UROGENITAL TRAUMA

Organ Injury Scaling: Spleen, Liver, and Kidney
Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, Flint LM, Gennarelli TA, Malangoni MA, Ramenofsky ML, et al.
Department of Surgery, Denver General Hospital, CO, USA
J Trauma. 1989; 29:1664-6

• The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) was appointed by President Trunkey at the 1987 Annual Meeting. The principal charge was to devise injury severity scores for individual organs to facilitate clinical research. The resultant classification scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. A number of similar scales have been developed in the past, but none has been uniformly adopted. In fact, this concept was introduced at the A.A.S.T. in 1979 as the Abdominal Trauma Index (A.T.I.) and has proved useful in several areas of clinical research. The enclosed O.I.S.’s for spleen, liver, and kidney represent an amalgamation of previous scales applied for these organs, and a consensus of the O.I.S. Committee as well as the A.A.S.T. Board of Managers. The O.I.S. differs from the Abbreviated Injury Score (A.I.S.), which is also based on an anatomic scale but designed to reflect the impact of a specific organ injury on ultimate patient outcome. The individual A.I.S.’s are, of course, the basic elements used to calculate the Injury Severity Score (I.S.S.) as well as T.R.I.S.S. methodology. To ensure that the O.I.S. interdiffuses with the A.I.S. and I.C.D.-9 codes, these are listed alongside the respective O.I.S. Both the currently used A.I.S. 85 and proposed A.I.S. 90 are provided because of the obligatory transition period. Indeed, A.I.S. 90 contains the identical descriptive text as the current O.I.S.’s. The Abdominal Trauma Index and other similar indices using organ injury scoring can be easily modified by replacing older scores with the O.I.S.’s.

Urgent Superselective Segmental Renal Artery Embolization in the Treatment of Life-threatening Renal Hemorrhage
Pappas P, Leonardou P, Papadoukakis S, Zavos G, Michail S, Boletis J, Tzortzis G
Department of Radiology, Laiko General Hospital, Athens, Greece
Urol Int. 2006; 77: 34-41

• Introduction: Renal hemorrhage is a major life-threatening condition that can be caused by trauma, operation, biopsy, as well as sudden spontaneous rupture of renal tumors or aneurysms. We report our experience with superselective segmental renal artery catheterization and embolization as therapeutic options for such cases.
• Patients and Methods: Over the last 8 years, 28 patients with severe renal hemorrhage were admitted for evaluation and possible further treatment. Twenty of them had a history of previous biopsy (6 of them one of a transplanted kidney), 1 patient had a recent percutaneous nephrostomy, 4 patients presented with renal mass ruptures (2 patients renal cell carcinoma, 1 patient angiomyolipoma, 1 patient hemorrhagic cysts), 1 patient had rupture of a renal aneurysm during delivery, 1 patient suffered bleeding after partial nephrectomy, and 1 patient was hospitalized after a car accident. They all presented with clinical signs of hemodynamic instability. Angiographic investigation of the kidneys preceded further intervention in all cases. 26 out of the 28 patients underwent superselective embolization of the specific bleeding vessel with the use of microcoils and/or Gelfoam particles.
• Results: All patients treated by superselective segmental renal artery embolization had a successful outcome, including a steady renal function and a stable clinical course. No complications occurred.
• Conclusion: Superselective segmental renal artery catheterization and embolization is a safe and efficient method for the treatment of patients with severe renal hemorrhage, preserving healthy renal parenchyma and renal function.
  
  
• Editorial Comment
  Increasingly, there is wide acceptance and support in the literature for the nonoperative management of nearly all blunt renal trauma, except for the potentially life-threatening injuries that are AAST Grade V. An aggressive approach at nonoperative management, inherently accepts an increased complication rate of delayed bleed or urinary leak. However, such complications can be effectively managed endoscopically or endo-vascularly. Delayed renal bleeding can occur up to several weeks after initial injury, although the period of greatest risk is within the first two to three weeks after injury. Clot lysis and hematoma liquefaction begins around day 5 to7 and continues for another 2 weeks or so. It is during this time that renal bleeding is most likely. The kidney can bleed either into the collecting system, into the perirenal space, or as an arteriovenous fistula. Overall, delayed bleeding after trauma is rare, effecting less then one percent of all renal injuries. Penetrating injuries managed conservatively, in particular stab wounds, are especially prone to delayed bleeding, occurring in up to 18% of cases. Conservatively managed large devascularized renal segments with an associated bowel injury are also prone to delayed hemorrhage.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA