UROGENITAL TRAUMA

Nonoperative management of blunt renal trauma: a prospective study
Toutouzas KG, Karaiskakis M, Kaminski A, Velmahos GC
Division of Trauma and Critical Care, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
Am Surg. 2002; 68: 1097-103

• Despite the abundance of literature on nonoperative management (NOM) of blunt trauma to the liver and spleen there is limited information on NOM of blunt renal injuries. In an effort to evaluate the role of NOM 37 consecutive unselected patients with renal injuries (grade 1, four; grade 2, 12; grade 3, 11; grade 4, six; and grade 5, four) were followed prospectively over 30 months (March 1999 to September 2001). Patients without peritonitis or hemodynamic instability were managed nonoperatively regardless of the appearance of the kidney on CT scan. Six (16%) patients were operated on immediately but only two (5.4%) for the kidney (grades 3 and 5 respectively). Of the remaining 31 patients 26 (84%) were managed successfully without an operation (grade 1 or 2, 12; grades 3-5, 14). Five patients were taken to the operating room after a period of observation (3, 3.5, 9, 36, and 44 hours respectively) but only three for the kidney (grades 4 and 5). The overall failure rate was 16 per cent (5 of 31); the rate of failure specifically related to the renal injury was 9.6 per cent (three of 31). Compared with the patients with successful NOM the five patients with failed NOM were more severely injured (Injury Severity Score > or = 15 in 80% vs 27%, P = 0.04), required in the first 6 hours more fluids (4.17 +/- 1.72 vs 1.87 +/- 1.4 liters, P = 0.003) and blood transfusions (2.40 +/- 2 vs 0.42 +/- 1.17 units, P = 0.005), and more frequently had a positive trauma ultrasound (80% vs 11.5%, P = 0.005). We conclude that NOM is the prevailing method of treatment after blunt renal trauma. It is successful in the majority of patients without peritonitis or hemodynamic instability and should be considered regardless of the severity of renal injury. Predictors of failure may exist on the basis of injury severity, fluid and blood requirements, and abdominal ultrasonographic findings and need validation by a larger sample size.
  
  
• Editorial Comment
  Prospective trials in genitourinary trauma are rare. This study attempts to show prospectively what at least a dozen studies over the years have shown retrospectively: that in the absence of clinically significant bleeding from the kidney, blunt renal trauma may be treated expectantly. Thirty-seven patients were seen. Only 2 (5%) underwent immediate renal exploration, and both of these patients had nephrectomy, one for a Grade V injury and one for a Grade III injury. Of note, it is my opinion that even this “conservative” center might have managed this patient without exploration of the Grade III injury and might have saved the patient the need for nephrectomy.
  Three (8%) patients required delayed surgery after a failed period of observation. Two of these patients had a Grade IV injury, hypotension and abdominal compartment syndrome, and one had a Grade V injury and peritonitis: all were treated with nephrectomy. It is not absolutely clear to me from the text that both of these patient’s problems stemmed from their kidney, but nonetheless nephrectomy was elected.
  As we would expect, patients managed without surgery did well. Even 5 (14%) patients with urinary extravasation did well, with spontaneous resolution of the urine leak. Five 5 (14%) of patients with devitalized renal segments also did well without complications.
  Although the authors delineate which factors seem to predict failure of nonoperative management, unfortunately this analysis is not very helpful. For instance, the need for fluids and blood resuscitation in the first 6 hours was associated with the failure of nonoperative management: but the ongoing need for blood is likely the same criteria the surgeons used to bring the patient to operation! Not unexpectedly, higher injury severity scores (ISS) and the presence of intraperitoneal fluid on fast ultrasound examination were also associated with the need for operation. None of this analysis is helpful in assisting us in figuring out when our next patient may need surgery, however.
  The message of the study is: continue to manage patients with isolated renal injury nonoperatively. Iatrogenic nephrectomy is avoided, complications are low, and the need for delayed surgery uncommon. Keep operating on those patient exsanguinating from the kidney, and those with ureteral or renal pelvis injury.

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