UROGENITAL TRAUMA

High-grade renal injuries in children - is conservative management possible?
Rogers CG, Knight V, MacUra KJ, Ziegfeld S, Paidas CN, Mathews RI
Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
Urology. 2004; 64: 574-9

• Objectives: To review our experience with the management of high-grade (grade IV and V) renal injuries to clarify the role of conservative management.
• Methods: From 1991 to 2003, 79 consecutive patients (age range 2 to 14 years) with renal injuries were treated in an urban level I pediatric trauma center. Twenty children were identified as having high-grade renal injury (grade IV, 10 children and grade V, 10 children). The mechanism of injury was blunt trauma in 17 patients (85%) and penetrating trauma in 3 (15%).
• Results: Of the 10 patients with grade IV injury, 8 (80%) were successfully treated conservatively with bedrest and catheter drainage. Two patients with persistent urine leaks required ureteral stenting, and one subsequently required open operative repair. The initial radiographic findings in both patients demonstrated complete renal fracture with retained vasculature to both renal segments. All 10 patients with grade V injury required open operative management and only 3 (30%) achieved long-term renal salvage.
• Conclusions: Most children with grade IV renal injury can be treated conservatively. Patients with complete renal fracture or significant urinary extravasation on initial radiographic imaging may be less likely to undergo spontaneous resolution. Patients with a persistent urinary leak can be successfully treated with internal drainage. Grade V injuries are associated with an increased risk of requiring open operative intervention, and the renal preservation rates are low.
  
  
• Editorial Comment
  Information on pediatric renal trauma has lagged behind information reported about adults. Now several excellent papers have been published which attempt to establish the “proper” amount of surgery for children with renal trauma.
  The paper by Rogers et al. attempted conservative management even for Grade IV injury. Only 1 of their 10 patients required a stent and 1 required open repair. All 10 Grade V injury patients required surgery, and this was a nephrectomy in 7/10 patients. (It is not clear to me that the remaining 3 patients truly had a Grade V injury by the description of the injuries provided in the paper). Conservative management was not without its problems. Patients had to stay at bed rest an average of 13 days, and required urinary catheterization an average of 9 days, although significant complications such as death or iatrogenic nephrectomy was avoided. Interestingly, 3 out of 3 cases of attempted vascular repair failed, further bolstering the opinion of most experts that significant unilateral renal vessel injury should be treated with nephrectomy (as repair never seems to work).
  The conclusions from this study are:
  1) Conservative management of even high-grade renal injuries (Grade IV) in children can be attempted.
  2) Conservative management will fail only in a small percentage of the population.
  3) Ureteral stents will need to be used in a small percentage.
  4) Even severe penetrating renal injury might be treated nonoperatively in children.
  5) Grade V renal injuries will likely still need surgery, and that surgery will likely be a nephrectomy.

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