Prise en charge des pseudo-anévrismes rénaux intraparenchymateux post-traumatiques : à propos d’une série de 325 patients traumatisés rénaux

[Renal Parenchyma Trauma and General Trauma Recommandations]

INTRODUCTION

Among trauma emergencies, kidney damage is uncommon. The urologist is frequently on the second line in the management of patients with multiple traumatic lesions. Knowledge of treatment is necessary to be able to integrate the different teams involved in an approach that is both vital in the context of damage control and functional with a concern for parenchymal preservation.

METHODS

A systematic review of the literature was carried out using the Medline database in order to identify the most relevant articles in English and French.

RESULTS

Kidney trauma occurs either by direct shock or by a deceleration mechanism. They are classified by severity according to the AAST classification. Management is mostly conservative by avoiding surgery and controlling bleeding by arterial embolization. Surveillance checks for complications occurrence in high-grade trauma. Traumatic dissection of the renal artery, with a poor functional prognosis requires a short delay before treatment.

CONCLUSION

The prognosis for trauma to the kidney, regardless of the grade, is currently good, with improvements of effective resuscitation and embolization in the event of bleeding.

Determination of the radiologic findings for predicting failure of conservative management with observation for blunt renal injury patients: A single-centre experience over 13 years

PURPOSE

Most blunt renal injuries (BRIs) are managed conservatively without complications. Because conservative management with observation (CMO) is widely conducted, failed CMO is frequent. Clarifying the role and indication of CMO is important to manage BRI patients. Therefore, this study was conducted to analyse factors related to failed CMO.

METHODS

BRI patients (aged >13 years) who were admitted via the emergency department in Wonju Severance Christian Hospital were analysed retrospectively between January 2008 and July 2020. Patient characteristics, including clinical data, laboratory findings, transfusion requirements, injury grade, initial CT findings, length of hospital stay, intensive care unit stay, and mortality, were investigated for all enrolled patients.

RESULTS

Kidney injury grade ≥ 4, perinephric haematoma rim distance (PHD), length of main laceration, intravascular contrast extravasation (ICE), Gerota's fascia discontinuity, multiple lacerations, dissociated renal fragment and complexity of laceration were statistically significantly different between the successful CMO and failed CMO groups in the comparative analysis. The multivariate analysis showed that perinephric haematoma rim distance [odds ratio (OR) 1.44 [95% confidence interval (CI) 1.09 - 1.90], p = 0.011] and ICE [OR 7.41 (95% CI 2.20 - 24.99), p = 0.001] were mutually independent risk factors associated with failed CMO. When the ROC curve of PHD and ICE was generated to predict the failure of CMO, the area under the curve (AUC) was 0.884 (95% CI, 0.826 - 0.942), p < 0.001), and the optimal cut-off value for PHD was 2.9 cm, and for ICE was presence of ICE on CT [sensitivity: 90.5% (95% CI, 0.70 - 0.99), specificity: 78.0% (95% CI, 0.73 - 0.83)].

CONCLUSION

PHD and ICE may be useful factors to predict failed CMO for BRI patients. PHD > 2.9 cm and the presence of ICE may indicate who will require invasive procedures. Close observation is wise for patients with these risk factors.

A rare case of spontaneous rupture of renal artery pseudoaneurysm in a previously hypertensive patient

Introduction. The renal artery and segmental renal artery pseudoaneurysm is a rare and usually asymptomatic vascular lesion which in most of the cases thrombose spontaneously, but at same time it can be a source of life-threatening hemorrhage and shock. Today, these pseudoaneurysms are discovered with increasing frequency due to unrelated abdominal imaging or on screening work-ups for hypertension, as well as widespread use of angiography. Typically, they are seen in patients after trauma, inflammation, or renal surgery or biopsy. Case outline. In our case, a 52-year-old male patient with no prior history of surgery, significant abdominal trauma and systemic disease, presented with left flank pain and signs of hypovolemic shock that manifested before the admission in the surgical emergency room. The CT scan promptly demonstrated rupture of large retroperitoneal hematoma with the massive intraperitoneal hemorrhage. The angiography confirmed the rupture of the renal artery pseudoaneurysm. The patient had the urgent operation. A life-saving nephrectomy was performed while intraperitoneal hemorrhage and retroperitoneal hematoma was evacuated. The fourteen days after surgery the patient was discharged fully recovered, with normal diuresis and serum levels of creatinine and urea within referential values. During the period of hospitalization, he was diagnosed and treated hypertension. Conclusion. Rupture of pseudoaneurysms with the following hemorrhage into the intraperitoneal cavity and retroperitoneum is a life-threatening condition, as proven with this case in which hypovolemic shock manifested before the admission. We would like to highlight the importance of high blood-pressure control and the importance of regular check-ups.

A Comparative Study of Conservation, Endovascular Embolization Therapy, and Surgery for Blunt Renal Trauma

Background

In this study, we evaluated the advantages and disadvantages of angioembolization in patients with Grade III–V blunt renal trauma compared with other treatments.

Material/Methods

We prospectively collected data on patients hospitalized for Grade III–V blunt renal trauma. Organ damage was graded according to the American Association for the Surgery of Trauma (AAST) criteria. Initial grouping was then performed according to the hemodynamics and “initial treatment”. The eligible patients were divided into 3 groups: conservative treatment group (Group A), arterial embolization group (Group B), and surgical group (Group C). The success rate, significance, and follow-up renal function were evaluated.

Results

In Group B of Grade IV, estimated glomerular filtration rate (eGFR) and serum creatinine (Scr) levels were slightly decreased and increased, respectively, after embolization compared with before embolization (P=0.002, P=0.039). In Grade V, the eGFR of Group B after embolization was lower than before embolization (P=0.041); The levels of serum urea (Urea) and Scr in Group B after treatment were higher than those before treatment (P=0.042, P=0.024). Conservative treatment and angioembolization were better than exploration in protecting renal function of Grade IV (P=0.035 and P=0.047, respectively).

Conclusions

The success rate of angioembolization was high and protected renal function to the greatest extent, and there were no differences in renal function at long-term follow-up. However, it is difficult to manage renal vessel laceration or avulsion by embolization alone, and various endovascular therapies are required to protect the function of residual kidneys.

Renal pseudoaneuryms and pulmonary embolism: A unique manifestation of complications following blunt renal trauma

This case report presents a unique manifestation of complications in a 71-year-old man following blunt renal trauma. Initially, computed tomography (CT) revealed a traumatic left kidney laceration. Hematuria ceased quickly after ureteral stent placement. One week later, hematuria reoccurred while the patient was treated for pulmonary embolism. Multiphase CT revealed two renal pseudoaneurysms as the underlying cause. Renal pseudoaneurysms are commonly associated with surgery or inflammation and rarely seen after trauma. Selective angiographic embolization successfully stopped hematuria. Thereafter, the patient was hemodynamically stable to continue therapeutic thrombolysis. After discharge, the patient remained symptom-free and had an unremarkable follow up assessment.