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UROGENITAL
TRAUMA
Renovascular
injury: an argument for renal preservation
Barsness KA, Bensard DD, Partrick D, Hendrickson R, Koyle M, Calkins CM,
Karrer F
Division of Pediatric Surgery, Department of Surgery, The Children’s
Hospital, University of Colorado Health Sciences Center, Denver, Colorado,
USA
J Trauma. 2004; 57: 310-5
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Background:
Renovascular injury is uncommon among children. This study hypothesized
that preservation of the severely injured kidney can be achieved safely
without renal insufficiency, postinjury hypertension, or the need for
hemodialysis.
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Methods: Retrospective chart review of renal injuries
seen between 1997 and 2001 at a level 1 pediatric trauma center was
conducted. Severity of injury was graded by the American Association
for the Surgery of Trauma Organ Injury Severity Scale. The outcome variables
included the need for hemodialysis, impaired renal function (creatinine),
and postinjury hypertension.
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Results: In
this study, 34 children presented with grade 1, 2, or 3 injury (74%),
whereas 13 children presented with grade 4 or 5 renovascular injury
(28%). The children with unilateral renovascular injury who underwent
either nephrectomy or renal preservation had comparable outcomes with
no hypertension, hemodialysis, or renal insufficiency in either group.
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Conclusions:
The treatment outcomes were not different between the patients who underwent
renal preservation and those who had immediate nephrectomy. The authors
conclude that renal preservation should be attempted for all children
with grade 4 or 5 renovascular injury.
- Editorial
Comment
In adults the consensus seems to be that major renovascular injury is
probably going to result in nephrectomy (see article below). Those with
complete avulsion are usually bleeding briskly and need speedy vascular
control to save their life; those with renal artery thrombosis nearly
always eventually require nephrectomy even if revascularization is attempted
(see paper below) and it is starting to be seen that even venous lacerations
have a high nephrectomy rate even in the best hands (1). This pediatric
series of 13 patients with grade IV (7 patients) or grade V (6 patients)
renovascular injury, supports observing these patients without nephrectomy
if possible. Six children in this series who had no treatment seemed
to do as well as 4 that had nephrectomy for their injury. Even one child
with bilateral hilar injuries (usually listed as a reason to attempt
vascular repair) was observed without vessel repair (although he later
developed renovascular hypertension). Unfortunately, the authors do
not specify the outcomes of those with grade IV injuries compared to
grade V. Obviously those with grade V avulsions should be expected to
do much worse! In any case, this paper is further evidence that you
should at least initially consider expectant management of renal trauma
- in a pediatric subset with nonexsanguinating renovascular trauma.
Reference
1. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch
JW, Nash P, Schmidlin F: Evaluation and management of renal injuries:
consensus statement of the renal trauma subcommittee. BJU Int. 2004; 93:
937-54.
Dr.
Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA |