UROGENITAL TRAUMA

Management of High Grade Renal Trauma: 20-Year Experience at a Pediatric Level-I Trauma Center
Henderson CG, Sedberry-Ross S, Pickard R, Bulas DI, Duffy BJ, Tsung D, Eichelberger MR, Belman AB, Rushton HG
Division of Urology, Children’s National Medical Center, Washington, DC 20010, USA
J Urol. 178, 246-250, 2007

• Purpose: In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution.
• Materials and Methods: We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V).
• Results: We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury.
• Conclusions: Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.
  
  
• Editorial Comment
  Henderson et al. is another paper supporting that contemporary management of blunt renal injury in the child is expectant management (1). They had a surprisingly high percentage of Grade IV and Grade V (shattered kidney) injuries that were managed successfully. As in other solid organs like the spleen and liver, where bunt trauma is managed almost exclusively conservatively, the same is true for the kidney. Clearly, the management pendulum for even high grade blunt injuries has shifted to a nonsurgical algorithim. Only in the exsanguinating and unstable patient, is surgical exploration of blunt renal injury an absolute indication. All other kidney injuries are just relative indications. One proviso when dealing with trauma in children, however, is that they do not manifest changes in their vital signs until severe degrees of blood loss. Due to increased physiologic reserve, vital signs in the child can stay in the normal range even in the presence of shock. Tachycardia and poor skin perfusion are often the only signs of hypovolumia. Only blood volume losses greater than 30% in children manifest drops in blood pressure, narrowed pulse pressure, and absent peripheral pulses.

Reference

1. Brandes SB, McAninch JW: Reconstructive surgery of the injured upper urinary tract. UroL Clin North Amer. 1999; 26: 183-199.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
E-mail: brandess@wudosis.wustl.edu