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

• 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
  This series, from the most reliable American center of excellence in GU trauma surgery, is one of the largest pediatric series ever published. The lessons from this series are clear:
  1. Most (96%) blunt pediatric renal injuries of low severity (Grades I-III).
  2. Overall, 41% of Grade IV injuries were managed nonoperatively (mostly blunt).
  Even some (24%) penetrating renal injuries were treated nonoperatively.
  3. Few patients (1/37 explored, overall 1/374 patients seen) patients required a nephrectomy.
  4. Worsening urinary extravasation required stent placement uncommonly—in only 1 case.
  Large and authoritative series such as this lend further support for an initial nonoperative approach to most hemodynamically stable renal injuries, even in children. Patients with suspected Grade V vascular injuries (avulsion of the hilar vessels, and those that acutely require more than 3 units of blood, are the only absolute indications for surgery.

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