UROGENITAL TRAUMA

Outcome after major renovascular injuries: a Western trauma association multicenter report
Knudson MM, Harrison PB, Hoyt DB, Shatz DV, Zietlow SP, Bergstein JM, Mario LA, McAninch JW
San Francisco General Hospital of the University of California, USA
J Trauma. 2000; 49: 1116-22

• Background: Major renal vascular injuries are uncommon and are frequently associated with a poor outcome. In addition to renal dysfunction, posttraumatic renovascular hypertension may result, although the true incidence of this complication is unknown. The objective of this study was to describe the factors contributing to outcome after major renovascular trauma. We hypothesized that the highest percentage of renal salvage would be achieved by minimizing the time from injury to repair.
• Methods: This was a retrospective chart review over a 16-year period conducted at six university trauma centers of patients with American Association for the Surgery of Trauma grade IV/V renal injuries surviving longer than 24 hours. Postinjury renal function with poor outcome was defined as renal failure requiring dialysis, serum creatinine greater than or equal to 2 mg/dL, renal scan showing less than 25% function of the injured kidney, postinjury hypertension requiring treatment, or delayed nephrectomy. Data collected for analysis included demographics, mechanism of injury, presence of shock, presence of hematuria, associated injuries, type of renal injury (major artery, renal vein, segmental artery), type of repair (primary vascular repair, revascularization, observation, nephrectomy), time from injury to definitive renal surgery, and type of surgeon performing the operation (urologist, vascular surgeon, trauma surgeon).
• Results: Eighty-nine patients met inclusion criteria; 49% were injured from blunt mechanisms. Patients with blunt injuries were 2.29 times more likely to have a poor outcome compared with those with penetrating injuries. Similarly, the odds ratio of having a poor outcome with a grade V injury (n = 32) versus grade IV (n = 57) was 2.2 (p = 0.085). Arterial repairs had significantly worse outcomes than vein repairs (p = 0.005). Neither the time to definitive surgery nor the operating surgeon’s specialty significantly affected outcome. Ten percent (nine patients) developed hypertension or renal failure postoperatively: three had immediate nephrectomies, four had arterial repairs with one intraoperative failure requiring nephrectomy, and two were observed. Of the 20 good outcomes for grade V injuries, 15 had immediate nephrectomy, 1 had a renal artery repair, 1 had a bypass graft, 1 underwent a partial nephrectomy, and 2 were observed.
• Conclusion: Factors associated with a poor outcome following renovascular injuries include blunt trauma, the presence of a grade V injury, and an attempted arterial repair. Patients with blunt major vascular injuries (grade V) are likely to have associated major parenchymal disruption, which contributes to the poor function of the revascularized kidney. These patients may be best served by immediate nephrectomy, provided that there is a functioning contralateral kidney.
  
  
• Editorial Comment
  This is not the newest paper, but it is one of the best. It establishes that “conservative” management of adult renovascular injury probably means “nephrectomy instead of vascular repair”. In a multicenter series of 89 patients with renovascular injuries, 3 of 4 patients that had a primary repair had a “poor” result, while only 3 of 18 of those with a primary nephrectomy had a poor result. In general, an attempted bypass graft was 15 times more likely to result in a poor result for the patient than nephrectomy. These data again support at least a trial of nonoperative treatment of the patient, and failing that, a “conservative” approach by performing nephrectomy instead of vascular repair. In this dataset, some patients who were initially observed eventually needed the kidney to be removed, but this could be achieved after a few days when the patient was stable. Two patients developed renovascular hypertension, but these patients had vascular repair instead of kidney removal.

Dr. Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA