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UROGENITAL
TRAUMA
The
literature increasingly supports expectant (conservative) management of
renal trauma -- a systematic review
Santucci RA, Fisher MB
Urology, Detroit Receiving Hospital, Wayne State University School of
Medicine, Michigan, USA
J Trauma. 2005; 59: 493-503
- Background:
The perfect degree of operative intervention in renal trauma
is unknown. However, expectant management for most blunt renal trauma
is the standard of care, and nonoperative management is increasingly
accepted for stab wounds. The best treatment of gunshot wounds and vascular
injuries is still unclear; however, recent data indicates that a trial
of nonoperative therapy may be warranted in those not exsanguinating
from the kidney. Conservative management has many benefits, the greatest
of which is decreasing the rate of iatrogenic nephrectomy. We have reviewed
the world’s literature to determine the level of support for expectant
management of renal injury.
- Methods:
The English language literature concerning renal trauma was
identified with the assistance of Medline, and additional cited works
not picked up in the initial search were obtained. One hundred and ten
citations were ultimately reviewed dating back to 1947.
- Results:
Most modern citations support at least a trial of expectant management
for renal trauma patients not exsanguinating from the kidney, and without
ureteral or renal pelvis injuries. The treatment of renovascular injuries
has less consensus, but it appears that ‘conservative’ management
by the application of nephrectomy is often the best approach, although
renovascular repair may be attempted in rare cases.
-
Conclusion:
Dozens of papers going back as far as 50 years seem to support the wider
use of nonoperative therapy of renal injuries, although for unclear
reasons, this approach is not yet universally accepted.
- Editorial
Comment
The take home message is that contemporary blunt renal trauma management
is nearly always conservative (expectant). Absolute criteria for renal
trauma exploration are life threatening renovascular injuries. A pulsatile,
expanding or uncontained retroperitoneal hematoma suggests a major vascular
injury and thus demands exploration. Also, the location of the hematoma,
zone 1 (medial, over the great vessels) usually demands exploration.
All other renal injuries are relative indications for exploration, which
include segmental renal infraction, urinary extravasations, or concomitant
pancreatic or colonic injuries. For blunt renal AAST Grade IV injuries
(parenchymal laceration with urinary extravasation), only 20% plus that
are managed expectantly will require ureteral stent placement, percutaneous
urinoma drain placement or selective embolization. UPJ avulsion injuries
typically require surgical repair. Penetrating injuries theoretically
should be able to be managed stage for stage, the same as blunt renal
injuries. The difference with penetrating injuries, particularly, gunshot
wounds, are that due to blast injury there is delayed parenchymal and
vascular injury - which can later upstage the injury and thus increase
delayed renal bleeding and urinary leak. Delayed bleeds and leaks can
still mostly be managed endoscopically or percutaneously. The last take
home message, is that in inexperienced or non-urologist hands, renal
exploration typically ends with a high nephrectomy rate. Thus, when
it comes to renal injuries, expectant management is usually best, unless
there is a major renovascular injury (1,2).
References
1. Brandes SB, McAninch JW: Reconstructive surgery for trauma of the upper
urinary tract. Urol Clin North Am. 1999; 26: 183-99.
2. Meng MV, Brandes SB, McAninch JW: Renal trauma: indications and techniques
for surgical exploration. World J Urol. 1999; 17: 71-7.
Dr.
Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA |