High-grade Renal Injuries Research Articles

Impact of Trauma Center Designation and Interfacility Transfer on Renal Trauma Outcomes: Evidence for Universal Management

BackgroundRenal trauma may be managed differently in tiered trauma systems and among those who requireinterfaculty transfer. ObjectiveTo evaluate the initial management of renal trauma, assess patterns of management based on hospital trauma level designation and interfacility transfer status, and analyze management trends over time. Design, setting, and participantsRetrospective cohort study of renal trauma from the National Trauma Data Bank 2010–2015. InterventionNephrectomy, angioembolization, or nonoperative management. Outcomes measurements and statistical analysisWe used generalized estimating equations to compare odds of each management outcome in patients transferred and directly admitted to a level I center, versus those directly admitted to a non–level I center, adjusting for vital signs, injury, demographic, and facility characteristics. We also used generalized estimating equations to examine linear time trends in management outcome, adjusting for injury characteristics. Results and limitationsA total of 51798 renal trauma records were included: 44 838 low-grade (American Association for the Surgery of Trauma I–III) and 6359 high grade (IV–V) injuries. After adjusting for comorbidities, demographics, and hospital characteristics, odds of nephrectomy, angioembolization, and nonoperative management were similar in patients transferred or directly admitted to a level I center compared with those treated at a non–level I center. Changes in management over time demonstrated a decreased rate of nephrectomy (p=0.007) in high-grade injuries, while the rate of angioembolization remained constant (p=0.33). Study limitations include mortality prior to hospital transfer or arrival, and its retrospective nature. ConclusionsIn this contemporary trauma analysis, outcomes of both low- and high-grade renal trauma are similar across patients managed in tiered trauma centers and those undergoing transfer, signifying dissemination of collective renal trauma management. The rate of nephrectomy has decreased for high-grade renal injury over our study period, suggesting new adoption of kidney-sparing management. Patient summaryRenal trauma is now managed similarly in tiered trauma centers and in patients requiring interfacility transfer. The rate of nephrectomy for high-grade renal injuries has decreased over time.

PD02-01 IMPACT OF TRAUMA CENTER DESIGNATION ON RENAL TRAUMA OUTCOMES: EVIDENCE FOR UNIVERSAL MANAGEMENT

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I1 Apr 2018PD02-01 IMPACT OF TRAUMA CENTER DESIGNATION ON RENAL TRAUMA OUTCOMES: EVIDENCE FOR UNIVERSAL MANAGEMENT Marc Bjurlin, Audrey Renson, Richard Jacob Fantus, and Richard Joseph Fantus Marc BjurlinMarc Bjurlin More articles by this author , Audrey RensonAudrey Renson More articles by this author , Richard Jacob FantusRichard Jacob Fantus More articles by this author , and Richard Joseph FantusRichard Joseph Fantus More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.226AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Tiered delivery of trauma care has resulted in improved trauma outcomes at level I trauma centers compared to non-level I centers. In the era of conservative management of kidney injuries, comparison of outcomes of renal trauma by hospital designation is not well studied. Our study objective was to evaluate the initial management of renal trauma, assess patterns of management based on hospital trauma level designation, and analyze management trends over time. METHODS This retrospective cohort study included renal trauma from the National Trauma Data Bank 2010-2015. We examined the association between hospital trauma level designation (level I vs transferred to level I vs non-level I), and renal trauma management including nephrectomy, angioembolization, and nonoperative management, along with presence of any annual linear time trends in management. RESULTS We analyzed 51,798 renal trauma records; 44,838 low grade (AAST I-III) and 6,359 high grade (IV-V) injuries. After adjusting for comorbidities, demographics, and hospital characteristics, odds of nephrectomy, angioembolization, and nonoperative management were similar in patients transferred to a level I and directly admitted to level I centers, compared to those treated at non-level I for both high and low grade injuries (Table 1), although mortality was lower in those transferred to level I centers (OR 0.70, 95% Cl 0.61-0.80, p<0.001). Change over time of management of high grade renal injuries demonstrated a decrease in the use of nephrectomy (p=0.007) while rates of angioembolization remained constant (p=0.33) (Figure 1). CONCLUSIONS In this contemporary trauma analysis, outcomes of both low and high grade renal trauma are similar across those patients managed in tiered trauma centers, signifying dissemination of collective renal trauma management. The rate of nephrectomy has decreased for high grade renal injury over our study period suggesting new adoption of kidney sparing management. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e64-e65 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Marc Bjurlin More articles by this author Audrey Renson More articles by this author Richard Jacob Fantus More articles by this author Richard Joseph Fantus More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of Major Blunt Renal Injury: A Twelve-Year Review at an Urban, Level I Trauma Hospital

The aim of this study was to describe the management of severe blunt renal injuries at a Level I trauma hospital. Data were collected through a record review of patients admitted from January 1, 2000, to December 31, 2011. These data were compiled as part of our hospital's participation in the Nonoperative Management of Grade IV and V Blunt Renal Injuries: A Research Consortium of New England Centers for Trauma Study. Thirty-six patients with severe blunt renal injuries were identified. Twenty-nine (80.6%) underwent nonoperative management (NOM) for their injuries. Seven (19.4%) received an immediate operation because of hemodynamic instability or CT findings of large hemoperitoneum or extravasation. No significant differences were observed on Injury Severity Score, Glasgow Coma Scale, injury grade, or systolic blood pressure on arrival to the emergency department. On arrival, the operative patients had higher heart rates and lower hematocrit and hemoglobin values relative to the NOM patients. The kidney was salvaged in three of the seven operative patients and was either saved or partially saved in all except one NOM patient. Three NOM patients died; none because of renal injuries. All other patients were successfully managed. None of the operative patients died. NOM management of high-grade renal injury was successful for these patients and should be considered in the management of grade IV and V blunt renal trauma.

Management of paediatric high-grade blunt renal trauma: a 10-year single-centre UK experience.

To report the management and outcome of paediatric patients sustaining high-grade blunt renal trauma. Medical records were examined for all American Association for the Surgery of Trauma (AAST) grade III-V blunt renal trauma cases admitted to a paediatric trauma centre from 2005 to 2015. Data collected and analysed included: demographics, imaging modalities, management, length of hospital stay (LOS), complications, and follow-up outcomes. In all, 18 children (12 boys, six girls) with mean (range) age 11 (4-15) years were included. According to the AAST grading criteria, 39% (seven of 18) of the patients had grade III, 50% (nine of 18) grade IV, and 11% (two of 18) grade V injuries; 44% (eight of 18) had concomitant injuries. Most of the patients were managed conservatively (89%, 16 of 18), although two of the 16 subsequently needed JJ-stent insertion during inpatient stay for symptomatic urinoma(s). In all, 11% (two of 18) of the patients required interventional radiology service(s), involving selective embolisation for life-threatening renal tract haemorrhage. Blood transfusion for renal injury exclusively was required in 11% (two of 18) of the patients. In all, 89% (16 of 18) of the patients had at least one follow-up imaging study before hospital discharge; most (13 of 16) had ultrasonography and three required computed tomography. The median (range) LOS was 11 (4-31) days. In all, 17% (three of 18) of the patients required hospital re-admission within 30 days for complications and all required interventional procedures: JJ stent for urinoma (one), embolisation of renal arterio-venous fistula (one), and embolisation for a post-traumatic pseudoaneurysm (one). Overall, the median (range) follow-up was 6 (2-60) months. In all, 78% (14 of 18) of the patients had dimercaptosuccinic acid studies, with 11 showing reductions in renal function (range 3-44%). This study supports a care pathway strategy advocating conservative management of high-grade renal injuries in children. However, patients may experience a relative decline in renal function with higher grade injuries indicating the need for monitoring and follow-up.

High Grade Renal Injury can be Safely Managed Non-operatively

Background: Among trauma patients, genitourinary injury occurs in 2%-5% of cases; with the kidney having the highest incidence of involvement. Grade IV/V renal injuries are typically associated with findings that necessitate intervention. However, non-operative management has been described even in severe cases. Our objective is to present our renal trauma experience in the blunt trauma patient population. Methods: We performed a retrospective chart review of all trauma patients from April 1, 2010-March 31, 2015. Those sustaining renal trauma were identified and patient demographics, injury parameters (grade of injury, injury severity score-ISS, cause and mechanism of injury), operative vs. non-operative management, outcomes (hospital length of stay-HLOS, ICU length of stay-ILOS) and discharge (mortality or disposition) were captured. Results: 8,054 patients were admitted to MDMC, with 112 meeting our inclusion criteria with 94 graded renal injuries. Renal operative management was noted in 6% of patients with ureteral stent placement (one Grade I), nephrorrhaphy (one Grade II), nephrectomy (two grade Vs, one grade IV) and renal vein repair (one grade IV). Nonoperative management of the renal injury occurred in 94% of cases. Conclusion: Low-grade injuries do well with non-operative management. However, Grade IV/V injuries can be challenging to manage. A significant concern is seen with the presence of major vascular or pelvicalyceal injury. Minimally invasive techniques by interventional radiology, vascular or urology surgery are ideal when possible. In conclusion, non-operative management for all grades of kidney injuries, despite the severity, is appropriate for the hemodynamically stable trauma patient.

Contemporary Role of Open Surgery in the Management of High-Grade Renal Injury

This review focuses on latest developments in kidney trauma management and the role of open surgical intervention. In the last decade, there had been an obvious drift towards conservative, non-operative, management of kidney trauma, undoubtedly when it is secondary to blunt trauma. Improved imaging, minimally invasive interventions, advancements including stent and nephrostomy insertions for urine extravasation, and angiography with angioembolization for acute or impending arterial bleeding have narrowed the necessity for open surgery, even when dealing with high-grade kidney injury. Still, open surgical intervention has its essential role, predominantly in the severely bleeding-unstable patient, high-grade penetrating kidney trauma, patients with concomitant intra-abdominal injuries, and the cases of non-operative surgical approach failure. Open surgical management has a contracted but still critical share in kidney trauma management. Being alert to the indications for open intervention and mastering the different surgical techniques could impact kidney salvageability and long-term clinical outcome.

MP79-01 NEPHRECTOMY AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

MP79-01 NEPHRECTOMY AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

PD63-02 COMPLIANCE WITH AUA GUIDELINES WITH EXCRETORY PHASE IMAGING FOR EVALUATION OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

PD63-02 COMPLIANCE WITH AUA GUIDELINES WITH EXCRETORY PHASE IMAGING FOR EVALUATION OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

Blunt Abdominal Trauma from Motor Vehicle Collisions from 2007 to 2011: Renal Injury Probability and Severity in Children versus Adults

There are sparse data directly comparing the probability of renal injury in children and adults. The kidney of the child is believed to be more susceptible to blunt injury for a variety of anatomical reasons. In a large cohort we tested the hypothesis that the pediatric kidney is more susceptible to any renal injury and to higher grade injury. We queried the NTDB® (National Trauma Data Bank®) on all hospital admissions following motor vehicle collisions in a pediatric population (age less than 21 years) and a referent adult population (age 30 to 50 years). Of 111,172 children who were admitted after motor vehicle collisions 1,093 had renal injury. Of the 111,172 children admitted to the hospital following motor vehicle collisions 59,385 had abdominal trauma and 1,093 had renal injury. In a multivariate logistic model adjusting for overall ISS (Injury Severity Score), region, year, driver/passenger status, presence of restraint or an airbag, we found that children had 48% higher odds of renal injury compared to adults ages 30 to 50 years (OR 1.48, 95% CI 1.32-1.66, p <0.001). Furthermore, children were at 33% higher risk for high grade renal injury (OR 1.33, 95% CI 1.05-1.69, p = 0.919). The effect remained when restricting analysis to patients with concomitant liver and spleen injuries (p <0.001). In a large national cohort of children, blunt renal injury following motor vehicle collisions is rare but substantially more common than in adults. The odds of high grade renal injury are approximately 50% higher in children. A greater index of suspicion and a lower threshold for renal imaging is prudent for children with blunt abdominal trauma from motor vehicle collisions.

Management of high-grade renal injury in children.

The management of severe renal trauma is disputable. Herein, we present diagnosis and treatment of patients with high-grade renal injury (grades IV and V). The records of 31 patients with severe renal trauma who were treated between 2009 and 2014 were analyzed retrospectively. All patients' CT results were evaluated by two radiologists and assigned grades of IV or V in accordance with the American Association for the Surgery of Trauma Organ Injury Severity Scale. All hemodynamically stable renal trauma patients were treated conservatively. Patients with renal traumas of grade IV and V were evaluated statistically via the SPSS 15.0 software program. Chi-square and Mann-Whitney U tests were used to evaluate the categorical data. Thirteen (42%) of 31 patients had grade IV, and 18 (58%) had grade V renal traumas. Twenty-seven (87%) of the patients had suffered blunt trauma, and four (13%) had sustained penetrating injuries. Additional organ injuries were seen in 16 patients (52%), and 15 (48%) had no concurrent injuries. Twenty-five patients (89%) were monitored conservatively, three (10%) underwent surgery, and three patients with grade V renal trauma and additional organ injuries died. There was no statistically significant difference between the grade IV and grade V groups, except in hemoglobin values and the affected kidney (P=0.07 and P=0.02, respectively). Computerized tomography can help to grade renal injury and assess additional organ injuries quickly. Most children with high-grade renal injury can be managed conservatively. However, conservative management of renal traumas relies on a multidisciplinary approach. Additionally, surgical intervention is generally required in the face of hemodynamic instability or other concurrent organ injuries.

JOURNAL CLUB: Incidence of Urinary Leak and Diagnostic Yield of Excretory Phase CT in the Setting of Renal Trauma.

The purpose of this article is to calculate the incidence of urinary leak, at both admission and delayed presentation, in the setting of blunt or penetrating renal trauma, and to determine the diagnostic yield of 5-minute excretory phase images on admission CT. Renal injuries were retrospectively identified from the trauma registry at an urban level I trauma center over a 6-year period. Follow-up imaging and clinical and surgical notes were reviewed and served as the aggregate reference standard. The total incidence of urinary leak, diagnostic yield of 5-minute-delayed admission CT scan, and the incidence of missed urinary leak not identified on admission 5-minute-delayed scan were calculated. There were a total of 431 renal injuries in 413 patients, of whom 201 patients (48.7%, including 60.8% of patients with grade IV or V injuries) underwent delayed phase imaging at admission, yielding 25 patients with 26 urinary leaks (all grade IV or V injuries). The incidence of urinary leak in grade IV or V injuries was 26.8%. One patient had a delayed diagnosis of urinary leak 36 hours after the initial CT scan, which did not show a urinary leak (0.23% of the total, or 1.0% of all high-grade renal injuries). The incidence of urinary leak after blunt or penetrating renal trauma was 6.1% and was seen in 26.8% of grade IV and V injuries. Admission excretory phase CT identified urinary leaks in 96% of patients. The incidence of delayed diagnosis of urinary leak is low.

MP18-10 LACTATE LEVELS AT ADMISSION CAN PREDICT NEPHRECTOMY AND MORTALITY IN PATIENTS WITH HIGH GRADE RENAL TRAUMA (AAST III-V)

INTRODUCTION AND OBJECTIVES: Prediction of nephrectomy or mortality on patients with high grade renal trauma after abdominal trauma is challenging. The objective of this study is to determine the early predictors of nephrectomy and mortality in high grade renal trauma patients. METHODS: From 2008 to 2013, Denver Health Medical Center, a regional level 1 Trauma Center admitted 12,749 consecutive trauma patients. After an IRB approval, a total of 105 patients presented high grade renal injuries (AAST III-V) and were eligible for the study. Variables that were analyzed were collected in the initial management of these patients. Univariable and multivariable logistic regression models were performed to identify the predictors of nephrectomy and mortality in these patients. RESULTS: Patients’ characteristics, trauma scores and outcomes are presented in Table 1. Univariable logistic regression was performed to determine predictors for nephrectomy and mortality. Lactate levels (p<0.001), Penetrating injury (p<0.001), pulse (p1⁄40.03), SBP (p1⁄40.001), and urgent laparotomy (p<0.001) were associated with nephrectomy. Gender (p1⁄40.03), SBP (p1⁄40.001), ISS (p1⁄40.002), urological consultation (p1⁄40.04), lactate (p1⁄40.003), and hemoglobin (p1⁄40.03) were associated with mortality. In multivariable analysis penetrating injury (p1⁄40.01), pulse (p1⁄40.04) and lactate (p1⁄40.01) were independent predictors for nephrectomy, and lactate (p1⁄40.01) was the only independent predictor for mortality. CONCLUSIONS: The understanding of predictors for nephrectomy and mortality in high grade renal trauma patients may guide the early management of this specific population of trauma patients and affect their clinical outcomes in the future. Lactate should be considered to be included in further nomograms, since it can predict nephrectomy and mortality. Table 1 Characteristics of patients with high grade renal trauma (AAST III-V) Overall Nephrectomy Non-nephrectomy Variables (n1⁄4 105) (n1⁄414) (n 1⁄4 91) P-Value Age (years) Mean (SD) 32.6 (14.8) 30.9 (28.5) 32.9 (14.6) 0.59 Median (IQR) 30 (21-41.5) 28.5 (18.7-41.7) 30 (21-42) Gender (n. pts, %) Male 87 (82.9) 12 (85.7) 75 (82.4) 0.76 Female 18 (17.1) 2 (14.3) 16 (16.7) Trauma Type (n. pts, %) Penetrate 16 (15.2) 9 (64.3) 7 (7.7) <0.001 Blunt 89 (84.8) 5 (35.7) 84 (92.3) Vital Signs SPB (mmHg) Mean (SD) 111.3 (29.8) 79.4 (40.6) 116.3 (24.4) <0.001 Median (IQR) 112 (96-134) 79 (67.5-104) 118.0 (98-137) Pulse (bpm) 95.8 (27.8) 110.3 (40.9) 93.5 (24.7) 0.02 Mean (SD) 93.5 (75-119) 112 (99.7-131.5) 89.5 (73.5-114) Median (IQR) Trauma Scores (median) GCS (median, IQR) 15 (12-15) 5 (3-13) 15 (14-15) <0.001 ISS (median, IQR) 25 (16-35) 34 (25-51) 22 (16-34) 0.01 AAST (n.pts, %) Grade III 50 (47.6) 0 (0) 50 (54.9) Grade IV 39 (37.1) 2 (21.4) 36 (39.6) <0.001 Grade V 16 (15.2) 11 (78.6) 5 (5.5) Lab Results Hb (mg/dL) Mean 13.2 (4.26) 11.5 (3.8) 13.47 (4.29) 0.15 Median 13.5 (10.515.2) 11.6 (8.5-14.5) 13.6 (11.1-15.2)

High-grade renal injuries are often isolated in sports-related trauma

IntroductionMost high-grade renal injuries (American Association for Surgery of Trauma (AAST) grades III–V) result from motor vehicle collisions associated with numerous concomitant injuries. Sports-related blunt renal injury tends to have a different mechanism, a solitary blow to the flank. We hypothesized that high-grade renal injury is often isolated in sports-related renal trauma. Material and methodsWe identified patients with AAST grades III–V blunt renal injuries from four level 1 trauma centres across the United States between 1/2005 and 1/2014. Patients were divided into “Sport” or “Non-sport” related groups. Outcomes included rates of hypotension (systolic blood pressure <90mm Hg), tachycardia (>110bpm), concomitant abdominal injury, and procedural/surgical intervention between sports and non-sports related injury. Results320 patients met study criteria. 18% (59) were sports-related injuries with the most common mechanisms being skiing, snowboarding and contact sports (25%, 25%, and 24%, respectively). Median age was 24 years for sports and 30 years for non-sports related renal injuries (p=0.049). Males were more commonly involved in sports related injuries (85% vs. 72%, p=0.011). Median injury severity score was lower for sports related injuries (10 vs. 27, p<0.001). There was no difference in renal abbreviated injury scale scores. Sports related trauma was more likely to be isolated without other significant injury (69% vs. 39% (p<0.001)). Haemodynamic instability was present in 40% and 51% of sports and non-sports renal injuries (p=0.30). Sports injuries had lower transfusion (7% vs. 47%, p<0.001) and lower mortality rates (0% vs. 6%, p=0.004). There was no difference in renal-specific procedural interventions between the two groups (17% sports vs. 18% non-sports, p=0.95). ConclusionsHigh-grade sports-related blunt renal trauma is more likely to occur in isolation without other abdominal or thoracic injuries and clinicians must have a high suspicion of renal injury with significant blows to the flank during sports activities.

Factors predicting the outcome of non-operative management of high-grade blunt renal trauma

ObjectivesIn this retrospective study we reviewed the outcome of non-operative management of high-grade blunt renal injuries (grade III–V) and evaluated the predictive indicators of management failure. Subjects and methodsThe data review included the patients’ demographics, the mechanism of trauma and the clinical characteristics, as well as the laboratory and imaging data upon admission and at follow-up. The data of the patients who were successfully managed non-operatively and of those who needed intervention for renal injuries were compared. ResultsTwo hundred and six patients were enrolled in this study. Grade III, grade IV and grade V renal injuries were found in 39.8%, 44.2% and 16% of the patients, respectively. The overall success rate of non-operative management was 87.9%, including all patients with grade III, 86.8% of patients with grade IV and 60.6% of those with grade V injuries. Multivariate analysis revealed that trauma secondary to motor vehicle accident, hypotension at presentation, associated injuries to other organs, grade V renal injury and computed tomography (CT) imaging features, namely medial renal parenchymal laceration, perirenal hematoma ≥3.5cm and intravascular extravasation were significant predictors for failure of non-operative management. ConclusionOur findings suggest that high-grade renal injuries in hemodynamically stable patients can be managed conservatively with a high success rate. Multiple clinical and radiological variables can predict the treatment outcome.

The Impact of Seat Belts and Airbags on High Grade Renal Injuries and Nephrectomy Rate in Motor Vehicle Collisions

Motor vehicle collisions are the most common cause of blunt genitourinary trauma. We compared renal injuries with no protective device to those with seat belts and/or airbags using NTDB. Our primary end point was a decrease in high grade (grades III-V) renal injuries with a secondary end point of a nephrectomy rate reduction. The NTDB research data sets for hospital admission years 2010, 2011 and 2012 were queried for motor vehicle collision occupants with renal injury. Subjects were stratified by protective device and airbag deployment. The AIS was converted to AAST renal injury grade and nephrectomy rates wereevaluated. Intergroup comparisons were analyzed for renal injury grades, nephrectomy, length of stay and mortality using the chi-square test or 1-way ANOVA. The relative risk reduction of protective devices was determined. A review of 466,028 motor vehicle collisions revealed a total of 3,846 renal injuries. Injured occupants without a protective device had a higher rate of high grade renal injuries (45.1%) than those with seat belts (39.9%, p = 0.008), airbags (42.3%, p = 0.317) and seat belts plus airbags (34.7%, p <0.001). Seat belts (20.0%), airbags (10.5%) and seat belts plus airbags (13.3%, each p <0.001) decreased the nephrectomy rate compared to no protective device (56.2%). The combination of seatbelts and airbags also decreased total hospital length of stay (p <0.001) and intensive care unit days (p = 0.005). The relative risk reductions of high grade renal injuries (23.1%) and nephrectomy (39.9%) were highest for combined protective devices. Occupants of motor vehicle collisions with protective devices show decreased rates of high grade renal injury and nephrectomy. Reduction appears most pronounced with the combination of seat belts and airbags.

MP3-04 OUTCOME OF PRIMARY URETHRAL REALIGNMENT IN THE MANAGEMENT OF POSTERIOR URETHRAL DISRUPTION

METHODS: We retrospectively reviewed patients’ records with renal trauma that were treated at adult level 1 trauma centers in Utah from January 2005 to January 2011. Data on patient demographics, injury characteristics, management, and outcomes was collected. All available radiological imaging was independently reviewed and renal injury was graded with the AAST organ injury scale. RESULTS: 138 patients were identified as having an AAST III-V renal injury. 30% (42 of 138) of renal injuries were sustained during sporting activities. The most common sports-related injuries were skiing and snowboarding in 26 (62%), being struck by another person or collision with stationary object in 10 (24%), and biking in 3 (7%). Mean AAST renal grade was 3.5 (SD 0.55) for sports and 3.7 (SD 0.78) for non-sports (p1⁄40.08). Male gender was over-represented amongst all renal injuries, but more so in sports related injuries (90.5% vs 61%, p<0.001). Mean injury severity scores (ISS) were 12.6 and 27.3 for sports and non-sports related trauma (p<0.001). Sports related trauma was more likely to be isolated without other solid abdominal organ injury, 78% vs 36% (p<0.001). Signs of hemodynamic instability (hypotension or tachycardia) were present in 47.6% and 67% of patients with sports and non-sports renal trauma (p1⁄40.037). 11.9% of sports injuries required intervention compared with 20% of non-sports injuries (p1⁄40.332). CONCLUSIONS: In a statewide trauma database, snow sports were the most common cause of high-grade sports related renal injuries. Sports associated renal trauma is more likely to occur in isolation without other abdominal solid organ injuries and without hemodynamic instability. Treating clinicians need to be aware that these injuries can present without the usual sequela associated with polytrauma.

MP3-01 SELECTIVE ARTERIAL EMBOLIZATION IN RENAL TRAUMA: THE PUERTO RICO TRAUMA CENTER EXPERIENCE

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 2014MP3-01 SELECTIVE ARTERIAL EMBOLIZATION IN RENAL TRAUMA: THE PUERTO RICO TRAUMA CENTER EXPERIENCE Jose Silva, Antonio Puras, Marcos Perez, and Fernando Joglar Jose SilvaJose Silva More articles by this author , Antonio PurasAntonio Puras More articles by this author , Marcos PerezMarcos Perez More articles by this author , and Fernando JoglarFernando Joglar More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.180AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The kidneys are the most common genitourinary organs affected from external trauma. Low-grade renal injuries are typically managed conservatively. Although most high-grade renal injuries require surgical interventions, their treatment still lacks standardized management. Furthermore, the treatment algorithm in some of the most prominent Urological publications fail to mention selective renal artery embolization as a feasible alternative. METHODS We retrospectively reviewed the trauma registry of the Puerto Rico Trauma Center for all patients treated for renal trauma (ICD-9 codes 866.0, 866.02, 866.10, and 866.12) between January 1, 2007 and December 31, 2010. We performed an extensive chart review to asses all the multiple variables involved and for further characterization of these injuries. RESULTS Of 7,291 total admission to Trauma Hospital, 215 included kidney lacerations. Trauma to male gender represented most of renal trauma with 92% (198/215). Blunt trauma represented more than half of all injuries with 58% (125/215) cases while penetrating trauma only 42% (90/215). Forty two percent (90/215) of all kidney lacerations underwent exploratory laparotomy by Trauma Surgery Staff, including renal exploration. Of the 215 patients, a total of 12 patients underwent selective renal artery embolization for their renal injuries. None of these patients required OR interventions or exploratory laparotomy. Sixty seven percent of the patients (8/12) sustained blunt trauma while 33% (4/12) suffered a penetrating injury. Grade V renal laceration was seen in 38% (3/8) of the total patients with blunt trauma. Fifty percent (4/8) of patients with grade III renal laceration underwent embolization due to active blush of IV contrast on CT scan. Of the patients that sustained penetrating injury, seventy five percent (3/4) sustained stab wounds while the remaining 25% (1/4) had gunshot injury. Two patients (67%, n=3) with stab wound injuries developed pseudoaneurysms, which required selective renal artery embolization. All had an unremarkable post-procedural hospital course with no complications from the embolization procedure. CONCLUSIONS Selective renal artery embolization is a feasible and less invasive procedure than conventional open surgical approaches in the management of renal trauma in select patients. At present and based on availability, selective renal artery embolization should be considered as first line treatment for high-grade renal lacerations in patients not undergoing exploratory laparotomy for other associated traumatic injuries. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e34 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jose Silva More articles by this author Antonio Puras More articles by this author Marcos Perez More articles by this author Fernando Joglar More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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.

Predictors of nephrectomy in high grade blunt renal trauma patients treated primarily with conservative intent

Introduction:There is no consensus on the optimal management of high grade renal trauma. Delayed surgery increases the likelihood of secondary hemorrhage and persistent urinary extravasation, whereas immediate surgery results in high renal loss. Hence, the present study was undertaken to evaluate the predictors of nephrectomy and outcome of high Grade (III-V) renal injury, treated primarily with conservative intent.Materials and Methods:The records of 55 patients who were admitted to our institute with varying degrees of blunt renal trauma from January 2005 to December 2012 were retrospectively reviewed. Grade III-V renal injury was defined as high grade blunt renal trauma and was present in 44 patients. The factors analyzed to predict emergency intervention were demographic profile, grade of injury, degree of hemodynamic instability, requirement of blood transfusion, need for intervention, mode of intervention, and duration of intensive care unit stay.Results:Rest of the 40 patients with high grade injury (grade 3 and 4)did not require emergency intervention and underwent a trail of conservative management. 7 of the 40 patients with high grade renal injury (grade 3 and 4), who were managed conservatively experienced complications requiring procedural intervention and three required a delayed nephrectomy. Presence of grade V injuries with hemodynamic instability and requirement of more than 10 packed cell units for resuscitation were predictors of nephrectomy. Predictors of complications were urinary extravasation and hemodynamic instability at presentation.Conclusion:Majority of the high grade renal injuries can be successfully managed conservatively. Grade V injuries and the need for more packed cell transfusions during resuscitation predict the need for emergency intervention.

Contemporary trends in the immediate surgical management of renal trauma using a national database

The National Trauma Data Bank was used to analyze open surgical management of renal trauma during the first 24 hours of hospital admission, excluding those who were treated with conservative measures. A descriptive analysis of initial management trends following renal trauma was also performed as a secondary analysis. With the use of the National Trauma Data Bank, patients with renal injuries were identified, and Abbreviated Injury Scale (AIS) codes were stratified to a corresponding American Association for the Surgery of Trauma (AAST) renal injury grade. Trends in initial management were assessed using the following initial treatment categories: observation, minimally invasive surgery, and open renal surgery. Analysis of initial open surgery was further examined according to etiology of injury (blunt vs. penetrating), type of open renal surgery, concomitant abdominal surgery, patient demographics, and time to surgery. A total of 9,002 renal injuries (0.3%) were mapped to an AAST renal grade. Of these, 1,183 patients underwent open surgery for their renal injury in the first 24 hours. There were 773 penetrating and 410 blunt injuries within this cohort. The majority of surgical patients sustained a high-grade renal injury (AAST Grades 4-5, 64%). The overall nephrectomy rate in the first 24 hours was 54% and 83% for the penetrating and blunt groups, respectively. While the overall nephrectomy rate for AAST Grade 1 to 3 renal injuries in the first 24 hours was low (1.8%), the nephrectomy rate was higher in the setting of an exploratory laparotomy (30%). Of those undergoing renal surgery in the first 24 hours, 86% had concomitant surgery performed for other abdominal injuries. Mean time from emergency department presentation to surgery was less for penetrating trauma. Of the patients requiring open surgery for renal trauma within 24 hours of admission, nephrectomy is the most common surgery. Continued effort to reduce nephrectomy rates following abdominal trauma is necessary. Epidemiologic study, level III.