Association for Surgery of Trauma (AAST) grades. ICD-9 codes were used to identify patients that had renal artery angiography, and additional renal interventions such as nephrectomy, partial nephrectomy, percutaneous nephrostomy tube or ureteral stent placement. RESULTS 536,379 pediatric trauma cases were in the NTDB from 2012 to 2015, with 4506 renal injury cases identified. A total of 88 patients had renal artery angiography (ICD-9 88.45). Only 10% (n = 9) of patients who received renal artery angiography underwent an additional urological intervention. Of those nine, two patients were excluded due to renal angiography taking place after nephrectomy was performed. The remaining seven patients had high grade laceration (AAST grade 4-5). Overall, two patients underwent post angiography nephrectomies, two patients had partial nephrectomies, one percutaneous nephrostomy tube was placed (prior to partial nephrectomy), one aspiration of a kidney (prior to ureteral stent placement), and three had ureteral stent placements. DISCUSSION The limitations of this study include: the NTDB is a national dataset that is not population based, inclusion is limited to the first hospitalization, inaccuracies exist in encounter coding, and the database is lacking laterality of the renal injury. Based on nonspecific nature of ICD-9 coding for angioembolization, we are unable to discern the number of cases that subsequently had angioembolization after or at the time of angiography. CONCLUSION Renal artery angiography in children remains a rare procedure, 88/4,506, in children with renal trauma. In pediatric trauma cases that undergo renal artery angiography additional procedures are more common with higher grade injuries. Further studies are needed to create pediatric specific trauma management algorithms.
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Affiliation(s)
| | | | | | | | - Micah Jacobs
- University of Texas Southwestern Department of Urology, USA
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Redmond EJ, Kiddoo DA, Metcalfe PD. Contemporary management of pediatric high grade renal trauma: 10 year experience at a level 1 trauma centre. J Pediatr Urol 2020; 16:656.e1-656.e5. [PMID: 32800481 DOI: 10.1016/j.jpurol.2020.06.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current guidelines advocating the conservative management of renal injuries in children are primarily extrapolated from adult series due to a dearth of evidence in the pediatric population. OBJECTIVES The aim of this study was to review our experience in the management of pediatric high-grade renal trauma and to clarify the role of conservative management in this cohort of patients. STUDY DESIGN The Alberta Trauma Registry (ATR) is a comprehensive web-based registry which functions to prospectively collect data on all trauma patients in the province who sustain a severe injury (i.e. Injury Severity Score (ISS) ≥12). The ATR was used to identify all pediatric patients who attended hospitals within the Edmonton region with high grade renal injuries (grade III-V) between January 2006 and December 2018. Hospital records and imaging were reviewed to identify patient demographics, mechanism of injury, AAST grade, haemodynamic stability, associated injuries, management, length of hospital stay (LOS), complications, and follow-up outcomes. RESULTS A total of 53 children (38 boys, 15 girls) were identified with a mean age of 13 years (1-16). The mechanism of injury was blunt trauma in 92.5% (49/53) of cases (Supplementary Table). AAST grade distribution was 37.8% Grade III (20/53), 49% Grade IV (26/53) and 13.2% Grade V (7/53). All Grade III injuries were successfully managed conservatively. Overall 11 patients with Grade IV/V injuries required urological intervention (ureteral stenting (5 patients), angioembolization (4 patients), bladder washout with clot evacuation (1 patient), emergency nephrectomy (3 patients)). The overall renal salvage rate was 92.4% (49/53). DISCUSSION Our series confirms the safety of expectant management in high grade pediatric renal trauma. All grade III injuries in our study were managed conservatively without the need for intervention. This suggests that these injuries may be managed safely outside of designated trauma centres. One third of children with grade IV/V injuries required intervention. Therefore we recommend that patients with these injuries are transferred to specialized units with the capacity to provide such procedures if required. CONCLUSION This study supports the conservative management of pediatric renal trauma in the setting of high-grade injury. Expectant management was associated with acceptable rates of intervention and excellent renal salvage rates.
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Affiliation(s)
- Elaine J Redmond
- Division of Urology, University of Alberta, Edmonton, Alberta, Canada. https://twitter.com/elainejredmond
| | - Darcie A Kiddoo
- Division of Urology, University of Alberta, Edmonton, Alberta, Canada
| | - Peter D Metcalfe
- Division of Urology, University of Alberta, Edmonton, Alberta, Canada
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8
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Edwards A, Hammer M, Artunduaga M, Peters C, Jacobs M, Schlomer B. Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imaging. J Pediatr Urol 2020; 16:557.e1-557.e7. [PMID: 32446678 DOI: 10.1016/j.jpurol.2020.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/13/2020] [Accepted: 04/18/2020] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The standard imaging modality for hemodynamically stable blunt abdominal trauma patients is a contrast enhanced CT scan, which is reflected in the current AUA urotrauma guidelines. This comes, however, with radiation exposure and the potential sequalae of IV contrast administration in the pediatric patient. OBJECTIVE We hypothesize that ultrasound imaging would be able to diagnose and rule out clinically significant renal injuries when compared to the gold standard of CT scan in the setting of pediatric blunt abdominal trauma. STUDY DESIGN All children <18 years of age who were evaluated for blunt abdominal trauma who had a CT scan and ultrasound imaging of kidneys were identified. The ultrasound images were reviewed by four reviewers who were blinded to CT results and all clinical information. The ability of ultrasound to diagnose and rule out clinically significant renal injury was evaluated by diagnostic test performance characteristics including sensitivity, specificity, negative predictive value and positive predictive value. RESULTS There were 76 patients identified, 24 of which had a renal injury (1 bilateral) diagnosed by CT scan for a total of 25 injuries in 152 renal units. There were six grade I-II injuries and 19 grade III-V injuries. The sensitivity of the four blinded reviewers by ultrasound alone to detect the 19 grade III-V injuries ranged from 79 to 100% with NPV between 97 and 100%. Three of the four reviewers identified all 19 grade III-V injuries by ultrasound. When combined with significant hematuria, all 19 grade III-IV injuries were identified. Of note, all patients with a grade III-V injury of the kidney had significant hematuria. Of the grade I-II renal injuries, all reviewers identified 1/5 or 2/5 by ultrasound alone. DISCUSSION The limitations of this study include: its retrospective nature, limited number of patients and reviewers, quality of the ultrasound machine. and experience of technologist, radiologist and urologist. A major limitation is the inability to assess other solid organ injuries during this initial study. CONCLUSIONS When compared to a CT scan as the gold standard, kidney ultrasound images had a sensitivity of 79-100% to detect grade III-V injuries and NPV of 97-100% by four blinded reviewers. All grade III-V injuries had either an episode of gross hematuria or microscopic hematuria >50 RBC/hpf. A prospective study that includes full abdominal imaging is needed to confirm that ultrasound can safely be used in place of CT scan for evaluation of hemodynamically stable blunt trauma patients.
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Affiliation(s)
| | - Matthew Hammer
- University of Texas Southwestern Department of Radiology, USA
| | | | - Craig Peters
- University of Texas Southwestern Department of Urology, USA
| | - Micah Jacobs
- University of Texas Southwestern Department of Urology, USA
| | - Bruce Schlomer
- University of Texas Southwestern Department of Urology, USA.
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9
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"Functional outcome in pediatric grade IV renal injuries following blunt abdominal trauma salvaged with minimally invasive interventions". J Pediatr Urol 2020; 16:657.e1-657.e9. [PMID: 32758417 DOI: 10.1016/j.jpurol.2020.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Non-operative management of higher-grade renal injuries has gradually become accepted in pediatric circles following multiple studies over the past decade which showed good renal salvage rates. However, some children do fail this conservative approach and need interventions which are mostly minimally invasive. There is still paucity of studies on the functional outcomes in this unique subgroup of patients. In this study, we review our management and functional outcome of children with grade IV renal injury due to blunt trauma of abdomen managed with minimally invasive interventions (MII) in a tertiary referral center. AIM The present study seeks to summarize contemporary management of pediatric grade IV renal injury due to blunt trauma at our tertiary care center and to assess the functional outcomes in the subgroup who needed MII. MATERIALS AND METHODS A retrospective review was performed on children≤18 years with abdominal blunt trauma managed at our tertiary care facility over the past 10 years (January 2008-January 2018) to identify those with grade IV renal injuries. Data collected included demographic data like age, sex, mechanism of injury, incidence of hematuria, incidence of pre-existing urologic conditions, associated non-renal injuries, transfusion requirements, imaging findings, type of interventions, length of hospital stay, complications and outcomes on follow up. RESULTS Review of our institutional database identified 10 children with grade IV renal injury. Mean age was 11.7 ± 3.6 years (range, 6-18) and majority (6/10) were male. Motor vehicle collision and fall from heights were the commonest mechanisms of injury. While one patient responded to non-operative management, one girl needed emergency renal exploration and later nephrectomy. Eight needed minimally invasive interventions following initial non-operative management. One patient needed nephrectomy due to delayed hemorrhage while three patients needed delayed open reconstruction. The salvage rate in the group which needed interventions was 87.5% (7 of 8) however, the functional outcome was good only in 50% (4 of 8) of patients. The outcomes were better in those who were managed with MII earlier (3/4) compared to those who underwent delayed intervention (1/4). The median hospital stay was 11.5 days (range 7-34 days). CONCLUSION Pediatric patients with non-exsanguinating grade IV renal injuries due to blunt trauma who fail non-operative management and need minimal invasive interventions have good renal salvage rates however, the functional outcomes are poorer. Judicious and early use of these minimally invasive interventions, instead of persisting with non-operative management can possibly improve these functional outcomes.
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10
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Farr BJ, Armstrong LB, Barnett SC, Mooney DP. Variation in management of pediatric post-traumatic urine leaks. Eur J Trauma Emerg Surg 2020; 48:173-178. [PMID: 32623483 DOI: 10.1007/s00068-020-01430-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/28/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE High-grade pediatric renal trauma may be associated with a urine leak and appropriate management remains unclear. METHOD Data on patients with a traumatic renal injury were retrieved from the trauma registry and data warehouse of a pediatric level 1 trauma center over a 15-year period. Demographics, diagnoses, imaging, interventions performed, and follow-up information on patients with a urine leak were analyzed. RESULTS 187 renal injuries were identified and 32 (17%) were high grade. There were 21 (11%) diagnoses of urine leak, comprising the study population. Leaks were identified 0-10 day post-injury. All patients underwent initial computerized tomography (CT); however, 10 (48%) lacked excretory-phase imaging, leading to repeat CT. Ten patients (48%) did not undergo an intervention for their leak, and 11 (52%) underwent at least one, most commonly stent placement (10). Comparing non-intervention and intervention groups: Injury Severity Score (ISS) and initial Shock Index - Pediatric Adjusted (SIPA) were similar, but there was variation in antibiotic prophylaxis (60% vs 100%), average number of imaging studies performed (6.4 vs 8.1) and average length of hospital stay in days (7.7 vs 8.6). CONCLUSION Traumatic urine leaks are unusual, and half require no intervention. Management is variable and the development of care guidelines could decrease variation. Given their infrequency a multi-institutional study is required to generate sufficient patient volume.
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Affiliation(s)
- Bethany J Farr
- Department of Surgery, Boston Children's Hospital, Fegan 3, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | | | - Samuel C Barnett
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - David P Mooney
- Department of Surgery, Boston Children's Hospital, Fegan 3, 300 Longwood Avenue, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
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11
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Zhang Z, Zhang Y, Wang X, Fang L, Chen D, Peng N, Thakker P, Wang Q, Zhang Y. Challenges in the diagnosis of severe renal trauma in child: A case report and literature review. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2020; 28:357-367. [PMID: 32039882 DOI: 10.3233/xst-190611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION To report the management and outcome of one case of pediatric patient sustaining high-grade blunt renal trauma. We present and discuss the clinical characteristics and radiologic features of the patient. PATIENTS AND METHODS A 10 years old child was admitted for serious blunt renal trauma formed a huge urinoma in the right renal after injury gradually in 2018. We treated the patient with synchronous percutaneous nephrostomy drainage and retrograde ureteral catheterization. A retrospective review was performed of this case, including the clinical features, imaging studies and short-term follow-up. A literature review was also performed to highlight the principals of diagnosis and treatment of severe blunt renal trauma in children. RESULTS After drainage, the symptoms of abdominal distension gradually disappeared, and the physical examination shows that the abdomen gradually reduced to normal. The huge urinoma was cured by synchronous drainge. No complications occurred in short-term follow-up. COMMENTS The choice of surgical treatment is based on the degree and location of renal trauma. Grade IV injuries are a heterogeneous group and management should be tailored to the patient, especially among pediatric patients. Persistent urinary extravasation and/or symptomatic urinoma is a common complication of high-grade renal trauma, which will be amenable to ureteral stent placement or percutaneous drainage. For huge urinoma, synchronous percutaneous nephrostomy drainage and retrograde ureteral catheterization can relieve symptoms quickly.
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Affiliation(s)
- Zejian Zhang
- Department of Urology, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province, China
| | - Yixiang Zhang
- Department of Urology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong Province, China
| | - Xisheng Wang
- Department of Urology, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province, China
| | - Liekui Fang
- Urinary Surgery Department of the Second Affiliated Hospital of Southern University of Scienceand Technology, Shenzhen third people's hospital, Shenzhen, Guangdong Province, China
| | - Dong Chen
- Department of Urology, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province, China
| | - Naixiong Peng
- Department of Urology, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province, China
| | - Parth Thakker
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Qinjun Wang
- Department of Urology, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province, China
| | - Yuanyuan Zhang
- Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Coccolini F, Moore EE, Kluger Y, Biffl W, Leppaniemi A, Matsumura Y, Kim F, Peitzman AB, Fraga GP, Sartelli M, Ansaloni L, Augustin G, Kirkpatrick A, Abu-Zidan F, Wani I, Weber D, Pikoulis E, Larrea M, Arvieux C, Manchev V, Reva V, Coimbra R, Khokha V, Mefire AC, Ordonez C, Chiarugi M, Machado F, Sakakushev B, Matsumoto J, Maier R, di Carlo I, Catena F. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:54. [PMID: 31827593 PMCID: PMC6886230 DOI: 10.1186/s13017-019-0274-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/23/2019] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia, 56124 Pisa, Italy
| | | | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Trauma Surgery Dept., Scripps Memorial Hospital, La Jolla, California USA
| | - Ari Leppaniemi
- General Surgery Dept., Mehilati Hospital, Helsinki, Finland
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Hospital, Chiba, Japan
| | - Fernando Kim
- Urology Department, University of Colorado, Denver, USA
| | | | - Gustavo P. Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Imitiaz Wani
- Department of Surgery, DHS Hospitals, Srinagar, Kashmir India
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Emmanouil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Martha Larrea
- General Surgery, “General Calixto García”, Habana Medicine University, Havana, Cuba
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics and Gynecology, University of Buea, Buea, Cameroon
| | - Carlos Ordonez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia, 56124 Pisa, Italy
| | - Fernando Machado
- General and Emergency Surgery Department, Montevideo Hospital, Montevideo, Paraguay
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Isidoro di Carlo
- Department of Surgical Sciences and Advanced Technologies “GF Ingrassia”, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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Gates RL, Price M, Cameron DB, Somme S, Ricca R, Oyetunji TA, Guner YS, Gosain A, Baird R, Lal DR, Jancelewicz T, Shelton J, Diefenbach KA, Grabowski J, Kawaguchi A, Dasgupta R, Downard C, Goldin A, Petty JK, Stylianos S, Williams R. Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review. J Pediatr Surg 2019; 54:1519-1526. [PMID: 30773395 DOI: 10.1016/j.jpedsurg.2019.01.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/14/2019] [Accepted: 01/19/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children. METHODS A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016. RESULTS LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries. CONCLUSION Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage. TYPE OF STUDY Systematic Review. LEVELS OF EVIDENCE Levels 2-4.
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Affiliation(s)
- Robert L Gates
- University of South Carolina School of Medicine - Greenville, Greenville, SC
| | - Mitchell Price
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | | | - Stig Somme
- Division of Pediatric Surgery, Children's Hospital of Colorado, Aurora, CO
| | - Robert Ricca
- Division of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Tolulope A Oyetunji
- University of Missouri - Kansas City School of Medicine, Department of Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Yigit S Guner
- University of California - Irvine, Division of Pediatric and Thoracic Surgery, Children's Hospital of Orange County, Irvine, CA
| | - Ankush Gosain
- Division of Pediatric Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN
| | - Robert Baird
- Department of Pediatric General and Thoracic Surgery, The British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tim Jancelewicz
- Division of Pediatric Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN
| | - Julia Shelton
- Division of Pediatric Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Julia Grabowski
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL
| | - Akemi Kawaguchi
- Department of Pediatric Surgery, McGovern School of Medicine, University of Texas at Houston, Houston, TX
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Cynthia Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - John K Petty
- Wake Forest University School of Medicine, Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - Steven Stylianos
- Department of Surgery, Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY
| | - Regan Williams
- Division of Pediatric Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN.
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14
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Hagedorn JC, Fox N, Ellison JS, Russell R, Witt CE, Zeller K, Ferrada P, Draus JM. Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. J Trauma Acute Care Surg 2019; 86:916-925. [PMID: 30741880 DOI: 10.1097/ta.0000000000002209] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Judith C Hagedorn
- From the Department of Urology (J.C.H.), University of Washington, Seattle, Washington; Division of Pediatric Surgery, Department of Surgery (N.F.), Cooper University, Camden, New Jersey; Children's Hospital of Wisconsin and Medical College of Wisconsin (J.S.E.), Milwaukee, Wisconsin; Department of Surgery (R.R.), Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (C.E.W.), University of Washington, Seattle, Washington; Department of Surgery (K.Z.), Section of Pediatric Surgery, Wake Forest School of Medicine, Wake Forest, North Carolina; Department of Surgery (P.F.), Virginia Commonwealth University, Richmond, Virginia; and Division of Pediatric Surgery, Department of Surgery (J.M.D.), University of Kentucky, Lexington, Kentucky
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15
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Basaran A, Ozkan S. Evaluation of intra-abdominal solid organ injuries in children. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 89:505-512. [PMID: 30657119 PMCID: PMC6502091 DOI: 10.23750/abm.v89i4.5983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 02/22/2017] [Indexed: 01/07/2023]
Abstract
AIM In our study we investigated characteristics and degree of intra-abdominal solid organ injuries according to tomographic imaging in pediatric patients who presented to our emergency clinic with possible abdominal injuries and to whom US and/or abdominal tomography were applied. MATERIALS AND METHODS 1066 pediatric patients were included in the study. The age, gender, injury localization, injury type, injury mechanism, abdominal US and CT results, and treatment specifics of patients were evaulated. RESULTS 58.5% of cases were male. Average age of children was 7.1±4.6 70.8% of the injuries occured in the outdoors. As for injury type, 92.8% of the injuries were blunt and 7.2% were penetrating traumas. The most common mechanism of injury was motor vehicle accidents at 41.4%. The most common abdominal physical examination finding was tenderness with a prevelance of 67%. In patients with solid organ injury, liver injury was detected in 47% of patients, spleen injury was detected in 36% of patients and renal injury was detected in 17% of patients. Grade II injury was the most common grade. 96.5 of patients were provided conservative treatment and 3.5% of patients were treated surgically. CONCLUSION Solid organ injuries due to abdominal trauma in children are generally related to blunt trauma and are severe injuries. CT angio is an important imaging method for detecting solid organ injuries, classification of the injury and treatment determination. Greater than 90% of solid organ injuries in children can be treated successfully with conservative methods.
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16
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Renal Trauma in Pediatrics: A Current Review. Urology 2018; 113:171-178. [DOI: 10.1016/j.urology.2017.09.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 09/22/2017] [Accepted: 09/29/2017] [Indexed: 12/25/2022]
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Wong KY, Jeeneea R, Healey A, Abernethy L, Corbett HJ, McAndrew HF, Losty PD. Management of paediatric high-grade blunt renal trauma: a 10-year single-centre UK experience. BJU Int 2018; 121:923-927. [PMID: 29359888 DOI: 10.1111/bju.14142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To report the management and outcome of paediatric patients sustaining high-grade blunt renal trauma. PATIENTS AND METHODS Medical records were examined for all American Association for the Surgery of Trauma (AAST) grade III-V blunt renal trauma cases admitted to a paediatric trauma centre from 2005 to 2015. Data collected and analysed included: demographics, imaging modalities, management, length of hospital stay (LOS), complications, and follow-up outcomes. RESULTS In all, 18 children (12 boys, six girls) with mean (range) age 11 (4-15) years were included. According to the AAST grading criteria, 39% (seven of 18) of the patients had grade III, 50% (nine of 18) grade IV, and 11% (two of 18) grade V injuries; 44% (eight of 18) had concomitant injuries. Most of the patients were managed conservatively (89%, 16 of 18), although two of the 16 subsequently needed JJ-stent insertion during inpatient stay for symptomatic urinoma(s). In all, 11% (two of 18) of the patients required interventional radiology service(s), involving selective embolisation for life-threatening renal tract haemorrhage. Blood transfusion for renal injury exclusively was required in 11% (two of 18) of the patients. In all, 89% (16 of 18) of the patients had at least one follow-up imaging study before hospital discharge; most (13 of 16) had ultrasonography and three required computed tomography. The median (range) LOS was 11 (4-31) days. In all, 17% (three of 18) of the patients required hospital re-admission within 30 days for complications and all required interventional procedures: JJ stent for urinoma (one), embolisation of renal arterio-venous fistula (one), and embolisation for a post-traumatic pseudoaneurysm (one). Overall, the median (range) follow-up was 6 (2-60) months. In all, 78% (14 of 18) of the patients had dimercaptosuccinic acid studies, with 11 showing reductions in renal function (range 3-44%). CONCLUSIONS This study supports a care pathway strategy advocating conservative management of high-grade renal injuries in children. However, patients may experience a relative decline in renal function with higher grade injuries indicating the need for monitoring and follow-up.
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Affiliation(s)
- Kee Y Wong
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Ram Jeeneea
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Andrew Healey
- Department ofRadiology, Alder Hey Children's Hospital, Liverpool, UK
| | | | - Harriet J Corbett
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Helen F McAndrew
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Paul D Losty
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
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18
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Ishida Y, Tyroch AH, Emami N, McLean SF. Characteristics and Management of Blunt Renal Injury in Children. J Emerg Trauma Shock 2017; 10:140-145. [PMID: 28855777 PMCID: PMC5566024 DOI: 10.4103/jets.jets_93_16] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Renal trauma in the pediatric population is predominately due to blunt mechanism of injury. Our purpose was to determine the associated injuries, features, incidence, management, and outcomes of kidney injuries resulting from blunt trauma in the pediatric population in a single level I trauma center. METHODS This was a retrospective chart and trauma registry review of all pediatric blunt renal injuries at a regional level I trauma center that provides care to injured adults and children. The inclusion dates were January 2001-June 2014. RESULTS Of 5790 pediatric blunt trauma admissions, 68 children sustained renal trauma (incidence: 1.2%). Only two had nephrectomies (2.9%). Five renal angiograms were performed, only one required angioembolization. Macroscopic hematuria rate was significantly higher in the high-grade injury group (47% vs. 16%; P = 0.031). Over half of the patients had other intra-abdominal injuries. The liver and spleen were the most frequently injured abdominal organs. CONCLUSION Blunt renal trauma is uncommon in children and is typically of low American Association for the Surgery of Trauma injury grade. It is commonly associated with other intra-abdominal injuries, especially the liver and the spleen. The nephrectomy rate in pediatric trauma is lower compared to adult trauma. Most pediatric blunt renal injury can be managed conservatively by adult trauma surgeons.
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Affiliation(s)
- Yuichi Ishida
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Alan H Tyroch
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Nader Emami
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Susan F McLean
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
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19
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Abstract
Background: Renal trauma is less common but often occurs in polytrauma. Most trauma is blunt and the severity of the injury varies in different circumstances. Assessment: There is a series of features that should prompt investigation but none are reliably seen in all trauma cases and a low threshold for suspecting renal injury should be taken. A urine dip is essential. Investigation: Computerised tomography is the main modality. Follow-up imaging may be used if complications arise and ultrasound may be used in some cases. Management: Approaches include surgical, radiological and conservative. The latter has been achieved in all grades but intervention will be required in haemodynamic instability. Complications: Haemorrhage, infection and urine extravasation are common and require intervention. There are many long-term complications and hypertension can occur by a variety of mechanisms.
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Affiliation(s)
- James Austin
- Department of Urology, Hampshire Hospitals Foundation Trust, UK
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20
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Murphy GP, Gaither TW, Awad MA, Osterberg EC, Baradaran N, Copp HL, Breyer BN. Management of Pediatric Grade IV Renal Trauma. Curr Urol Rep 2017; 18:23. [PMID: 28233229 DOI: 10.1007/s11934-017-0665-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Review the current literature regarding the management of grade IV renal injuries in children. RECENT FINDINGS Children are at increased risk for renal trauma compared to adults due to differences in anatomy. Newer grading systems have been proposed and are reviewed. Observation of most grade IV renal injuries is safe. Operative intervention is necessary for the unstable patient to control life-threatening bleeding with either angioembolization or open exploration. Symptomatic urinomas may require percutaneous drainage and/or endoscopic stent placement. Ureteropelvic junction (UPJ) disruption, seen more often in children, requires immediate surgical repair. Grade IV renal injuries in children are increasingly managed in a conservative manner.
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Affiliation(s)
- Gregory P Murphy
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Thomas W Gaither
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Mohannad A Awad
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
- Department of Surgery, King Abdulaziz University, Rabigh, Saudi Arabia
| | - E Charles Osterberg
- Department of Urology, Dell Medical School, University of Texas, Austin, TX, USA
| | - Nima Baradaran
- Department of Urology, Medical University of South Carolina, Charleston, USA
| | - Hillary L Copp
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA.
- Department of Biostatistics and Epidemiology, University of California - San Francisco (UCSF), San Francisco, CA, USA.
- Zuckerberg San Francisco General Hospital and Trauma Center, 1001 Potrero Suite 3A, San Francisco, CA, 94110, USA.
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Kpatcha TM, Tengué K, Botcho G, Darré T, Sabi KA, Sikpa KH, Léloua E, Séwa EV, Amegayibor O, Anoukoum T, Amégbor K, Dosseh ED. Papillary Renal Cell Carcinoma Revealed by Renal Traumatism: A Case Report in Lomé. Urol Case Rep 2017; 13:89-91. [PMID: 28462166 PMCID: PMC5408146 DOI: 10.1016/j.eucr.2016.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/28/2016] [Accepted: 11/30/2016] [Indexed: 11/29/2022] Open
Abstract
This study is a report on a case of papillary carcinoma of the kidney revealed by an abdominal contusion. The results of radiological investigations were discordant with the low intensity of the shock. The treatment consisted of radical nephrectomy because of the suspicion of a pre-existing malignancy. Histological analysis revealed a papillary carcinoma pT3N0M0. We focus on the need for performing diagnostic tests in order to avoid missing a pre-existing anomaly to the kidney trauma.
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Affiliation(s)
| | - Kodjo Tengué
- Department of Urology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Gnimdou Botcho
- Department of Urology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Tchin Darré
- Department of Pathology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Kossi Akomola Sabi
- Department of Nephrology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Komi Hola Sikpa
- Department of Urology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Essomendedou Léloua
- Department of Urology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Edoé Viyomé Séwa
- Department of Urology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Obube Amegayibor
- Department of Urology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Tsipa Anoukoum
- Department of Urology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Koffi Amégbor
- Department of Pathology, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
| | - Ekoue David Dosseh
- Department of Surgery, The University Teaching Hospital of Lomé, BP: 57 Lomé, Togo
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Ahmed Z, Nabir S, Ahmed MN, Al Hilli S, Ravikumar V, Momin UZ. Renal Artery Injury Secondary to Blunt Abdominal Trauma - Two Case Reports. Pol J Radiol 2016; 81:572-577. [PMID: 28058071 PMCID: PMC5181523 DOI: 10.12659/pjr.899710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 06/03/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Blunt abdominal trauma is routinely encountered in the Emergency Department. It is one of the main causes of morbidity and mortality amongst the population below the age of 35 years worldwide. Renal artery injury secondary to blunt abdominal trauma however, is a rare occurrence. Here, we present two such cases, encountered in the emergency department sustaining polytrauma following motor vehicle accidents. CASE REPORT We hereby report two interesting cases of renal artery injury sustained in polytrauma patients. In these two cases we revealed almost the entire spectrum of findings that one would expect in renal arterial injuries. CONCLUSIONS Traumatic renal artery occlusion is a rare occurrence with devastating consequences if missed on imaging. Emergency radiologists need to be aware of the CT findings so as to accurately identify renal artery injury. This case report stresses the need for immediate CT assessment of polytrauma patients with suspected renal injury, leading to timely diagnosis and urgent surgical or endovascular intervention.
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Affiliation(s)
- Zahoor Ahmed
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Syed Nabir
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | | | - Shatha Al Hilli
- Department of Radiology, Hamad General Hospital, Doha, Qatar
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Abstract
BACKGROUND Blunt trauma remains a significant cause of morbidity and mortality in the pediatric population. The use of conservative management for blunt renal trauma is widely accepted in adult trauma literature and is now increasingly accepted for use in the pediatric patient population. This study aimed to review current practices in pediatric blunt renal trauma management and to highlight current practices in conservative protocols, success rates of conservative management strategies, as well as short- and long-term outcomes of blunt renal trauma management. METHODS This is a systematic review of PubMed, Ovid, and the Cochrane Library. The following search was performed in each of the three databases: (Renal or Kidney) AND (Pediatric or Children) AND Trauma AND Management. Publications were limited to publish date after January 1, 2000. Inclusion criteria were (1) original research articles regarding management of pediatric blunt renal trauma, (2) involvement of cases of high-grade renal (Grades IV and V) trauma, and (3) more than one patient presented per study. Literature reviews and meta-analyses were excluded. RESULTS Titles and abstracts (n = 308) were screened to identify scientific articles reporting original research findings. A total of 32 articles met the selection criteria and were included in the review. CONCLUSION The literature supports application of conservative management protocols to high-grade blunt pediatric renal trauma. Criteria for early operative intervention are not well understood. At this time, emergent operative intervention only for hemodynamic instability is recommended. Minimally invasive interventions including angioembolization, stenting, and percutaneous drainage should be used when indicated. Short- and long-term outcomes are favorable when using conservative management approaches to Grade IV and V renal injuries. Further studies including prospective studies and randomized control trials are necessary. Cost analyses of current treatment protocols are also necessary to guide efficient management strategies. LEVEL OF EVIDENCE Systematic review, level III.
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24
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Predictive factors for conservative treatment failure in grade IV pediatric blunt renal trauma. J Pediatr Urol 2016; 12:93.e1-7. [PMID: 26292911 DOI: 10.1016/j.jpurol.2015.06.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 06/16/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Most children with grade IV renal injury are treated using a conservative approach with a high success rate. However, a small minority of patients with grade IV renal injury require urological intervention because of symptomatic urinomas. The challenge lies in predicting which of the patients receiving initial conservative treatment may require delayed interventional management because of urological complications. OBJECTIVE To identify clinical factors and radiological features associated with the need for urological intervention in grade IV pediatric, blunt renal trauma patients who were initially treated with a conservative approach. STUDY DESIGN The medical records of consecutive 26 children presenting to our center between 1996 and 2014 with grade IV renal injury, were retrospectively reviewed. Clinical factors, radiological features on computed tomography (CT), use of urological intervention, and patient outcomes were analyzed. RESULTS The population algorithm of this study is shown in the figure. The patients who required urological intervention had a higher transfusion rate and larger perinephric hematomas (>2.2 cm) than those who did not require intervention. The main laceration was located in the antero-medial portion of the kidney, and intravascular contrast extravasation was observed more often in patients who underwent urological intervention compared with patients with successful conservative management. DISCUSSION The authors recommend the use of cautious observation and timely imaging studies for unresolved or expanding urinomas in children with grade IV renal trauma with predictive factors. Moreover, most patients received urological intervention 4-8 days after the trauma. Therefore, it is suggested that a follow-up image study for early detection of urological complications should be conducted 4-5 days after trauma in grade IV renal trauma children with predictive factors. If none of these factors are observed on the initial CT or during the clinical course, follow-up imaging study may be avoided during hospitalization. CONCLUSION The need for transfusion, and the presence of specific image features on initial CT, such as the main laceration location in the antero-medial portion of kidney, intravascular contrast extravasation, and a large perinephric hematoma, served as useful predictive factors for urological intervention in grade IV pediatric blunt renal trauma patients who were initially treated with a conservative approach. The findings indicate that early detection and appropriate intervention should be considered a priority in the conservative treatment of grade IV pediatric renal trauma with predictive factors.
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Management of high-grade renal injury in children. Eur J Trauma Emerg Surg 2016; 43:99-104. [DOI: 10.1007/s00068-016-0636-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
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Dangle PP, Fuller TW, Gaines B, Cannon GM, Schneck FX, Stephany HA, Ost MC. Evolving Mechanisms of Injury and Management of Pediatric Blunt Renal Trauma--20 Years of Experience. Urology 2016; 90:159-63. [PMID: 26825488 DOI: 10.1016/j.urology.2016.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/11/2016] [Accepted: 01/19/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To review 20 years of a prospectively maintained trauma database to identify changing trends in mechanisms of renal injury, demographics, and management outcomes. MATERIALS AND METHODS Following the approval from the institutional review board, a prospectively maintained trauma database was reviewed for renal trauma patient demographics, management, and mechanisms of injury. Data were reviewed first for the entire cohort and then incrementally to identify mechanisms of injury associated with increasing frequency or grade of injury. RESULTS A total of 228 graded renal injuries were identified from 1993 to 2013. The majority of renal injuries occurred in males (77.2%) >6 years of age (85.1%). Low grade (I-III) injuries were more common (70.6%). The most frequent mechanisms of injury identified were falls, recreational motor vehicle (RMV) accidents, bike accidents, motor vehicle collisions, and sports accidents, in descending order of frequency. RMV-related injuries have become frequent with time despite recommendations against use in the pediatric age population. Surgical intervention was rarely necessary. Over the 20 year study period, 5 nephrectomies (1.4%) were required, whereas 10 endoscopic interventions or percutaneous drainage procedures were needed (2.4%). CONCLUSION The majority of blunt pediatric renal injuries are low grade and can be managed nonoperatively. Nephrectomy is rarely required but is indicated for hemodynamic instability refractory to resuscitation. Pediatric blunt renal trauma secondary to RMV use is increasing despite recommendations against their use in the pediatric population.
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Affiliation(s)
- Pankaj P Dangle
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Thomas W Fuller
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Barbara Gaines
- Department of Pediatric Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Glenn M Cannon
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Francis X Schneck
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Heidi A Stephany
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael C Ost
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
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Zundel S, Szavay P. Konservative vs. chirurgische Therapie des Bauchtraumas. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-015-3472-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lin WC, Lin CH. The role of interventional radiology for pediatric blunt renal trauma. Ital J Pediatr 2015; 41:76. [PMID: 26471981 PMCID: PMC4608263 DOI: 10.1186/s13052-015-0181-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 09/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to appraise the role of interventional radiology in children with blunt renal trauma. METHODS The clinical data, injury severity score, days of hospital stay, outcomes and complications of pediatric renal trauma were recorded and evaluated. The two groups: the transcatheter arterial embolization (TAE) group and the non-TAE group were compared for clinical features and laboratory data. RESULTS Eighteen pediatric patients (12 boys, 6 girls with average age 12.4 ± 4.7 years) with blunt renal injury were included in the study. Six patients underwent angiography because of contrast medium extravasations in the kidney found on computed tomography of which four subsequently underwent a TAE. The clinical features and laboratory data of patients in the TAE and non-TAE groups were not significantly different. All patients were managed successfully by conservative treatment without complications except one in the non-TAE group who required nephrectomy due to renal arterial hypertension directly related to trauma. Both groups had relatively good results and all patients had normal renal function at follow-up. CONCLUSION TAE is an alternative therapeutic modality for blunt renal injury in children who have contrast medium extravasations in the kidney on angiography.
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Affiliation(s)
- Wei-Ching Lin
- Department of Radiology, China Medical University Hospital, Taichung, Taiwan. .,Depatment of Biomedical Imaging and Radiological Science, College of Health Care, China Medical University, Taichung, Taiwan.
| | - Chien-Heng Lin
- Depatment of Biomedical Imaging and Radiological Science, College of Health Care, China Medical University, Taichung, Taiwan. .,Division of Pediatric Pulmonology, Children's Hospital of China Medical University, No. 2, Yuh-Der Road, Taichung, Taiwan, R.O.C.
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Abstract
BACKGROUND Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network. METHODS We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries. RESULTS A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73-80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65-73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7-9.4%) at non-freestanding children's hospitals and 6 (2.8%) of 213 (95% CI, 1.0-6.0%) at freestanding children's hospitals (difference, 2.6%; 95% CI, -7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%. CONCLUSION Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.
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Abstract
The pediatric patient is especially prone to blunt renal trauma due to the size and location of pediatric kidneys. No clear guidelines have been established for the management of these injuries in children to achieve the highest rate of renal salvage with low morbidity. Wide-ranging literature exists on this subject, but consists of vastly different management strategies. This review is written to summarize the different approaches to blunt renal trauma and highlight opportunities for further research.
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Affiliation(s)
- Brian G A Dalton
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jeff J Dehmer
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Sohail R Shah
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
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Dahlstrom K, Dunoski B, Zerin JM. Blunt renal trauma in children with pre-existing renal abnormalities. Pediatr Radiol 2015; 45:118-23; quiz 115-7. [PMID: 25552392 DOI: 10.1007/s00247-014-3188-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/25/2014] [Accepted: 09/11/2014] [Indexed: 11/28/2022]
Abstract
The kidneys are the most commonly injured genitourinary organ in children following blunt abdominal trauma. Though the retroperitoneal location affords the kidneys some protection from the forces experienced in blunt abdominal trauma, the kidneys are at greater risk of injury when a disease process exposes them from their normal shielded location. In such cases, the injuries may appear to be disproportionate in relation to the severity of the trauma history, confusing the imaging findings. Recognition of both the underlying disease process as well as the manifestations of acute trauma is important; therefore, we present a pictorial essay of traumatized kidneys in children with pre-existing renal abnormalities.
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Affiliation(s)
- Kelly Dahlstrom
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
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Reese JN, Fox JA, Cannon GM, Ost MC. Timing and Predictors for Urinary Drainage in Children with Expectantly Managed Grade IV Renal Trauma. J Urol 2014; 192:512-7. [DOI: 10.1016/j.juro.2014.02.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Jeremy N. Reese
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Janelle A. Fox
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Glenn M. Cannon
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael C. Ost
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Graziano KD, Juang D, Notrica D, Grandsoult VL, Acosta J, Sharp SW, Murphy JP, St Peter SD. Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children. J Pediatr Surg 2014; 49:198-200; discussion 200-1. [PMID: 24439609 DOI: 10.1016/j.jpedsurg.2013.09.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are no published management schemes for blunt renal injuries. We are conducting a 2-center prospective observational study with a fixed management scheme. METHODS Children with CT proven renal injuries were enrolled with permission. Ambulation is allowed when able regardless of grade. Discharge occurs when tolerating a diet and pain is controlled regardless of hematuria. Urinalysis occurs at follow up in 2-4weeks and repeated as indicated. RESULTS Between 9/2008 and 9/2012, 70 patients were enrolled. Mean age was 11.8years (3-17), and 70% were male. The mean grade of injury was 2.8±1.1 [1-5]. One nephrectomy (1.4%) was performed for a grade 5 injury. Other renal interventions included an embolization for the hilar bleed and one cystotomy for a clot. Mean LOS was 2.9days±2.4days. In patients without other major injury, LOS was 1.9±1.7days (0.4-8days). There were 5 (7%) readmissions: 3 for pain, 1 for hematuria, and 1 for a bladder clot. 58 patients (83%) gave urinalysis samples at initial follow up (med 18days), where 31 (53%) were positive for blood. CONCLUSIONS Children with blunt renal injury may benefit from management without strict bedrest guidelines. Hematuria appears to have little influence on recovery.
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Affiliation(s)
| | - David Juang
- Children's Mercy Hospitals and Clinics, Kansas City, MO
| | | | | | | | - Susan W Sharp
- Children's Mercy Hospitals and Clinics, Kansas City, MO
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Non-operative management of renal trauma in very young children: experiences from a dedicated South African paediatric trauma unit. Injury 2012; 43:1476-81. [PMID: 21269622 DOI: 10.1016/j.injury.2010.12.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 12/17/2010] [Accepted: 12/23/2010] [Indexed: 02/02/2023]
Abstract
Blunt abdominal trauma results in renal injury in 10% of paediatric cases. Over the last twenty years, the management of paediatric renal trauma has shifted towards a primarily non-operative approach that is now well-established for children up to 18 years old. This retrospective study reviews our experiences of non-operatively managing blunt renal trauma in a very young cohort of patients up to 11 years old. Between June 2006 and June 2010, 118 children presented to the Red Cross War Memorial Children's Hospital in Cape Town with blunt abdominal trauma. 16 patients shown to have sustained renal injury on abdominal computed tomography (CT) scanning were included in this study. Medical records were reviewed for the mechanism of injury, severity of renal injury, clinical presentation, associated injuries, management method and clinical outcomes. All renal injuries were graded (I-V) according to the American Association for the Surgery of Trauma Organ Injury Severity Scale. All renal trauma patients included in this study were aged between 1 and 11 years (mean of 6.5 years). 1 patient sustained grade V injuries; 2 grade IV, 6 grade III and 7 grade I injuries. The majority of injuries (9/16) were caused by motor vehicle crashes, whilst 5 children fell from height, 1 was struck by a falling tree and 1 hit by a moving train. 1 of 16 patients was haemodynamically unstable on presentation as a result of multiple splenic and hepatic lacerations. He was resuscitated and underwent immediate laparotomy. However, his renal injuries were not indications for surgical management. 15 haemodynamically stable patients were non-operatively managed for their renal injuries. Following lengths of admissions ranging from 4 to 132 days, all 16 patients were successfully discharged with no mortalities. No significant complications of renal trauma, such as new-onset hypertension, were detected during their first follow up outpatient appointments. Our findings successfully extend non-operative management of haemodynamically stable renal injuries to a very young cohort up to 11 years old. However, we still advocate immediate resuscitation and surgical intervention for any haemodynamically unstable child who had sustained any abdominal injury. We also argue for a limited role for abdominal CT imaging for diagnosing renal injury and routine follow up, instead recommending a greater emphasis on clinical observations for possible complications.
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Jacobs MA, Hotaling JM, Mueller BA, Koyle M, Rivara F, Voelzke BB. Conservative management vs early surgery for high grade pediatric renal trauma--do nephrectomy rates differ? J Urol 2012; 187:1817-22. [PMID: 22424678 DOI: 10.1016/j.juro.2011.12.095] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Indexed: 11/15/2022]
Abstract
PURPOSE Guidelines for management of pediatric high grade renal injuries are currently based on limited pediatric data and algorithms from adults, for whom initial nonoperative management is associated with decreased nephrectomy risk. Using a national database, we compared nephrectomy rates between children with high grade renal injury managed conservatively and those undergoing early surgical intervention. MATERIALS AND METHODS All children with high grade renal injuries were identified in the National Trauma Data Bank®. High grade renal injuries were defined as American Association for the Surgery of Trauma grade IV or V renal injuries. After excluding fatalities within 24 hours of hospitalization, 419 pediatric patients comprised our study cohort. A total of 81 patients underwent early (within 24 hours of hospitalization) surgical intervention, while 338 were initially treated conservatively. Using stratified analysis with adjustment for relevant covariates, we compared nephrectomy rates between these groups. RESULTS Nephrectomy was performed less often in patients treated conservatively (RR 0.24, 95% CI 0.16 to 0.36, adjusted for age, renal injury grade and injury mechanism). The decreased risk of nephrectomy was more marked among children with grade IV vs grade V renal injuries (adjusted RR 0.16, 95% CI 0.08 to 0.23). Multiple procedures were more common in patients initially observed. Of pediatric patients with grade IV and V renal injuries 11% still underwent nephrectomy. CONCLUSIONS Conservative management of high grade renal injuries is common in children. Although mechanism of injury and renal injury grade impact initial clinical management decisions, the risk of nephrectomy was consistently decreased in children with high grade renal trauma managed conservatively regardless of injury characteristics.
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Affiliation(s)
- Micah A Jacobs
- Children's Medical Center Dallas, 2350 Stemmons Frwy., Suite D-4300, Mail Code F4.04, Dallas, Texas 75207, USA.
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Fiard G, Rambeaud JJ, Descotes JL, Boillot B, Terrier N, Thuillier C, Chodez M, Skowron O, Berod AA, Arnoux V, Long JA. Long-term renal function assessment with dimercapto-succinic acid scintigraphy after conservative treatment of major renal trauma. J Urol 2012; 187:1306-9. [PMID: 22341289 DOI: 10.1016/j.juro.2011.11.103] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Indexed: 11/27/2022]
Abstract
PURPOSE The management of high grade blunt renal injury has evolved with time to become increasingly conservative with the ultimate objective of renal preservation. We evaluated relative renal function with dimercapto-succinic acid renal scintigraphy 6 months after major renal trauma (grade IV or V). MATERIALS AND METHODS This prospective observational study was done between January 2004 and April 2010. All patients who presented with grade IV or V renal trauma and were treated conservatively were included in analysis. Patient and trauma characteristics, and initial management were recorded. Relative renal function was evaluated by dimercapto-succinic acid renal scintigraphy 6 months after trauma. RESULTS A total of 88 patients were included in the study. Conservative management was possible in 79 patients (90%), including 69 and 10 with grade IV and V trauma, respectively. Dimercapto-succinic acid renal scintigraphy was done at 6 months for 22 patients (28%). Mean relative renal function for grade IV and V injuries was 39% and 11%, respectively (p=0.0041). The percent of devascularized parenchyma (p=0.0033) and the vascular subtype of grade IV injuries (p=0.0194) also correlated with decreased renal function. No complication or de novo arterial hypertension was noted. CONCLUSIONS Conservative treatment achieves the objective of renal function preservation for grade IV lesions. Grade V and specific subtypes of grade IV injury have a poor functional outcome. Further study must be performed to determine which patients will benefit from conservative treatment vs early nephrectomy to avoid a longer hospital stay and useless procedures.
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Affiliation(s)
- Gaelle Fiard
- Department of Urology, Grenoble University Hospital, Grenoble, France
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Gouli JC, Merrot T, Kalfa N, Faure A, Chaumoître K, Galifer RB, Alessandrini P. [Outcome of severe closed kidney injuries in children]. Prog Urol 2011; 22:58-62. [PMID: 22196007 DOI: 10.1016/j.purol.2011.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 07/06/2011] [Accepted: 07/07/2011] [Indexed: 11/20/2022]
Abstract
AIMS To analyze the results of treatment of major renal injuries according imaging data in order to determine their function after follow-up. PATIENTS AND METHODS This is a retrospective study of 22 cases of fracture of the kidney (grade V) in two pediatric surgical services that were reviewed over a period of 16 years. After initial conservative treatment in 19 patients (86.5%), a scan and/or Uro-MRI were realized in all patients in monitoring evolving. Three children with vascular injury were treated by interventional radiology. The morphology and functional evolution of the injured kidney were determined. RESULTS A DMSA scan investigation was performed in 21 patients (95.5%) associated with Uro-MRI in two cases; one patient was only explored with Uro-MRI. A complete restitution of the renal parenchyma was confirmed in 10 children (45.5%), we noted an atrophy of the upper pole in 30%, a lower pole atrophy in 4.5%, two complete renal atrophy in 9%. An urinoma was present in six patients (27%) that required drainage in five cases and declined during the surveillance in one case. Normal function of the injured kidney was noticed in half of grade V (11 of 22 patients) with a mean follow-up of 19 months. None of our patients did present hypertension. CONCLUSION Non-operative conservative treatment in severe renal trauma was efficient, morphological and functional sequelae were present in 50% on scintigraphy and/or Uro-MRI.
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Affiliation(s)
- J-C Gouli
- Service de chirurgie infantile, CHU Nord, Assistance publique-Hôpitaux de Marseille, université Méditerranée, chemin des Bourrely, 13915 Marseille cedex 20, France
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Abib SDCV, Leite MTC, Ribeiro RC, Fachin CG, Demuner MS, Cypriano M, Schettini ST. Renal tumor and trauma: a pitfall for conversative management. Int Braz J Urol 2011; 37:514-8. [DOI: 10.1590/s1677-55382011000400011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2011] [Indexed: 11/21/2022] Open
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López López R, Alcaraz Romero A, Alvarez Blanco O, Sánchez Alegre ML, Luque De Pablos A, Echenagusia Boyra M. [Embolisation using selective renal angiography for the treatment of haemorrhage after performing percutaneous renal biopsy]. An Pediatr (Barc) 2011; 75:148-50. [PMID: 21515100 DOI: 10.1016/j.anpedi.2011.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 01/18/2011] [Accepted: 03/03/2011] [Indexed: 10/17/2022] Open
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Instituting a Conservative Management Protocol for Pediatric Blunt Renal Trauma: Evaluation of a Prospectively Maintained Patient Registry. J Urol 2011; 185:1058-64. [DOI: 10.1016/j.juro.2010.10.045] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Indexed: 11/19/2022]
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Severe spasm of the renal artery after blunt abdominal trauma simulating end-organ infarction. Case Rep Med 2010; 2010:207152. [PMID: 21209808 PMCID: PMC3014801 DOI: 10.1155/2010/207152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 11/25/2010] [Indexed: 11/17/2022] Open
Abstract
Traumatic occlusion of the renal artery is a serious injury. Management differs according to the grade of injury. In most circumstances, emergency surgical revascularization or endovascular intervention is required. We describe the case of a child with multiorgan injuries and spasm of the main renal artery after blunt trauma simulating arterial occlusion or end-organ infarction.
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Mohamed AZ, Morsi HA, Ziada AM, Habib EM, Aref AM, Kotb EA, Eissa MA, Daw M. Management of major blunt pediatric renal trauma: single-center experience. J Pediatr Urol 2010; 6:301-5. [PMID: 19854105 DOI: 10.1016/j.jpurol.2009.09.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Accepted: 09/21/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To review the impact of major pediatric renal trauma and its management on long-term function and morphology of the injured kidney. METHODS Thirty-six blunt trauma patients (20 males, 16 females) presented in 2004-2007 (age range 2 days to 14 years; mean 6.2 years). Thirty-seven renal units were included: 13 grade III, 14 grade IV, and 10 grade V injuries. Follow up was for 3-38 (mean 14) months. Patients were managed non-operatively unless vitally unstable. The most common causes of trauma were motor vehicle accidents and falls. Fourteen patients had associated non-renal injuries. Four patients had pre-existing renal problems. RESULTS The surgical intervention group (13 patients, 36%) included 9/10 grade V and 4/14 grade IV renal injuries. Surgical repair of lacerations was performed in seven cases, partial nephrectomy in four cases and nephrectomy in two cases. Follow up showed no significant change in renal function, and none developed hypertension. The non-operative group (24 patients, 63.2%) included all grade III injuries, 10 grade IV injuries, and one grade V injury. There was an excellent outcome for 18/24 patients (75%) with kidney preservation, no complications from urinary extravasation and hematoma resolution. The remaining patients had lower polar infarction (1), renal atrophy (1), persistent subcapsular collection (2), recurrent hematuria requiring angioembolization (1), and there was one death related to central nervous system injury. CONCLUSION The outcome of our management of pediatric major renal trauma was favorable overall. Longer follow up is needed with regard to renal function and development of hypertension.
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Affiliation(s)
- A Z Mohamed
- Division of Pediatric Urology, Cairo University Pediatric Hospital, Cairo, Egypt.
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Morita S, Inokuchi S, Tsuji T, Fukushima T, Higami S, Yamagiwa T, Shinichi I. Arterial embolization in patients with grade-4 blunt renal trauma: evaluation of the glomerular filtration rates by dynamic scintigraphy with 99mTechnetium-diethylene triamine pentacetic acid. Scand J Trauma Resusc Emerg Med 2010; 18:11. [PMID: 20205949 PMCID: PMC2841086 DOI: 10.1186/1757-7241-18-11] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2009] [Accepted: 03/07/2010] [Indexed: 11/10/2022] Open
Abstract
Background High-grade blunt renal trauma has been treated by arterial embolization (AE). However, it is unknown whether AE preserves renal function, because conventional renal function tests reflect total renal function and not the function of the injured kidney alone. Dynamic scintigraphy can assess differential renal function. Methods We performed AE in 17 patients with grade-4 blunt renal trauma and determined their serum creatinine (sCr) level and glomerular filtration rate (GFR; estimated by dynamic scintigraphy) after 3 months. In 4 patients with low GFR of the injured kidney (<20 ml·min-1·1.73 m-2), the GFR and sCr were measured again at 6 months. Data are presented as median and interquartile range (25th, 75th percentile). Results The median GFR of the injured kidney, total GFR, and median sCr at 3 months were 29.3 (23.7, 35.3) and 96.8 (79.1, 102.6) ml·min-1·1.73 m-2 and 0.6 (0.5, 0.7) mg/dl, respectively. In the patients with low GFR (ml·min-1·1.73 m-2), the median GFR of the injured kidney, total GFR, and median sCr (mg/dl) were 16.2 (15.7, 16.3), 68.7 (61.1, 71.6), and 0.7 (0.7, 0.9), respectively, at 3 months and 34.5 (29.2, 37.0), 90.9 (79.1, 98.8), and 0.7 (0.7, 0.8), respectively, at 6 months. Conclusions The function of the injured kidney was preserved in all patients, indicating the efficacy of AE for the treatment of grade-4 blunt renal trauma.
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Affiliation(s)
- Seiji Morita
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya Isehara-City, Japan.
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Single Center Experience With Application of the ALARA Concept to Serial Imaging Studies After Blunt Renal Trauma in Children—Is Ultrasound Enough? J Urol 2009; 181:1834-40; discussion 1840. [DOI: 10.1016/j.juro.2008.12.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Indexed: 11/18/2022]
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Abstract
Knowledge of the characteristics of thoraco-abdominal trauma in children is important to optimize the imaging work up while keeping radiation exposure to a minimum. Because of the plasticity of the pediatric rib cage, rib fractures are infrequent, and severe parenchymal injuries may be present in the absence of rib fracture. Mediastinal injuries are unusual. The increased mobility of solid intraabdominal organs combined with a weaker abdominal wall are specific to pediatric patients. First-line imaging typically includes chest radiograph and abdominal US with Doppler imaging. Contrast-material enhanced CT is used as a second-line technique, with delayed imaging in patients with urinary tract lesions. Dedicated pediatric acquisition protocols are mandatory. Follow-up is obtained mainly with US.
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Lesma A. Editorial comment on: Nonoperative management of grade 5 renal injury in children: does it have a place? Eur Urol 2009; 57:161-2. [PMID: 19223116 DOI: 10.1016/j.eururo.2009.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Elder JS. Editorial comment on: Nonoperative management of grade 5 renal injury in children: does it have a place? Eur Urol 2009; 57:162-3. [PMID: 19223114 DOI: 10.1016/j.eururo.2009.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eassa W, El-Ghar MA, Jednak R, El-Sherbiny M. Nonoperative management of grade 5 renal injury in children: does it have a place? Eur Urol 2009; 57:154-61. [PMID: 19223117 DOI: 10.1016/j.eururo.2009.02.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Accepted: 02/02/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Nonoperative treatment of blunt renal trauma in children is progressively gaining acceptance; grade 5 renal trauma is associated with a significant rate of complications. OBJECTIVE To assess the feasibility and outcome of initial nonoperative management of grade 5 blunt renal trauma in children. DESIGN, SETTING, AND PARTICIPANTS This retrospective study included 18 children (12 boys and 6 girls; mean age: 8.4+/-3.4 yr) who presented to the authors' institutes with grade 5 blunt renal trauma between 1990 and 2007. MEASUREMENTS An intravenous contrast-enhanced computed tomography (CT) scan demonstrated grade 5 renal trauma in all patients. Associated major vascular injuries were suspected in four patients. All were initially managed conservatively. Indications for intervention included hemodynamic instability, progressive urinoma, or persistent bleeding. Dimercaptosuccinic acid (DMSA) scans were performed at a mean time of 3.1 yr (range: 1-17) following the injury in nine patients. RESULTS AND LIMITATIONS Four patients (22%) with suspected major vascular injuries required nephrectomy 1-21 d following the trauma. Two patients with continuing hemorrhage required selective lower-pole arterial embolization (11%). Three patients (17%) had their progressive urinoma drained percutaneously, and two of them required delayed reparative surgery for ureteropelvic junction (UPJ) avulsion. Nine patients (50%) were successfully managed nonoperatively. Kidneys were salvaged in 78% of patients. DMSA scanning showed a split function >40% in 44% of evaluated kidneys. Two patients (22%) had split function <30%. At last follow-up, none of the children were hypertensive or had any abnormality on urine analysis. CONCLUSIONS Nonoperative management of grade 5 renal trauma is feasible. Prompt surgical intervention is required for those with major vascular injuries. Superselective arterial embolization can be an excellent option in patients with continuing hemorrhage and who have pseudoaneurysms. Patients with UPJ disruption can be salvaged by initial drainage of the urinoma followed by deferred correction.
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Affiliation(s)
- Waleed Eassa
- Pediatric Urology Unit, Urology and Nephrology Center, Mansoura, Egypt.
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Fraser JD, Aguayo P, Ostlie DJ, St Peter SD. Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int 2009; 25:125-32. [PMID: 19130062 DOI: 10.1007/s00383-008-2316-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2008] [Indexed: 11/27/2022]
Abstract
Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.
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Affiliation(s)
- Jason D Fraser
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
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Keller MS, Green MC. Comparison of short- and long-term functional outcome of nonoperatively managed renal injuries in children. J Pediatr Surg 2009; 44:144-7; discussion 147. [PMID: 19159732 DOI: 10.1016/j.jpedsurg.2008.10.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 10/07/2008] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to better determine the long-term functional outcome of nonoperatively managed renal injuries in children. METHODS After Institutional Review Board approval, all children with blunt renal injuries were retrospectively reviewed. Renal function, after complete healing had been documented radiographically (3 months postinjury), was evaluated through measurements of blood urea nitrogen, serum creatinine, blood pressure, and split percentage of renal function using technetium-99m-dimercaptosuccinic acid nuclear scanning. Repeated data at 1 year postinjury were compared with the early follow-up results. RESULTS Sixteen consecutive children (mean age, 10 years; range, 3-16 years) had complete follow-up over the study period. All children were managed without laparotomy. Injury grades were as follows: grades I to III, 4; grade IV, 9; and grade V, 3. No child had an abnormal blood urea nitrogen, serum creatinine, or blood pressure measurement at follow-up. Consistent with previous results, percentage of renal function by technetium-99m-dimercaptosuccinic acid scanning was influenced by injury grade at the early 3-month follow-up (46.5% +/- 4.5%, 42% +/- 7.1%, and 32.7% +/- 5.9% [mean +/- SD] for grades I-III, grade IV, and grade V, respectively). One-year functional results for the high-grade injuries also correlated to initial injury grade and were not significantly different from the results at early follow-up (43.8% +/- 4.8%, 41.9% +/- 6.6%, and 31.35 +/- 5.7% [mean +/- SD] for grades I-III, grade IV, and grade V, respectively; P = not significant). No child required delayed surgery. CONCLUSIONS Long-term (1 year) functional outcome in nonoperatively managed renal injuries in children appears preserved and is influenced by injury grade.
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Affiliation(s)
- Martin S Keller
- Department of Surgery, St Louis Children's Hospital, St Louis, MO 63110, USA.
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