Outcome after major renovascular injuries: a Western trauma association multicenter report

Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma

CONTEXT

The European Association of Urology (EAU) Guidelines Panel for Urological Trauma has produced guidelines in order to assist medical professionals in the management of urological trauma in adults for the past 20 yr. It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients regarding other parameters such as experience and available facilities. Guidelines are not mandates and do not purport to be a legal standard of care.

OBJECTIVE

To present a summary of the 2023 version of the EAU guidelines on the management of urological trauma.

EVIDENCE ACQUISITION

A systematic literature search was conducted from 1966 to 2022, and articles with the highest certainty evidence were selected. It is important to note that due to its nature, genitourinary trauma literature still relies heavily on expert opinion and retrospective series.

EVIDENCE SYNTHESIS

Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 1, 2021 and April 29, 2022. A total of 1236 unique records were identified, retrieved, and screened for relevance.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of urological trauma.

PATIENT SUMMARY

Trauma is a serious public health problem with significant social and economic costs. Urological trauma is common; traffic accidents, falls, intrapersonal violence, and iatrogenic injuries are the main causes. Developments in technology, continuous training of medical professionals, and improved care of polytrauma patients reduce morbidity and maximise the opportunity for quick recovery.

[Clinical Role of Interventional Radiology in Abdominal Solid Organ Trauma]

Interventional management is commonly used for traumatic injuries to the abdominal solid organs. The American Association for the Surgery of Trauma (AAST) and the World Society of Emergency Surgery (WSES) recently published guidelines for the management and treatment of liver, spleen, and kidney injuries, emphasizing the importance of interventions. Here, we discuss the characteristics of each organ and the procedure method for each organ that interventional radiologists need to know when treating trauma patients.

Conservative treatment of blunt traumatic right renal venous pseudoaneurysm: A case report

Introduction

Venous pseudoaneurysm is uncommon in blunt trauma patients, and renal venous pseudoaneurysm is especially rare, even though renal trauma occurs in approximately 8–10 % of abdominal trauma cases. There is controversy regarding the modality of treatment between surgery, conservative care, and radiologic intervention to manage renal venous pseudoaneurysms. We would like to share our experience treating blunt trauma patients having renal venous pseudoaneurysm with conservative care.

Presentation of case

A 53-year-old female patient was transferred to our trauma center following a pedestrian accident. Contrast-enhanced abdominal computed tomography (CT) showed right renal injury (grade II) with partial infarction (approximately 30–40 %) and peri-renal hematoma confined to Gerota's fascia without extravasation, a 3 cm sized right renal venous pseudoaneurysm, and a liver laceration (grade III) with a small amount of perihepatic hemoperitoneum. Since her vital signs were stable, with no decrease in the hemoglobin level in the short-term follow-up laboratory test, we decided to treat the patient conservatively in the trauma intensive care unit without angioembolization or surgery. The patient was discharged on the 14th day after OR/IF surgery for a right distal tibiofibular fracture. On a CT scan performed 1 month after discharge, a peri-renal hematoma was no longer observed, and the renal venous pseudoaneurysm had nearly improved.

Discussion

Patients with renal arterial injury with unstable vital signs require surgery or angioembolization. Even if vital signs are stable, arterial pseudoaneurysms are more likely to rupture; therefore, surgery or angioembolization is required. In contrast, venous pseudoaneurysms can be managed conservatively compared to intervention or surgery in vitally stable patients because they have a lower possibility of rupture due to relatively low pressure.

Conclusion

Renal venous pseudoaneurysms are very rare. Surgery, conservative care, and radiologic intervention should be considered depending on the patient's condition. Because venous blood flow is slower than arterial blood flow, renal venous pseudoaneurysm can be treated with conservative care if there are no injuries requiring further management and if the patient's vital signs are stable.

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Renal venous pseudoaneurysm is very rare in blunt abdominal trauma.

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The choice of treatment modality among surgery, conservative care, and radiologic intervention for renal venous pseudoaneurysm remains controversial.

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Renal venous pseudoaneurysms can be treated with conservative care if there are no injuries that require further management and the patient's vital signs are stable.

Bilateral traumatic renal artery dissection managed by endovascular therapy

We present the case of post-traumatic bilateral renal artery injury with renal perfusion disorder, successfully treated by endovascular treatment. This therapeutic approach avoided the need for long-term dialysis by maintaining a sufficient renal function. This case is an illustration of the feasibility and the efficiency of endovascular treatment in severe post-traumatic renal artery lesions.

Epidemiology and management of isolated blunt renal artery injuries

BACKGROUND

Isolated blunt renal artery injury (BRAI) is uncommon. Treatment options include observation, nephrectomy, surgical reconstruction and endovascular stenting. Over the last decade, there has been an increasing use of angiointervention techniques in vascular trauma. Previous studies reported underutilization of endovascular stenting in BRAI, in favor of observation. The aim of this study was to examine the epidemiology and assess changes in the management of isolated BRAI over the last decade.

METHODS

Patients with BRAI identified from the National Trauma Data Bank (2016-2017). Deaths in the emergency department, transferral from outside hospital, and those with associated high-grade kidney injuries were excluded. Demographics, type of renal artery injury, and renal artery management were analyzed. Multivariate analysis was used to identify independent factors associated with isolated BRAI.

RESULTS

During the study period, there were 1,708,076 patients with blunt trauma and 873 (0.05%) of them had BRAI. After exclusions, 563 patients with isolated BRAI who met the criteria for inclusion in the analysis. Auto versus pedestrian mechanism and male sex were associated with the highest risk for isolated BRAI. Comorbidities, such as hypertension or diabetes, were not associated with an increased risk of BRAI. Seatbelt use had a protective effect against BRAI. In the majority of patients (534, 95%), the renal artery injury was treated with observation, 23 (4%) with nephrectomy, 5 (0.9%) with endovascular stent and 1 (0.2%) with open renal artery repair. Among the 103 patients with isolated major renal artery laceration, 91.2% were treated with observation, 7.8% with nephrectomy and 1% with stenting.

CONCLUSION

Isolated blunt renal artery trauma is rare. The vast majority of patients with BRAI is managed with observation with only a small number undergoing endovascular intervention. Endovascular stenting utilization has remained very low and has not changed in the last decade.

Damage Control for renal trauma: the more conservative the surgeon, better for the kidney

Urologic trauma is frequently reported in patients with penetrating trauma. Currently, the computerized tomography and vascular approach through angiography/embolization are the standard approaches for renal trauma. However, the management of renal or urinary tract trauma in a patient with hemodynamic instability and criteria for emergency laparotomy, is a topic of discussion. This article presents the consensus of the Trauma and Emergency Surgery Group (CTE) from Cali, for the management of penetrating renal and urinary tract trauma through damage control surgery. Intrasurgical perirenal hematoma characteristics, such as if it is expanding or actively bleeding, can be reference for deciding whether a conservative approach with subsequent radiological studies is possible. However, if there is evidence of severe kidney trauma, surgical exploration is mandatory and entails a high probability of requiring a nephrectomy. Urinary tract damage control should be conservative and deferred, because this type of trauma does not represent a risk in acute trauma management.

A bizarre case of fatal main renal artery partial laceration without primary kidney injury due to a single stab wound in the chest

Reno-vascular injuries are a rare type of renal injury, and their second most frequent cause is penetrating wounds. The majority of the reports and of the studies are present in the urological and radiological literature and they focus on the clinical approach to such injuries. In the case here presented, an 18-year-old male died after being stabbed in the left hemithorax. During body examination, thoracic organs were found to be unremarkable (except for a small peripheral laceration of the left lung), but the diaphragm was transfixed and the upper wall of the left main renal artery was lacerated. The adjacent renal vein, the kidney, the aorta, the vena cava and the surrounding internal structures were not damaged (except for a small laceration of the pancreatic tail). A massive haemothorax and a large retroperitoneal haematoma in the left kidney area were observed. The cause of death was attributed to haemorrhagic shock following a partial laceration of the left main renal artery due to the stab wound to the chest. No other cases of similar fatal renovascular injuries due to stab wounds have been published in the current forensic literature.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Contemporary management of pediatric high grade renal trauma: 10 year experience at a level 1 trauma centre

BACKGROUND

Current guidelines advocating the conservative management of renal injuries in children are primarily extrapolated from adult series due to a dearth of evidence in the pediatric population.

OBJECTIVES

The aim of this study was to review our experience in the management of pediatric high-grade renal trauma and to clarify the role of conservative management in this cohort of patients.

STUDY DESIGN

The Alberta Trauma Registry (ATR) is a comprehensive web-based registry which functions to prospectively collect data on all trauma patients in the province who sustain a severe injury (i.e. Injury Severity Score (ISS) ≥12). The ATR was used to identify all pediatric patients who attended hospitals within the Edmonton region with high grade renal injuries (grade III-V) between January 2006 and December 2018. Hospital records and imaging were reviewed to identify patient demographics, mechanism of injury, AAST grade, haemodynamic stability, associated injuries, management, length of hospital stay (LOS), complications, and follow-up outcomes.

RESULTS

A total of 53 children (38 boys, 15 girls) were identified with a mean age of 13 years (1-16). The mechanism of injury was blunt trauma in 92.5% (49/53) of cases (Supplementary Table). AAST grade distribution was 37.8% Grade III (20/53), 49% Grade IV (26/53) and 13.2% Grade V (7/53). All Grade III injuries were successfully managed conservatively. Overall 11 patients with Grade IV/V injuries required urological intervention (ureteral stenting (5 patients), angioembolization (4 patients), bladder washout with clot evacuation (1 patient), emergency nephrectomy (3 patients)). The overall renal salvage rate was 92.4% (49/53).

DISCUSSION

Our series confirms the safety of expectant management in high grade pediatric renal trauma. All grade III injuries in our study were managed conservatively without the need for intervention. This suggests that these injuries may be managed safely outside of designated trauma centres. One third of children with grade IV/V injuries required intervention. Therefore we recommend that patients with these injuries are transferred to specialized units with the capacity to provide such procedures if required.

CONCLUSION

This study supports the conservative management of pediatric renal trauma in the setting of high-grade injury. Expectant management was associated with acceptable rates of intervention and excellent renal salvage rates.

Traumatic renal artery dissection: from imaging to management

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

Long-Term Outcomes of Endovascular Stenting for Blunt Renal Artery Injuries with Stenosis: A Report of Five Consecutive Cases

BACKGROUND

Renal artery stenting is performed for renal artery injuries to preserve renal function and prevent renovascular hypertension. However, its indications are controversial and its long-term prognosis remains unknown. Here, we evaluate the characteristics and long-term outcomes of renal artery stenting for blunt renal artery injuries at our institution.

METHODS

We retrospectively reviewed patients with blunt renal artery injuries who had been treated with stenting over a 12-year period at our institution. Five patients (three men and two women) were included.

RESULTS

Trauma resulted from falls in three patients and motor vehicle accidents in two. All patients had experienced multiple injuries (median injury severity score, 24 [range, 16-48]; median revised trauma score, 5.9672 [4.0936-7.8408]; and median probability of survival, 0.689 [0.533-0.980]). All renal artery injuries involved stenosis because of traumatic arterial dissection or intimal tear; no cases of total occlusion were observed. No complications due to the intervention itself were observed. Although two patients developed reversible acute renal failure, none required long-term hemodialysis. One patient with renovascular hypertension was treated with antihypertensive agents for a month and subsequently became normotensive without further medication. All patients underwent postoperative computed tomography, which revealed no stent occlusion or renal atrophy. Renal scintigraphy for three patients demonstrated preserved differential renal function. All five patients survived.

CONCLUSIONS

Renal artery stenting for hemodynamically stable blunt renal artery injuries with stenosis is suggested to be safe and helps in avoiding long-term hemodialysis and renovascular hypertension.

Percutaneous renal artery revascularization after prolonged ischemia secondary to blunt trauma: pooled cohort analysis

PURPOSE

We aimed to identify factors related to technical and clinical success of percutaneous revascularization for blunt renal arterial trauma.

METHODS

All cases of percutaneous revascularization for blunt renal arterial trauma were searched in the available literature. We included a case of iatrogenic renal artery occlusion at our institution treated by percutaneous stenting 20 hours after injury. A pooled cohort analysis of percutaneous revascularization for blunt renal artery injury was then performed to analyze factors related to technical and clinical success. Clinical failure was defined as development of new hypertension, serum creatinine rise, or significant asymmetry in split renal function.

RESULTS

A total of 53 cases have been reported, and 54 cases were analyzed including our case. Median follow-up was 6 months. Technical success was 88.9% and clinical success was 75%. Of 12 treatment failures (25%), 66.7% occurred during the first postprocedure month. Time from injury to revascularization was not a predictor of clinical success (OR=1.00, P = 0.681). Renal artery occlusion was significantly associated with clinical failure (OR=7.50, P = 0.017) and postintervention antiplatelet therapy was significantly associated with treatment success (OR=0.16, P = 0.043). At 37-month follow-up, the stented renal artery in our case remained patent and the patient was normotensive with preserved glomerular filtration rate.

CONCLUSION

Percutaneous revascularization for blunt renal arterial injury resulted in relatively high technical and clinical success. Time-to-revascularization was independent of successful outcomes. Clinical success was significantly associated with a patent renal artery at the time of intervention and with postprocedure antiplatelet therapy.

Renal trauma

The kidney is the most commonly injured genitourinary organ, and renal involvement has been reported in 1–5% of all trauma cases. Two mechanisms of renal injury are described, namely blunt (direct blow to the kidney, rapid acceleration/deceleration or a combination) and penetrating (from stab or gunshot wounds), with blunt injuries being most common in the UK. It is important to keep an index of suspicion for renal trauma as given by the mechanism of the injury or in poly-trauma. Accurate assessment and resuscitation are vital in the initial management. Imaging with computed tomography is critical to the accurate grading of the injury and helps guide subsequent treatment. The approach to management of renal injuries has changed over time. During the past two decades, advances in cross-sectional imaging coupled with minimally invasive intervention strategies (like angiography, embolisation and ureteric stenting) for managing traumatic renal injuries have allowed increased renal preservation by reducing the need for major surgical intervention. Nowadays, the vast majority of blunt injuries (up to 95%) are managed conservatively with accumulated experience suggesting this is safe. However, there is still a role for open surgical exploration in patients with haemodynamic instability or those who fail initial conservative/minimally invasive management.

Laparotomy for blunt abdominal trauma-some uncommon indications

Trauma laparotomy after blunt abdominal trauma is conventionally indicated for patients with features of hemodynamic instability and peritonitis to achieve control of hemorrhage and control of spillage. In addition, surgery is clearly indicated for the repair of posttraumatic diaphragmatic injury with herniation. Some other indications for laparotomy have been presented and discussed. Five patients with blunt abdominal injury who underwent laparotomy for nonroutine indications have been presented. These patients were hemodynamically stable and had no overt signs of peritonitis. Three patients had solid organ (spleen, kidney) infarction due to posttraumatic occlusion of the blood supply. One patient had mesenteric tear with internal herniation of bowel loops causing intestinal obstruction. One patient underwent surgery for traumatic abdominal wall hernia. In addition to standard indications for surgery in blunt abdominal trauma, laparotomy may be needed for vascular thrombosis of end arteries supplying solid organs, internal or external herniation through a mesenteric tear or anterior abdominal wall musculature, respectively.

An update on urotrauma

PURPOSE OF REVIEW

The subject of genitourinary trauma was recently reviewed as an American Urologic Association guideline as well as recently updated as a European Association of Urology guideline. These guidelines, while complete and authoritative, deserve review, amplification and clarification. Also, notably absent from the guidelines is a section on the management of renovascular injuries, which will be reviewed here.

RECENT FINDINGS

In the 2014, the American Urologic Association and updated European Association of Urology guidelines were published with highlighted features or changes described here.

SUMMARY

We report the updated features of the guidelines as well as sections of update from our own experiences in which the guidelines remain vague or are absent.

The incidence of long-term hypertension in children after high-grade renal trauma

INTRODUCTION

It is generally accepted that there is a risk of hypertension after renal trauma, particularly in high-grade and devascularizing injuries. Hypertension following renal trauma is estimated to occur in five percent of adults, however, the incidence is unknown in the pediatric population.

MATERIALS AND METHODS

We performed a retrospective review of all pediatric trauma patients at Primary Children's Hospital in Salt Lake City, Utah between 2002 and 2012. We included all children age ≤17years old with American Association for Surgery of Trauma (AAST) grade 3-5 renal injury. Hypertension was defined as persistent hypertension that required anti-hypertensive medications. Our primary outcomes were incidence of hypertension during the acute trauma and in long-term follow.

RESULTS

A total of 62 children were identified with AAST grade 3-5 renal injuries during our study period. Follow up blood pressures were recorded in 36 (58%) of these children with a median follow of 4.1years (IQR 2.1-5.1years) after trauma. Four children (6.5%) were identified to have some degree of hypertension while hospitalized after trauma and started on anti-hypertensive medication. Two out of these four children remained on hypertensive medication at follow up, while the remaining two children's hypertension resolved. No children who were normotensive in the immediate post-trauma period, developed delayed hypertension during long-term follow up.

CONCLUSIONS

There is a low risk of developing hypertension following severe renal trauma in the pediatric population. Patients who develop long-term problems with hypertension after renal trauma manifest it during the initial hospitalization, rather than subsequently during the long-term.

Management of blunt renal trauma

Non-operative management of renal injuries has gained acceptance in the past few decades. We report our experience of the management of blunt renal trauma at our hospital between January 2007 and July 2014. This study illustrates that non-operative treatment of major renal lacerations with or without urinary extravasation is safe and effective in haemodynamically stable patients. A significantly higher rate of double J stent insertions was deployed in this study for injuries with significant extravasation, which did not have any detrimental effect and an overall excellent outcome was observed.

Traumatic renal vein pseudoaneurysm

Traumatic renal injury is infrequent, occurring in ∼1% to 3% of trauma cases, with major renal vein injury an even more rare traumatic entity. Conservative, operative, and endovascular management strategies have been infrequently reported in the literature. We report a patient with traumatic renal vein injury with pseudoaneurysm formation that was successfully treated with endovascular stenting.

Salvageability of kidney in Grade IV renal trauma by minimally invasive treatment methods

Context:

Renal trauma is increasingly being managed conservatively. Grade I-III injuries are managed conservatively whereas Grade V injuries may end in surgery. Managing Grade IV renal trauma is individualized and managed accordingly.

Aims:

To evaluate retrospectively all Grade IV renal injuries managed in our institute over five years and to review the available literature.

Settings and Design:

Reviewing the records of patients who sustained renal trauma and study all Grade IV renal injuries.

Materials and Methods:

We retrospectively analyzed all Grade IV renal injuries (16) managed at our institute between July 2008-August 2013. All patients were treated conservatively initially by hemodynamic stabilization, strict bed rest, if required endoscopic procedures. These patients were followed up with CECT.

Statistical analysis:

Descriptive statistics was performed using Microsoft excel spreadsheet 2007. Continuous data were described as mean and range. Categorical data was described as percentages.

Results:

Sixteen patients with Grade IV renal injury were included in the study. All patients had gross hematuria and 15 had urinary extravasation. D-J Stenting was done in 7 patients; perinephric tube drainage with D-J stentingwas done in 2 patients. One required selective upper pole arterial embolisation. Nephrectomy was not required in any of the patients. In the follow-up period, no patient had delayed complications.

Conclusions:

Successful conservative management of Grade IV renal trauma requires constant monitoring both clinically and radiologically, and if properly managed, kidneys can be salvaged in all stable patients as reinforced by our study.

Endovascular intervention in renovascular disease: a pictorial review

Interventional radiologic procedures offer a significant and expanding role in the management of various renovascular diseases including renal artery stenosis, renal artery aneurysm and pseudoaneurysm, renal vascular malformations, renal tumours, trauma, and resistant hypertension. In this article, we discuss these entities in the context of currently accepted definitions, incidence, modes of diagnosis, and management as they pertain to the practice of interventional radiology. Particular emphasis is placed on current interventional procedures for managing and treating these diseases as well as emerging procedures and technologies.

• Highlights the literature on renovascular diseases

• Reviewing the role of various interventional procedures in the management of renovascular disease

• Review of imaging techniques in the identification and characterisation of renovascular disease

Advances in renal intervention for trauma

Renal trauma is predominantly secondary to blunt trauma and is managed nonoperatively. Endovascular interventions are reserved for patients with a significant vascular injury recognized early. Renal injuries are uncommon among intra-abdominal injuries and account for a minority of injuries treated by the vascular specialist.

Effect of renal angioembolization on post-traumatic acute kidney injury after high-grade renal trauma: a comparative study of 52 consecutive cases

BACKGROUND

Acute kidney injury (AKI) is associated with unfavourable outcomes and higher mortality after trauma. Renal angioembolization (RAE) has proved efficiency in the management of high-grade renal trauma (HGRT), but inevitably expose to unavoidable ischaemic areas or contrast medium nephrotoxicity which may impair renal function in the following hours. The aim of this study was to assess the potential acute impact of RAE on renal function in a consecutive series of HGRTs treated nonoperatively.

MATERIALS AND METHODS

Of 101 cases of renal trauma admitted to our Regional Trauma Center between January 2005 and January 2010, 52 cases of HGRT were treated nonoperatively; they were retrospectively classified into 2 groups according to whether RAE was used. Incidence and progression of AKI (RIFLE classification), maximum increase in serum creatinine (SCr), level since admission and recovery of renal function at discharge were compared between the groups. Multivariable analysis was performed to determine the role of RAE as an independent risk factor of AKI.

RESULTS

RAE was performed in 10 patients within the first 48h. The RAE and no RAE groups were comparable in terms of severity score, renal injury grade, and level of SCr on admission. AKI incidence (RIFLE score Risk or worse) after 48 and 96h was 33% and 10%, respectively and did not differ significantly between groups at 48h (p=1.00) or 96h (p=1.00). The median maximum increase in SCr was significantly higher in no RAE than RAE group (30.4% vs. 6.9%, p=0.04). RAE was not found to be a significant variable in a multiple linear regression analysis predicting maximum SCr rise (p=0.34). SCr at discharge was >120% of baseline in only 5 patients, with no difference according to RAE (p=0.24).

CONCLUSION

In a population of nonoperatively treated HGRT, the incidence of AKI decreased from almost 30% to 10% at 48h and 96h. RAE proceeding did not seem to affect significantly the occurrence and course of AKI or renal recovery. The decision to use RAE should probably not be restricted by fear of worsening renal function.

Management of giant posttraumatic abdominal aortic pseudoaneurysm and aortic occlusion using a unique hybrid procedure combining transcatheter device closure and open surgical repair

Posttraumatic abdominal aortic pseudoaneurysm (AAP) is a rare but life-threating disease. Here, we described a case of posttraumatic AAP with acute abdominal aortic occlusion and its successful treatment using a unique hybrid procedure. An 18-year-old male was referred, with a giant AAP among visceral arteries, which occluded the aorta and left renal artery. An infrequently used ventricular septal device was delivered via femoral access and successfully plugged the tear. Then the isolated pseudoaneurysm was resected through open surgery without major bleeding. At 6 months after operation, the patient was alive without evidence of complications. This hybrid procedure combining transcatheter device closure and open surgery was a successful attempt in the subemergency treatment of posttraumatic AAP.

Death or Dialysis? the Risk of Dialysis-Dependent Chronic Renal Failure after Trauma Nephrectomy

Although renal trauma is increasingly managed nonoperatively, severe renovascular injuries occasionally require nephrectomy. Long-term outcomes after trauma nephrectomy are unknown. We hypothesized that the risk of end-stage renal disease (ESRD) is minimal after trauma nephrectomy. We conducted a retrospective review of the following: 1) our university-based, urban trauma center database; 2) the National Trauma Data Bank (NTDB); 3) the National Inpatient Sample (NIS); and 4) the U.S. Renal Data System (USRDS). Data were compiled to estimate the risk of ESRD after trauma nephrectomy in the United States. Of the 232 patients who sustained traumatic renal injuries at our institution from 1998 to 2007, 36 (16%) underwent a nephrectomy an average of approximately four nephrectomies per year. The NTDB reported 1780 trauma nephrectomies from 2002 to 2006, an average of 356 per year. The 2005 NIS data estimated that in the United States, over 20,000 nephrectomies are performed annually for renal cell carcinoma. The USRDS annual incidence of ESRD requiring hemodialysis is over 90,000, of which 0.1 per cent (100 per year) of renal failure is the result of traumatic or surgical loss of a kidney. Considering the large number of nephrectomies performed for cancer, we estimated the risk of trauma nephrectomy causing renal failure that requires dialysis to be 0.5 per cent. National data regarding the etiology of renal failure among patients with ESRD reveal a very low incidence of trauma nephrectomy (0.5%) as a cause; therefore, nephrectomy for trauma can be performed with little concern for long-term dialysis dependence.

Bilateral traumatic renal artery dissection

We present a case of bilateral renal artery dissection, with the related computed tomographic images, caused by blunt torso trauma. Discussion includes the etiologies of this type of injury, the diagnostic modalities, and treatment options.

[Functional damages after blunt renal trauma in children]

PURPOSE

The purpose of this study was to determine the long-term functional outcome of renal injuries.

METHODS

We retrospectively reviewed the charts of patients under 16 sustaining renal trauma and admitted to our department between 1990 et 2010. There were 66 renal lesions categorized as follows: grade I to III, 33, grade IV, 28 and grade V, 5. Whatever their initial status, all children were followed using ultrasonography or computed tomography. After complete healing, data of technetium-99m-dimercaptosuccinic acid nuclear were collected.

RESULTS

There was no bilateral injury. Thirteen patients proceeded to laparotomy leading to nephrectomy in three cases, partial nephrectomy in two others cases. Four renovascular injuries required interventional radiologic management. Nine urinomas were managed with eight stentings and one percutaneous drainage. Percentage of renal function by technetium-99m-dimercaptosuccinic acid nuclear scanning concerning 26 patients was analysed. Split percentage of renal function was 43.4% (±6.2%), 35.7% (±5.3%) et 30.3% (±12.2%) (mean±SD); P=no significant, for grade I-III, IV and V, respectively.

CONCLUSION

Functional outcome after blunt renal trauma appeared influenced by injury grade. Functional sequelae existed even with low-grade traumas. In keeping with literature, these results justified a close follow-up in which radionuclide study was the essential element.

Routine follow-up imaging of kidney injuries may not be justified

BACKGROUND

The purpose of this investigation was to determine the yield of repeat follow-up imaging in patients sustaining renal trauma.

METHODS

The Los Angeles County+University of Southern California Medical Center trauma registry was reviewed to identify all patients with a diagnosis of kidney injury from 2005 to 2008. All final attending radiologist interpretations and the dates of the initial and follow-up computerized tomography (CT) scans were also reviewed. Grades I, II, and III were grouped as low-grade injuries and grades IV and V as high-grade injuries.

RESULTS

During the 4-year study period, 120 (1.2% of all trauma admissions) patients had a total of 121 kidney injuries: 85.8% were male, and the mean age±SD was 31.1 years±14.5 years. Overall, 22.6% of blunt and 35.6% of penetrating kidney injuries were high grade (IV-V; p=0.148). These high-grade injuries were managed operatively in 35.7% and 76.2% of blunt and penetrating injuries, respectively, (p=0.022). Overall, 31.7% underwent at least one follow-up CT; 24.2% of patients with blunt and 39.7% of patients with penetrating kidney injury, respectively. None of the patients with a low-grade injury managed nonoperatively developed a complication, independent of the injury mechanism. High-grade blunt and penetrating kidney injuries managed nonoperatively were associated with 11.1% and 20.0% complication rate identified on follow-up CT, respectively. For patients who underwent surgical interventions for penetrating kidney injuries, the diagnosis of the complication was made at 9.8 days±7.0 days (range, 1-24 days), with 83.3% of them diagnosed within 8 days postoperatively. The most frequent complication identified was an abscess in the renal fossa (50.0% of all complications). Other complications included urinoma, ureteral stricture, and pseudoaneurysm. All patients who developed complications were symptomatic, prompting the imaging that led to the diagnosis. All patients who developed a complication after a penetrating injury required intervention for the management of the complication.

CONCLUSION

Selective reimaging of renal injuries based on clinical and laboratory criteria seems to be safe regardless of injury mechanism or management. High-grade penetrating injuries undergoing operative intervention should carry the highest degree of vigilance and lowest threshold for repeat imaging.

Abordagem do trauma renal - artigo de revisão: review of the literature

A incidência de traumatismo é uma realidade crescente nos dias de hoje. O acometimento dos reina ocorre em cerca de 10% dos pacientes com trauma abdominal fechado ou penetrante, podendo elevar muito a morbimortalidade quando não bem conduzido. Os autores fizeram um levantamento de artigos recentes para esclarecimentos no diagnóstico e na conduta no traumatismo renal, desde os detalhes anatômicos até o tratamento definitivo. A correta condução do paciente é fundamental para a preservação e manutenção da função do órgão, sobretudo da vida, após o evento traumático.

A 10-year review of blunt renal artery injuries at an urban level I trauma centre

INTRODUCTION

Little consensus exists over the management of high-grade renal injuries, with continued debate over observation versus invasive surgery. Blunt renal artery injury (BRAI) is a high-grade injury that may result in renal dysfunction, hypertension, or failure.

MATERIALS AND METHODS

Management of BRAI at a level I trauma centre during a decade was retrospectively reviewed to determine incidence, assess management strategy, and evaluate hospital outcomes. Data collected included demographics, injury details, standardised scoring, renal injury grade, haemodynamic stability, diagnostic modalities, medical interventions, mortality, and hospitalisation length.

RESULTS

Thirty-eight BRAI patients (21 Grade IV and 17 Grade V injuries) were admitted, representing 0.16% of trauma admissions, and consisting primarily of young males. Ultrasonography and CT was performed in 92.1% and 76.3% of patients, respectively. Primary management included exploratory laparotomy in 42.9%, angiography and embolisation in 34.3%, and observation in 22.9%. Six nephrectomies and one revascularisation were performed. The incidence of BRAI and use of angiography are higher than those reported in previous studies.

CONCLUSION

Over the past decade, increased use of CT as a diagnostic tool for confirming renal injury in haemodynamically stable patients at our institution may have contributed to the increase in BRAI detection. Higher utilisation of angiography has enabled a more conservative approach. In this series, angiography had a success rate of 94.4%. Angiography and embolisation or observation with careful monitoring are viable management options in haemodynamically stable patients with isolated BRAI.

Hand-assisted laparoscopic partial nephrectomy combined with caliceal ureterostomy for the treatment of post-traumatic ureteropelvic junction disruption

Ureteropelvic junction (UPJ) disruption seldom occurs in patients with blunt abdominal trauma. The diagnosis of UPJ disruption is delayed in more than 50% of patients, and it can lead to difficulty in further treatment or increase the risk of nephrectomy. We present a 25-year-old man who was found to have left UPJ disruption 2 months after blunt abdominal trauma and who was successfully treated by partial nephrectomy combined with caliceal ureterostomy under hand-assisted laparoscopy. We review the literature and discuss the possible images to help early diagnosis of UPJ disruption. As a reconstructive procedure, caliceal ureterostomy under hand-assisted laparoscopy can be an effective and facilitated option.

Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.

Renal arterial injuries: a single center analysis of management strategies and outcomes

PURPOSE

Management of main and segmental renal artery injury following external trauma is controversial. After main renal artery injury the controversy surrounds nephrectomy vs revascularization, whereas after segmental renal artery injury the debate involves operative vs nonoperative management. We reviewed our experience with renal artery injury management at a single trauma center with the goal of identifying optimal clinical management strategies.

MATERIALS AND METHODS

Data on a total of 82 renal artery injuries in 81 patients collected between 1978 and 2006 were retrospectively reviewed. Patient demographics, length of stay, transfusion requirements and injury characteristics (artery subtype, grade, mechanism, and associated parenchymal, venous and nonrenal injuries) were recorded. Management strategies and outcomes for each renal artery injury subtype were compared.

RESULTS

Median patient age was 28 years (range 4 to 74) and 90% of the patients were male. Main renal artery injury occurred in 36 of 81 patients (43%) and segmental renal artery injury occurred in 45 (57%). Injury characteristics were similar for each renal artery injury subtype. For main renal artery injury the respective outcomes of nephrectomy vs vascular repair were a mean transfusion of 10,275 vs 6,125 ml (p = 0.39), length of stay 18 days for each, mortality rate 26% vs 13%, renal failure rate 8% vs 25% and renal insufficiency/impaired selective function by renal scintigraphy 4% vs 13% (each p not significant). For segmental renal artery injury operative vs nonoperative management was associated with a mean transfusion of 4,994 vs 820 ml (p = 0.01), length of stay 29 vs 11 days (p = 0.23) and mortality rate 8% vs 6% (p = 1.0). Renal failure and impaired selective renal function on scintigraphy were similar between the groups.

CONCLUSIONS

Nephrectomy for main renal artery injury has outcomes similar to those of vascular repair and it does not worsen posttreatment renal function in the short term. Nonoperative management for segmental renal artery injury results in excellent outcomes.

Urinary tract injuries in patients with multiple trauma

This article mainly reviews urinary tract injuries in patients with multiple trauma. Approximately 10% of all traumatic injuries resulting from an external force will involve the genitourinary system. The article discusses mechanisms of injury, diagnosis, and therapeutical approaches for renal, ureteral, bladder, and urethral trauma. Due to the complexity of such injuries--despite several attempts to provide a standard strategy in trauma patients with urinary tract involvement--an individual and patient-specific-therapeutic approach is mandatory in most cases. However, the availability of classified guidelines may help the surgeon to reach the most accurate decision. Because of the similarity of American and European guidelines on urological trauma, this article adapts injury severity scales and classification from the American Association for the Surgery of Trauma.