UROGENITAL TRAUMA

Nonoperative Management Outcomes of Isolated Urinary Extravasation Following Renal Lacerations Due To External Trauma
Alsikafi NF, McAninch JW, Elliott SP, Garcia M
Department of Urology, Mount Sinai Medical Center and University of Chicago Medical Center, Chicago, IL, USA
J Urol. 2006; 176 (6 Pt 1): 2494-7

• Purpose: Urinary extravasation is a common finding in grade 4 and 5 renal injuries. To date there has been little written about the natural course of urinary extravasation following renal trauma. We reviewed data on the outcomes of urinary extravasation in the traumatized kidney when managed nonoperatively.
• Materials and Methods: A retrospective review of the prospectively entered urological trauma database from San Francisco General Hospital was performed from 1979 to 2005. All patients with urinary extravasation after sustaining traumatic injury to the kidney as seen on computerized tomography were included in analysis.
• Results: A total of 61 patients with urinary extravasation were identified. Of these patients 27 (44%) were treated operatively (26 of 27 underwent immediate and 1 of 27 underwent delayed open surgery). All (100%) operatively treated patients underwent renal exploration and repair at primary surgical management of associated abdominal and/or vascular injuries. Open surgical exploration resulted in nephrectomy in 5 of 27 (19%) patients. Of the 34 (56%) patients treated nonoperatively only 3 (9%) had persistent, nonprogressing urinary extravasation by computerized tomography 3 to 7 days after injury. All 3 (100%) of these patients underwent uncomplicated endoscopic ureteral stent placement followed by complete resolution of urinary extravasation.
• Conclusions: Nonoperative management of urinary extravasation in patients sustaining traumatic injury to the kidney without associated abdominal or vascular injury is safe and results in resolution in more than 90%. In patients with persistent urinary leakage endoscopic ureteral stent placement may be needed and is successful.
  
  
• Editorial Comment
  This article by Alsikafi et al., reports on the experience from San Francisco General Hospital over a 26-year period. This article further illustrates that the paradigm of blunt renal trauma management is typically conservative and expectant. American Association for the Surgery of Trauma grade IV injuries with extravasation of contrast are merely relative indications for renal exploration. The only absolute indications for renal exploration are grade V injuries that are life threatening due to massive bleeding. All other types of kidney trauma have a relative indication. Further points illustrated are that the treatment algorithm of nonoperative management of urinary extravasation is bed rest till the urine clears, serial hematocrits, followed by repeat CT a couple of days after initial injury. Extravasation that is stable or worse (i.e. an expanding urinoma) warrants ureteral stenting for 4 to 6 weeks. Extravasation that improves on subsequent imaging should be followed. Overall, 90% of grade IV renal injuries without major associated vascular or abdominal injuries are managed successfully without intervention.

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