NONOPERATIVE TREATMENT OF RENAL TRAUMA: OUR EXPERIENCE
We present our experience regarding 19 patients (pts) with renal trauma treated at our Centre; only one of them was subjected to surgical exploration. Both our results and a brief review of literature seem to confirm the soundness of our “hands-off” policy.
Materials and Methods
We retrieved the files of 19 pts (18 males, one female) treated from January 2008 to December 2014 at our Hospital. They are not all cases observed in the aforementioned time span: since our Hospital is a tertiary referral centre, not all cases of renal injury were directly referred to the department of surgery and/or not all of them were retrievable, owing to different archiviation methods in the various departments.
The cases were staged, according to the American Association for Surgery of Trauma (AAST), as follows: grade I trauma, one; grade II, 6; grade III, 11; grade IV, one.
CT scan was performed in all cases.
The age range as 10-85 years (mean: 44). 14 pts had a politrauma (skull injury or liver trauma or orthopaedic fractures); for 4 of them admission to the local Intensive Care Unit (ICU), owing to the severity of the clinical situation, was necessary.
The causes of trauma were: motor vehicle accidents (16), falls from height (1), domestic accident (2),stab wound (1).
Pleural effusion was found in 7 pts.
Only one pt underwent surgical exploration and repair because of progressively expanding retroperitoneal haematoma and anemization with acute abdominal pain.
4 patients underwent arterial embolization (AE) with metallic coils; one pt with urinary extravasation was treated with ureteral stenting; one case of renal artery dissection was treated by means of a metallic stent.
Blood transfusions were necessary in 8 pts.
No significant complication was reported at a follow-up based on thoracoabdominal CT scan, ultrasonography and renal scintigraphy.
Renal injuries occur in approximately 8-10% of blunt or penetrating abdominal trauma, and most of them are defined as minor ones (1).
Proper and timely diagnosis based on imaging techniques is of the utmost importance: any delay in the diagnosis can defer effective treatment and significantly increase the risk of morbidity and mortality.
Acute kidney injury is associated with unfavourable outcomes ad higher mortality. AE was proved to be a reliable and efficacious method in the management of high grade renal trauma; therefore, conservative treatment , if possible, is the treatment of choice(3).
Complications occur in a wide – from 3% to 33% – range of cases (1).
Early complications occur usually in four weeks and include: urinary extravasation or urinoma, delayed bleeding, infected urinoma, development of perinephric abscess, sepsis, pseudoaneurysm, artero-venous fistula and hypertension. Late complications include hydronephrosis, hypertension, calculus formation or chronic pyelonephritis.
In our experience late complications were not observed.
Even in the presence of severe associated injuries requiring surgical exploration, pts with AAST grade I-III renal injury can be treated by means of a conservative strategy safely and effectively.
Patients with primary conservative treatment of blunt kidney rupture seem to need less surgery, and loose less blood and renal parenchyma than patients surgically treated (3). Moreover, posttraumatic hypertension rates are not higher than in a similar control population, irrespectively of the type of treatment adopted.
Therapy of renal trauma has evolved in the last years from mainly surgical to predominantly conservative treatment. Multimodality treatment is nowadays an effective alternative to surgery in clinically stable patients. Stenting of the urinary tract is highly effective in the treatment of the cases presenting with urinary extravasation. AE is an effective treatment in the great majority of significant arterial bleeding and save patients from unnecessary exploration and loss of functioning renal parenchyma (2,4,5); its use should probably not be restricted by fear of worsening renal function (5). Our experience seems to confirm the effectiveness of our “hands off” policy and, more generally, the widespread trend toward conservative treatment: a non operative strategy must be nowadays considered as a valid and reasonable option for the majority of minor penetrating renal injuries as well as in many selected high-grade injuries.
1)Wojiciech Szmigielski, Rajendra Kumar, Shatha Al Hilli, Mostafa Ismail: Renal trauma imaging: diagnosis and management. A pictorial review, Pol J radiol 2013 Oct-Dec; 78(4): 27-35
2)Song P, Wang MQ, Liu FY, Duan F, Wang Y: Iatrogenic renovascular injuries treated by transarterial embolization. Eur Rev Med Pharmacol Sci 2013 Dec; 17 (24): 3398-404
3)Danuser H, Wille S, Zoscher G, Studer U: How to treat blunt kidney ruptures: primary open surgery or conservative treatment with deferred surgery when necessary? Eur Urol 2001, 39(1): 9-14
4) Cheng D LW , Lazan D., Stone N.: Conservative treatment of type III renal trauma. Journal of trauma -Injury Infection and critical care, 1994 Apr
5)Yanagi M, Kondo Y, Nishimura T,Mizunuma K, Arai M, Yokota H, Nakazawa K, Murata S, Kumita S: Role of transcatheter arterial embolization for deep renal injury. Nihon Hinyokika Gakkai Zasshi 2013 Nov; 104(6):688-96