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Nti BK, Benzoni N, Starr R, Hays M, Vish D, End B, Russell F. Serial Trauma Abdominal Ultrasound in Children (STAUNCH): A Pilot Study. Pediatr Emerg Care 2024:00006565-990000000-00430. [PMID: 38587011 DOI: 10.1097/pec.0000000000003208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Ultrasound has established utility within pediatric emergency medicine and has an added benefit of avoiding excessive radiation exposure. The serial focused assessment with sonography in trauma (sFAST) examination is a potential alternative to improve pediatric trauma evaluation. We sought to evaluate the accuracy of sFAST in pediatric patients with blunt abdominal trauma. METHODS We performed a multicenter, retrospective observational study of electronic medical records, trauma registry data, and image archiving records of previous sFAST examinations. Examinations from pediatric patients (18 years or younger) who presented to an emergency department with blunt abdominal trauma were eligible for inclusion as long as the period between the first and second FAST was at least 30 minutes but no more than 24 hours. Demographic data and patient and outcomes were collected. RESULTS Data collected from 3 institutions found a total of 38 sFAST performed between July 2017 and September 2021 on eligible patients. Of these, there were 6 (15.4%) FAST examinations that were positive after an initial negative or indeterminate interpretation. The overall sensitivity and specificity of sFAST were 66.7% (95% confidence interval 22.3-95.7%) and 93.8% (79.2-99.3%), respectively. CONCLUSIONS This pilot study found that sFAST can enhance blunt trauma evaluation and improve sensitivity and diagnostic accuracy. More data are needed to determine how sFAST can be utilized in pediatric patients with blunt abdominal trauma.
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Affiliation(s)
- Benjamin K Nti
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Nicole Benzoni
- Franciscan Critical Care Medicine at St. Michael, Silverdale, WA
| | - Rebecca Starr
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
| | - Matthew Hays
- Department of Biostatistics and Health Science Data, Indiana University School of Medicine, Indianapolis, IN
| | - Dylan Vish
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
| | - Bradley End
- Department of Emergency Medicine, West Virginia University, Morgantown, WV
| | - Frances Russell
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
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Gadelkareem RA, Hamdan A, Faddan AA, Hammouda HM, Zarzour MA. Factors affecting and effects of hemodynamic stability of pediatric patients with grades 3-5 renal trauma: a prospective non-randomized comparative study. BMC Urol 2023; 23:203. [PMID: 38066553 PMCID: PMC10704659 DOI: 10.1186/s12894-023-01381-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Researches on the effect of hemodynamic stabilization on the implantation of conservative management for pediatric high-grade renal traumas are lacking. We aimed to assess the effect of maintaining the initial hemodynamic stability of pediatric patients with grades 3-5 renal trauma on the implementation of the conservative treatment and identify its defining factors. METHODS A prospective study was performed on pediatric patients with grade 3-5 renal traumas who presented to our hospital during July 2020-June 2022. Hemodynamically stable patients were compared with the unstable patients for clinical characteristics, hemodynamic stabilization, and rates of success of conservative treatment. RESULTS Forty-three patients were studied, including 26 boys and 17 girls. Of them, 28 (65.1%) patients presented with hemodynamic stability and 15 (34.9%) patients were unstable. Overall, 32 (74.4%) patients achieved and/or maintained hemodynamic stability for conservative management. There was a significant difference in blood pressure level at presentation (p < 0.001). The improvement of the hemodynamic parameters was significant per group and, in comparison (p < 0.001). The size of hematoma was significantly smaller in patients with hemodynamic stability (p = 0.023). Despite the longer (p = 0.033) hospital stay with conservative management, the rates of blood transfusion (p = 0.597) and hospital stay (p = 0.785) were not significantly different between both groups. The rates of nephrectomy and mortality were 14% and 0%, respectively. Blood pressure was independently associated with the achievement of maintained hemodynamic stability for conservative management (p = 0.022). CONCLUSIONS Hemodynamic stabilization seems to be effective and safe for implementing successful conservative management for pediatric patients with high-grade renal traumas. Blood pressure was the only independent factor of maintaining hemodynamic stability.
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Affiliation(s)
- Rabea Ahmed Gadelkareem
- Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Elgamaa Street, Assiut, 71515, Egypt.
| | - Ahmed Hamdan
- Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Elgamaa Street, Assiut, 71515, Egypt
| | - Amr Abou Faddan
- Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Elgamaa Street, Assiut, 71515, Egypt
| | - Hisham Mokhtar Hammouda
- Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Elgamaa Street, Assiut, 71515, Egypt
| | - Mohamed Ali Zarzour
- Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Elgamaa Street, Assiut, 71515, Egypt
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Werner Z, O'Connor L, Wasef K, Abdelhalim A, Al-Omar O. Pediatric renal trauma at a level 1 trauma center in a rural state: A 10-year institutional review and protocol implementation. J Pediatr Urol 2023; 19:400.e1-400.e5. [PMID: 37156709 DOI: 10.1016/j.jpurol.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Unintentional injury is a leading cause of mortality and morbidity in children. There is no consensus on the ideal, discrete management of pediatric renal trauma (PRT). Therefore, management protocols tend to be institution-specific. OBJECTIVE This study aimed to characterize PRT at a rural level-1 trauma center and subsequently develop a standardized protocol. STUDY DESIGN A retrospective review of a prospectively maintained database of PRT at a rural level 1 trauma center between 2009 and 2019 was conducted. Injuries were characterized regarding renal trauma grade, associated multi-organ involvement and the need for intervention. The benefit of patient transfer from regional hospitals and length and cost of stay were evaluated. RESULTS Of 250 patients admitted with renal trauma diagnosis 50 patients <18 years were analyzed. Of those, the majority (32/50, 64%) had low-grade (grade I-III) injuries. Conservative management was successful in all low-grade injuries. Of 18 high-grade PRT, 10 (55.6%) required intervention, one prior to transfer. Among patients with low-grade trauma, 23/32 (72%) were transferred from an outside facility. A total of 13 (26%) patients with isolated low-grade renal trauma were transferred from regional hospitals. All isolated, transferred low-grade renal trauma had diagnostic imaging before transfer and none required invasive intervention. Interventional management of renal injury was associated with a longer median LOS [7 (IQR = 4-16.5) vs 4 (IQR = 2-6) days for conservative management, p = 0.019)] and an increased median total cost of $57,986 vs. $18,042 for conservative management (p = 0.002). DISCUSSION The majority of PRT, particularly low-grade, can be managed conservatively. A significant proportion of children with low-grade trauma are unnecessarily transferred to higher level centers. Review of pediatric renal trauma at our institution over a decade has allowed us to develop an institutional protocol which we believe allows for safe and effective patient monitoring. CONCLUSION Isolated, low-grade PRT can be managed conservatively at regional hospitals without needing transfer to a level 1 trauma center. Children with high-grade injuries should be closely monitored and are more likely to need invasive intervention. Development of a PRT protocol will help to safely triage this population and identify those who may benefit from transfer to a tertiary care center.
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Affiliation(s)
- Zachary Werner
- Department of Urology, West Virginia University, Suite 1400 Health Sciences Center South, Morgantown, WV 26506, USA.
| | - Luke O'Connor
- Department of Urology, West Virginia University, Suite 1400 Health Sciences Center South, Morgantown, WV 26506, USA
| | - Kareem Wasef
- Department of Urology, West Virginia University, Suite 1400 Health Sciences Center South, Morgantown, WV 26506, USA
| | - Ahmed Abdelhalim
- Department of Urology, West Virginia University, Suite 1400 Health Sciences Center South, Morgantown, WV 26506, USA; Mansoura Urology and Nephrology Center, Mansoura University, Egypt
| | - Osama Al-Omar
- Department of Urology, West Virginia University, Suite 1400 Health Sciences Center South, Morgantown, WV 26506, USA
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Lindner AK, Luger AK, Fritz J, Stäblein J, Radmayr C, Aigner F, Rehder P, Tulchiner G, Horninger W, Pichler R. Do we need repeated CT imaging in uncomplicated blunt renal injuries? Experiences of a high-volume urological trauma centre. World J Emerg Surg 2022; 17:38. [PMID: 35799209 PMCID: PMC9264658 DOI: 10.1186/s13017-022-00445-9] [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: 05/19/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Current guidelines recommend repeat computed tomography (CT) imaging in high-grade blunt renal injury within 48–96 h, yet diagnostic value and clinical significance remain controversial. The aim of this work was to determine the possible gain of CT re-imaging in uncomplicated patients with blunt renal trauma at 48 h after injury, presenting one of the largest case series. Methods A retrospective database of patients admitted to our centre with isolated blunt renal trauma due to sporting injuries was analysed for a period of 20 years (2000–2020). We included only patients who underwent repeat imaging at 48 h after trauma irrespective of AAST renal injury grading (grade 1–5) and initial management. The primary outcome was intervention rates after CT imaging at 48 h in uncomplicated patients versus CT scan at the time of clinical symptoms. Results A total of 280 patients (mean age: 37.8 years; 244 (87.1%) male) with repeat CT after 48 h were included. 150 (53.6%) patients were classified as low-grade (grade 1–3) and 130 (46.4%) as high-grade (grade 4–5) trauma. Immediate intervention at trauma was necessary in 59 (21.1%) patients with high-grade injuries: minimally invasive therapy in 48 (81.4%) and open surgery in 11 (18.6%) patients, respectively. In only 16 (5.7%) cases, intervention was performed based on CT re-imaging at 48 h (low-grade vs. high-grade: 3.3% vs. 8.5%; p = 0.075). On the contrary, intervention rate due to clinical symptoms was 12.5% (n = 35). Onset of clinical progress was on average (range) 5.3 (1–17) days post trauma. High-grade trauma (odds ratio [OR]grade 4 vs. grade 3, 14.62; p < 0.001; ORgrade 5 vs. grade 3, 22.88, p = 0.004) and intervention performed at the day of trauma (OR 3.22; p = 0.014) were powerful predictors of occurrence of clinical progress. Conclusion Our data suggest that routine CT imaging 48 h post trauma can be safely omitted for patients with low- and high-grade blunt renal injury as long as they remain clinically stable. Patients with high-grade renal injury have the highest risk for clinical progress; thus, close surveillance should be considered especially in this group.
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Affiliation(s)
- Andrea Katharina Lindner
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | | | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Stäblein
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Friedrich Aigner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Rehder
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Gennadi Tulchiner
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Wolfgang Horninger
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Renate Pichler
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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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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Kelly CE, Bowers KE, Holton AE, Van Embden D. Non-operatively managed blunt and penetrating renal trauma: Does early follow up CT scan change management? A systematic review. Injury 2022; 53:69-75. [PMID: 34392984 DOI: 10.1016/j.injury.2021.07.029] [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: 12/02/2020] [Revised: 07/11/2021] [Accepted: 07/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Renal injury accounts for 1-5% of all traumatic injuries. Non-operative management (NOM) of renal trauma has demonstrated higher renal salvage rates and reduced morbidity. AIMS The aim of this review is to clarify the indications of early follow up CT scan for adult patients, with NOM, renal trauma, with a view to avoiding unnecessary CT scanning and radiation exposure in this cohort of patients. METHODS A systematic search was conducted using PubMed (MEDLINE), Web of Science, Embase, and Cochrane library, with references from relevant articles also evaluated. Inclusion criteria were defined as studies reporting outcomes of patients ≥12 years of age, with NOM, renal trauma and early CT re-imaging. The outcomes of interest were renal complications requiring intervention, specifically collecting system and vascular complications. RESULTS Five studies met the inclusion criteria. In total, 542 patients were included in this analysis; study sizes ranged from 48 to 207 patients. Early re-imaging was performed for 510 patients, including 489 CTs and 31 Ultrasounds (US). Mean time to re-imaging ranged from 1 - 35.9 days. Twenty three patients required intervention following re-imaging, all of which were for injuries grade ≥ 3 and presented with clinical deterioration prior to re-imaging, had a collecting system injury identified on initial CT scan or both. The number needed to re-image, in order to change the management of one patient, was 22. CONCLUSIONS Although the findings of this review are based on retrospective data, they suggest routine early re-imaging can be safely omitted for all NOM, renal injuries which remain asymptomatic, with no collecting system injury diagnosed on initial CT, provided appropriate delayed phase imaging is available. Future prospective studies are required to further clarify the indications of early re-imaging, specifically for NOM penetrating injuries, and the appropriate modality and timing of early re-imaging for all NOM renal trauma.
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Affiliation(s)
- Caroline E Kelly
- Blizard Institute, Queen Mary University of London, United Kingdom.
| | - Kevin E Bowers
- James Connolly Memorial Hospital, Blanchardstown, Mill Rd, Abbotstown D15, X40D, Dublin, Ireland
| | - Alice E Holton
- RCSI School of Pharmacy and Bio Molecular Sciences, 111 St. Stephen's Green, Saint Peter's D02 VN51, Dublin, Ireland
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Abstract
In pediatric trauma, the kidney is the most commonly injured organ of the urinary tract. Renal trauma occurs in 10% to 20% of all pediatric blunt abdominal trauma cases. The vast majority of renal injuries can be treated conservatively. However, cases associated with hemodynamic instability require operative interventions. Injuries to the ureter, bladder or urethra are almost exclusively encountered in polytraumatized children. The aim of this article is to give an overview on traumatic injuries to the pediatric urinary system.
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Affiliation(s)
- Georg Singer
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria.
| | - Christoph Arneitz
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | - Sebastian Tschauner
- Division of Paediatric Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Christoph Castellani
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | - Holger Till
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
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Fromm J, Meuwly E, Wendling-Keim D, Lehner M, Kammer B. Clival fractures in children: a challenge in the trauma room setting! Childs Nerv Syst 2021; 37:1199-1208. [PMID: 33245407 DOI: 10.1007/s00381-020-04963-2] [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: 06/13/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE A clival fracture is a rare but life-threatening traumatic brain injury in the adult and pediatric populations. To date, there are very few conclusive recommendations in the literature concerning the diagnosis and treatment of pediatric clival fractures. METHODS In 2014 and 2015, two pediatric patients with severe blunt head trauma and clival fractures were evaluated and treated at a level I trauma center. Both cases are documented and supplemented by an extensive review of the literature focusing on the diagnostic workup, classification, and clinical course of clival fractures in children. RESULTS The clinical course of two children (8 and 9 years old) with clival fractures in concert with other intra- and extracranial injuries was analyzed. A total of 17 papers encompassing 37 patients (age range, 1-18 years) were included for a systematic review. The literature review revealed a mortality rate of 23% in pediatric patients with a clival fracture. Over 50% of the patients presented with cranial nerve damage, and two-thirds suffered from intracranial vascular damage or intracerebral bleeding. CONCLUSIONS Clival fractures are a very rare but severe consequence of blunt head trauma in the pediatric population and may be challenging to diagnose, especially in cases with an unfused sphenooccipital synchondrosis. Vascular damage following clival fractures appears to be as common in pediatric patients as in adults. Therefore, contrast-enhanced CT of the cervical spine and head and/or magnetic resonance angiography is strongly recommended to rule out vascular injury of the extra- and intracranial brain-supplying vessels within the trauma room setting.
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Affiliation(s)
- Julian Fromm
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Eliane Meuwly
- Department of Pediatric Surgery, Children's Hospital Lucerne, Luzerner Kantonsspital, Spitalstrasse 20, 6000, Lucerne 16, Switzerland
| | - Danielle Wendling-Keim
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Markus Lehner
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany. .,Department of Pediatric Surgery, Children's Hospital Lucerne, Luzerner Kantonsspital, Spitalstrasse 20, 6000, Lucerne 16, Switzerland.
| | - Birgit Kammer
- Pediatric Radiology, Department of Clinical Radiology, Ludwig-Maximilians-University Munich, Lindwurmstr. 4, 80337, Munich, Germany
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Choudhury S, Ray P, Pal DK. Changing paradigms of management of isolated blunt renal trauma. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620965446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction The last thirty years has seen a change in management of renal trauma with progression more towards nonoperative management; however there is lack of guidelines of many practical aspects for conservative management of renal trauma. Here we are sharing our experience of managing isolated renal trauma over a period of five years. Materials and methods The study was conducted in a tertiary care centre of eastern part of India from April 2015–March 2020. It was a retro-prospective study and included cases of isolated blunt renal trauma managed in our hospital. Results A total of 61 cases of isolated blunt renal trauma were treated in the mentioned time period. Seventeen (28%) cases were of AAST Grade IV and five (8%) Grade V injury. Blood transfusion was required in eighteen (29%) cases during management. In eight (47%) cases of Grade IV injury and two (40%) cases of Grade V injury angioembolization was done. In two (11.7%) cases of Grade IV injury ureteral stenting was performed. Delayed surgical exploration and nephrectomy was required in one case of Grade V injury because of failed angioembolization and one Grade IV injury due to sepsis. One death was encountered in Grade V injury who had delayed presentation with haemorrhagic shock and underwent immediate surgical exploration. On follow up four patients (23%) of Grade IV injury and one patient of Grade III injury and two patients (40%) of Grade IV injury developed hypertension. The remaining patients were found to be normal. Conclusion Conservative management of renal trauma is the norm nowadays. Angioembolisation was found to be one of the strongest armamentarium when patient needs intervention. Surgery is rarely contemplated, mostly in hemodynamically unstable high grade trauma patients.
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Affiliation(s)
- Sunirmal Choudhury
- Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Pinaki Ray
- Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Dilip Kumar Pal
- Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India
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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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"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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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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13
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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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Abstract
The purpose of this study was to determine the need of repeat follow-up computed tomography imaging in patients with renal trauma.All patients who were admitted in the trauma center of the Military Institute of Medicine with a diagnosis of kidney injury from January 2008 to December 2017 were identified. A retrospective review of all patients' medical records and radiologic imaging was conducted.Data on the following factors were collected - patients' demographics, mechanism of trauma, American Association for the Surgery of Trauma renal injury scale, injury severity score, laboratory examinations, multiorgan injuries, transfusion of fresh frozen plasma and packed red blood cells, time of surgical procedure in multiorgan injuries, length of hospital stay, and acute kidney injury.This group consisted of 37 patients with left renal injuries, 32 with right renal injuries, and 5 with bilateral renal injuries. Renal trauma due to blunt injury secondary to a motor vehicle accident was noted in 45 patients, falling from a height in 14 patients, injury from battery in 4 patients, sports-related activities in 1 patient, and other factors in 10 patients.Of the 63 patients treated conservatively due to multiorgan trauma or isolated trauma, values of morphology, serum creatinine and blood urea nitrogen, and ultrasonography in all patients did not reveal any pathological changes within earlier kidney damage.The conservative treatment of grade I-IV renal injury in the American Association for the Surgery of Trauma scale provided good outcome and only involved noninvasive ultrasonography.This study confirms that routine follow-up computed tomography imaging can be safely omitted in renal injuries graded I-IV providing that the patient remains in good clinical state.
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Affiliation(s)
| | | | | | - Saracyn Marek
- Department of Endocrinology and Radioisotope Therapy, Military Institute of Medicine, Warsaw, Poland
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16
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Abstract
Traumatic renal injuries are more common in pediatrics because of the relatively larger size of the kidneys in the pediatric patient. Although computerized tomography remains the criterion standard for the initial evaluation of blunt renal trauma, there is evidence that renal ultrasound may serve a role in postinjury surveillance. Here, we present a case in which point-of-care ultrasound was used to image severe blunt renal trauma in a 17-year-old adolescent boy. In this case, point-of-care ultrasound identified severely distorted renal parenchyma after a grade 5 renal laceration was identified on computerized tomography scan.
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17
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Missed Opportunities to Decrease Radiation Exposure in Children with Renal Trauma. J Urol 2018; 199:552-557. [DOI: 10.1016/j.juro.2017.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 11/22/2022]
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18
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Zu'bi F, Sidler M, Harvey E, Lopes RI, Hojjat A, Naoum N, Pokarowski M, Lorenzo AJ, Farhat WA, Papanikolaou F, Dos Santos J. Stone growth patterns and risk for surgery among children presenting with hypercalciuria, hypocitraturia and cystinuria as underlying metabolic causes of urolithiasis. J Pediatr Urol 2017; 13:357.e1-357.e7. [PMID: 28865885 DOI: 10.1016/j.jpurol.2017.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 06/29/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Hypercalciuria, hypocitraturia and cystinuria are the most common underlying metabolic stone abnormalities in children. The present study compared stone growth patterns, stone burden, and the risk of stone-related surgery among these underlying metabolic conditions. METHODS A retrospective cohort of 356 children with renal stones, followed from 2000 to 2015, was studied. Differences among metabolic groups were determined using Kruskal-Wallis test; the Scheffé-test was used for multiple comparisons to determine differences among single groups. Independent sample t-test was used when adequate, given the sample size, and Chi-squared test was used for categorical variables. Stone growth rates were calculated as differences in diameter divided by time elapsed between U/Ss (mm/year). Logistic regression was performed to assess the effect of initial stone size on the likelihood of surgery. RESULTS Median stone size at presentation was significantly different among groups, with cystinuria being the group with the largest proportion of stones >10 mm, while patients with stones <5 mm were likely to have a normal metabolic workup (P < 0.05). Stones with a higher growth rate were found in the operative group, while slower growing stones were mostly managed conservatively (3.4 mm/year vs 0.8 mm/year, respectively; P = 0.014). However, stone growth rates were not significantly different among metabolic groups. On the other hand, the rate of new stone formation in cystinuric patients at their first follow-up was 30.4%, which was significantly higher than in patients with hypercalciuria (16.3%) or with a normal metabolic workup (17.2%; P < 0.05). Compared with stones <5 mm, stones measuring 5-10 mm were more than four times more likely to result in surgery, whereas the likelihood of surgery for 10-20 mm or >20 mm stones was almost 16 or 34 times, respectively (P < 0.001). CONCLUSIONS It is believed that this is the first study to evaluate stone growth patterns, stone burden and surgical risk among children with hypercalciuria, hypocitraturia and cystinuria. Cystinuric patients presented with larger stones at the time of diagnosis, higher new stone formation rates, and were at higher risk of surgery. While no significant difference of growth rate was found among metabolic groups, stones with a higher growth rate were significantly more likely to result in surgical treatment than slower growing stones. Initial stone size, location of largest stone, previous urinary tract infection, and patient's metabolic type significantly influenced the likelihood of a surgical intervention. Better understanding of the natural history ultimately helps surgeons and clinicians defining prognosis, treatment, and prevention plans for pediatric urolithiasis.
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Affiliation(s)
- F Zu'bi
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Sidler
- Department of Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK.
| | - E Harvey
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - R I Lopes
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Asal Hojjat
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - N Naoum
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Pokarowski
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - A J Lorenzo
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - W A Farhat
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - F Papanikolaou
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - J Dos Santos
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
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Au JK, Tan X, Sidani M, Stanasel I, Roth DR, Koh CJ, Seth A, Gargollo PC, Tu D, Gonzales ET, Smith TG, Janzen N. Imaging characteristics associated with failure of nonoperative management in high-grade pediatric blunt renal trauma. J Pediatr Urol 2016; 12:294.e1-294.e6. [PMID: 27160977 DOI: 10.1016/j.jpurol.2016.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 02/28/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Some children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention. MATERIALS AND METHODS A retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain. RESULTS One patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect (P = 0.040) (Fig. A) and lacked ureteral opacification (P = 0.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5-2.5), additional operative interventions occurred from day 4-16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission (Fig. B). CONCLUSIONS Collecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised.
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Affiliation(s)
- J K Au
- Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
| | - X Tan
- Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, 10th Floor, Suite A10.136, Houston, TX 77030, USA
| | - M Sidani
- Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, 10th Floor, Suite A10.136, Houston, TX 77030, USA
| | - I Stanasel
- Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA
| | - D R Roth
- Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA
| | - C J Koh
- Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA
| | - A Seth
- Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA
| | - P C Gargollo
- Department of Urology, 200 1st St SW, Rochester, MN 55902, USA
| | - D Tu
- Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA
| | - E T Gonzales
- Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA
| | - T G Smith
- Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, 10th Floor, Suite A10.136, Houston, TX 77030, USA
| | - N Janzen
- Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA
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20
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Chong ST, Cherry-Bukowiec JR, Willatt JM, Kielar AZ. Renal trauma: imaging evaluation and implications for clinical management. Abdom Radiol (NY) 2016; 41:1565-79. [PMID: 27108132 DOI: 10.1007/s00261-016-0731-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Severe renal injuries are usually associated with multisystem injuries, may require interventional radiology to control hemorrhage and improve the chances for renal salvage, and are more likely to fail nonoperative management. However, most renal injuries are mild in severity and successfully managed conservatively. The AAST classification is the most widely used system to describe renal injuries and carries management and prognostic implications. CT with intravenous contrast is the imaging test of choice to assess for renal injuries. Contrast extravasation indicating active bleeding should be mentioned as its presence is predictive for failure of nonoperative management. Radiologists play a critical role in identifying renal injuries and should make every effort to describe renal injuries according to the AAST grading scheme to better inform the surgeon's management decisions.
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21
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Amerstorfer EE, Haberlik A, Riccabona M. Imaging assessment of renal injuries in children and adolescents: CT or ultrasound? J Pediatr Surg 2015; 50:448-55. [PMID: 25746706 DOI: 10.1016/j.jpedsurg.2014.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 07/02/2014] [Accepted: 07/03/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since the introduction of the ALARA ("as low as reasonably achievable") concept, ultrasound (US) has been progressively advocated for paediatric diagnostic imaging. This study aimed to analyse the role and accuracy of US in paediatric renal trauma. METHODS From 1999 to 2009, the tertiary-care-hospital database was retrospectively evaluated for renal trauma with regards to aetiology, type of injury, diagnostics, management and outcome. RESULTS Forty-seven patients (29 males, 18 females; median age=14years, range 1-17 years) were identified. US was initially applied in 45 patients with correct results in 86.6%. Computed tomography (CT) was performed in 16 patients in the acute trauma setting - complementary to US in 14 cases, with a diagnostic accuracy of 93%. Most renal injuries were grade I° (n=30), followed by grade III° (n=8), IV° (n=5), and II°/V° (n=2 each). All patients were initially managed conservatively and followed by US. Clinical deterioration necessitated surgery in four patients (2 nephrectomies, 1 partial nephrectomy, 1 urinoma drainage). The outcome was generally favourable with a renal preservation rate of 95%. CONCLUSION With respect to the ALARA principle, US can be safely and reliably applied as the first-line diagnostic imaging technique and for follow-up for suspected traumatic paediatric renal injuries.
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Affiliation(s)
- Eva Elisa Amerstorfer
- Department for Paediatric and Adolescent Surgery, Medical University of Graz, Austria
| | - Axel Haberlik
- Department for Paediatric and Adolescent Surgery, Medical University of Graz, Austria.
| | - Michael Riccabona
- Department for Radiology, Division of Paediatric Radiology, Medical University of Graz, Austria
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22
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Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of current indications and limitations. Eur J Trauma Emerg Surg 2015; 41:469-80. [PMID: 26038013 DOI: 10.1007/s00068-014-0492-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 12/27/2014] [Indexed: 01/13/2023]
Abstract
Accurate hemodynamic and intravascular volume status assessment is essential in the diagnostic and therapeutic management of critically ill patients. Over the last two decades, a number of technological advances were translated into a variety of minimally invasive or non-invasive hemodynamic monitoring modalities. Despite the promise of less invasive technologies, the quality, reliability, reproducibility, and generalizability of resultant hemodynamic and intravascular volume status data have been lacking. Since its formal introduction, ultrasound technology has provided the medical community with a more standardized, higher quality, broadly applicable, and reproducible method of accomplishing the above-mentioned objectives. With the advent of portable, hand-carried devices, the importance of sonography in hemodynamic and volume status assessment became clear. From basic venous collapsibility and global cardiac assessment to more complex tasks such as the assessment of cardiac flow and tissue Doppler signals, the number of real-life indications for sonology continues to increase. This review will provide an outline of the essential ultrasound applications in hemodynamic and volume status assessment, focusing on evidence-based uses and indications.
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McCombie SP, Thyer I, Corcoran NM, Rowling C, Dyer J, Le Roux A, Kuan M, Wallace DMA, Hayne D. The conservative management of renal trauma: a literature review and practical clinical guideline from Australia and New Zealand. BJU Int 2014; 114 Suppl 1:13-21. [DOI: 10.1111/bju.12902] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Steve P. McCombie
- School of Surgery; University of Western Australia; Crawley WA Australia
- Department of Urology; Fremantle Hospital; Fremantle WA Australia
| | - Isaac Thyer
- Department of Urology; Fremantle Hospital; Fremantle WA Australia
| | - Niall M. Corcoran
- Departments of Urology and Surgery; Royal Melbourne Hospital and University of Melbourne; Parkville VIC Australia
| | | | - John Dyer
- Department of Infectious Diseases; Fremantle Hospital; Fremantle WA Australia
| | - Anton Le Roux
- Department of Radiology; Fremantle Hospital; Fremantle WA Australia
| | - Melvyn Kuan
- Department of Urology; Fremantle Hospital; Fremantle WA Australia
| | | | - Dickon Hayne
- School of Surgery; University of Western Australia; Crawley WA Australia
- Department of Urology; Fremantle Hospital; Fremantle WA Australia
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Canon S, Recicar J, Head B, Linam L, Swearingen C, Maxson T. The utility of initial and follow-up ultrasound reevaluation for blunt renal trauma in children and adolescents. J Pediatr Urol 2014; 10:815-8. [PMID: 24631271 DOI: 10.1016/j.jpurol.2014.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 01/06/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To discover if renal ultrasound (RUS) can be utilized as the primary follow-up imaging modality in the management of blunt renal injuries in children and adolescents. METHODS We initiated a protocol utilizing RUS reevaluations for children and adolescents treated for blunt renal injuries. Patients following this protocol (Post) had initial computerized tomography (CT) with RUS reevaluation at day 2 and 2 weeks. We retrospectively compared this group to a 2-year cohort treated between 2007 and 2009 (Pre). RESULTS In our study, 28 Post protocol patients were retrospectively compared with 22 Pre cohort patients. No significant differences were observed in age, length of stay (LOS), injury severity score (ISS), and utilization of CT reevaluation. Follow-up reevaluation was obtained in 13 Pre patients versus 21 Post patients (p = 0.231). No patients had any evidence of long-term complications in either cohort. CONCLUSION Our results suggest that RUS can be utilized as the primary surveillance imaging modality in the management of blunt renal injuries in children and adolescents. The lack of benefit of usage of RUS demonstrated in the acute post-injury surveillance period calls into question the benefit of RUS immediately following the blunt trauma.
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Affiliation(s)
- Stephen Canon
- Division of Pediatric Urology, Arkansas Children's Hospital, Little Rock, AR, USA
| | - John Recicar
- Division of Surgery, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Bryan Head
- University of Arkansas for Medical Sciences, College of Medicine, 4301 W. Markham, Little Rock, AR 72205, USA.
| | - Leann Linam
- Division of Radiology, Arkansas Children's Hospital, Little Rock, AR, USA
| | | | - Todd Maxson
- Division of Surgery, Arkansas Children's Hospital, Little Rock, AR, USA
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Burnette JO, Klaassen Z, Donohoe JM, Williams H. Reply. Urology 2013. [DOI: 10.1016/j.urology.2012.11.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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ESPR uroradiology task force and ESUR paediatric working group: imaging recommendations in paediatric uroradiology, part IV: Minutes of the ESPR uroradiology task force mini-symposium on imaging in childhood renal hypertension and imaging of renal trauma in children. Pediatr Radiol 2011; 41:939-44. [PMID: 21710387 DOI: 10.1007/s00247-011-2089-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 04/04/2011] [Indexed: 10/18/2022]
Abstract
Two new recommendations of the European Society of Radiology task force and the European Society of Uroradiology workgroup on paediatric uroradiology are presented. One deals with diagnostic imaging in children after trauma to the urinary tract-renal trauma, in particular. The other concerns the evaluation of suspected renal hypertension. Available data in the paediatric literature are either unsatisfactory or controversial for both of these clinical settings. Therefore, the following consensus-based proposals aim at outlining effective imaging algorithms to reduce invasive imaging procedures while optimising diagnostic accuracy. The objective of following a more uniform imaging approach is to facilitate future meta-analysis as well as multicentre and other more evidence-based studies. The practise in paediatric radiology is typically based on local availability and on the limitations of professional expertise and equipment, balanced against the perceived needs of the individual child. Although this is unlikely to change in the near future, it does not release the physicians in charge of diagnostic imaging from their responsibility in choosing and providing state-of-the-art imaging and management protocols that are adapted specifically for use in children.
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Stratton KL, Pope JC, Adams MC, Brock JW, Thomas JC. Implications of ionizing radiation in the pediatric urology patient. J Urol 2010; 183:2137-42. [PMID: 20399463 DOI: 10.1016/j.juro.2010.02.2384] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Indexed: 11/19/2022]
Abstract
PURPOSE We reviewed the literature on the effects of ionizing radiation in pediatric patients, and discuss current recommendations and challenges facing radiologists and pediatric urologists. MATERIALS AND METHODS We performed a MEDLINE(R) search to identify articles evaluating the risk of ionizing radiation in pediatric patients. Particular attention was focused on computerized tomography. Standard radiography, fluoroscopy and nuclear imaging were also evaluated. RESULTS To date the literature relating radiation exposure to imaging has primarily focused on the role of the pediatrician and radiologist as decision makers. However, these imaging modalities are important to treat and monitor many conditions treated by the pediatric urologist. Conflicting reports have made clinical decision making and patient education challenging. CONCLUSIONS A lack of consensus on the risk of radiation exposure in pediatric patients increases the need for heightened awareness by the urologist requesting radiographic evaluation. Monitoring future studies is required to better understand the impact of radiation on children and ensure prompt implementation of appropriate guidelines for patient care.
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Affiliation(s)
- Kelly L Stratton
- Division of Pediatric Urology, Department of Urologic Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee 37232-9820, USA
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