UROGENITAL TRAUMA

Effect of an institutional policy of nonoperative treatment of grades I to IV renal injuries
Hammer CC, Santucci RA
Department of Urology, Wayne State University School of Medicine, Detroit,
Michigan, USA
J Urol. 2003; 169: 1751-3

• Purpose: Nonoperative treatment of serious renal injuries has been advocated and yet to our knowledge the optimum level of operative treatment has not been established to date. We report a unique data set, in which patients with severe renal injuries were treated with an ultraconservative nonoperative approach during a period when urological consultation was not available at a major urban trauma center.
• Materials and Methods: We retrospectively reviewed the charts of 51 patients identified with renal trauma in the Detroit Receiving Hospital trauma database from 1997 to 2001.
• Results: Injuries were grades I to V in 15, 7, 11, 14 and 4 cases, respectively, and had a tendency toward serious injury. Renorrhaphy was never performed. Nephrectomy was done sparingly, only for grade V renal injuries and only in patients who were exsanguinating from the kidney. Two of the 4 patients with grade V injury died of multiple injuries, including massive head injuries. Only 2 of the patients treated nonoperatively (4%) had complications, including fever and hematuria in 1 each.
• Conclusions: This data set seems to support an ultraconservative approach of limiting renal surgery to only patients with active exsanguination. The nephrectomy rate for 14 grade IV injuries, including some gunshot wounds to the kidney, was 0%. When comparing this rate with that in the literature, we would expect it to be 1 patient to as high as 10. This approach was safe and resulted in a low complication rate of 4%. Series in which more aggressive therapy for renal injuries is advocated should compare favorably to ultraconservative therapy if aggressive therapy is to continue to be widely advocated.
  
• Editorial Comment
  Most renal trauma literature is written by urologists, but at many centers the General Surgery trauma team not the urologist dictates what therapies are provided to injured patients. In some cases the trauma surgeons may elect not to consult the urology service, or they may elect to remove a briskly bleeding kidney even before urology can be notified. At our trauma center, the trauma surgeons, many of them internationally famous names, correctly (I believe) determined that most severely injured kidneys healed without the need for surgery. Even 6 patients with gunshot wound were given a trial of conservative therapy - all of them successfully. Only those who where actively bleeding to death (in the estimation of the attending general surgeon) had renal surgery, and that was a speedy nephrectomy in all cases. In this way, these surgeons have turned classic urologic trauma teaching on its head, reducing the operative rate over that reported in previous urologic series, and most importantly decreasing the rate of nephrectomy towards 0% for Grade I-IV injuries. This series mirrors the general trend towards conservative therapy in trauma, and reports like it must be closely followed by anyone with an interest in treating renal injury. Less is turning out to be more in the field of renal trauma. While it takes more courage to observe the patient than go to the operating room, it may ultimately turn out to be the best treatment in the majority of patients.

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