UROGENITAL TRAUMA

Pediatric renal injuries: management guidelines from a 25-year experience
Buckley JC, McAninch JW
Department of Urology, University of California School of Medicine and Urology Service, San Francisco General Hospital, USA
J Urol. 2004; 172: 687-90; discussion 690

• Purpose: We defined the mechanism and cause of pediatric renal trauma, and developed guidelines for management based on the outcome analysis of operative vs. nonoperative management.
• Materials and Methods: We retrospectively reviewed 374 pediatric renal injuries at San Francisco General Hospital, comparing operative vs. nonoperative management based on clinical presentation, type of renal injury, hemodynamic stability, associated injuries and the results of radiographic imaging.
• Results: Blunt trauma accounted for 89% of pediatric renal trauma with a renal exploration rate of less than 2%. Penetrating trauma represented the remaining 11% with a renal exploration rate of 76%. Of grade IV renal injuries 41% were successfully managed nonoperatively based on computerized tomography and staging in hemodynamically stable children. Our overall renal salvage rate was greater than 99%.
• Conclusions: Pediatric renal trauma is often minor and observation poses no significant danger to the child. In serious pediatric renal injuries early detection and staging based on clinical presentation and computerized tomography are critical for determining operative vs. nonoperative management. Regardless of the type of management the standard of care is renal preservation (less than 1% nephrectomy rate in this series).
  
  
• Editorial Comment
  The study by Buckley & McAninch is the largest pediatric renal trauma series ever reported. Although this center is now devoted to conservative management when appropriate, some of this series is 25 years old, and predates the time when conservative management was used widely by anyone. Interestingly, even though this series reports 374 patients, they had fewer Grade IV and V injuries than that reported in Roger’s et al. smaller series of 79 patients (Urology. 2004; 64: 574-9)! In this series, 8/9 blunt Grade IV renal trauma patients were managed nonoperatively. The overall rate of exploration was higher than that seen now, however, because of the policy of exploring all penetrating trauma patients with gross hematuria, and all patients who are taken immediately to the operating room “in whom renal staging (imaging) was incomplete”. To the credit of this group, only 1 patient (1%) got a nephrectomy.
  The conclusions from this study are:
  1) As has been reported elsewhere, blunt renal trauma patients can probably be imaged just like adults (that is, CT only with gross hematuria, major associated injuries, hypotension or deceleration).
  2) Most pediatric renal injuries are minor and can be observed.
  3) Major blunt renal injuries can be managed nonoperatively.
  4) Nonoperative management of renal trauma may require a long hospitalization (average 14 days in McAninch and 13 days in Rogers).

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