Conservative management of high-grade renal trauma

INTRODUCTION

Renal trauma is the most common of urological trauma and accounts for up to 5% of all. The AAST scale is the most widely used to assess renal trauma. This study focuses on high-grade trauma, whose treatment has evolved towards a conservative approach, with techniques such as angioembolization. The aim is to describe the evolution in the management of high-grade renal trauma in all patients treated at La Paz University Hospital from 2001 to 2022.

METHODS

A descriptive retrospective study was conducted on patients treated at the hospital. The study was divided into two periods (2001-2010 and 2011-2022). A total of 285 patients with renal trauma were collected, of which 54 were high grade. The main variable is the type of management, conservative (embolization) or interventional through nephrectomy.

RESULTS

In the completed series, there was a decrease in radical nephrectomy in high-grade renal trauma from 50% to 13.8% over time, with an increase in embolization from 23,1% to 44,8%. In patients with isolated renal trauma, those treated with embolization increased from 28.6% to 69.2%, while those undergoing radical/partial nephrectomy decreased from 42.8% to 7.69%.

CONCLUSION

The management of renal trauma has evolved over the years in our center. The number of patients treated by embolization has increased, while the number of complications and nephrectomies has decreased.

Pediatric genitourinary injuries: 7-year experience at the largest tertiary referral hospital in Eastern part of Indonesia

INTRODUCTION

The anatomical variations between children and adults render pediatric patients more prone to urogenital trauma. However, it is not known for certain whether children are more prone to genitourinary trauma than adults. The aim of the study is to scrutinize the characteristic of pediatric genitourinary trauma at, the largest tertiary hospital in Eastern part of Indonesia.

STUDY DESIGN

The design of the study was analytic retrospective gathering medical records of all pediatric patients with urogenital trauma with total sampling. The number of patients, ages, genders, etiology, locations, and management were collected. Data was statistically analyzed using SPSS®, and p < 0.05 was considered statistically significant.

RESULTS

We found 13.5 (10-15.5) years as the median age in our 60 samples. Boy (75.00%), renal trauma (56.67%), abdominal and pelvic trauma (96.67%), traffic accident (91.67%), suprapubic catheterization (52.17%), and hemodynamically stable (91.67) was among the majority. We also found that non-operative management was in majority. Statistical analysis demonstrated significant differences for management and grade of injury (p < 0.05).

DISCUSSIONS

This is, to the best of our knowledge, the first study of genitourinary injuries in children who were treated at a tertiary hospital in Indonesia during the course of the 7-year research period. The limitations of this study are retrospective character and conducted in single institution.

CONCLUSION

The highest incidence of pediatric urogenital trauma is renal trauma due to traffic accident, which often multitrauma. Future prospective multi-center studies should be done to corroborate the results.

Factors affecting and effects of hemodynamic stability of pediatric patients with grades 3-5 renal trauma: a prospective non-randomized comparative study

BACKGROUND

Researches on the effect of hemodynamic stabilization on the implantation of conservative management for pediatric high-grade renal traumas are lacking. We aimed to assess the effect of maintaining the initial hemodynamic stability of pediatric patients with grades 3-5 renal trauma on the implementation of the conservative treatment and identify its defining factors.

METHODS

A prospective study was performed on pediatric patients with grade 3-5 renal traumas who presented to our hospital during July 2020-June 2022. Hemodynamically stable patients were compared with the unstable patients for clinical characteristics, hemodynamic stabilization, and rates of success of conservative treatment.

RESULTS

Forty-three patients were studied, including 26 boys and 17 girls. Of them, 28 (65.1%) patients presented with hemodynamic stability and 15 (34.9%) patients were unstable. Overall, 32 (74.4%) patients achieved and/or maintained hemodynamic stability for conservative management. There was a significant difference in blood pressure level at presentation (p < 0.001). The improvement of the hemodynamic parameters was significant per group and, in comparison (p < 0.001). The size of hematoma was significantly smaller in patients with hemodynamic stability (p = 0.023). Despite the longer (p = 0.033) hospital stay with conservative management, the rates of blood transfusion (p = 0.597) and hospital stay (p = 0.785) were not significantly different between both groups. The rates of nephrectomy and mortality were 14% and 0%, respectively. Blood pressure was independently associated with the achievement of maintained hemodynamic stability for conservative management (p = 0.022).

CONCLUSIONS

Hemodynamic stabilization seems to be effective and safe for implementing successful conservative management for pediatric patients with high-grade renal traumas. Blood pressure was the only independent factor of maintaining hemodynamic stability.

Traumatic segmental renal infarction due to renal apical artery thrombosis by minor blunt abdominal trauma: the role of CEUS

Post-traumatic segmental renal infarction is an extremely rare event, especially in case of minor blunt abdominal trauma. While major trauma guidelines are well established, several problems account for the adequate management of minor trauma. Herein, we report a case of minor blunt abdominal trauma determining traumatic thrombosis of the apical renal artery and segmental renal infarction, firstly diagnosed by CEUS in emergency care setting.

Extracorporeal shock wave lithotripsy-induced renal blunt trauma in young adult patient: A case report

Extracorporeal Shock Wave Lithotripsy (ESWL) is an option in the management of urolithiasis. Despite its significant benefits, it has an undesirable outcome such as renal trauma. We report a case of a 38-year-old male with iatrogenic left kidney blunt trauma (AAST Grade IV-V) due to left ESWL, presented initially with unstable hemodynamic and successfully managed conservatively.

Analysis and approach to renal trauma: A five-year experience at a level I trauma centre in north India

PURPOSE

Renal trauma constitutes 0.5% - 5% of all trauma patients, and 10% - 20% of abdominal trauma. It is the most commonly injured organ in the genitourinary tract. Road traffic crash (RTC) is the most common cause. In recent years due to the advances in radiological imaging and endovascular techniques, there has been an increase in the nonoperative management of renal trauma. We investigated a large trauma cohort at a level I trauma centre to evaluate patients' demographics with renal trauma, their management, and the outcomes.

METHODS

This was a retrospective analysis of the prospectively collected data of renal trauma patients managed from January 2016 to December 2020. Patients who visited the level I trauma centre in north India with renal trauma were included in this study. Patients who were dead on arrival in the emergency department were excluded. Demographics, mechanism of injury, presence of hemorrhagic shock, associated injuries, complications, length of hospital stay (LOS), discharge, and mortality were recorded. The data were entered in Microsoft Excel 365 and analysed using SPSS version 21.

RESULTS

This study collected data from 303 renal trauma patients. Males constituted 86.5% of the patients. Most patients were young, aged from 20 - 40 years. Blunt renal trauma was the predominant mode of injury (n = 270, 89.1%). RTCs (n = 190, 62.7%) and falls from height (n = 65, 21.4%) were the 2 most common mechanisms of injury. Focused assessment with sonography in trauma was positive in 68.4% of patients. Grade III (grading by the American Association for the Surgery of Trauma) renal trauma (30.4%) was the most common grade in our study. The liver (n = 104, 34.3%) and splenic trauma (n = 96, 31.7%) were the most commonly associated injuries. Of the 303 patients, 260 (85.8%) were managed nonoperatively. The mean (SD) of the patients' LOS was 12.5 (6.5) days. There were 25 (8.3%) mortalities during the study period and all of them had associated other injuries. The comparison of LOS of isolated renal trauma group and renal trauma with associated injuries group was not statistically significant (p = 0.322). All the patients who died during the study period had renal trauma with associated other organ injuries. None of the patients with isolated renal trauma died during the study. The outcome comparison between both groups was not statistically significant (p = 0.110).

CONCLUSION

Renal trauma predominantly occurs in young males, especially due to RTCs followed by fall from height. Focused assessment with sonography in trauma is not reliable in detecting renal injuries, other diagnostic tools such as contrast enhanced computed tomography torso should be considered in diagnosing and grading these injuries. Renal trauma usually does not occur in isolation. Majority are associated with other abdominal and extra abdominal injuries. Most of the times these injuries can be managed nonoperatively, which can achieve a low mortality. The patients who required surgery had high mortality as compared to patients who managed nonoperatively. These patients who required surgery had either severe renal or extra renal trauma and were in hemorrhagic shock. Renal trauma from this large cohort may contribute to improving the quality of care for patients with renal trauma by obtaining knowledge about the patient's characteristics, management, and outcomes.

Traumatic renal artery occlusion secondary to blunt trauma in a second-trimester pregnant woman who managed successfully with non-operative management: A rare case report

Blunt renal injuries in pregnancy are seldom isolated, with resultant renal vascular injury following this type of injury being extremely rare. We present a rare case of complete blockage of the left renal artery about 1 cm from the aortic opening in a second-trimester pregnant woman after she sustained a motor-vehicle-accident. She was managed successfully with NOM. Traumatic renal artery blockage is a rare condition with devastating consequences if missed on imaging. Although blunt renal trauma during pregnancy is a rare condition, NOM has become increasingly popular to reduce morbidity associated with nephrectomy resulting in higher rates of renal salvage.

Pediatric renal trauma at a level 1 trauma center in a rural state: A 10-year institutional review and protocol implementation

INTRODUCTION

Unintentional injury is a leading cause of mortality and morbidity in children. There is no consensus on the ideal, discrete management of pediatric renal trauma (PRT). Therefore, management protocols tend to be institution-specific.

OBJECTIVE

This study aimed to characterize PRT at a rural level-1 trauma center and subsequently develop a standardized protocol.

STUDY DESIGN

A retrospective review of a prospectively maintained database of PRT at a rural level 1 trauma center between 2009 and 2019 was conducted. Injuries were characterized regarding renal trauma grade, associated multi-organ involvement and the need for intervention. The benefit of patient transfer from regional hospitals and length and cost of stay were evaluated.

RESULTS

Of 250 patients admitted with renal trauma diagnosis 50 patients <18 years were analyzed. Of those, the majority (32/50, 64%) had low-grade (grade I-III) injuries. Conservative management was successful in all low-grade injuries. Of 18 high-grade PRT, 10 (55.6%) required intervention, one prior to transfer. Among patients with low-grade trauma, 23/32 (72%) were transferred from an outside facility. A total of 13 (26%) patients with isolated low-grade renal trauma were transferred from regional hospitals. All isolated, transferred low-grade renal trauma had diagnostic imaging before transfer and none required invasive intervention. Interventional management of renal injury was associated with a longer median LOS [7 (IQR = 4-16.5) vs 4 (IQR = 2-6) days for conservative management, p = 0.019)] and an increased median total cost of $57,986 vs. $18,042 for conservative management (p = 0.002).

DISCUSSION

The majority of PRT, particularly low-grade, can be managed conservatively. A significant proportion of children with low-grade trauma are unnecessarily transferred to higher level centers. Review of pediatric renal trauma at our institution over a decade has allowed us to develop an institutional protocol which we believe allows for safe and effective patient monitoring.

CONCLUSION

Isolated, low-grade PRT can be managed conservatively at regional hospitals without needing transfer to a level 1 trauma center. Children with high-grade injuries should be closely monitored and are more likely to need invasive intervention. Development of a PRT protocol will help to safely triage this population and identify those who may benefit from transfer to a tertiary care center.

Who Is at Risk of Death after Renal Trauma? An Analysis of Thirty-Day Mortality after 1,799 Cases of Renal Trauma

INTRODUCTION

The aim of the study was to report the 30-day mortality (30DM) after renal trauma and identify the risk factors associated with death.

METHODS

The TRAUMAFUF project was a retrospective multi-institutional study including all patients with renal trauma admitted to 17 French hospitals between 2005 and 2015. The included population focused on patients of all age groups who underwent renal trauma during the study period. The primary outcome was death within 30 days following trauma. The multivariate logistic regression model with a stepwise backward elimination was used to identify predictive factors of 30DM.

RESULTS

Data on 1,799 renal trauma were recorded over the 10-year period. There were 59 deaths within 30 days of renal trauma, conferring a 30DM rate of 3.27%. Renal trauma was directly involved in 5 deaths (8.5% of all deaths, 0.3% of all renal trauma). Multivariate stepwise logistic regression analysis revealed that age >40 years (odds ratio [OR] 2.18; 95% confidence interval [CI]: 1.20-3.99; p = 0.01), hemodynamic instability (OR 4.67; 95% CI: 2.49-9; p < 0.001), anemia (OR 3.89; 95% CI: 1.94-8.37; p < 0.001), bilateral renal trauma (OR 6.77; 95% CI: 2.83-15.61; p < 0.001), arterial contrast extravasation (OR 2.09; 95% CI: 1.09-3.96; p = 0.02), and concomitant visceral and bone injuries (OR 6.57; 95% CI: 2.41-23.14; p < 0.001) were independent predictors of 30DM.

CONCLUSION

Our large multi-institutional study supports that the 30DM of 3.27% after renal trauma is due to the high degree of associated injuries and was rarely a consequence of renal trauma alone. Age >40 years, hemodynamic instability, anemia, bilateral renal trauma, arterial contrast extravasation, and concomitant visceral and bone lesions were predictors of death. These results can help clinicians to identify high-risk patients.

Traumatic renal injury revealing a horseshoe kidney: A case report

Having a kidney disease is a major risk factor of renal injury during blunt traumas. We present a case of abdominal blunt trauma due to motor-vehicle accident in a 48 year old male patient. Abdominal computed tomography scan showed a high-volume retroperitoneal hematoma with rupture in the isthmus of the horseshoe kidney with active contrast-enhanced extravasation. He underwent a partial nephrectomy of the left lower pole.

Penetrating renal injuries: an observational study of non-operative management and the impact of opening Gerota's fascia

Background

Non-operative management has become increasingly popular in the treatment of renal trauma. While data are robust in blunt mechanisms, the role of non-operative management in penetrating trauma is less clear. Additionally, there is a paucity of data comparing gunshot and stab wounds.

Methods

A retrospective review of patients admitted to a high-volume level 1 trauma center (Groote Schuur Hospital, Cape Town) with penetrating abdominal trauma was performed. Patients with renal injuries were identified and compared based on mechanism [gunshot (GSW) vs. stab] and management strategy (operative vs. non-operative). Primary outcomes of interest were mortality and failure of non-operative management. Secondary outcomes of interest were nephrectomy rates, Clavien-Dindo complication rate, hospital length of stay, and overall morbidity rate.

Results

A total of 150 patients with renal injuries were identified (82 GSW, 68 stab). Overall, 55.2% of patients required emergent/urgent laparotomy. GSWs were more likely to cause grade V injury and concurrent intra-abdominal injuries (p > 0.05). The success rate of non-operative management was 91.6% (89.9% GSW, 92.8% stab, p = 0.64). The absence of hematuria on point of care testing demonstrated a negative predictive value of 98.4% (95% CI 96.8–99.2%). All but 1 patient who failed non-operative management had associated intra-abdominal injuries requiring surgical intervention. Opening of Gerota’s fascia resulted in nephrectomy in 55.6% of cases. There were no statistically significant risk factors for failure of non-operative management identified on univariate logistic regression.

Conclusions

NOM of penetrating renal injuries can be safely and effectively instituted in both gunshot and stab wounds with a very low number of patients progressing to laparotomy. Most patients fail NOM for associated injuries. During laparotomy, the opening of Gerota’s fascia may lead to increased risk of nephrectomy. Ongoing study with larger populations is required to develop effective predictive models of patients who will fail NOM.

[Late complications after blunt renal trauma: A French multicenter study]

INTRODUCTION

Among genitourinary traumas, blunt trauma to the kidney are the most frequent: their initial management has been well studied but their development at a distance is poorly documented. The objective of this study was to assess the late complications of blunt renal trauma, and to investigate their predictive factors for occurrence.

MATERIALS AND METHODS

A retrospective observational study of the TraumAFUF project was conducted, including, between 2005 and 2018, all blunt renal trauma treated in 18 French hospitals and followed for more than 3 months. The characteristics of the initial trauma, as well as any complications occurring after three months, were identified. The patients were divided into two groups: onset of a late complication (LC) or uncomplicated (UC). The groups were compared in univariate and multivariate analyses to identify the risk factors for the occurrence of these complications.

RESULTS

Among the 454 patients included, 50 presented with LC (11%), as symptomatic morphologically altered kidney (2.9%), secondarily impaired biological renal function (2.9%), or secondary arterial hypertension (2.4%). The risk factors identified were, during initial medical care, a high-grade renal trauma≥IV (OR=2.4, P=0.025), active bleeding (OR=2.6, P=0.007), the need for transfusion (OR=2.3, P=0.001), or interventional (R=1.7, P=0.09) or endoscopic treatment (OR=2.0, P=0.035).

CONCLUSION

In this study, late complications occurred in 11% of cases after blunt renal trauma. The risk factors identified make it possible to draw up a patient profile who would benefit from prolonged follow-up to detect these complications.

LEVEL OF EVIDENCE

3.

Autologous omentum transposition for regeneration of a renal injury model in rats

BACKGROUND

After renal trauma, surgical treatment is vital, but sometimes there may be loss of function due to fibrosis. This study aimed to evaluate the effect of autologous omentum flaps on injured renal tissues in a rat model.

METHODS

A total of 30 Wistar albino rats were included and randomly divided equally into a control group and four intervention groups. Iatrogenic renal injuries were repaired using a surgical technique (primary repair 1 group and primary repair 2 group) or transposition of the autologous omentum (omentum repair 1 group and omentum repair 2 group). Blood samples were taken preoperatively and on the 1st and 7th postoperative days in all groups and on the 18th postoperative day in the control and two intervention groups. All rats were sacrificed on the 7th or 18th day postoperatively, and their right kidneys were taken for histopathological evaluation.

RESULTS

The mean urea level significantly decreased from day 1 to day 7 and from day 1 to day 18 in the omentum repair 2 group (P = 0.005 and P = 0.004, respectively). There were no other significant changes in urea or creatinine levels within the intervention groups (P > 0.05). There was no significant correlation between the urea and creatinine levels and the histological scores (P > 0.05). The primary repair 1 and 2 groups had significantly higher median granulation and inflammation scores in the kidney specimen than the control and omentum repair groups (P < 0.05). The omentum repair 2 group had significantly lower median granulation and inflammation scores in the surrounding tissues than the primary repair 2 group (P < 0.05). The completion score for the healing process in the kidney specimen was significantly higher in the omentum repair groups than in the primary repair groups (P < 0.05). The omentum repair 2 group had significantly lower median granulation and inflammation scores in the surrounding tissues than the primary repair 2 group (P < 0.05). Granulation degree in the kidney specimen was strongly and positively correlated with the inflammation degree (r = 0.824, P < 0.001) and foreign body reaction in the kidney specimen (r = 0.872, P < 0.001) and a strong and negative correlation with the healing process completion score in the kidney (r = - 0.627, P = 0.001). Inflammation degree in the kidney specimen was strongly and positively correlated with the foreign body reaction in the kidney specimen (r = 0.731, P = 0.001) and strongly and negatively correlated with the healing process completion score in the kidney specimen (r = - 0.608, P = 0.002).

CONCLUSION

Autologous omentum tissue for kidney injury repair attenuated inflammation and granulation. Additionally, the use of omental tissue to facilitate healing of kidney injury may theoretically lead to a more effective healing process and reduced fibrosis and tissue and function loss.

On the black slope: analysis of the course of a blunt renal trauma collective in a winter sports region

Purpose

The aim of this study was to analyze the injury patterns and clinical course of a winter sport dominated by blunt renal trauma collective.

Methods

Blunt renal trauma cases (N = 106) treated in a Level 1 Trauma Center in Austria were analyzed.

Results

We encountered 12.3% grade 1, 10.4% grade 2, 32.1% grade 3, 38.7% grade 4 and 6.6% grade 5 renal traumata classified according to the American Association for the Surgery of Trauma (AAST). The mechanisms of injury (MOI) did not have an influence on the frequency of HG trauma (i.e., grade 4 and 5). No concomitant injuries (CIs) were found in 57.9% of patients. The number of patients without CIs was significantly higher in the sports associated trauma group compared to other MOIs (p < 0.01). In 94.3% the primary treatment was a non-operative management (NOM) including 56.6% conservative, 34.0% endourological, and 3.8% interventional therapies. A follow-up computed tomography (FU-CT) was performed in 81.1%, 3.3 days after trauma. After FU-CT, the primary therapy was changed in 11.4% of cases (grade ≥ 3). Comparing the Hb loss between the patients with grade 3 and 4 kidney trauma with and without revision surgery, we find a significantly increased Hb loss within the first 96 h after the trauma in the group with a needed change of therapy (p < 0.0001). The overall rate of nephrectomy (primary or secondary) was 9.4%. Independent predictors of nephrectomy were HG trauma (p < 0.01), age (p < 0.05), and sex (p < 0.05). The probability of nephrectomy was lower with (winter) sports-associated trauma (p < 0.1).

Conclusions

Sports-associated blunt renal trauma is more likely to occur isolated, and has a lower risk of severe outcomes, compared to other trauma mechanisms. NOM can successfully be performed in over 90% of all trauma grades.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01830-w.

[Conservative management of grade IV kidney lacerations due to stab wounds]

We report on two patients who were in initially circulatory stable condition with grade IV kidney trauma after knife stab accident. Patient 1 underwent reconstructive surgery to retrieve a broken knife blade, while patient 2 was treated conservatively for bleeding that did not require intervention. Both patients could ultimately be discharged in stable condition. These case studies show that even in the case of high-grade kidney trauma with the appropriate constellation of findings, conservative management and, if exploration is necessary, a reconstructive approach is possible.

Characteristics and outcomes of pediatric blunt renal trauma: a nationwide cohort study in Japan

PURPOSE

The aim of this study was to describe epidemiologic features of pediatric blunt renal trauma.

METHODS

We performed a retrospective analysis using the Japan Trauma Data Bank over 15 years. We included patients younger than 18 years with blunt renal trauma. We analyzed temporal trends and variations across age groups in patient characteristics, intervention, and in-hospital mortality. We also assessed factors associated with in-hospital mortality.

RESULTS

We identified 435 pediatric patients with blunt renal trauma. Their median age was 14 years and median Injury Severity Score (ISS) was 17. The most common mechanism of injury was traffic accident in all age groups. Nephrectomy was performed in 3.2%, and the overall in-hospital mortality was 4.6%, both of which showed decreasing trends. The most common mechanism of injury by age group was a pedestrian accident in infants/toddlers/preschoolers (43.5%), pedestrian accident in middle childhood (18.5%), bicycle accident in young teens (24.7%), and motorcycle accident in teenagers (41.2%). Sports-related injury was common in young teens (23.3%) and teenagers (15.2%). Factors such as ISS, shock, concomitant injury, and nephrectomy were associated with high in-hospital mortality.

CONCLUSIONS

We described decreasing trends in nephrectomy and in-hospital mortality in pediatric blunt renal trauma and found traffic accident and sports-related injury were common in the pediatric population in Japan.

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.

Endovascular embolization in renal trauma: a narrative review

Approximately 1–3% of all trauma patients have a renal injury. Eighty percent of renal trauma is due to blunt injury, with the remainder due to penetrating trauma which is most often iatrogenic. Contrast enhanced computed tomography is used to triage patients and offers a quick and accurate assessment of any potential organ injury. If injury is present, The American Association for the Surgery of Trauma grading system can both grade renal injuries and be used to help guide management and intervention. Grades are assigned based on imaging and clinical features of renal trauma, and have prognostic and treatment implications for patients. The objective of this narrative review is to identify optimal management of patients with renal trauma, specifically which patients can be treated with endovascular interventions following renal trauma, which can be observed, and which would be best managed surgically. For hemodynamically stable patients with renal trauma, endovascular angiography and embolization is a non-invasive approach that can be used to control bleeding and potentially avoid surgery or nephrectomy in select cases. Future research is needed to determine if a specific antibiotic regimen is needed prior to or following embolization. Further research is needed to evaluate the effectiveness of endovascular management of high-grade renal trauma (grade V). Complications of renal embolization include short-term hypertension, long term hypertension in cases of significant ischemia, acute kidney injury, and infection.

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.

Vicarious excretion of intravenous contrast masquerading as a nephroenteric fistula in a patient with a grade IV renal injury

We describe a case of a patient who suffered a grade IV renal injury who demonstrated vicarious excretion of intravenous contrast into the bowel masquerading as a nephroenteric fistula. Despite concerning imaging features, given the patient's lack of clinical symptoms of a nephroenteric fistula, negative oral activated charcoal test, and our understanding of the pharmacokinetics of intravenous contrast, our suspicion for nephroenteric fistula was low. This case highlights the importance of carefully considering the mechanism of injury when developing a differential diagnosis of potential sequela after trauma and understanding the pharmacokinetics of intravenous contrast in the trauma setting.

Factors Predictive of Selective Angioembolization Failure for Moderate- to High-grade Renal Trauma: A French Multi-institutional Study

BACKGROUND

Angiography with selective angioembolization (SAE) is safe and effective in addressing bleeding in patients with renal trauma. However, there are no validated criteria to predict SAE efficacy.

OBJECTIVE

To evaluate factors predictive of SAE failure after moderate- to high-grade renal trauma.

DESIGN, SETTING, AND PARTICIPANTS

TRAUMAFUF was a retrospective multi-institutional study including all patients who underwent upfront SAE for renal trauma in 17 French hospitals between 2005 and 2015.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was SAE efficacy, defined as the absence of repeat SAE, salvage nephrectomy, and/or death for each patient.

RESULTS AND LIMITATIONS

Out of 1770 consecutive patients with renal trauma, 170 (9.6%) with moderate- to high-grade renal trauma underwent SAE. Overall upfront SAE was successful in 131 patients (77%) and failed in 39 patients: six patients died after the embolization, ten underwent repeat SAE, 22 underwent open nephrectomy, and one underwent open surgical exploration. In multivariate logistic regression analysis, gross hematuria (odds ratio [OR] 3.16, 95% confidence interval [CI] 1.29-8.49; p=0.015), hemodynamic instability (OR 3.29, 95% CI 1.37-8.22; p=0.009), grade V trauma (OR 2.86, 95% CI 1.06-7.72; p=0.036), and urinary extravasation (OR 3.49, 95% CI 1.42-8.83; p=0.007) were predictors of SAE failure. The success rate was 64.7% (22/34) for patients with grade V trauma and 59.6% (31/52) for those with hemodynamic instability. The study was limited by its retrospective design and the lack of a control group managed with either surgery or surveillance.

CONCLUSIONS

We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure. However, success rates in these subgroups remained relatively high, suggesting that SAE might be appropriate for those patients as well.

PATIENT SUMMARY

Selective angioembolization (SAE) is a useful alternative to nephrectomy to address bleeding in patients with renal trauma. Currently, there are no validated criteria to predict SAE efficacy. We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure.

Impact of trauma center designation in pediatric renal trauma: National Trauma Data Bank analysis

INTRODUCTION

The pediatric kidney is the most common urinary tract organ injured in blunt abdominal trauma. Trauma care in the United States has been established into a hierarchical system verified by the American College of Surgeons (ACS). Literature evaluating management of pediatric renal trauma across trauma tier designations is scarce.

OBJECTIVE

To examine the differences in the management and outcomes of renal trauma in the pediatric population based on trauma level designation across the United States.

STUDY DESIGN

We performed a review of the ACS - National Trauma Data Bank database. Pediatric patients (age 0-18 years) who were treated for renal injury between years 2011-2016 were identified. Our primary outcome was the difference in any complication rate amongst Level I versus Non-Level I trauma centers. Management strategies were evaluated as secondary outcomes. Propensity score matching (PSM) was utilized to adjust for baseline differences between cohorts. Multivariable regression analysis was performed to determine the independent effects of individual factors on complications, operative intervention, minimally invasive procedure, and blood transfusions.

RESULTS

Overall, 12,097 pediatric patients were diagnosed with renal trauma between 2011 and 2016 using target ICD-9 and AAST codes. After PSM, there was a total of 1623 subjects withing each group. No difference was identified between groups for occurrence on any complication [105 (6.5%) vs 114 (7.0%), p = 0.576. There were no differences in the rate of minimally invasive interventions [67 (4.1%) vs 48 (3.0%), p = 0.087], operative intervention [58 (3.6%) vs 68 (4.2%), p = 0.413], or nephrectomy [42 (2.6%) vs 47 (2.9%), p = 0.667] between Level I and Non-Level I trauma designations, respectively. Length of stay was longer in the Level I cohort compared to Non-Level I (days (SD)) [6.9 (8.8) vs 6.2 (7.9), p = 0.024. When specifically looking at risk factors associated with operative intervention, higher renal injury grade and injury severity score were highly correlated, whereas, trauma level designation was not found to be predictive for more aggressive management.

DISCUSSION & CONCLUSION

Our results corroborate with previous literature that renal injury grade and injury severity score are strong predictors of morbidity, invasive management, and complications. Pediatric renal trauma was managed similarly across trauma center designations, with the rate of complication and intervention more prevalent in patients with high grade renal injuries and concomitant injuries. Further studies are necessary to identify patients who will benefit most from transfer to a level I center.

Renal artery angiography in pediatric trauma using a national data set

INTRODUCTION

With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking.

OBJECTIVE

This study uses the National Trauma Data Bank (NTDB), to evaluate renal outcomes after use of renal artery angiography. We hypothesized that patients undergoing renal artery angiography for renal trauma are unlikely to require additional surgical interventions.

STUDY DESIGN

All children ≤18 years old treated for traumatic renal injuries from 2012 to 2015 were identified by the Abbreviated Injury Scaled Score (AISS) codes in the NTDB. AISS codes were converted to American Association for Surgery of Trauma (AAST) grades. ICD-9 codes were used to identify patients that had renal artery angiography, and additional renal interventions such as nephrectomy, partial nephrectomy, percutaneous nephrostomy tube or ureteral stent placement.

RESULTS

536,379 pediatric trauma cases were in the NTDB from 2012 to 2015, with 4506 renal injury cases identified. A total of 88 patients had renal artery angiography (ICD-9 88.45). Only 10% (n = 9) of patients who received renal artery angiography underwent an additional urological intervention. Of those nine, two patients were excluded due to renal angiography taking place after nephrectomy was performed. The remaining seven patients had high grade laceration (AAST grade 4-5). Overall, two patients underwent post angiography nephrectomies, two patients had partial nephrectomies, one percutaneous nephrostomy tube was placed (prior to partial nephrectomy), one aspiration of a kidney (prior to ureteral stent placement), and three had ureteral stent placements.

DISCUSSION

The limitations of this study include: the NTDB is a national dataset that is not population based, inclusion is limited to the first hospitalization, inaccuracies exist in encounter coding, and the database is lacking laterality of the renal injury. Based on nonspecific nature of ICD-9 coding for angioembolization, we are unable to discern the number of cases that subsequently had angioembolization after or at the time of angiography.

CONCLUSION

Renal artery angiography in children remains a rare procedure, 88/4,506, in children with renal trauma. In pediatric trauma cases that undergo renal artery angiography additional procedures are more common with higher grade injuries. Further studies are needed to create pediatric specific trauma management algorithms.

Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imaging

INTRODUCTION

The standard imaging modality for hemodynamically stable blunt abdominal trauma patients is a contrast enhanced CT scan, which is reflected in the current AUA urotrauma guidelines. This comes, however, with radiation exposure and the potential sequalae of IV contrast administration in the pediatric patient.

OBJECTIVE

We hypothesize that ultrasound imaging would be able to diagnose and rule out clinically significant renal injuries when compared to the gold standard of CT scan in the setting of pediatric blunt abdominal trauma.

STUDY DESIGN

All children <18 years of age who were evaluated for blunt abdominal trauma who had a CT scan and ultrasound imaging of kidneys were identified. The ultrasound images were reviewed by four reviewers who were blinded to CT results and all clinical information. The ability of ultrasound to diagnose and rule out clinically significant renal injury was evaluated by diagnostic test performance characteristics including sensitivity, specificity, negative predictive value and positive predictive value.

RESULTS

There were 76 patients identified, 24 of which had a renal injury (1 bilateral) diagnosed by CT scan for a total of 25 injuries in 152 renal units. There were six grade I-II injuries and 19 grade III-V injuries. The sensitivity of the four blinded reviewers by ultrasound alone to detect the 19 grade III-V injuries ranged from 79 to 100% with NPV between 97 and 100%. Three of the four reviewers identified all 19 grade III-V injuries by ultrasound. When combined with significant hematuria, all 19 grade III-IV injuries were identified. Of note, all patients with a grade III-V injury of the kidney had significant hematuria. Of the grade I-II renal injuries, all reviewers identified 1/5 or 2/5 by ultrasound alone.

DISCUSSION

The limitations of this study include: its retrospective nature, limited number of patients and reviewers, quality of the ultrasound machine. and experience of technologist, radiologist and urologist. A major limitation is the inability to assess other solid organ injuries during this initial study.

CONCLUSIONS

When compared to a CT scan as the gold standard, kidney ultrasound images had a sensitivity of 79-100% to detect grade III-V injuries and NPV of 97-100% by four blinded reviewers. All grade III-V injuries had either an episode of gross hematuria or microscopic hematuria >50 RBC/hpf. A prospective study that includes full abdominal imaging is needed to confirm that ultrasound can safely be used in place of CT scan for evaluation of hemodynamically stable blunt trauma patients.

Trends and outcomes of blunt renal trauma management: a nationwide cohort study in Japan

Background

There is a paucity of information for predicting patient outcomes other than the American Association for the Surgery of Trauma (AAST) renal injury scale. The aim of this study was to evaluate the association between the patient characteristics and outcomes of patients with blunt renal trauma using a nationwide database in Japan.

Methods

We performed a retrospective analysis of the Japan Trauma Data Bank (JTDB) from 2004 to 2018. We identified patients with blunt renal trauma by AIS codes converted to AAST grades. We evaluated trends in patient characteristics and management and assessed factors associated with mortality and nephrectomy using a multivariable logistic regression analysis.

Results

We identified 3550 patients with blunt renal trauma. Their median age was 43 years and 74.2% were male. Nephrectomy was performed in 3.8%, and the overall mortality rate was 9.5%. We found increasing trends in age and emergency abdominal angiography and decreasing trends in nephrectomy and mortality over the 15-year period. The following factors were associated with mortality: age ≥ 65 years (adjusted OR 3.36); pedestrian accident (adjusted OR 1.94); fall from height (adjusted OR 1.91); shock on arrival (adjusted OR 4.02); concomitant injuries to the head/neck (adjusted OR 3.14), pelvis/lower-extremity (adjusted OR 1.59), liver (adjusted OR 1.68), spleen (adjusted OR 1.45), and gastrointestinal tract (adjusted OR 1.90); AAST grades III–V (adjusted ORs 1.42, 2.16, and 5.55); and emergency abdominal angiography (adjusted OR 0.70). The following factors were associated with nephrectomy: shock on arrival (adjusted OR 1.98), concomitant injuries to the thorax (adjusted OR 0.46) and spleen (adjusted OR 2.07), AAST grades III, IV, and V (adjusted ORs 18.40, 113.89, and 468.17), and emergency abdominal angiography (adjusted OR 0.28).

Conclusions

We demonstrated that the AAST grade and emergency angiography were associated with mortality and nephrectomy in blunt renal trauma in the Japanese population.

[Report on management of severe renal trauma.]

OBJECTIVE

To characterize the clinical condition, the type of therapeutic approach and outcome of patients with severe renal trauma (AAST: 4 and 5) treated in a tertiary hospital. Cali, Colombia.

METHODS

A descriptive observational study was conducted with patients older than 15 years treated between January 1, 2015 and January 1, 2019, with a diagnosis of renal trauma and renal vessel trauma. Demographic, clinical and trauma severity variables were collected. A univariate analysis was carried out with frequency tables, measures of central tendency, depending on type of intervention, associated lesions, use of blood products and severity indices.

RESULTS

71 medical records were analyzed, 82% male, the average age was 25 years (range: 15-55). Regarding renal traumatic grade, 69% of the patients were grade IV and 31% grade V. Penetrating injuries were seen in 87% versus 13% of injuries due to blunt (non-penetrating) mechanism. 54% of the patients weres cored with a trauma severity index >= 25 and 51% of the patients had an abdominal trauma index <= 24. Surgical management was managed in 67% vs. 32% for non-trauma management surgical. The hospital stay was 17 days on average and 16.9% had complications.

CONCLUSIONS

Severe renal trauma is a frequent clinical condition in male patients between the second and third decade of life, in our environment the majority corresponds to penetrating traumas. Most cases were managed with some surgical procedure, however, with asignificant percentage of conservative management with complication rates of less than 30%, which changes the paradigm of treatment of high-grade renal trauma.

Traumatic renal injury: Five-year experience at a major trauma centre in South Africa

BACKGROUND

This study is intended to assess the current optimal management of traumatic renal injuries (TRIs), with a focus on high-grade and penetrating injuries.

METHODS

The Pietermaritzburg Metropolitan Trauma Service registry was interrogated retrospectively for patients managed for TRI between 1 January 2012 and 31 December 2016.

RESULTS

Of 13,315 inured patients treated by the PMTS, 223 (1.7%) had TRIs with an incidence of 1.5 per 100,000 population per year. The majority were males between 20 and 39 years of age. The distribution of mechanism of injury was 56.1% (n = 125) blunt and 43.9% (n = 98) penetrating trauma with no association between mechanism and grade of injury. Penetrating trauma was associated with hollow viscus and diaphragm injuries and blunt trauma with solid organ injuries. A total of 118 patients (52.9%) were managed non-operatively, 60 (26.9%) were not explored at operation, 27 (12.1%) underwent initial nephrectomy and 8 (3.6%) underwent renorraphy. Low-grade injuries (AAST I and II) and high-grade injuries (AAST III-V) were managed without renal intervention (non-operatively or not explored at laparotomy for associated injuries) in 88.7% (n = 87) and 72.0% (n = 91) of cases respectively. Blunt and penetrating injuries were managed without renal intervention in 87.9% (n = 109) and 70% (n = 69) of cases respectively. The initial nephrectomy rate was 1% (n = 1) and 20.6% (n = 26) for low- and high-grade injuries respectively, and 6.5% (n = 8) and 19% (n = 19) for blunt and penetrating injuries respectively. High grade (AAST III-V) injury (OR 14.94; 95% CI 3.36 - 66.34; p<0.001), penetrating mechanism (OR 4.99; 95% CI 1.98 - 12.52; p = 0.001) and metabolic acidosis (OR 2.73; 95% CI 1.04 - 7.20; p = 0.042) were significant risk factors for nephrectomy. Four patients (1.8%) underwent ureteral stent insertion and 2 (0.9%) underwent embolisation. The failure rate of initial non-operative management was 1.1%. The mortality rate was 8.1% (n = 18), but no patients with solitary renal injuries died.

CONCLUSION

Even in high-grade injuries and penetrating trauma, the majority of patients with TRI can be managed non-operatively or with the assistance of endourological or endovascular techniques, with good outcomes. Risk factors for nephrectomy include the presence of high-grade injuries, penetrating trauma and metabolic acidosis on presentation.

Identical injuries in 2 sisters (victims of motor vehicle collision): Two cases report

BACKGROUND

Children sometimes are victims of motor vehicle collision (MVC) along with their families. Motor vehicle collision can cause several patterns of blunt trauma resulting from the impact itself or penetrating trauma by broken glass or other sharp objects. Most cases can be managed conservatively as long as the hemodynamic parameters are stable & hollow viscera are intact. Usually, cases shared the same accident have different injury patterns. But herein, we present 2 sisters as victims of MVC with same lesions but at variable degrees.

CASE PRESENTATION

Two sisters were referred to our hospital as victims of MVC and presented by nearly identical injuries (left lung injury, left kidney injury, retroperitoneal fluid collection, & left humerus fracture). Both girls were managed non-operatively until improved and became ready for discharge from the hospital in stable good health status.

CONCLUSION

Identical injuries in pediatric trauma victims do occur and should be considered and reported to raise the awareness about the importance of submission to vehicle safety protective rules especially for children.

Successfully managed grade IV renal injury and retained bullet in third-trimester pregnant woman

Gunshot injury to the kidney in pregnant women is extremely rare describing a significant cause of maternal and fetal morbidity and mortality. This case report demonstrates the management of renal trauma by presenting 24years old third-trimester pregnant women who sustained gunshot wounds to the abdomen. Renal trauma management has evolved in the last decades from immediate surgical exploration to non-operative management (NOM). Based on our patient's outcome, we review the role of conservative management to a high grade of penetrating renal trauma which is potentially life-threatening describing the safety of this approach.

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.

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.

[Zinner`s syndrome in a polytrauma patient.]

OBJECTIVE

To report two Zinner`s syndrome cases, a rare anatomical variant with risk of complications.

METHODS

Analysis of two Zinner syndrome cases, detected during acute recurrent epididimytis and after a grade IV renal trauma. Review of the literature focusing on its diagnosis and possible complications.

RESULTS

The conservative management of the polytrauma patient allowed to preserve the kidney, while maintaining normal renal function. It is the first Zinner`s syndrome diagnosed in this clinical context.

CONCLUSIONS

Zinner`s syndrome is a rare entity and often goes unnoticed because of the few symptoms it produces.

Impact of Trauma Center Designation and Interfacility Transfer on Renal Trauma Outcomes: Evidence for Universal Management

BACKGROUND

Renal trauma may be managed differently in tiered trauma systems and among those who requireinterfaculty transfer.

OBJECTIVE

To evaluate the initial management of renal trauma, assess patterns of management based on hospital trauma level designation and interfacility transfer status, and analyze management trends over time.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of renal trauma from the National Trauma Data Bank 2010-2015.

INTERVENTION

Nephrectomy, angioembolization, or nonoperative management.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS

We used generalized estimating equations to compare odds of each management outcome in patients transferred and directly admitted to a level I center, versus those directly admitted to a non-level I center, adjusting for vital signs, injury, demographic, and facility characteristics. We also used generalized estimating equations to examine linear time trends in management outcome, adjusting for injury characteristics.

RESULTS AND LIMITATIONS

A total of 51798 renal trauma records were included: 44 838 low-grade (American Association for the Surgery of Trauma I-III) and 6359 high grade (IV-V) injuries. After adjusting for comorbidities, demographics, and hospital characteristics, odds of nephrectomy, angioembolization, and nonoperative management were similar in patients transferred or directly admitted to a level I center compared with those treated at a non-level I center. Changes in management over time demonstrated a decreased rate of nephrectomy (p=0.007) in high-grade injuries, while the rate of angioembolization remained constant (p=0.33). Study limitations include mortality prior to hospital transfer or arrival, and its retrospective nature.

CONCLUSIONS

In this contemporary trauma analysis, outcomes of both low- and high-grade renal trauma are similar across patients managed in tiered trauma centers and those undergoing transfer, signifying dissemination of collective renal trauma management. The rate of nephrectomy has decreased for high-grade renal injury over our study period, suggesting new adoption of kidney-sparing management.

PATIENT SUMMARY

Renal trauma is now managed similarly in tiered trauma centers and in patients requiring interfacility transfer. The rate of nephrectomy for high-grade renal injuries has decreased over time.

Incidence of urinary extravasation and rate of ureteral stenting after high-grade renal trauma in adults: a meta-analysis

Background

Collecting system injury and urinary extravasation is an important yet understudied aspect of renal trauma. We aimed to examine the incidence of urinary extravasation and also the rates of ureteral stenting after high-grade renal trauma (HGRT) in adults.

Methods

A search strategy was developed to search Ovid Medline, Embase, CINAHL, and Cochrane Library. Two reviewers screened titles and abstracts, followed by full-text review of the relevant publications. Studies were included if they indicated the number of patients with HGRT [the American Association for the Surgery of Trauma (AAST) grades III–IV or equivalents] and number of patients with urinary extravasation. A descriptive meta-analysis of binary proportions was performed with random-effects model to calculate the incidence of urinary extravasation and rates of ureteral stenting.

Results

After screening, 24 and 20 studies were included for calculating urinary extravasation and stenting rates, respectively. Most studies involved blunt injury and were retrospective single-center case series. Incidence of urinary extravasation was 29% (95% CI: 17–42%) after HGRT (grade III–V), and 51% (95% CI: 38–64%) when only grade IV–V injuries were combined. Overall, 29% (95% CI: 22–36%) of patients with urinary extravasation underwent ureteral stenting.

Conclusions

Approximately 30% of patients with HGRT are diagnosed with urinary extravasation and 29% of those with urinary extravasation undergo ureteral stenting. Understanding the rate of urinary extravasation and interventions is the first step in creating a prospective trial designed to demonstrate when ureteral stenting and aggressive management of urinary extravasation is needed.

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.

Management of Pediatric Grade IV Renal Trauma

PURPOSE OF REVIEW

Review the current literature regarding the management of grade IV renal injuries in children.

RECENT FINDINGS

Children are at increased risk for renal trauma compared to adults due to differences in anatomy. Newer grading systems have been proposed and are reviewed. Observation of most grade IV renal injuries is safe. Operative intervention is necessary for the unstable patient to control life-threatening bleeding with either angioembolization or open exploration. Symptomatic urinomas may require percutaneous drainage and/or endoscopic stent placement. Ureteropelvic junction (UPJ) disruption, seen more often in children, requires immediate surgical repair. Grade IV renal injuries in children are increasingly managed in a conservative manner.

Papillary Renal Cell Carcinoma Revealed by Renal Traumatism: A Case Report in Lomé

This study is a report on a case of papillary carcinoma of the kidney revealed by an abdominal contusion. The results of radiological investigations were discordant with the low intensity of the shock. The treatment consisted of radical nephrectomy because of the suspicion of a pre-existing malignancy. Histological analysis revealed a papillary carcinoma pT3N0M0. We focus on the need for performing diagnostic tests in order to avoid missing a pre-existing anomaly to the kidney trauma.

Imaging Genitourinary Trauma

Contrast-enhanced multidetector computed tomography (MDCT) has become a critical tool in the evaluation of the trauma patient. MDCT can quickly and accurately assess trauma patients for renal, ureteral, and bladder injuries. Moreover, CT guides clinical management triaging patients to those requiring discharge, observation, angioembolization, and surgery. Recognition of urinary tract trauma on initial scan acquisition should prompt delayed excretory phase imaging to identify urine leaks. Urethral and testicular trauma are imaged with retrograde urethrography and sonography, respectively.

Utility of MDCT findings in predicting patient management outcomes in renal trauma

PURPOSE

The purpose of this study is to assess the utility of computed tomography (CT) in predicting clinical outcomes in renal trauma.

MATERIALS/METHODS

This retrospective study was IRB approved and HIPAA compliant; informed consent was waived. One-hundred-sixty-two, trauma-related renal injuries (157 adults) from January 01, 2006 to December 31, 2013 were included in this retrospective study. CT findings of vascular and collecting system (CS) injuries were recorded, and American Association for the Surgery of Trauma (AAST) renal injury grades were assigned. Fisher's exact test evaluated correlations between AAST grade and active hemorrhage, AAST grade and surgical/endovascular therapy, active hemorrhage and surgical/endovascular therapy, and size of perinephric hematomas and CS injuries. The unpaired t test correlated to the size of perinephric hematomas in CS injuries diagnosed on initial versus repeat imaging.

RESULTS

AAST grades were as follows: 120 grades I-III and 42 grade IV/V. Active hemorrhage was diagnosed in 25 (15%) patients and CS injury in 22 (14%) patients. Seven (8%) patients received surgical/endovascular therapy. There were statistically significant correlations between AAST grade and active hemorrhage (p = 0.003), active hemorrhage and surgical/endovascular therapy (p < 0.0001), and large perinephric hematomas (>2 cm) and CS injuries (p < 0.0001). There was no significant correlation between AAST grade and surgical/endovascular therapy (p = 0.08). Of the CS injuries (50%), 11/22 had no evidence of CS injury on initial imaging, being detected on follow-up CT. These "masked cases" demonstrated significant differences in perinephric hematoma size when compared to CS injuries diagnosed on initial imaging (p = 0.01).

CONCLUSION

Active hemorrhage in renal trauma is a significant predictor of surgical/endovascular therapy, in contradistinction to the AAST grade. In collecting system injuries, a large fraction was not detectable on initial CT, supporting the need for repeat imaging in cases with large perinephric hematomas.

Diagnosis value of multi-slice spiral CT in renal trauma

Computed tomography (CT) is most commonly used as a noninvasive approach in diagnosis of internal organ injures. Use of multi-slice spiral CT becomes more popular in diagnosis of trauma because of its ability to generate 3D volumetric information. This study evaluated the diagnostic value of multi-slice spiral computed tomography (MSCT) with enhanced scanning in renal trauma. In total, 126 patients with kidney injury underwent MSCT scanning from a single hospital in the southern of China between January 2012 and February 2016. According to kidney injury grading standards of American Association for the Surgery of Trauma (AAST), 30 were diagnosed and classified in level I, 26 in level II, 42 in level III, 17 in level IV, 11 in level V. The outcomes of MSCT enhanced scanning achieve a 100% diagnostic accuracy rate, which was confirmed by surgical findings. We concluded that the enhanced MSCT scan permits reliable detection of renal trauma and the associated organ or tissue injuries, providing important clinical value for the diagnosis and classification of renal trauma or internal organ injures.

Imaging characteristics associated with failure of nonoperative management in high-grade pediatric blunt renal trauma

INTRODUCTION

Some children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention.

MATERIALS AND METHODS

A retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain.

RESULTS

One patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect (P = 0.040) (Fig. A) and lacked ureteral opacification (P = 0.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5-2.5), additional operative interventions occurred from day 4-16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission (Fig. B).

CONCLUSIONS

Collecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised.

Arterial embolization of retained kidney remnant following blunt traumatic injury: A case report

INTRODUCTION

There has been a recent trend toward nonoperative management of solid organ injuries with arteriography and embolization as alternatives to surgical exploration. We examine the use of arterial embolization in the management of a post-subtotal nephrectomy urinoma in a patient with severe renal injury secondary to blunt trauma.

METHODS

This case report has been reported in line with the CARE criteria [13].

PRESENTATION OF CASE

A 35-year-old female patient presented with a persistent urinoma after an incomplete nephrectomy for blunt renal trauma. Computed tomography scan of the abdomen demonstrated a 47×68×101 mm³ collection superior to the remnant of the resected right kidney. With persistence of the urinoma after placement of an 8 French drainage catheter, the patient was taken for arterial embolization of the lower renal artery for ablation of the kidney remnant.

DISCUSSION

Most kidney injuries with urinoma formation are treated successfully with supportive measures, however refractory cases require intervention. Arterial embolization has been used successfully in the treatment of traumatic pseudoaneurysms, arteriovenous fistulas, and some renal tumors. In this patient, we extended the use of embolization to infarct vessels of the functioning kidney remnant as an alternative to surgery. Post-embolization the patient recovered well with permanent resolution of the urinoma and short-term side effects limited to short-lived fever and lumbar pain.

CONCLUSION

Arterial embolization should be considered as an alternative to surgery in cases of persistent urinoma following renal trauma with retained remnants.

Renal trauma: imaging evaluation and implications for clinical management

Severe renal injuries are usually associated with multisystem injuries, may require interventional radiology to control hemorrhage and improve the chances for renal salvage, and are more likely to fail nonoperative management. However, most renal injuries are mild in severity and successfully managed conservatively. The AAST classification is the most widely used system to describe renal injuries and carries management and prognostic implications. CT with intravenous contrast is the imaging test of choice to assess for renal injuries. Contrast extravasation indicating active bleeding should be mentioned as its presence is predictive for failure of nonoperative management. Radiologists play a critical role in identifying renal injuries and should make every effort to describe renal injuries according to the AAST grading scheme to better inform the surgeon's management decisions.

Renal Trauma: The Rugby Factor

INTRODUCTION

Renal trauma accounts for 5% of all trauma cases. Rare mechanisms of injuries including sports participation are increasingly common. Rugby-related trauma poses a conundrum for physicians and players due to the absence of clear guidelines and a paucity of evidence. Our series highlights traumatic rugby-related renal injuries in our institution, and emphasize the need for international guidelines on management.

METHODS

A retrospective review of all abdominal traumas between January 2006 and April 2013, specifically assessing for renal related trauma that were secondary to rugby injuries was performed. All patients' demographics, computerized tomography results, hematological and biochemical results and subsequent management were recorded.

RESULTS

Five male patients presented with rugby-related injuries. Mean age was 21 years old. All patients were hemodynamically stable and managed conservatively in acute setting. One patient was detected to have an unknown pre-existing atrophic kidney that had been subsequently injured, and was booked for an elective nephrectomy an 8-week interval.

CONCLUSION

Rugby-related trauma has generated essential attention. This paper serves to highlight this type of injury and the need for defined guidelines on role of imaging and international consensus on timing of return to contact sport, in both professional and amateur settings.

[Conservative management of upper tract urinary fistulae using ureteral trans-vesico-parietal stent]

OBJECTIVES

Ureteral stents and ureteral catheters externalized through the urethra are not ideal solutions to manage complicated upper urinary tract fistulae. We sought an effective method of drainage, minimally invasive, reproducible allowing a rapid patient's discharge.

PATIENTS AND METHODS

Between November 2013 and February 2015, an ureteral stent was exteriorized in trans-vesico-parietal by an endoscopic and percutaneous access in patients with complicated upper urinary tract fistulae. Monitoring of tolerance, complications and urinary fistula healing was performed.

RESULTS

Nine consecutive patients had an ureteral stent exteriorized in trans-vesico-parietal to manage complicated upper urinary tract fistulae. There was no failure in introducing the catheter, or postoperative complication. Catheters were left in place on average 36.1days (24-55). The patients were able to return home with the catheter in place in 77.8% of cases. The tolerance of the catheter was good. All fistulae were able to be treated conservatively at the end of the drainage period.

CONCLUSION

Trans-vesico-parietal ureteral catheters enable efficient and reproducible conservative treatment of upper tract urinary fistulae regardless of their cause.

LEVEL OF EVIDENCE

5.

2015 William Hunter Harridge lecture: how did we go from operating on nearly all injured kidneys to operating on almost none of them?

The 2015 William H. Harridge lecture of the 2015 Midwest Surgical Association concentrated on the evolution and performance characteristics of nonoperative management of even severe renal injury. One of the first mentions of nonoperative renal trauma occurs after World War II. Since that time through the early 2000s, only 1 or fewer papers per year appeared in the literature. The mid-2000s had an explosion of interest and publications on the subject, resulting in our modern understanding of the principles. The principles of nonoperative management are as follows: (1) operate immediately if the patient is bleeding to death; (2) observe initially, but step in with metered responses as necessary; (3) use ureteral stents for symptomatic or growing urinoma; (4) use angioembolization for nonemergent bleeding or for urgent bleeding if your center can manage this; and (5) do open surgery when needed (not "never").

Imaging of Urinary System Trauma

Computed tomography (CT) imaging of the kidney, ureter, and bladder permit accurate and prompt diagnosis or exclusion of traumatic injuries, without the need to move the patient to the fluoroscopy suite. Real-time review of imaging permits selective delayed imaging, reducing time on the scanner and radiation dose for patients who do not require delays. Modifying imaging parameters to obtain thicker slices and noisier images permits detection of contrast extravasation from the kidneys, ureters, and bladder, while reducing radiation dose on the delayed or cystographic imaging. The American Association for the Surgery of Trauma grading system is discussed, along with challenges and limitations.

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.

Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children

BACKGROUND

There are no published management schemes for blunt renal injuries. We are conducting a 2-center prospective observational study with a fixed management scheme.

METHODS

Children with CT proven renal injuries were enrolled with permission. Ambulation is allowed when able regardless of grade. Discharge occurs when tolerating a diet and pain is controlled regardless of hematuria. Urinalysis occurs at follow up in 2-4weeks and repeated as indicated.

RESULTS

Between 9/2008 and 9/2012, 70 patients were enrolled. Mean age was 11.8years (3-17), and 70% were male. The mean grade of injury was 2.8±1.1 [1-5]. One nephrectomy (1.4%) was performed for a grade 5 injury. Other renal interventions included an embolization for the hilar bleed and one cystotomy for a clot. Mean LOS was 2.9days±2.4days. In patients without other major injury, LOS was 1.9±1.7days (0.4-8days). There were 5 (7%) readmissions: 3 for pain, 1 for hematuria, and 1 for a bladder clot. 58 patients (83%) gave urinalysis samples at initial follow up (med 18days), where 31 (53%) were positive for blood.

CONCLUSIONS

Children with blunt renal injury may benefit from management without strict bedrest guidelines. Hematuria appears to have little influence on recovery.