Blunt Renal Trauma In Children Research Articles

Commentary to “Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imagingˮ

Commentary to “Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imagingˮ

Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imaging

The standard imaging modality for hemodynamically stable blunt abdominal trauma patients is a contrast enhanced CT scan, which is reflected in the current AUA urotrauma guidelines. This comes, however, with radiation exposure and the potential sequalae of IV contrast administration in the pediatric patient. We hypothesize that ultrasound imaging would be able to diagnose and rule out clinically significant renal injuries when compared to the gold standard of CT scan in the setting of pediatric blunt abdominal trauma. All children <18 years of age who were evaluated for blunt abdominal trauma who had a CT scan and ultrasound imaging of kidneys were identified. The ultrasound images were reviewed by four reviewers who were blinded to CT results and all clinical information. The ability of ultrasound to diagnose and rule out clinically significant renal injury was evaluated by diagnostic test performance characteristics including sensitivity, specificity, negative predictive value and positive predictive value. There were 76 patients identified, 24 of which had a renal injury (1 bilateral) diagnosed by CT scan for a total of 25 injuries in 152 renal units. There were six grade I-II injuries and 19 grade III-V injuries. The sensitivity of the four blinded reviewers by ultrasound alone to detect the 19 grade III-V injuries ranged from 79 to 100% with NPV between 97 and 100%. Three of the four reviewers identified all 19 grade III-V injuries by ultrasound. When combined with significant hematuria, all 19 grade III-IV injuries were identified. Of note, all patients with a grade III-V injury of the kidney had significant hematuria. Of the grade I-II renal injuries, all reviewers identified 1/5 or 2/5 by ultrasound alone. The limitations of this study include: its retrospective nature, limited number of patients and reviewers, quality of the ultrasound machine. and experience of technologist, radiologist and urologist. A major limitation is the inability to assess other solid organ injuries during this initial study. When compared to a CT scan as the gold standard, kidney ultrasound images had a sensitivity of 79-100% to detect grade III-V injuries and NPV of 97-100% by four blinded reviewers. All grade III-V injuries had either an episode of gross hematuria or microscopic hematuria >50 RBC/hpf. A prospective study that includes full abdominal imaging is needed to confirm that ultrasound can safely be used in place of CT scan for evaluation of hemodynamically stable blunt trauma patients.

Is Delayed Phase Computed Tomography Imaging Necessary After Blunt Renal Trauma in Children?

To characterize the utilization of delayed phase computed tomography (CT) imaging in blunt renal trauma and determine if the omission of delayed phase CT imaging affected clinical outcomes in children. A prospectively collected trauma database was reviewed between 2006 and 2016 to identify patients aged ≤21 years with a diagnosis of renal injury from blunt trauma. Demographic characteristics, injury grade, Injury Severity Score, non-kidney organ injuries, radiologic studies, and clinical course were reviewed. Patients were categorized into 2 groups: those who received CT with delayed images in the emergency room and those who did not. In total, 121 patients met the inclusion criteria. Delayed scans were obtained in 50 patients (41%) but omitted in 71 (59%). Age, weight, non-kidney organ injuries, and imaging location did not differ between groups. Injury Severity Score was higher in the no-delay group than in the delay group (median 16 vs 10, respectively, P = .40). Median length of stay was 3 days without significant differences by cohort (P = .24). The proportion of patients who received abdominal CT scans after admission, underwent a urologic procedure, or were readmitted did not differ significantly between groups. This study was unable to demonstrate a difference in outcomes between patients who had a CT with delayed imaging and patients who did not. This questions the universal necessity for delayed images after blunt renal trauma. Future prospective studies are necessary to develop pediatric trauma guidelines that balance imaging needs and radiation exposure.

Blunt renal trauma in children with pre-existing renal abnormalities.

The kidneys are the most commonly injured genitourinary organ in children following blunt abdominal trauma. Though the retroperitoneal location affords the kidneys some protection from the forces experienced in blunt abdominal trauma, the kidneys are at greater risk of injury when a disease process exposes them from their normal shielded location. In such cases, the injuries may appear to be disproportionate in relation to the severity of the trauma history, confusing the imaging findings. Recognition of both the underlying disease process as well as the manifestations of acute trauma is important; therefore, we present a pictorial essay of traumatized kidneys in children with pre-existing renal abnormalities.

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

We determined which children sustaining blunt grade IV renal trauma are at greatest risk for failing nonoperative management and in what time frame they will likely present. We retrospectively reviewed children presenting with nonvascular grade IV blunt renal trauma between 2003 and 2012. We compared characteristics on computerized tomography, reasons for intervention, type and timing of surgery, length of hospital stay and need for readmission between children undergoing early intervention (less than 72 hours after admission) and those managed conservatively (with any subsequent intervention undertaken more than 72 hours after admission). A total of 26 children were identified with nonvascular grade IV blunt renal trauma. Conservative management was attempted in 16 cases (62%). Seven of these patients (44%) required intervention (ureteral stent and/or percutaneous drain placement), with a mean time to intervention of 11 days. Collecting system clot and larger urinoma (1.45 cm in cases with successful and 4.29 cm in those with failed conservative management) significantly predicted failure of conservative management (p<0.05). Presence of dissociated renal fragments (57% vs 11%) and interpolar contrast extravasation (57% vs 0%) were increased in the early intervention group compared to the conservatively managed group (p>0.05), as was rehospitalization (43% vs 0%), mean length of stay (7.9 vs 5.4 days) and transfusion (14% vs 0%, p>0.05). Collecting system hematoma and urinoma size significantly predicted failure of conservative management, with a mean time to intervention of 11 days. Children with failed conservative management had a greater incidence of dissociated renal fragments and interpolar extravasation. Early identification of these patients may decrease hospital readmissions, length of stay and prolonged morbidity.

The utility of initial and follow-up ultrasound reevaluation for blunt renal trauma in children and adolescents

ObjectiveTo discover if renal ultrasound (RUS) can be utilized as the primary follow-up imaging modality in the management of blunt renal injuries in children and adolescents. MethodsWe initiated a protocol utilizing RUS reevaluations for children and adolescents treated for blunt renal injuries. Patients following this protocol (Post) had initial computerized tomography (CT) with RUS reevaluation at day 2 and 2 weeks. We retrospectively compared this group to a 2-year cohort treated between 2007 and 2009 (Pre). ResultsIn our study, 28 Post protocol patients were retrospectively compared with 22 Pre cohort patients. No significant differences were observed in age, length of stay (LOS), injury severity score (ISS), and utilization of CT reevaluation. Follow-up reevaluation was obtained in 13 Pre patients versus 21 Post patients (p = 0.231). No patients had any evidence of long-term complications in either cohort. ConclusionOur results suggest that RUS can be utilized as the primary surveillance imaging modality in the management of blunt renal injuries in children and adolescents. The lack of benefit of usage of RUS demonstrated in the acute post-injury surveillance period calls into question the benefit of RUS immediately following the blunt trauma.

Blunt renal trauma in children: a retrospective analysis of 41 cases

The majority of renal injury secondary to blunt abdominal trauma can be successfully treated conservatively. In the present study, the clinical features and outcomes of children who presented with renal injury secondary to blunt abdominal trauma were evaluated. This study was carried out retrospectively using data from children at the Department of Pediatric Surgery who were hospitalized for renal injury due to blunt abdominal trauma between 2000 and 2012. Patient characteristics, clinical presentation, management strategy, and outcome were evaluated. Forty-one patients were hospitalized. The mean age of the patients was 10±4.85 years. The majority of renal injuries were grade 1 and 2. Falling was the cause of most renal injuries. All patients were initially treated conservatively. Three patients underwent acute surgical exploration for life-threatening renal bleeding (grade 4-5 injury). Nephrectomy was performed in 3 patients due to injury to the pedicle. The conservative treatment of pediatric renal parenchymal injuries is safe and effective in children. Although the vast majority of renal injuries do not require surgical intervention, life-threatening renal bleeding, regardless of the grade of injury, should be treated surgically.

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

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

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

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. 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. 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. 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.

Nonoperative Management of Nonvascular Grade IV Blunt Renal Trauma in Children: Meta-analysis and Systematic Review

To evaluate nonoperative management of grade IV blunt renal trauma in pediatric patients by performing a systematic review and meta-analysis of published studies. MEDLINE, EMBASE, Cochrane, and Scopus databases were searched between January 1992 and June 2008 for studies of pediatric renal trauma management. Inclusion criteria were patient age <or= 18 years and use of the American Association for the Surgery of Trauma renal injury scale. A total of 95 children with grade IV injuries were identified. No intervention was required in 72% (68/95). Hemodynamic instability necessitated surgical exploration in 11% of patients (11/95). Of these, 46% (5/11) required a partial nephrectomy, 27% (3/11) underwent nephrectomy, and 27% (3/11) were salvaged. Angiographic infarction was not used for patients with delayed or persistent hemorrhage. Symptomatic urinoma developed in 17% (16/95). Of these patients, 81% (13/16) were successfully managed by percutaneous drainage or ureteral stent placement, and open intervention to manage complications became necessary in the remaining 19% (3/16). Partial renal preservation was possible in 95% of patients (90/95). Nonoperative management of children with grade IV blunt renal injuries is highly successful, with at least partial renal preservation possible in 95% (90/95) of patients.

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

After properly staged renal injury many children will undergo radiological reevaluation with computerized tomography, the modality frequently favored for its widespread availability and anatomical detail. The ALARA (as low as reasonably achievable) concept attempts to balance the potential future risk of radiation induced malignancy with the added information obtained by the study. At our institution ultrasound has been increasingly adopted as the followup imaging technique of choice. We sought to evaluate this practice in pediatric blunt renal trauma management. We retrospectively analyzed the trauma database of a pediatric referral center for patients treated between 1997 and 2007. A total of 73 children with blunt renal trauma were identified. Associated injuries, mechanism of trauma, type of management, imaging studies, complications and delayed/missed injuries were evaluated. Mean patient age was 10.5 years and the male-to-female ratio was 3:2. In all patients the mechanism was blunt trauma. Average grade of injury at hospitalization was 2.4, with high grade injury observed in 32% of patients. Repeat computerized tomography was obtained in 11 patients (9 for nonurological injuries). Three nephrectomies were done in the setting of hemodynamic instability and 1 pseudoaneurysm was embolized. Four enlarging symptomatic urinomas were suspected by ultrasound. No clinically important injuries or complications due to delayed diagnosis were detected in patients followed with ultrasound. Our experience suggests that after initial computerized tomography for accurate staging of pediatric blunt renal trauma monitoring can be performed with ultrasound in most patients (excluding those with hemodynamic instability or deemed to require computerized tomography for associated injuries). Selective reevaluation with computerized tomography can be reserved for those with serial or ambiguous abnormalities detected on ultrasound, thus decreasing exposure to radiation.

Nonoperative Management of Grade 5 Renal Injury in Children: Does It Have a Place?

BackgroundNonoperative treatment of blunt renal trauma in children is progressively gaining acceptance; grade 5 renal trauma is associated with a significant rate of complications. ObjectiveTo assess the feasibility and outcome of initial nonoperative management of grade 5 blunt renal trauma in children. Design, setting, and participantsThis retrospective study included 18 children (12 boys and 6 girls; mean age: 8.4±3.4 yr) who presented to the authors’ institutes with grade 5 blunt renal trauma between 1990 and 2007. MeasurementsAn intravenous contrast-enhanced computed tomography (CT) scan demonstrated grade 5 renal trauma in all patients. Associated major vascular injuries were suspected in four patients. All were initially managed conservatively. Indications for intervention included hemodynamic instability, progressive urinoma, or persistent bleeding. Dimercaptosuccinic acid (DMSA) scans were performed at a mean time of 3.1 yr (range: 1–17) following the injury in nine patients. Results and limitationsFour patients (22%) with suspected major vascular injuries required nephrectomy 1–21 d following the trauma. Two patients with continuing hemorrhage required selective lower-pole arterial embolization (11%). Three patients (17%) had their progressive urinoma drained percutaneously, and two of them required delayed reparative surgery for ureteropelvic junction (UPJ) avulsion. Nine patients (50%) were successfully managed nonoperatively. Kidneys were salvaged in 78% of patients. DMSA scanning showed a split function >40% in 44% of evaluated kidneys. Two patients (22%) had split function <30%. At last follow-up, none of the children were hypertensive or had any abnormality on urine analysis. ConclusionsNonoperative management of grade 5 renal trauma is feasible. Prompt surgical intervention is required for those with major vascular injuries. Superselective arterial embolization can be an excellent option in patients with continuing hemorrhage and who have pseudoaneurysms. Patients with UPJ disruption can be salvaged by initial drainage of the urinoma followed by deferred correction.

Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.

Treatment in Pediatric Renal Trauma: A Conservative Management Approach

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) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

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

We sought to determine if initial computerized tomography findings in pediatric patients suffering blunt renal trauma with urinary extravasation were predictive of the need for operative intervention. A total of 17 patients with grade IV blunt renal trauma and urinary extravasation were identified between 2000 and 2007. Each computerized tomogram was reviewed to determine location, size and number of sites of extravasation, as well as the presence of contrast material in the ipsilateral ureter. These findings were compared with subsequent ureteral stent placement, percutaneous urinoma drainage, angiographic embolization and nephrectomy. A total of 13 male and 4 female patients (mean age 11.1 years) were identified. Eight patients (47%) required delayed intervention. Conservative treatment was unsuccessful in patients with absence of contrast material in the ipsilateral ureter and large separation of the upper and lower poles, and in 3 of 5 patients with multiple areas of extravasation and 4 of 5 patients with transfusion requirements. The diameter (9.6 vs 9.7 mm, p = 0.96) and location of extravasation were not predictive of subsequent intervention. Two of 5 patients with posterior extravasation required intervention, both for symptomatic urinoma. Early ureteral stent placement may be considered for pediatric patients with blunt renal trauma who demonstrate absence of contrast material in the ipsilateral ureter, since clinical indications for stent placement will likely develop. Further study may show if wide separation of the upper and lower poles, multiple areas of extravasation and transfusion requirement are factors in the decision for early intervention.

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

In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution. We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V). We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury. Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.

1210: Can CT Scan Findings Shorten the Recovery for Grade IV Blunt Renal Trauma in Children?

You have accessJournal of UrologyPodium 35, Monday, May 21, 2007, 3:30 - 5:30 pm1 Apr 20071210: Can CT Scan Findings Shorten the Recovery for Grade IV Blunt Renal Trauma in Children? Glenn M. Cannon, Marc C. Smaldone, Ethan G. Polsky, Francis X. Schneck, Mark F. Bellinger, Steven G. Docimo, and Hsi-Yang Wu Glenn M. CannonGlenn M. Cannon More articles by this author , Marc C. SmaldoneMarc C. Smaldone More articles by this author , Ethan G. PolskyEthan G. Polsky More articles by this author , Francis X. SchneckFrancis X. Schneck More articles by this author , Mark F. BellingerMark F. Bellinger More articles by this author , Steven G. DocimoSteven G. Docimo More articles by this author , and Hsi-Yang WuHsi-Yang Wu More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)31424-1AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1210: Can CT Scan Findings Shorten the Recovery for Grade IV Blunt Renal Trauma in Children?." The Journal of Urology, 177(4S), p. 399 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 177Issue 4SApril 2007Page: 399 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Glenn M. Cannon More articles by this author Marc C. Smaldone More articles by this author Ethan G. Polsky More articles by this author Francis X. Schneck More articles by this author Mark F. Bellinger More articles by this author Steven G. Docimo More articles by this author Hsi-Yang Wu More articles by this author Expand All Advertisement PDF downloadLoading ...

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children

Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.

Blunt renal trauma in children: 26 years clinical experience in an alpine region.

From 1975 to 2001, 254 children aged younger than 17 were transferred to our department for renal trauma. We performed a retrospective study to assess causality and kind of the trauma, diagnostic procedures and therapeutic consequences, respectively. The 254 children at a mean age of 10.56 years (+/-3.8) ranging from 2 to 17 years were treated for kidney trauma. Among these, 166 presented with a grade I trauma according to the kidney injury scale of the American Association for the Surgery of Trauma without any other accompanying injuries and 88 had a grade II-V lesion, respectively. Diagnostic evaluation included various standard lab tests such as urinalysis and routine blood parameters, ultrasound, IVP and/or CT. Most of the traumatic injuries resulted from skiing accidents. However, 18 children had a severe polytrauma with laceration of other vital organs. Most of the renal injuries could be treated conservatively. Surgical treatment options included immediate exploration, reconstruction, partial resection, or even nephrectomy. No child died. Due to leisure time activities in our region, skiing accidents often result in isolated laceration of the kidney. About one third presented with a severe kidney trauma, and approximately 20% of all affected children required surgical therapy. However, most of the injured kidneys could be preserved and only four nephrectomies had to be performed.

Blunt renal trauma in children with previously undiagnosed pre-existing renal lesions and guidelines for effective initial management of kidney injury.

To record pre-existing renal lesions (PERL) found incidentally during evaluation for blunt renal trauma in children, determine their importance, suggest guidelines for the effective initial management of children with significant renal trauma and to evaluate the role of temporary percutaneous nephrostomy tube drainage (TPND) in these patients. We reviewed 338 children who were hospitalized with blunt abdominal trauma between 1992 and 2000. Thirty-one patients had significant renal injury, 17 before 1997 (reviewed retrospectively) and the others reviewed and followed prospectively. Eleven of the 31 children had a PERL, which had been undiagnosed before the injury. The mean (range) follow-up was 52 (15-104) months. There were 22 boys and nine girls (mean age 9.1 years, range 2-13). The mean age was lower in patients with a PERL than in children with isolated renal injury. The most common cause of blunt renal injuries was a fall (45%) followed by motor vehicle accidents. Renal stones were present in five children, pelvi-ureteric junction obstruction in four, megaureter in one and a renal cyst in one. The mean injury severity scores were 12 in the children with a PERL and 14 in patients without. TPND was used in seven (22%) children; four were associated with a PERL. The mean grade of injury score for the kidney was higher in patients with a PERL and in children who underwent TPND than in patients who previously had a normal kidney and in children who did not undergo TPND. Early surgical intervention was required in three children; all were associated with a PERL. Of the 13 children who underwent surgery 11 had previous disease. The frequency of PERL is high (36%) in children with blunt renal trauma. PERL can predispose minor trauma to cause kidney injury even with no evidence of hydronephrosis. When a minor trauma results in renal injury, it is important to seek a PERL. In selected patients, TPND may decrease the length of hospital stay and improve the outcome of the injured kidney, thereby decreasing the need for further surgery in those with isolated renal injury; however, it appears not to decrease the need for later operations in children with a PERL.