Instituting a Conservative Management Protocol for Pediatric Blunt Renal Trauma: Evaluation of a Prospectively Maintained Patient Registry

Timing and Predictors for Urinary Drainage in Children with Expectantly Managed Grade IV Renal Trauma

Computerized Tomography Findings in Pediatric Renal Trauma—Indications for Early Intervention?

Single Center Experience With Application of the ALARA Concept to Serial Imaging Studies After Blunt Renal Trauma in Children—Is Ultrasound Enough?

Bloody Urine after Minor Trauma in a Child: Isolated Renal Injury versus Congenital Anomaly?

Analysis of Diagnostic Angiography and Angioembolization in the Acute Management of Renal Trauma Using a National Data Set

43 A SUCCESSFUL PROSPECTIVE TRAIL OF CONSERVATIVE MANAGEMENT FOR PEDIATRIC BLUNT RENAL TRAUMA

Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma. Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded. When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%. Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma. Guidelines study, level III.

Blunt trauma remains a significant cause of morbidity and mortality in the pediatric population. The use of conservative management for blunt renal trauma is widely accepted in adult trauma literature and is now increasingly accepted for use in the pediatric patient population. This study aimed to review current practices in pediatric blunt renal trauma management and to highlight current practices in conservative protocols, success rates of conservative management strategies, as well as short- and long-term outcomes of blunt renal trauma management. This is a systematic review of PubMed, Ovid, and the Cochrane Library. The following search was performed in each of the three databases: (Renal or Kidney) AND (Pediatric or Children) AND Trauma AND Management. Publications were limited to publish date after January 1, 2000. Inclusion criteria were (1) original research articles regarding management of pediatric blunt renal trauma, (2) involvement of cases of high-grade renal (Grades IV and V) trauma, and (3) more than one patient presented per study. Literature reviews and meta-analyses were excluded. Titles and abstracts (n = 308) were screened to identify scientific articles reporting original research findings. A total of 32 articles met the selection criteria and were included in the review. The literature supports application of conservative management protocols to high-grade blunt pediatric renal trauma. Criteria for early operative intervention are not well understood. At this time, emergent operative intervention only for hemodynamic instability is recommended. Minimally invasive interventions including angioembolization, stenting, and percutaneous drainage should be used when indicated. Short- and long-term outcomes are favorable when using conservative management approaches to Grade IV and V renal injuries. Further studies including prospective studies and randomized control trials are necessary. Cost analyses of current treatment protocols are also necessary to guide efficient management strategies. Systematic review, level III.

Contemporary management of pediatric high grade renal trauma: 10 year experience at a level 1 trauma centre

Objective To study the management of severe blunt renal trauma in children. Methods From 2000 to 2008, clinical outcomes of 33 children with blunt renal trauma were retrospectively analyzed, especially focusing on the 15 severe blunt renal trauma cases (3 cases were hydronephrosis complicating with renal trauma).Results Neither deaths nor early nephrectomy was noted in this study. Eighteen patients with mild renal injury were cured after non operative management. Of the 15 severe cases, 8 were cured after conservative treatment, 3 with active bleeding were treated by selective renal artery embolization, and 1 with renal vascular injury underwent exploratory surgery and surgical repair of renovascular trauma; the other 3 were hydronephrosis complicating with renal trauma, of which 2 underwent pyloplasty and early postoperative drainage, and the last patient with renal failure and contralateral congenital renal atrophy underwent early post-injury nephrostomy and delayed pyloplasty to conserve more renal function. All severe cases have been followed-up for 5-28 months (mean follow-up duration: 18 months). One patient underwent nephrectomy of the atrophic kidney 6 months later for persistent secondary hypertension. Of the 4 cases complicated with urinary cysts, 1 underwent early ureteropelvic anastomosis, the other 3 underwent delayed urinary cysts resection.Conclusions Mild renal injury has a good prognosis after conservative treatment. The management of severe renal trauma should be based on specific clinical conditions of individuals. Early exploratory surgery and nephrectomy are not advocated on most severe renal trauma cases. The selective renal artery hemostatic embolization is a good option to stop active bleeding in blunt renal trauma patients. The severe renal trauma patients need close interval postoperative follow-up to prevent the complications such as urinary cyst and secondary hypertension. Key words: Renal trauma; Treatment; Children

Purpose: Retrospective studies show that even high grade pediatric renal trauma can be safely managed conservatively. We evaluated a prospective patient registry at our level 1 pediatric trauma center, where patients with renal trauma were treated with an institutional review board approved conservative blunt renal trauma protocol. Standardized treatment included a trial of expectant management for all stable cases. Materials and Methods: We identified 39 children with blunt renal trauma treated between 2003 and 2008. A strict conservative approach was used, ie nonoperative management in cases that were hemodynamically stable or had a favorable response with up to 2 units of blood transfused and no operative renal lesion on imaging. Adult imaging protocols were followed and exploratory laparotomy for nonrenal causes did not alter course of expectant renal management. Outcomes evaluated were injury grade, hematuria, operative management, length of stay and associated injuries. Results: Based on the American Association for the Surgery of Trauma organ injury severity scale, 13 patients were considered to have grade I disease, 8 grade II, 11 grade III, 6 grade IV and 1 grade V. Conservative management resulted in a 97% nonoperative rate and a single renorrhaphy. Conclusions: Using a prospective patient registry, this study demonstrates that conservative treatment of blunt pediatric renal trauma is safe and effective. Also, serious renal injuries are not missed by applying adult diagnostic imaging protocols in children.

Management of High Grade Renal Trauma: 20-Year Experience at a Pediatric Level I Trauma Center

Pediatric blunt renal trauma: Its conservative management and patterns of associated injuries

Renal Trauma from Recreational Accidents Manifests Different Injury Patterns than Urban Renal Trauma

Purpose: The management of pediatric trauma is substantially derived from the results of adult trauma patient. Despite the increasing of pediatric renal trauma, the management of them still remains controversial. The aim of this study is to evaluate our experience with the expectant conservative management of blunt trauma in children. Materials and Methods: We retrospectively studied 45 pediatric patients with renal trauma between 1995 and 2007. We reviewed medical records for clinical symptoms, mechanism of injury, assigned grade of renal injury, associated injuries, indication of surgery, and treatment outcomes. We graded renal injuries according to the American Association for the Surgery of Trauma Organ Injury Scale. Results: All patients of grade I, II, III, and IV were managed conservatively at beginning, if the hemodynamic state is stable. Among them, 2 patients of grade IV were done delayed operation. One patient underwent delayed renorrhaphy for persistent anemia and hypotension, and the other patient needed delayed nephrectomy because of persistent fever and worsening abdominal pain with significant urinary extravasation. All patients of grade V were undergone early nephrectomy. Conclusions: Except for persistent fever with significant extravasation and grade V injury, initial conservative management of blunt renal trauma in children is effective and recommendable at beginning, if the hemodynamic state is stable. Prospective larger randomized controlled trials will be needed. (Korean J Urol 2009;50:1125-1132) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏