The conservative management of renal trauma: a literature review and practical clinical guideline from Australia and New Zealand

Trauma resulting in rare avulsion-type renal injury and lobe migration: An uncommon case report

In this case report, we discuss a rare incident of avulsion-type renal injury in a 24-year-old male with no significant medical history. The injury occurred during a traffic accident, where he was involved in a direct impact collision between a motorcycle and a vehicle, leading to altered corticomedullary differentiation in the right kidney, a retroperitoneal hematoma, and free fluid in the cavity. The patient underwent successful emergency abdominal surgery, which involved the removal of the damaged kidney due to the severity of the injury. During his postoperative recovery in the ICU, he received extensive care, including sedation, mechanical ventilation, and vasopressor support. Ultimately, he made a successful recovery and was discharged after rehabilitation. This case highlights the complexities involved in managing patients with renal injuries resulting from high-energy impact accidents. It emphasizes the importance of a multidisciplinary approach in treatment, the challenges associated with deciding on surgical intervention, and the significance of rehabilitation in patient recovery. The uniqueness of this case, characterized by its distinct mechanism of injury and the severity of the trauma, contributes to our broader understanding of renal trauma management in the field of trauma medicine. It underscores the need for personalized patient care strategies and emphasizes the effectiveness of surgical interventions in severe cases of renal trauma.

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.

Tc-99m DMSA SPECT for Follow-Up of Non-Operative Treatments in Renal Injuries: A Prospective Single-Center Study

OBJECTIVE

The assessment of cortical integrity following renal injuries with planar Tc-99m dimercaptosuccinic acid (DMSA) scintigraphy depends on measuring relatively decreased cortical uptake (i.e., split renal function [SRF]). We analyzed the additive values of the volumetric and quantitative analyses of the residual cortical integrity using single-photon emission computed tomography (SPECT) compared to the planar scintigraphy.

MATERIALS AND METHODS

This prospective study included 47 patients (male:female, 32:15; age, 47 ± 22 years) who had non-operatively managed renal injuries and underwent DMSA planar and SPECT imaging 3-6 months after the index injury. In addition to planar SRF, SPECT SRF, cortical volume, and absolute cortical uptake were measured for the injured kidney and both kidneys together. The correlations of planar SRF with SPECT SRF and those of SRF with volumetric/quantitative parameters obtained with SPECT were analyzed. The association of SPECT parameters with renal function, grades of renal injuries, and the risk of renal failure was also analyzed.

RESULTS

SPECT SRF was significantly lower than planar SRF, with particularly higher biases in severe renal injuries. Planar and SPECT SRF (dichotomized with a cutoff of 45%) showed 19%-36% of discrepancies with volumetric and quantitative DMSA indices (when dichotomized as either high or low). Absolute cortical uptake of the injured kidney best correlated with glomerular filtration rate (GFR) at follow-up (ρ = 0.687, P < 0.001) with significant stepwise decreases by GFR strata (90 and 60 mL/min/1.73 m²). Total renal cortical uptake was significantly lower in patients with moderate-to-high risk of renal failure than those with low risk. However, SRF did not reflect GFR decrease below 60 mL/min/1.73 m² or the risk of renal failure, regardless of planar or SPECT (count- or volume-based SRF) imaging.

CONCLUSION

Quantitative measurements of renal cortical integrity assessed with DMSA SPECT can provide more clinically relevant and comprehensive information than planar imaging or SRF alone.

Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study

PURPOSE

To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management.

METHODS

We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery).

RESULTS

Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found.

CONCLUSION

Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

Imaging modalities and management of pediatric high-grade renal trauma in an Indonesian tertiary hospital: a report of two cases and literature review

As one of the most commonly injured organs in the genitourinary system during trauma, a thorough understanding of pediatric renal trauma's diagnosis and management is essential for physicians. The improvement of imaging modalities in recent years has shifted most treatments to a conservative approach. Non-operative management could reduce the risk of nephrectomy while increasing renal salvage rate. However, high-grade pediatric renal injury management remains controversial. We aimed to report two children with high-grade renal trauma, diagnosed using computed tomography and retrograde pyelography studies, undergoing different approaches. The first patient underwent a nephrectomy, whereas the second patient underwent non-operative management.

Implementation of a Standardized Renal Trauma Protocol at a Level 1 Trauma Center: 7-Year Protocol and 10-Year Institutional Review

Objective

Current urologic renal trauma guidelines favor conservative management. In 2012, we implemented an institution-wide renal trauma protocol to standardize management. This protocol details initiation of DVT (deep vein thrombosis) prophylaxis, cessation of bed rest, and frequency of laboratory studies. We hypothesized that low-grade injuries (grade I–III) could be managed without urologic consultation and that our chemical DVT prophylaxis regimen would not pose an increased risk of hemorrhage requiring transfusion.

Methods

We performed a cross-sectional analysis of a prospectively maintained database containing all renal trauma at our institution from 2009 to 2019. We segregated injuries based on grade, presence of multi-organ trauma, and evaluated the presence and types of intervention, initiation of chemical DVT prophylaxis, and post-DVT prophylaxis hemorrhage requiring transfusion.

Results

We identified 295 cases of renal trauma, of which 62 were isolated injuries. Forty-three of the isolated renal injuries were transferred from outside facilities, 70% of which were classified as low-grade injuries. There were 220 low-grade lacerations and 75 high-grade lacerations. No grade I or II lacerations required any interventions. Two (2.5%) grade III lacerations required IR embolization. Twenty-five (41%) grade IV lacerations required intervention, of which five were nephrectomy. Seven (54%) grade V lacerations required intervention, of which 5 were nephrectomies. Upon review of our protocol with early ambulation and DVT prophylaxis, there were no cases of isolated renal injury where initiation of either treatment resulted in delayed hemorrhage requiring transfusion or surgical intervention.

Conclusion

Only 2/220 low-grade renal lacerations required intervention. Our data suggest that grade I and II renal lacerations can be managed safely without urologic consultation. Consultation is warranted for grade III injuries given the possibility of initial understaging. Furthermore, we believe our renal laceration protocol in our admittedly small, isolated sample has shown our DVT prophylaxis initiation to not pose increased risk.

High grade renal trauma: Does the mechanism of penetrating injury influence renal salvage rate?

BACKGROUND

Most of the data on high grade Traumatic renal injuries (TRI) has come from centres which predominantly encounter blunt trauma. Blunt and penetrating mechanisms are not analogous, and it is imprudent to blindly extrapolate management strategies between the two groups. In addition, within the broad group of penetrating mechanisms of injury there are also major differences between gunshot wounds (GSW) and stab wounds (SW). The aim of this comparative study of GSW and SW to the kidney is to quantify the impact of the mechanism of injury on nephrectomy rate in high grade TRI.

METHODS

A prospective trauma registry was interrogated retrospectively. All patients sustaining a high grade (Grade III to V) penetrating TRI were included. The diagnosis was made either with cross-sectional imaging or intra-operative findings. The nephrectomy rate of the different mechanisms of penetrating (GSW vs SW) TRI was compared in each grade.

RESULTS

A total of 28 GSW and 27 SW causing high grade TRIs (Grade III-V) were included over the 85 months of the study. GSW lead to a higher nephrectomy rate than SWs 50.0 vs 19%, (p = 0.023). When comparing grade for grade, Grade III: 20.0 (GSW) vs 21% (SW), (p = 1). Grade IV: 71 (GSW) vs 17%, (SW) (p = 0.058) and Grade V: 100 (GSW) vs 0%, (SW) (p = 0.28). When comparing Grade IV - V together, the difference is 85 (GSW) vs 15%, (SW) (p = 0.001).

CONCLUSION

On a grade to grade comparison GSWs have a much higher risk for nephrectomy than SW's in grade IV and V TRI. TRI secondary to GSWs appears to be an independent risk factor for nephrectomy in high grade injuries. The mechanism of penetrating TRI should be considered in future management algorithms and clinical approaches.

Role of Emergent Nephrectomy for Grade V Blunt Renal Injuries

Case series

Patients: Male, 18-year-old • Female, 21-year-old

Final Diagnosis: Grade V renal laceration

Symptoms: Abdominal pain • flank pain

Medication: —

Clinical Procedure: Nephrectomy

Specialty: Surgery

“Bullet colic” following renal gunshot wound

Selective non-operative management for penetrating injuries to the kidney is widely accepted. The management of a retained projectile within the kidney remains unclear. We present a case of bilateral renal gunshot wound (GSW) which was managed non-operatively. The patient presented with a peculiar complication of renal colic due to a migrated projectile 5 months post injury. Retained projectiles within the renal collecting system have a risk for stone formation and migration.

Review of Multimodality Imaging of Renal Trauma

Blunt trauma accounts for more than 95% of traumatic renal injury and results from shear forces from rapid acceleration or deceleration and/or collision against the spine or ribs. The use of multiphasic contrast-enhanced computed tomography (CT) has proven pivotal in the evaluation and management of traumatic kidney injury, and CT imaging features provide the basis for nonsurgical staging. This article describes the epidemiology and mechanisms of blunt and penetrating traumatic renal injury and reviews the range of findings from various imaging modalities, with a particular emphasis on contrast-enhanced CT.

Outcome of angioembolization for blunt renal trauma in haemodynamically unstable patients: 10-year analysis of Queensland public hospitals

BACKGROUND

The aim of the study was to evaluate whether angioembolization is an appropriate alternative method for the management of blunt renal trauma in haemodynamically unstable patients.

METHODS

A retrospective analysis was conducted from 2002 to 2012 at three tertiary trauma hospitals in the state of Queensland. Patients who had blunt renal trauma and underwent renal angioembolization or had a trauma nephrectomy were identified using patient records and operating theatre and interventional radiology databases. The inclusion criteria were - haemodynamically unstable patients with blunt renal trauma treated with angioembolization, above the age of 16 years. Patients who underwent angioembolization for other causes such as: penetrating renal trauma, post-procedure, renal tumours, renal angiomyolipomas or arteriovenous malformations were excluded. Patients below the age of 16 were also excluded. Post-embolization renal function, blood pressure, morbidity and mortality were analysed using the paired t² test.

RESULTS

A total of 668 renal trauma patients were identified during this period. Sixteen patients underwent angioembolization for blunt renal trauma. Post-procedure renal function normalized without any hypertension with the median follow up being 4 months. Four patients had post-embolization complications including a urinoma, two devascularized kidneys and one ureteric stricture requiring nephrectomy. There was no mortality.

CONCLUSION

Selective angioembolization, where feasible, is an alternative method in the management of haemodynamically stable patients with blunt renal trauma maximizing nephron sparing and producing acceptable long-term outcomes with avoidance of the morbidity of trauma nephrectomy. This is the first study that we know of in Australia analysing the outcome of angioembolization for blunt renal trauma.

Kidney and uro-trauma: WSES-AAST guidelines

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.

Spontaneous renal hemorrhage: critical analysis of different lines of management in non-traumatic patients: a single tertiary center experience

PURPOSE

To assess clinical presentation and outcomes of different treatment strategies in cases of spontaneous renal hemorrhage (SRH).

METHODS

A retrospective analysis of patients with SRH between 2000 and 2018 was performed. Patients' demographics, clinical presentation, laboratory and radiological investigations, and different lines of treatment were retrieved. The primary outcome was to assess the predictors of the success of conservative treatment. The secondary outcome was to assess the long-term renal function outcome comparing serum creatinine, e GFF, and CT-assessed renal volume at last follow-up with baseline values.

RESULTS

The study included 42 (23 males and 19 women) patients with mean ± SD age was 48.1 ± 17.8 years. Conservative management was successful in 19 (46%) patients. Trans-arterial embolization (TAE) was performed in 13 patients (30%) to control active bleeding. Ten patients (25%) required surgical exploration and nephrectomy. Lower serum creatinine (P = 0.003), higher prothrombin concentration (P = 0.04), lower hematoma size (P = 0.02), and non-AML lesions (P = 0.03) were independent predictors of conservative management success. Unlike the TAE-treated group, serum creatinine increased significantly (P = 0.04) with a significant decrease in e-GFR (P = 0.02) and renal volume (P < 0.001) of affected kidneys at last follow-up after conservative treatment.

CONCLUSION

Although SRH is a life-threatening condition, conservative treatment is successful in a certain subset of patients. However, it is associated with significant deterioration of the affected kidney function as well as renal volume.

High grade renal trauma management: a survey of practice patterns and the perceived need for a prospective management trial

Background

To evaluate the current practice patterns of practitioners managing high grade renal trauma and determine perceived need for a prospective trial on the management of renal trauma.

Methods

We distributed an electronic survey to members of the American Association for the Surgery of Trauma (AAST) and The Society of Genitourinary Reconstructive Surgeons (GURS). The survey evaluated demographics, interventional radiology (IR) access, and renal trauma management. Descriptive statistics were utilized to analyze participants' responses.

Results

A total of 253 practitioners responded (age 48.4±10.4 years). The majority were acute care/trauma surgeons (ACS/TS) (63.2%), followed by urologists (34.4%) practicing at level 1 trauma centers (80.6%) in 39 US states. Most participants were in practice >10 years (62.8%); and had completed an ACS/TS (53.8%), or trauma/reconstructive urology (25.7%) fellowship. Ninety-five percent (241/253) found value in renal preservation with 74% utilizing IR embolization in the last year. However, there was wide variation in threshold for angiography, low rates of renal repair (24%) or packing (20%) and half reported performing a nephrectomy within the prior year. More than 80% believed there was value in a prospective trial to evaluate a protocol to decrease nephrectomy rates in renal trauma management.

Conclusions

The majority of respondents had access to IR, reported comfort in renorrhaphy, and valued renal preservation. There was variation in thresholds for bleeding intervention, and nephrectomy was still a common management strategy. There is great interest among trauma surgeons and urologists for a prospective trial of renal trauma management aimed at decreasing nephrectomy when possible.

The American Association for the Surgery of Trauma Organ Injury Scale 2018 update for computed tomography-based grading of renal trauma: a primer for the emergency radiologist

The most widely used trauma injury grading system is the Organ Injury Scale (OIS) by the American Association for the Surgery of Trauma (AAST). The AAST OIS for renal trauma was revised in 2018 to reflect necessary updates based on decades of experience with computed tomography (CT)-based injury diagnosis and, specifically, to better incorporate vascular injuries, which were not comprehensively addressed in the original OIS. In this review article, we describe CT findings of the AAST OIS for the kidney according to the 2018 revision, with an emphasis on real-world application, and highlight important differences from the prior grading scheme. Routine use of this grading system allows for a standardized classification of the range of renal injuries to aid in management, adding value in the imaging care of trauma patients.

Value of early repeated abdominal CT in selective non-operative management for blunt bowel and mesenteric injury

OBJECTIVES

To evaluate the performance of an early repeated computed tomography (rCT) in initially non-operated patients with blunt bowel and mesenteric injuries (BBMI).

METHODS

This was a monocentric retrospective observational study from 2009 to 2017 of patients with a BBMI on initial CT (iCT). Patients initially non-operated on were scheduled for a rCT within 48 h. Initial CT and rCT diagnostic performance were compared based on a surgical injury prediction score previously described. For statistical analysis, we used the chi-square analyses for paired data (McNemar test).

RESULTS

Eighty-four patients (1.9% of trauma) had suspected BBMI on iCT. Among these patients, 22 (26.2%) were initially operated on, 18 (21.4%) were later operated on, and 44 (52.4%) were not operated on. The therapeutic laparotomy rate was 85%. Thirty-four patients initially non-operated on had a rCT. The absolute value of the CT scan score increased for 15 patients (44.1%). The early rCT diagnostic performance, compared with iCT, showed an increase in sensitivity (from 63.6 to 91.7%), in negative predictive value (from 77.4 to 94.7%), and in AUC (from 0.77 to 0.94).

CONCLUSION

In initially non-operated patients with BBMI lesions, the performance of an early rCT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for non-operative treatment.

KEY POINTS

• Selective non-operative treatment for hemodynamically stable patients with blunt bowel and/or mesenteric injuries on CT is developing but remains controversial. • An early repeated CT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for conservative treatment.

Renal trauma: the current best practice

The kidneys are the most vulnerable genitourinary organ in trauma, as they are involved in up to 3.25% of trauma patients. The most common mechanism for renal injury is blunt trauma (predominantly by motor vehicle accidents and falls), while penetrating trauma (mainly caused by firearms and stab wound) comprise the rest. High-velocity weapons impose specifically problematic damage because of the high energy and collateral effect. The mainstay of renal trauma diagnosis is based on contrast-enhanced computed tomography (CT), which is indicated in all stable patients with gross hematuria and in patients presenting with microscopic hematuria and hypotension. Additionally, CT should be performed when the mechanism of injury or physical examination findings are suggestive of renal injury (e.g. rapid deceleration, rib fractures, flank ecchymosis, and every penetrating injury of the abdomen, flank or lower chest). Renal trauma management has evolved during the last decades, with a distinct evolution toward a nonoperative approach. The lion's share of renal trauma patients are managed nonoperatively with careful monitoring, reimaging when there is any deterioration, and the use of minimally invasive procedures. These procedures include angioembolization in cases of active bleeding and endourological stenting in cases of urine extravasation.

Conservative Management of High-grade Renal Trauma Does Not Lead to Prolonged Hospital Stay

OBJECTIVE

To evaluate the effect of conservative management of high-grade renal trauma on length of hospitalization, we aim to describe characteristics of patients with high-grade renal trauma that are associated with an increased length of stay (LOS) and the effect of conservative vs surgical management on hospital LOS.

METHODS

A retrospective review of all patients who suffered unilateral high-grade renal trauma (grade 3 or higher) from September 1977 to August 2012 at San Francisco General Hospital in San Francisco, CA was performed. Patients' demographic information, mechanism of injury, injury grade, data about associated injuries, hospital LOS, and management were collected. Descriptive analysis was performed using chi-square, ordered logistic regression, and linear regression analysis. Multivariable analysis was performed using a Fine-Gray model of competing risks survival analysis, adjusting for trauma type, grade, surgery, associated injury, and complications.

RESULTS

The cohort consisted of 408 patients with high-grade unilateral renal trauma of which 257 patients underwent renal exploration. The adjusted multivariable analysis revealed that trauma type, injury grades, nongenitourinary surgery, associated injuries, and complications were associated with increased hospital LOS (P <.01 for all). Renal exploration compared to conservative management for high-grade renal trauma was not associated with an increased hospital LOS (P = .10).

CONCLUSION

There is no significant difference between conservative and surgical management of high-grade renal trauma in terms of hospital LOS. Conservative management of high-grade renal trauma does not impact patients' length of hospitalization.

Challenging case of horseshoe kidney double fracture

INTRODUCTION

Renal injuries occur in 10% of blunt abdominal traumas, 7% of these occur in kidneys with congenital or acquired disorders. Trauma of horseshoe kidney is an uncommon finding.

PRESENTATION OF A CASE

We present the case of 31 year-old caucasian man with no remarkable personal records, who was brought to our Trauma Unit soon after being involved in a motorcycle collision. A Contrast Enhanced - Multi Detector Computed Tomography (ce-MDCT) revealed a double disconnection of a horseshoe kidney. The patient was not aware of bearing such abnormality.

DISCUSSION

Trauma of horseshoe kidney is an uncommon finding. The abdominal ce-MDCT scan is the diagnostic tool of choice since the renal anatomy, injury grading and vascular or urinary tract abnormalities are well depicted and easily identified. The conservative management of these injuries is associated with a lower rate of nephrectomies and kidney failure while selective trans-catheter renal embolization is a challenging treatment option. However surgery can be a treatment of choice and should be aimed to preserve renal function.

CONCLUSION

the interest in our case lies in the rarity and particular anatomical aspect of such injuries and the implication related to its management in an emergency setting.

The role of facility-based surgical services in addressing the national burden of disease in New Zealand: An index of surgical incidence based on country-specific disease prevalence

BACKGROUND

Surgery is a crucial component of health systems, yet its contribution has been difficult to define. We linked national hospital service utilization with national epidemiologic data to describe the use of surgical procedures in the management of a broad spectrum of conditions.

METHODS

We compiled International Classification of Diseases-10-Australian Modification codes from the New Zealand National Minimum Dataset, 2008-2011. Using primary cause of admission, we aggregated hospitalizations into 119 disease states and 22 disease subcategories of the World Health Organization Global Health Estimate (GHE). We queried each hospitalization for any surgical procedure in a binary manner to determine the volume of surgery for each disease state. Surgical procedures were defined as requiring general or neuroaxial anesthesia. We then divided the volume of surgical cases by counts of disease prevalence from the Global Burden of Disease Study 2010 to determine annual surgical incidence.

RESULTS

Between 2008 and 2011, there were 1,108,653 hospital admissions with 275,570 associated surgical procedures per year. Surgical procedures were associated with admissions for all 22 GHE disease subcategories and 116 of 119 GHE disease states. The sub-categories with the largest surgical case volumes were Unintentional Injuries (48,073), Musculoskeletal Diseases (38,030), and Digestive Diseases (27,640). Surgical incidence ranged widely by individual disease states with the highest in: Other Neurological Conditions, Abortion, Appendicitis, Obstructed Labor, and Maternal Sepsis.

CONCLUSION

This study confirms that surgical care is required across the entire spectrum of GHE disease subcategories, illustrating a critical role in health systems. Surgical incidence might be useful as an index to estimate the need for surgical procedures in other populations.

Guideline of guidelines: a review of urological trauma guidelines

OBJECTIVE

To review the guidelines released in the last decade by several organisations for the optimal evaluation and management of genitourinary injuries (renal, ureteric, bladder, urethral and genital).

METHODS

This is a review of the genitourinary trauma guidelines from the European Association of Urology (EAU) and the American Urological Association (AUA), and renal trauma guidelines from the Société Internationale d'Urologie (SIU).

RESULTS

Most recommendations are guided by the American Association for the Surgery of Trauma (AAST) organ injury severity system. Grade A evidence is rare in genitourinary trauma, and most recommendations are based on Grade B or C evidence. The findings of the most recent urological trauma guidelines are summarised. All guidelines recommend conservative management for low-grade injuries. The major difference is for haemodynamically stable patients who have high-grade renal trauma; the SIU guidelines recommend exploratory laparotomy, the EAU guidelines recommend renal exploration only if the injury is vascular, and the AUA guidelines recommend initial conservative management.

CONCLUSION

There is generally consensus among the three guidelines. Recommendations are based on observational or retrospective studies, as well as clinical principles and expert opinions. Multi-institutional collaborative research can improve the quality of evidence and direct more effective evaluation and management of urological trauma.

MDCT of blunt renal trauma: imaging findings and therapeutic implications

Objectives

To show the wide spectrum of computed tomography (CT) findings in blunt renal trauma and to correlate them with consequent therapeutic implications.

Methods

This article is the result of a literature review and our personal experience in a level II trauma centre. Here we describe, discuss and illustrate the possible CT findings in blunt renal trauma, and we correlate them with the American Association for the Surgery of Trauma (AAST) classification and their therapeutic implications.

Results

CT findings following blunt renal trauma can be grouped into 15 main categories, 12 of them directly correlated with the AAST classification and 3 of them not mentioned in it. Non-operative management, which includes the “watchful waiting” approach, endourological treatments and endovascular treatments, is nowadays widely adopted in blunt renal trauma, and surgery is limited to haemodynamically unstable patients and a minority of haemodynamically stable patients.

Conclusions

The interpretation of CT findings in blunt renal trauma may be improved and made faster by the knowledge of their therapeutic consequences.

Teaching Points

• The majority of blunt renal injuries do not require surgical treatment.

• CT findings in blunt renal injury must be evaluated considering their therapeutic consequences.

• Some CT findings in blunt renal trauma are not included in the AAST classification.