UROGENITAL TRAUMA

Does Nephrectomy for Trauma Increase the Risk of Renal Failure?
Velmahos GC, Constantinou C, Gkiokas G
Department of Surgery, Division of Trauma and Critical Care, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
World J Surg. 2005; 29: 1472-5

• Renal failure is a feared complication following operations for severe trauma. Injuries to the kidney may be managed by nephrectomy or nephrorrhaphy. Nephrectomy may increase the risk of renal failure in already at-risk trauma patients. Nephrectomy for trauma should be avoided to the extent possible because it is associated with renal failure. From a prospectively collected trauma database, 59 patients with nephrectomy were matched at 1:1 ratio with 59 patients with nephrorrhaphy. Matching criteria were age (+/- 5 years), Injury Severity Score (+/- 3), abdominal Abbreviated Injury Score (+/- 1), and mechanism of injury (blunt or penetrating). The rates of renal function compromise (defined as a serum creatinine level >2 mg/dl for more than 2 days) and renal replacement therapy (continuous or intermittent) were compared in the two groups. The two groups were well-matched and similar with regard to injury severity and organs injured. Between nephrectomy and nephrorrhaphy patients, there were no differences in renal function compromise (10% vs. 14%, p = 0.57), renal replacement therapy (5% vs. 0%, p = 0.12), length of hospital stay (19 +/- 26 vs. 20 +/- 21, p = 0.8), and mortality (15% vs. 12%, p = 0.59). Salvaging the injured kidney does not seem to offer an obvious clinical benefit regarding postoperative renal function. Given the increased operative complexity of nephrorrhaphy in comparison to nephrectomy and the frequent need to abbreviate the operation in patients with severe trauma, nephrectomy should not be avoided when appropriate.
  
  
• Editorial Comment
  Contemporary trauma management employs a damage control principle. Patients who become cold, coagulopathic, and acidotic have a very high mortality rate. In order to avoid this fatal triad, it was observed that if the trauma patient underwent an abbreviated operation to control bleeding and fecal soiling, followed by ICU resuscitation, then followed by a staged definitive repair, the patient survival rates were dramatically improved. Currently, abbreviated surgeries and staged definitive repair are standard of trauma care and have been applied to all organ system, including genitourinary. Although as urologists, we are in the kidney preservation business, the overall survival of the patient should not be compromised in order to save the kidney. In other words, do not kill the patient trying to save the kidney. In trauma circles, the way to damage control injures organs is to quickly control bleeding and fecal and urinary soiling. To control bleeding the organ can be packed, quickly repaired or removed. To control urinary spillage, the ureter can be exteriorized, ligated or quickly repaired. The use of damage control to urology was popularized (1). To the trauma surgeons, since most trauma patients are young healthy adults with 2 normal kidneys and a normal creatinine, the kidney can be removed without too much overall kidney function compromise. Velmahos et al., puts up a good argument in the above article, but I would argue a different conclusion. The authors are trying to support the high 50-60% nephrectomy rates of yester-year. I would argue that the nephrectomy rate does not have to be higher the 20% and we can still follow a damage control method. Furthermore, palpating for a normal feeling contralateral kidney can be unreliable. I have personally seen 2 cases of trauma patients with a nonfunctioning contralateral multi-cystic dysplastic kidney and one hypertrophied psoas muscle that was thought to be palpably normal kidney by the trauma service. In the stable blunt trauma patient, all grade 1-4 renal injuries should managed conservatively if possible. In the blunt trauma patient who is explored, a stable, nonpulsatile, nonexpanding, contained perinephric hematoma should be left alone. In the penetrating trauma patient who is explored and the kidney does not have much blast injury and not really bleeding, I would just cover the gunshot holes with a surgi-cell and place a drain. The kidney can also be packed. Once resuscitated on a staged celiotomy, the kidney can be reexamined and a more definitive repair can be performed.

Reference
1. Brandes SB: Damage control for urologic trauma: an approach for improved survival. J Urol. 2003; 169: 69A.

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