ReviewConservative Management of Renal Trauma: A Review
Section snippets
Blunt Renal Trauma
The foundation of nonoperative management for renal trauma goes back at least 50 years.13 Despite the variability in different medical centers’ comfort level with the management of renal trauma, most would advocate that grade I and many grade II injuries can be managed conservatively. The reports have varied for the treatment of grade III and IV parenchymal injuries, but most favor a conservative approach, especially in the most modern series. Even some grade V parenchymal injuries have been
Penetrating Renal Trauma
Conservative protocols have also been applied to penetrating renal injuries.3, 7, 8, 9, 10, 26 These reports have been retrospective and applied to select patients; however, the dogma of unavoidable laparotomy after a gunshot wound has been undergoing a revision in modern times.14, 27 In a study of 1856 patients with abdominal gunshot injuries, 42%, who were hemodynamically stable and without peritoneal signs, qualified for an observation protocol involving serial abdominal examinations and the
Renovascular Injury
The proportion of renal trauma patients with renovascular injury is approximately 2.5% to 4%, and few large studies are available.11, 33 The application of conservative management must be redefined in the face of renovascular injury. Avulsion injuries resulting in hemodynamic instability necessitate immediate nephrectomy. Specific cases such as solitary functional kidneys or bilateral renovascular injuries require exploration with attempted repair; however, vascular repairs are highlighted by
Benefits of Renal Salvage
Patients who undergo trauma nephrectomy can be harmed by the loss of the kidney. If the nephrectomy was not truly necessary, this harm becomes an unacceptable iatrogenic injury. As expected, trauma nephrectomy patients have a lower creatinine clearance (55 mL/min versus 103 mL/min) in the critical peri-injury period.38 Of the 45 patients with severe renal injury versus those with no renal injury, renal surgery doubled the mortality rate from 8% to 16%. The rate of acute renal failure is also
Complications
Critics of conservative management cite the theoretical risk of delayed complications that could be avoided by nephrectomy or renorrhaphy. To date, no prospective randomized trials of conservative versus surgical management of renal trauma have been performed.
Damage Control
Damage control was conceived by trauma teams concerned about the risk of lengthy operations on seriously injured patients with hypothermia, acidosis, and coagulopathy.43 Damage control principles include the control of significant hemorrhage by abdominal packing and subsequent stabilization of the patient in the intensive care unit. Formal operative repair of abdominal injuries is performed later.44 Reports concerning damage control in urology are limited, but we believe any urologic injury
Special Case of Active Extravasation of Intravascular Contrast
A CT finding that we believe warrants special attention is active extravasation of contrast-enhanced blood (Fig. 1). This can herald brisk bleeding even in those who are not yet hemodynamically unstable and warrants either speedy exploration or percutaneous angiography.47, 48
This entity was first described in 1989 by Sivit et al.,49 and, in the intervening period, only a few studies about it have been published (and none of those in the urologic literature).47, 48, 50 In a multicenter
Case 1: Nonoperative Management of Blunt Renal Injury
A 31-year-old man, who was hemodynamically stable after being struck by a car as a pedestrian, had a grade IV right renal injury noted on CT (Fig. 2). The patient did not require any blood transfusions or operative intervention.
Case 2: Nonoperative Management of Renal Stab Wound
A 41-year-old man had been stabbed in the left flank posterior to the axillary line and had a grade IV left renal injury (Fig. 3). His hemoglobin decreased from 11.8 to 9.5 during the hospital course, but he did not require transfusion.
Case 3: Nonoperative Management of Renal Gunshot Wound
A 21-year-old man was taken
Conclusions
A growing trend in published reports supports the conservative management of grade I to IV blunt renal parenchymal injuries in the absence of hemodynamic instability of renal origin. Even some select patients with grade V parenchymal injuries can undergo an attempted trial of conservative management. Penetrating renal injuries can be managed nonoperatively in selected patients who are hemodynamically stable. Renal imaging should be used to rule out associated injuries and ureteral and renal
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