Management Of High-grade Renal Trauma Research Articles

Predictors of outcomes in conservative management of high-grade renal trauma

BackgroundManagement of high-grade renal trauma is debatable, with the recent evidence embracing a conservative approach in the management of even grade 5 renal injuries. The study aimed to analyze the clinical profile of patients with high-grade renal trauma, assessing their management strategies, outcomes, complications, and need for ancillary procedures.MethodsA retrospective analysis of prospectively maintained data was performed involving blunt abdominal trauma patients with high-grade renal injuries (Grade 4 and 5) presenting to our hospital from January 2018 to December 2022. Patient data analyzed included demographics, clinical presentation, injury characteristics, complications, ancillary procedures, and mortality rates. All patients underwent renal functional assessment using an isotope renogram scan at the 3-month follow-up. Data collected were entered into a database and subjected to descriptive analysis using Jamovi version 2.3.28.ResultsThe study included 45 patients with a mean age of 29 years and a male-to-female ratio of 41:4. Most patients (n = 42) were managed conservatively. Thirty-eight patients had grade 4 injuries, and seven had grade 5 injuries. Twenty-six patients suffered renal parenchymal injuries alone, three patients had renal vascular injuries alone, and 16 patients had both parenchymal and vascular injuries. Grade 5 renal injury (p < 0.001), vascular high-grade injury (p < 0.001), angioembolization (p < 0.001), and blood transfusions (p = 0.021) were significantly associated with the incidence of poorly functioning kidney in high-grade renal trauma patients managed conservatively. Multinomial logistic regression analysis revealed angioembolization (p < 0.001), poorly functioning kidney post-trauma (p < 0.001), and blood transfusions (p < 0.001) were significantly associated with high-grade renal vascular injuries compared to high-grade renal parenchymal injuries.ConclusionConservative management is advisable for high-grade renal trauma in hemodynamically stable patients. High-grade vascular injuries are more severe than parenchymal injuries and correlate with poorer renal functional outcomes. Grade 5 renal injury, predominantly vascular high-grade injury, and the requirement for angioembolization and blood transfusions serve as significant predictors of poorly functioning kidneys post-trauma. Urologists should consider these predictors when counseling patients regarding potential outcomes following conservative management of high-grade renal trauma.

Implementation and Interim Analysis of a Standardized Renal Trauma Imaging and Urinary Extravasation Management Protocol.

The AUA recommends delayed-phase imaging (DPI) in renal injuries to evaluate the collecting system. A renal trauma imaging protocol for early conservative management of urinary extravasation (UE) was implemented to improve guideline adherence. We aimed to determine if increased adherence led to changes in outcomes. Patients with American Association for the Surgery of Trauma III to V renal injury presenting from January 2018 to September 2022 were identified from an institutional trauma registry. Patients were included if a contrasted CT scan of the abdomen was obtained on admission. Frequency of DPI and patient outcomes were compared before and after protocol implementation. Of 223 included patients, 131 (58.7%) were pre protocol and 92 (41.3%) were post protocol. Following protocol implementation, the rate of DPI on admission nearly doubled from 32.8% to 58.7% (P < .001). The rate of follow-up cross-sectional imaging increased from 18.3% to 58.7% (P < .001). Although there were no significant differences in rates of immediate or delayed interventions following protocol implementation, the postprotocol immediate intervention rate did decrease to 0%. Readmissions due to symptomatic UE were unchanged after protocol implementation (0.0% vs 0.0%). Implementation of a multidisciplinary renal trauma early imaging and management protocol improved AUA guideline adherence. With protocol adherence, there was also an elimination of immediate interventions for UE. Despite decreases in early intervention, there was no significant increase in interval interventions or UE-related readmissions. More research is needed to determine the role for routine follow-up imaging in conservative management of high-grade renal trauma.

Perinephric Hematoma Size can be a Strong Prognostic Factor of Need of Surgical Intervention in High Grade Renal Trauma

Background: For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. The aim of our study is to assess the characteristics of perinephric hematoma and other prognostic factors of surgical intervention for high grade renal trauma independent of AAST OIS. Materials and Methods: A total of 119 patients with high grade renal trauma from January 2005 to September 2021 were identified for analysis. Hospital records and diagnostic imaging were reviewed to identify the need for surgical intervention, including total and partial nephrectomy. Factors examined include patient age, gender, ISS (Injury severity score), AAST-OIS, laceration location, length and number, perinephric hematoma characteristics, intravascular contrast extravasation and devitalised segment status. Descriptive statistics and binary logistic regression were performed as appropriate. Results: Mean patient age was 31, 39 and mean ISS was 22, 80. A total of 24 surgical intervention were required (20%) including partial and total nephrectomy. On univariate analysis, hypotension on admission, hematoma diameter, degree of devitalised fragment superior of 25% and AAST OIS grade were associated with the need of surgical intervention. On multivariate analysis, only hypotension on admission (p: 0,029), hematoma diameter greater than 3,5 cm (p:0,021) and AAST-OIS grade (p: 0,010) remained independently associated with surgical intervention. Conclusions: Perinephric hematoma size remains among prognostic factors for surgical intervention that allow better stratification of renal lesions and its study allows a better management of high-grade renal trauma.

Conservative management of high-grade renal trauma

IntroductionRenal trauma is the most common of urological trauma and accounts for up to 5% of all. The AAST scale is the most widely used to assess renal trauma. This study focuses on high-grade trauma, whose treatment has evolved towards a conservative approach, with techniques such as angioembolization. The aim is to describe the evolution in the management of high-grade renal trauma in all patients treated at La Paz University Hospital from 2001 to 2022. MethodsA descriptive retrospective study was conducted on patients treated at the hospital. The study was divided into two periods (2001–2010 and 2011–2022). A total of 285 patients with renal trauma were collected, of which 54 were high grade. The main variable is the type of management, conservative (embolization) or interventional through nephrectomy. ResultsIn the completed series, there was a decrease in radical nephrectomy in high-grade renal trauma from 50% to 13.8% over time, with an increase in embolization from 23,1% to 44,8%. In patients with isolated renal trauma, those treated with embolization increased from 28.6% to 69.2%, while those undergoing radical/partial nephrectomy decreased from 42.8% to 7.69%. ConclusionThe management of renal trauma has evolved over the years in our center. The number of patients treated by embolization has increased, while the number of complications and nephrectomies has decreased.

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

Background: For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. The aim of our study is to assess the characteristics of perinephric hematoma and other prognostic factors of surgical intervention for high-grade renal trauma independent of AAST OIS. Materials and methods: A total of 119 patients with high-grade renal trauma from January 2005 to September 2021 were identified for analysis. Hospital records and diagnostic imaging were reviewed to identify the need for surgical intervention, including total and partial nephrectomy. Factors examined include patient age, gender, ISS (Injury severity score), AAST-OIS, laceration location, length and number, perinephric hematoma characteristics, intravascular contrast extravasation, and devitalized segment status. Descriptive statistics and binary logistic regression were performed as appropriate. Results: The mean patient age was 31,39 and the mean ISS was 22,80. A total of 24 surgical interventions were required (20%) including partial and total nephrectomy. On univariate analysis, hypotension on admission, hematoma diameter, degree of devitalized fragment superior of 25%, and AAST OIS grade was associated with the need for surgical intervention. On multivariate analysis, only hypotension on admission (p: 0,029), hematoma diameter greater than 3,5 cm (p: 0,021), and AAST-OIS grade (p: 0,010 ) remained independently associated with surgical intervention. Conclusion: Perinephric hematoma size remains among prognostic factors for surgical intervention that allow better stratification of renal lesions and its study allows a better management of high-grade renal trauma.

Manejo conservador del traumatismo renal de alto grado

IntroductionRenal trauma is the most common of urological trauma and accounts for up to 5% of all. The AAST scale is the most widely used to assess renal trauma. This study focuses on high-grade trauma, whose treatment has evolved towards a conservative approach, with techniques such as angioembolization. The aim is to describe the evolution in the management of high-grade renal trauma in all patients treated at La Paz University Hospital from 2001 to 2022. Material and methodsA descriptive retrospective study was conducted on patients treated at the hospital. The study was divided into two periods (2001-2010 and 2011-2022). A total of 285 patients with renal trauma were collected, of which 54 were high grade. The main variable is the type of management, conservative (embolization) or interventional through nephrectomy. ResultsIn the completed series, there was a decrease in radical nephrectomy in high-grade renal trauma from 50% to 13.8% over time, with an increase in embolization from 23.1% to 44.8%. In patients with isolated renal trauma, those treated with embolization increased from 28.6% to 69.2%, while those undergoing radical/partial nephrectomy decreased from 42.8% to 7.69%. ConclusionThe management of renal trauma has evolved over the years in our center. The number of patients treated by embolization has increased, while the number of complications and nephrectomies has decreased.

Evolution in the management of high-grade renal trauma over the last two decades: A retrospective review

Evolution in the management of high-grade renal trauma over the last two decades: A retrospective review

OUTCOME OF RENAL TRAUMA IN A TERTIARY CARE CENTER OF NEPAL: A RETROSPECTIVE STUDY

Background: Management of renal trauma has evolved over past decades from surgical exploration to renal preservation. Conservative management of high-grade renal trauma is possible due to advancement in imaging modality, dedicated critical care and availability of selective embolization. The objective to this research was to analyze the demographics, characteristics and management of renal trauma in our institution. Methods: All patient who were admitted to College of Medical Sciences Teaching Hospital with diagnosis of renal trauma from 2017 to 2022 were retrospectively analyzed. Ethical approval was taken from institutional review committee of college of Medical Sciences. Data was collected from hospital medical records. Data was analyzed using descriptive statistical tools. For the categorical variable frequency and percentage was calculated while for continuous variables mean and standard deviation was calculated. Results: Sixty-three patients were included in this study and Median age of patient admitted with renal trauma was 31 years with male to female ratio of 7:3. Blunt renal trauma was the most common type (96.8 %) with Road traffic accidents responsible for the majority of mechanisms of injury 66.7% (42) followed by fall 11(17.5%). Majority of Renal trauma was in AAST Grade III 26(41.3%). Right sided renal injury was common 33 (52.4%) than left sided renal injury 30 (47.6%). Intervention was required in 9 patients. Conclusions: High-grade renal trauma can be managed conservatively in selected cases with close monitoring in critical care unit and with use of minimally invasive technique such as Selective angioembolization, Double J Ureteric stenting or Nephrostomy Insertion. But hemodynamically unstable patient after resuscitation warrants immediate surgical exploration.

This Month in Adult Urology.

This Month in Adult Urology.

Delayed Management of High-Grade Renal Trauma in a Child with Bilateral Lower Polar Artery: A Case Report

High-grade renal trauma rarely occurs due to low-velocity mechanisms. With its clinical presentation, delayed diagnosis rarely happens. We report the case of a 12-year-old girl diagnosed seven days post-trauma with grade IV renal trauma complicated with infected urinoma and bilateral lower polar vessels. She was non-operatively managed with ultrasound-guided percutaneous drainage of the urinoma, which resolved, and had unremarkable six months follow-up. We discuss the role of preexistent hydronephrosis in low-velocity impact, pitfalls of diagnosis in resource-constrained settings, and management of high-grade trauma.

Endovascular embolization in renal trauma: a narrative review

Approximately 1–3% of all trauma patients have a renal injury. Eighty percent of renal trauma is due to blunt injury, with the remainder due to penetrating trauma which is most often iatrogenic. Contrast enhanced computed tomography is used to triage patients and offers a quick and accurate assessment of any potential organ injury. If injury is present, The American Association for the Surgery of Trauma grading system can both grade renal injuries and be used to help guide management and intervention. Grades are assigned based on imaging and clinical features of renal trauma, and have prognostic and treatment implications for patients. The objective of this narrative review is to identify optimal management of patients with renal trauma, specifically which patients can be treated with endovascular interventions following renal trauma, which can be observed, and which would be best managed surgically. For hemodynamically stable patients with renal trauma, endovascular angiography and embolization is a non-invasive approach that can be used to control bleeding and potentially avoid surgery or nephrectomy in select cases. Future research is needed to determine if a specific antibiotic regimen is needed prior to or following embolization. Further research is needed to evaluate the effectiveness of endovascular management of high-grade renal trauma (grade V). Complications of renal embolization include short-term hypertension, long term hypertension in cases of significant ischemia, acute kidney injury, and infection.

Successful Conservative Management of Isolated High-Grade Blunt Renal Trauma: Case Report and Follow Up

The management of high-grade renal trauma remains debatable in various education and research centers, especially the cases of patients with stable hemodynamics. This paper reports the case of a 24-year-old man with high-grade renal trauma due to blunt injury in the left flank. The patient had stable hemodynamics and was managed conservatively, followed by three months of post-trauma follow up. In this case, the conservative management has resulted in a satisfactory outcome, confirming that conservative management is an appropriate alternative treatment for patients with similar cases.

A nomogram predicting the need for bleeding interventions after high-grade renal trauma: Results from the American Association for the Surgery of Trauma Multi-institutional Genito-Urinary Trauma Study (MiGUTS).

The management of high-grade renal trauma (HGRT) and the indications for intervention are not well defined. The American Association for the Surgery of Trauma (AAST) renal grading does not incorporate some important clinical and radiologic variables associated with increased risk of interventions. We aimed to use data from a multi-institutional contemporary cohort to develop a nomogram predicting risk of interventions for bleeding after HGRT. From 2014 to 2017, data on adult HGRT (AAST grades III-V) were collected from 14 level 1 trauma centers. Patients with both clinical and radiologic data were included. Data were gathered on demographics, injury characteristics, management, and outcomes. Clinical and radiologic parameters, obtained after trauma evaluation, were used to predict renal bleeding interventions. We developed a prediction model by applying backward model selection to a logistic regression model and built a nomogram using the selected model. A total of 326 patients met the inclusion criteria. Mechanism of injury was blunt in 81%. Median age and injury severity score were 28 years and 22, respectively. Injuries were reported as AAST grades III (60%), IV (33%), and V (7%). Overall, 47 (14%) underwent interventions for bleeding control including 19 renal angioembolizations, 16 nephrectomies, and 12 other procedures. Of the variables included in the nomogram, a hematoma size of 12 cm contributed the most points, followed by penetrating trauma mechanism, vascular contrast extravasation, pararenal hematoma extension, concomitant injuries, and shock. The area under the receiver operating characteristic curve was 0.83 (95% confidence interval, 0.81-0.85). We developed a nomogram that integrates multiple clinical and radiologic factors readily available upon assessment of patients with HGRT and can provide predicted probability for bleeding interventions. This nomogram may help in guiding appropriate management of HGRT and decreasing unnecessary interventions. Prognostic and epidemiological study, level III.

Successful Conservative Management of Isolated High-Grade Blunt Renal Trauma: Case Report And Follow Up

The management of high-grade renal trauma remains debatable in various education and research centers, especially the cases of patients with stable hemodynamics. This paper reports the case of a 24-year-old man with high-grade renal trauma due to blunt injury in the left flank. The patient had stable hemodynamics and was managed conservatively, followed by three months of post-trauma follow up. In this case, the conservative management has resulted in a satisfactory outcome, confirming that conservative management is an appropriate alternative treatment for patients with similar cases.

Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study: Erratum.

Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study: Erratum.

Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study.

The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for high-grade renal trauma (HGRT). We aimed to describe the contemporary management of HGRT in the United States and also evaluate clinical factors associated with nephrectomy after HGRT. From 2014 to 2017, data on HGRT (American Association for the Surgery of Trauma grades III-V) were collected from 14 participating Level-1 trauma centers. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Management was classified into three groups-expectant, conservative/minimally invasive, and open operative. Descriptive statistics were used to report management of renal trauma. Univariate and multivariate logistic mixed effect models with clustering by facility were used to look at associations between proposed risk factors and nephrectomy. A total of 431 adult HGRT were recorded; 79% were male, and mechanism of injury was blunt in 71%. Injuries were graded as III, IV, and V in 236 (55%), 142 (33%), and 53 (12%), respectively. Laparotomy was performed in 169 (39%) patients. Overall, 300 (70%) patients were managed expectantly and 47 (11%) underwent conservative/minimally invasive management. Eighty-four (19%) underwent renal-related open operative management with 55 (67%) of them undergoing nephrectomy. Nephrectomy rates were 15% and 62% for grades IV and V, respectively. Penetrating injuries had significantly higher American Association for the Surgery of Trauma grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy. Expectant and conservative management is currently utilized in 80% of HGRT; however, the rate of nephrectomy remains high. Clinical factors, such as surrogates of hemodynamic instability and metabolic acidosis, are associated with nephrectomy for HGRT; however, higher renal injury grade and penetrating trauma remain the strongest associations. Prognostic/epidemiologic study, level III; Therapeutic study, level IV.

Conservative Management of High-grade Renal Trauma Does Not Lead to Prolonged Hospital Stay

To evaluate the effect of conservative management of high-grade renal trauma on length of hospitalization, we aim to describe characteristics of patients with high-grade renal trauma that are associated with an increased length of stay (LOS) and the effect of conservative vs surgical management on hospital LOS. A retrospective review of all patients who suffered unilateral high-grade renal trauma (grade 3 or higher) from September 1977 to August 2012 at San Francisco General Hospital in San Francisco, CA was performed. Patients' demographic information, mechanism of injury, injury grade, data about associated injuries, hospital LOS, and management were collected. Descriptive analysis was performed using chi-square, ordered logistic regression, and linear regression analysis. Multivariable analysis was performed using a Fine-Gray model of competing risks survival analysis, adjusting for trauma type, grade, surgery, associated injury, and complications. The cohort consisted of 408 patients with high-grade unilateral renal trauma of which 257 patients underwent renal exploration. The adjusted multivariable analysis revealed that trauma type, injury grades, nongenitourinary surgery, associated injuries, and complications were associated with increased hospital LOS (P <.01 for all). Renal exploration compared to conservative management for high-grade renal trauma was not associated with an increased hospital LOS (P = .10). There is no significant difference between conservative and surgical management of high-grade renal trauma in terms of hospital LOS. Conservative management of high-grade renal trauma does not impact patients' length of hospitalization.

Concurrent use of endourological and radiologic methods in the management of high-grade renal trauma.

This case report explores the efficacy of simultaneous use of endourological and radiological methods to assess and manage high-grade renal trauma. A male rugby player was diagnosed with Grade 4 blunt renal trauma. A segment of the patient's kidney was isolated from the main renal pelvis with intact perfusion. This resulted in urinary extravasation. Ureteral stenting and angioembolization were used to treat the patient's severe symptoms. Angioembolization ablated functional tissue that was causing a persistent urinary leak. Following the treatment, the patient was discharged with no significant bleeding or leakage from the kidney. This report illustrates an uncommon use of this combined approach. Followup 18 months post-trauma revealed normal blood pressure and approximately 30% loss of volume of the affected kidney.

MP18-04 HIGH-GRADE RENAL TRAUMA: DOES MANAGEMENT PREDICT LENGTH OF HOSPITAL STAY?

You have accessJournal of UrologyTrauma/Reconstruction: Ureter, Bladder, External Genitalia and Urotrauma I1 Apr 2015MP18-04 HIGH-GRADE RENAL TRAUMA: DOES MANAGEMENT PREDICT LENGTH OF HOSPITAL STAY? Lindsay Hampson, Anobel Odisho, Benjamin Breyer, and Jack McAninch Lindsay HampsonLindsay Hampson More articles by this author , Anobel OdishoAnobel Odisho More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , and Jack McAninchJack McAninch More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1036AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Costs of hospitalization for trauma are a significant burden on the healthcare system. As management of high-grade renal trauma shifts towards more non-operative management, we sought to describe the characteristics of patients with high-grade renal trauma by hospital stay and to evaluate the effect of conservative versus surgical management on length of hospital stay. METHODS We performed a cross-sectional retrospective analysis of a prospective contiguous database of patients who sustained unilateral high-grade renal trauma at San Francisco General Hospital from 9/21/77 - 8/10/2012. Patients' injury mechanism & grade, details about associated injuries and management, and length of hospital stay were recorded. Descriptive analysis was performed using chi-squared and linear regression. Multivariate analysis was performed using a Fine-Gray model of competing risks survival analysis adjusting for trauma type, grade, surgery, associated injury, and complications, where discharge was defined as the event of interest and death was considered a competing event; an interaction term for renal and non-GU surgery was included due to significant collinearity. P-value < 0.05 was considered significant. RESULTS The cohort included 413 patients, of whom 257 underwent renal exploration (Table 1). In multivariate analysis, blunt trauma, non-GU surgery, associated injuries, grade 4/5 injuries, and complications were associated with a significantly longer hospital stay, whereas renal exploration was not found to be significantly associated (Table 2). CONCLUSIONS The etiology, grade, and non-GU management of renal trauma are predictive of length of hospital stay, yet there is no significant difference between operative and non-operative management of high-grade renal trauma in terms of hospital stay. These results can reassure us that the movement to more conservative management of high-grade renal trauma does not impact patients' length of hospitalization. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e206-e207 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lindsay Hampson More articles by this author Anobel Odisho More articles by this author Benjamin Breyer More articles by this author Jack McAninch More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effect of renal angioembolization on post-traumatic acute kidney injury after high-grade renal trauma: A comparative study of 52 consecutive cases

BackgroundAcute kidney injury (AKI) is associated with unfavourable outcomes and higher mortality after trauma. Renal angioembolization (RAE) has proved efficiency in the management of high-grade renal trauma (HGRT), but inevitably expose to unavoidable ischaemic areas or contrast medium nephrotoxicity which may impair renal function in the following hours. The aim of this study was to assess the potential acute impact of RAE on renal function in a consecutive series of HGRTs treated nonoperatively. Materials and methodsOf 101 cases of renal trauma admitted to our Regional Trauma Center between January 2005 and January 2010, 52 cases of HGRT were treated nonoperatively; they were retrospectively classified into 2 groups according to whether RAE was used. Incidence and progression of AKI (RIFLE classification), maximum increase in serum creatinine (SCr), level since admission and recovery of renal function at discharge were compared between the groups. Multivariable analysis was performed to determine the role of RAE as an independent risk factor of AKI. ResultsRAE was performed in 10 patients within the first 48h. The RAE and no RAE groups were comparable in terms of severity score, renal injury grade, and level of SCr on admission. AKI incidence (RIFLE score Risk or worse) after 48 and 96h was 33% and 10%, respectively and did not differ significantly between groups at 48h (p=1.00) or 96h (p=1.00). The median maximum increase in SCr was significantly higher in no RAE than RAE group (30.4% vs. 6.9%, p=0.04). RAE was not found to be a significant variable in a multiple linear regression analysis predicting maximum SCr rise (p=0.34). SCr at discharge was >120% of baseline in only 5 patients, with no difference according to RAE (p=0.24). ConclusionIn a population of nonoperatively treated HGRT, the incidence of AKI decreased from almost 30% to 10% at 48h and 96h. RAE proceeding did not seem to affect significantly the occurrence and course of AKI or renal recovery. The decision to use RAE should probably not be restricted by fear of worsening renal function.