PEDIATRIC UROLOGY

Late renal functional and morphological evaluation after non-operative treatment of high-grade renal injuries in children
El-Sherbiny MT, Aboul-Ghar ME, Hafez AT, Hammad AA, Bazeed MA
The Mansoura Urology and Nephrology Center, Mansoura, Egypt
BJU Int. 2004; 93: 1053-6

• Objective: To assess the long-term results in children with high-grade renal trauma who were managed without surgery, as such treatment was initially successful but little is known about the late ipsilateral renal function and morphology.
• Patients and Methods: The study included 13 children (nine boys and four girls; mean age 8 years, sd 5) with high-grade renal injury who were managed without surgery between 1997 and 2001, and followed for a mean (sd, range) of 3 (2, 0.5-7) years. The trauma was caused by a motor-car accident in five and falling from a height in eight children, and was on the right in 10 and on the left in three. There was gross and microscopic haematuria in 10 and three patients, respectively. The trauma was graded according to the American Association for Surgery of Trauma, with grades III, IV and V renal injury in six, four and three children, respectively. All patients were treated initially by observation; one required super-selective embolization because of continuing haemorrhage. Three children with progressive urinary extravasation were treated with a percutaneous tube drain and JJ stent for 6 weeks. Patients were discharged after a mean (sd) hospital stay of 9 (6) days. Ultrasonography then showed resolving haematoma in all patients with a mean (sd) size of 7 (2) cm (2). At the last follow-up patients were re-evaluated by a clinical examination, renal scintigraphy and computed tomography angiography.
• Results: None of the children was hypertensive nor had any abnormality on urine analysis; all had normal serum creatinine levels, and scintigraphy and angiography showed normal contralateral kidneys in all. Ipsilateral abnormalities were detected in 12 patients, and included a single scar in five, multiple scars in six and a cystic lesion with multiple septa in one. There was no vascular complication or hydronephrosis, and no significant functional loss, with all affected kidneys having a split function of 41-50% at the last follow-up.
• Conclusion: Although there is no late functional loss there are residual morphological changes in almost all children with high-grade renal injury. This study provides objective support for the non-operative management of high-grade renal injury in children, but a prolonged follow-up is warranted to assess the risk of progression of these abnormalities.
  
  
• Editorial Comment
  The authors demonstrate the remarkable results of “non-operative” management of severe renal trauma. Of 6 patients with Grade III, 4 with Grade IV and 3 with Grade V injuries, none required open surgery and despite some morphological abnormalities, none had significant functional loss.
  Their data however should be interpreted with some caution however. Seven patients required blood transfusion, one had an arterial embolization and 3 had percutaneous flank drains and internal stent placement. In other words, “non-operative” management has some morbidity and may require procedures. Moreover, this is a select population. No patient in this series had other abdominal injuries, as those patients are managed at a different center. Hence there is a significant selection bias in this series. This leaves unresolved, the question of whether operative intervention may be indicated in patients being operated on for other abdominal injuries. Nonetheless, the authors do demonstrate that impressive results can be obtained in children with major injuries who are managed expectantly.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA