Diagnosis and management of urinary extravasation after high-grade renal trauma

The Japanese Urological Association's clinical practice guidelines for urotrauma 2023

The Japanese Urological Association's guidelines for the treatment of renal trauma were published in 2016. In conjunction with its revision, herein, we present the new guidelines for overall urotrauma. Its purpose is to provide standard diagnostic and treatment recommendations for urotrauma, including iatrogenic trauma, to preserve organ function and minimize complications and fatality. The guidelines committee comprised urologists with experience in urotrauma care, selected by the Trauma and Emergency Medicine Subcommittee of the Specialty Area Committee of the Japanese Urological Association, and specialists recommended by the Japanese Association for the Surgery of Trauma and the Japanese Society of Interventional Radiology. The guidelines committee established the domains of renal and ureteral, bladder, urethral, and genital trauma, and determined the lead person for each domain. A total of 30 clinical questions (CQs) were established for all domains; 15 for renal and ureteral trauma and five each for the other domains. An extensive literature search was conducted for studies published between January 1, 1983 and July 16, 2020, based on the preset keywords for each CQ. Since only few randomized controlled trials or meta-analyses were found on urotrauma clinical practice, conducting a systematic review and summarizing the evidence proved challenging; hence, the grade of recommendation was determined according to the 2007 "Minds Handbook for Clinical Practice Guidelines" based on a consensus reached by the guidelines committee. We hope that these guidelines will be useful for clinicians in their daily practice, especially those involved in urotrauma care.

Does a collecting system injury with grade iv renal blunt trauma always need urinary intervention?

PURPOSE

This study aimed to identify the characteristics associated with the need for urinary intervention for a blunt renal injury with collection system involvement using a computed tomography (CT) protocol for trauma.

MATERIALS AND METHODS

Abdominal CT images of patients with blunt renal injuries from 2016 to 2020 were reviewed. Patients with low-grade renal trauma, non-collecting system involvement, American Association for the Surgery of Trauma grade V shattered kidney, and emergent nephrectomy were excluded. The largest perinephric mass thickness was measured in the axial view using CT, and a cutoff value was obtained using a receiver-operating characteristic curve analysis. Risk factors for further urinary intervention were analyzed.

RESULTS

Among the 70 patients included in this study, those with perinephric mass thicknesses < 25 mm (n = 36) had a significantly lower rate of urinary intervention than those with perinephric mass thicknesses ≥ 25 mm (0 vs. 5; p = 0.023). There was no significant difference in the follow-up durations of the groups (19 days vs. 38 days; p = 0.198). More than 90% of the perinephric mass in the < 25 mm group resolved within a median follow-up duration of 38 days, whereas nearly half of the ≥ 25 mm group had a residual perinephric mass during a median follow-up duration of 19 days.

CONCLUSION

The initial CT protocol for trauma was useful for predicting the need for further urinary interventions for collecting system injuries. A perinephric mass thickness < 25 mm is predictive of a low likelihood of requiring urinary intervention.

Shattered Kidney After Renal Trauma: Should It Be Classified As an American Association for the Surgery of Trauma Grade V Injury?

OBJECTIVE

To study the prevalence and management of shattered kidney and to evaluate if the new description of "loss of identifiable renal anatomy" in the 2018 American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) would improve the ability to predict bleeding control interventions.

METHODS

We used high-grade renal trauma data from 21 Level-1 trauma centers from 2013 to 2018. Initial CT scans were reviewed to identify shattered kidneys, defined as a kidney having ≥3 parenchymal fragments displaced by blood or fluid on cross-sectional imaging. We further categorized patients with shattered kidney in two models based on loss of identifiable renal parenchymal anatomy and presence or absence of vascular contrast extravasation (VCE). Bleeding interventions were compared between the groups.

RESULTS

From 861 high-grade renal trauma patients, 41 (4.8%) had shattered kidney injury. 25 (61%) underwent a bleeding control intervention including 18 (43.9%) nephrectomies and 11 (26.8%) angioembolizations. 18 (41%) had shattered kidney with "loss of identifiable parenchymal renal anatomy" per 2018 AAST OIS (model-1). 28 (68.3%) had concurrent VCE (model-2). Model-2 had a statistically significant improvement in area under the curve over model-1 in predicting bleeding interventions (0.75 vs 0.72; P = .01).

CONCLUSION

Shattered kidney is associated with high rates of active bleeding, urinary extravasation, and interventions including nephrectomy. The definition of shattered kidney is vague and subjective and our definition might be simpler and more reproducible. Loss of identifiable renal anatomy per the 2018 AAST OIS did not provide better distinction for bleeding control interventions over presence of VCE.

Right-Sided Urinary Extravasation Caused by a Ureteral Stone and Associated With Peritonitis in an Older Woman

Right upper quadrant pain can originate from the liver, cholecystic duct, gallbladder, pancreas, or surrounding organs. Peritonitis in the right upper quadrant of the abdomen can be caused by lesions in these organs as well as the adjacent organs, such as the kidney and colon. The kidneys are surrounded by Gerota's fascia and fat; therefore, mild local inflammation may not cause peritonitis. Herein, we report the case of a 72-year-old woman with right-sided abdominal pain who was diagnosed with urinary extravasation due to a ureteral stone. Urinary extravasations can present with peritonitis. For effective diagnosis, prompt physical examination and abdominal ultrasound are essential, with the extent of extravasation being key to effective management. Therefore, general physicians should consider urinary extravasation, which is typically caused by kidney and urinary stones, in patients with right upper quadrant pain.

Urine Leaks in Children Sustaining Blunt Renal Trauma

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.

Urinoma following blunt renal trauma in a patient with anomalous solitary kidney: A case report

INTRODUCTION AND IMPORTANCE

Blunt traumatic injury to the genitourinary system is uncommon. Urinoma formation may occur in patients with blunt trauma after high grade renal injuries. In such cases, the presence of solitary kidney must be ruled out as it may affect treatment decisions.

CASE PRESENTATION

A 21 years old male presented to our facility with complaints of abdominal pain and frank hematuria following physical assault. Physical examination revealed tenderness at the right flank. Laboratory evaluation showed a decreased hemoglobin level and urinalysis showed proteinuria and marked hematuria. Imaging findings were consistent with AAST Grade IV right renal injury affecting the renal pelvis with urinoma formation and congenital megacalyces. Incidental finding of unilateral renal agenesis on the left side was also noted. Our patient underwent Ureteroscopy with double-J stenting. Subsequent ultrasonography after the procedure showed resolution of the perirenal collection.

DISCUSSION

The presence of solitary kidney must be ruled out in cases of high grade renal trauma as operative procedures may lead to catastrophic consequences in such cases. Urinoma formation after renal trauma may occur if the renal pelvis is injured and should be managed preferably by urinary diversion in the form of ureteral stenting over other operative procedures, especially in patients with anomalous solitary kidney.

CONCLUSION

Presence of bilateral kidneys should be confirmed before subjecting patients with high grade renal injury to operative procedures. Early ureteric stenting appears to be an effective method of urinary diversion for management of symptomatic urinomas in patients with anomalous solitary kidney.

The American Association for the Surgery of Trauma renal injury grading scale: Implications of the 2018 revisions for injury reclassification and predicting bleeding interventions

BACKGROUND

In 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions.

METHODS

Data on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared.

RESULTS

Of the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34).

CONCLUSION

About one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions.

LEVEL OF EVIDENCE

Prognostic and Epidemiological Study, level III.

A Near-Infrared Fluorescent Probe Coated with β-Cyclodextrin Molecules for Real-Time Imaging-Guided Intraoperative Ureteral Identification and Diagnosis

Although iatrogenic ureteral injury and its lack of recognition due to ureteral invisibility are serious incidents in open and laparoscopic abdominal surgeries, there are currently no safe and effective methods for intraoperative ureteral identification (IUI) and diagnosis (IUD). In this study, I designed and chemically synthesized a near-infrared fluorescence (NIRF) imaging probe (CD-NIR-1) and evaluated its clearance and ability for IUI and IUD in animal models. CD-NIR-1 demonstrated high specificity and ultrarapid clearance by rat kidneys to the urinary bladder following intravenous administration of a single dose (25 nmol/kg of body weight), with 96% of the dose ultimately excreted at the first urination with no chemical modification. Furthermore, urine containing CD-NIR-1 in ureters showed strong NIRF, thereby enabling IUI and IUD via NIRF imaging. These results demonstrated the efficacy of CD-NIR-1 for clinical use.

Observation vs. early drainage for grade IV blunt renal trauma: a multicenter study

INTRODUCTION

The aim of this study was to compare observation and early drainage by ureteral stenting in patients with blunt renal trauma and urinary extravasation.

MATERIALS AND METHODS

A retrospective national multicenter study was performed including all patients admitted for renal trauma at 17 hospitals between 2005 and 2015. Patients presenting with a urinary extravasation on initial imaging were considered for inclusion. Patients were divided in two groups according to the initial approach: observation vs. early drainage by ureteral stent (within 48 h after admission). The primary endpoint was the persistence of urinary extravasation on follow-up imaging.

RESULTS

Out of 1799 patients with renal trauma, 238 were included in the analysis (57 in the early drainage and 181 in the observation group). In the early drainage group, 29 patients had persistent urinary extravasation vs. 77 in the observation group (50.9% vs. 42.5%; p value = 0.27). The rates of secondary upper urinary tract drainage did not differ significantly between the early drainage group (26.4%) and the observation group (16%) (p = 0.14). There were no statistically significant differences between the two groups in terms of secondary nephrectomy (0% vs. 2.8%; p = 0.34), and death from trauma (0% vs. 1.8%; p = 0.99). In multivariate analysis, early drainage remained not statistically associated with persistence of urinary extravasation on follow-up imaging (OR = 1.35; p = 0.36) CONCLUSION: In this multicenter cohort, observation was not different from early drainage in terms of persistent urinary extravasation after grade IV blunt renal trauma. Further randomized controlled prospective trials are needed to confirm these findings.

Renal trauma: a 6-year retrospective review from a level 1 trauma center in Denmark

Background: Management of renal trauma injuries is shifting towards more conservative approaches in hemodynamically stable adult patients, even for high grade and/or penetrating trauma. The objective of this study was to analyze the patterns of injury, management and complications in renal trauma patients at a Danish university hospital with a level 1 trauma center.Method: Patients diagnosed with renal trauma at Rigshospitalet, Copenhagen, Denmark, between January 2010 and December 2015 were identified retrospectively by the ICD-10 code. Data were collected from electronic patient records. Imaging was classified by radiologists.Results: Out of 107 patients identified, blunt injuries comprised 93%. Median age was 28. The distribution of injury grade according to AAST was 20% grade I, 4% grade II, 33% grade III, 33% grade IV and 10% grade V. All patients with grade I-III were managed conservatively. Two patients were treated with angioembolization (1 with grade IV and 1 with grade V). Five patients with grade IV were treated with an internal ureteral stent and one patient with grade IV blunt trauma had an emergency nephrectomy performed. Overall complication rate was 7%. No patient died due to their renal injury. Renal function was normal in all patients at discharge, assessed by eGFR measurement. Of the 50% of patients who were followed up with a renography, none developed obstruction due to the renal trauma.Conclusion: The vast majority of renal injuries were due to blunt trauma. Hemodynamically stable patients, even with penetrating and/or high-grade blunt trauma, were managed non-operatively and there was a low rate of complications.