| Abstract|| |
To evaluate the pre-existing renal lesions (PERL) found incidentally during evaluation for blunt renal trauma, determine their importance, and suggest guidelines for effective management, including conservative treatment, we reviewed 180 patients who were hospitalized with blunt renal trauma between 1992 and 2008. Thirty of the 180 (16.6%) patients had PERL, which had been undiagnosed. The mean follow-up was 5 years (range 1-9 years). There were 24 men and 6 women with a mean age of 30 years (range 14-80 years). The most common cause of blunt renal injuries was falls and sports. Renal stones were present in 14 patients, pelvi-ureteric junction obstruction in 12, ectopic kidney in two, and megaureter and renal cyst in one case each. Ureteral stenting was used in four cases, and early nephrectomy was required in the other four. Fourteen patients underwent surgery for the PERL and not trauma, with a pyeloplasty in eight cases, partial nephrectomy in three cases, percutaneous nephrololithotomy in two cases, and ureteroneocystostomy in one case. In our study, the conservative treatment was possible in 73% of cases. We believe the published data support increasing conservative attempts in the hemodynamically stable patient.
|How to cite this article:|
El-Atat R, Derouiche A, Slama MB, Chebil M. Kidney trauma with underlying renal pathology: Is conservative management sufficient?. Saudi J Kidney Dis Transpl 2011;22:1175-80
|How to cite this URL:|
El-Atat R, Derouiche A, Slama MB, Chebil M. Kidney trauma with underlying renal pathology: Is conservative management sufficient?. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2013 May 23];22:1175-80. Available from: http://www.sjkdt.org/text.asp?2011/22/6/1175/87228
| Introduction|| |
Renal abnormalities associated with traumatic injuries increase the risk of renal injury, and these abnormal kidneys are easily injured, even with relatively minor blunt trauma. , The traditional controversy between conservative and invasive surgery for patients with trauma still exists, and the optimal strategy for managing this uncommon injury has not been developed yet.
The aim of this study was to evaluate the preexisting renal lesions (PERL) found incidentally during evaluation for blunt renal trauma, determine their importance, and suggest guidelines for effective management, including conservative treatment.
| Patients and Methods|| |
The records of 180 patients who were hospitalized with blunt abdominal trauma between 1992 and 2008 were reviewed. The diagnosis of renal injury was confirmed in all the patients by abdominal computed tomography (CT) scan with intravenous contrast. The grade of renal injury was classified by an independent radiologist according to the kidney injury scale of the American Association for the Surgery of Trauma Organ Injury Severity Scale. Initial treatment included intravenous fluids, broad-spectrum antibiotics, bed rest, and close clinical observation with monitoring of vital signs and serial hematocrits. The study patients were transfused for hemodynamic instability or a hematocrit < 20%. Patients with gross hematuria were kept on bed rest until the urine was grossly clear. Daily clinical examinations and abdominal ultrasound were used to monitor the size of the hematoma/urinoma.
A repeat CT scan was performed 7, 15, and 21 days following the trauma, CT scans were repeated in patients with persistent bleeding or increasing hematomas/urinomas as detected clinically or by ultrasound at any time during the course of initial management. The findings on repeated CT scans were compared with the initial studies, and data were used for planning of subsequent interventions.
Patients with hemodynamic instability (refractory to blood transfusion) or those with persistent bleeding (hematuria and/or increasing hematoma size) underwent surgical exploration. Patients with progressively increasing urinomas were treated by ureteral stenting.
Data were collected with respect to the type of injury, symptoms at presentation, complications and their treatment, duration of hospital stay, initial radiologic evaluation, and radiologic evaluation prior to any intervention.
The patients were evaluated at follow-up visits by clinical examination, serial blood pressure measurements, urinalysis, serum creatinine levels, and CT scan. Dimercaptosuccinic acid (DMSA) scanning was reserved for those patients with salvaged kidneys.
| Results|| |
Of 180 patients, 30 (16.6%) had PERL. Men (24 cases) outnumbered women (6 cases) in an almost 4:1 ratio. The mean age was 30 years (range 14-80) and included six children.
The injured kidneys were on the right in 10 patients and on the left in 20 patients. Four patients had only microscopic hematuria on initial urinalysis and 26 revealed gross hematuria.
Four patients had hemodynamic instability. All 30 kidneys showed variable degrees of renal perfusion and multiple lacerations at the initial CT scan. The grades of renal injuries included grade I in 14 cases, grade II in six, grade III in three, grade IV in four, and grade V in four.
The most common cause of blunt renal injuries was falls (11 cases) and sports (10 cases), followed by motor vehicle accidents (5 cases) and abuse or assault (4 cases). A renal stone was the most common finding (14 cases), with a mean stone size of 25 mm (10-29 mm). Ten patients revealed PUJ obstruction [Table 1], [Table 2]. Four patients underwent nephrectomy on the first day of trauma due to hemodynamic instability. At the time of surgery, a partial injury of the main renal pedicle (grade V) was found in all the patients, and renal pathology included renal pelvis stone with parenchymal injury and urinomas in the four cases. Four patients developed enlarged urinomas with PUJ partial disruption in two cases [Figure 1] and obstructed renal stone in other two detected by CT scan one week following the initial trauma.
|Figure 1: Active extravasation of urine due to uretero-pelvic rupture on CT scan.|
Click here to view
All the patients endured a high-grade renal trauma. Ureteral stents were required in the four cases. However, 26 patients were successfully managed nonoperatively with no active intervention for the trauma.
All the patients were discharged with stable vital signs and laboratory profiles as well as grossly clear urine. The mean hospital stay was 21 days (range 4-45 days). Fourteen patients underwent surgery for the PERL 2-3 months after discharge from the first hospitalization, with a pyeloplasty in eight cases, partial nephrectomy for stone [Figure 2] in three, percutaneous nephrololithotomy in two, and ureteroneocystostomy in one case.
In four cases, stones were treated with extracorporeal shock wave lithotripsy. Abstention was indicated in one case of cyst kidney [Figure 3] and two cases of ectopic kidneys. Delayed total nephrectomy was performed in six cases; pyelo-ureteral junction in four cases, stone in two cases. The renal parenchyma was destructured on DMSA scanning.
|Figure 2: Partial nephrectomy was performed for this case of renal stone.|
Click here to view
The mean follow-up of the patients was five years (range 1-9 years). At last follow-up, all patients were normotensive with a normal urinalysis and serum creatinine levels. The traumatized kidney was preserved in 22 of 30 (73%) patients.
A follow-up CT scan was performed in all patients in whom the kidneys were salvaged at a mean time of nine months (range 6-18 months) following the injury, and the initially shattered kidneys demonstrated reapproximation of the parenchyma; there were no vascular abnormalities or hydronephrosis.
On DMSA, preserved renal function with split function > 40% on the affected side was revealed in 20 (90%) patients; one patient (10%) showed variable degrees of renal dysfunction, and another patients treated entirely nonoperatively demonstrated a split function of 30%.
| Discussion|| |
In our study, 16.6% of all blunt renal trauma occurred in pathologic kidneys. This figure is consistent with the ranges published in the trauma literature. Cass et al  found two (1%) of 248 congenital abnormalities in their review of renal trauma with a fortuitous discovery of a case of hydronephrosis and a second case of bilateral hydroureters, McAleer et al  found 4 (9%) of 50 cases of pre-existing pathology, and Giannopoulos et al  found that 24 (3.5%) of 675 blunt renal trauma-involved kidneys with underlying pathology. In this age group, the underlying pathology included nephrolithiasis (n=12), renal masses (n=7), unilateral renal agenesis (n=1), duplication of renal pelvis (n=1), bilateral ureterocele (n=2), and retroperitoneal fibrosis (n=1).
There are several differences in the presentation when normal and pathologic kidneys are subjected to blunt abdominal forces. Motor vehicle collisions have been the cause of most (47%-82%) blunt traumatic renal injuries in previous series. In this report, most of the mechanisms of injury involved fairly minimal forces. This point lends support to the theory that abnormal renal size, position, consistency, or location diminishes the effectiveness of the natural protective mechanisms and predisposes the kidney to injury even with minimal insult.
In adult trauma protocols, radiographic evaluation is performed on any patient who presents with either gross hematuria or microscopic hematuria combined with hemodynamic instability. It has been argued that hypotension rarely develops in children who sustain major blunt renal injuries; therefore, the criteria of microscopic hematuria accompanied by hypotension are nonreliable indicators of major renal injury.
Underlying congenital malformations causing hydronephrosis (PUJ stenosis, extrarenal pelvis) predispose the kidney to significant injury even with minor forces.
The larger size and possible increased fluid density could be related factors. Other malformations, such as horseshoe kidneys (lower position) also can be injured more easily because the protective thoracic cage is too high in such cases. Abnormalities of parenchymal consistency as a result of reflux and resulting pyelonephritis or cystic kidney disease (single or multiple) also could be hypothesized to provide less resistance to traumatic forces. Obstruction of the genitourinary system due to a stone, pelvic mass, pregnancy, retroperitoneal fibrosis, or posterior urethral valves can increase intraluminal pressure and cause rupture of the collecting system. Rarely, iatrogenic injury causes renal urine leak. ,,,,
Urine extravasation may be clinically occult or lead to acute abdomen symptoms. Hydronephrosis, paralytic ileus, electrolyte imbalances, or abscess formation may complicate the condition. , The management of patients with blunt renal trauma has become increasingly conservative, and surgical intervention is uncommon.
The management of high-grade renal injury in hemodynamically unstable patients is clearly defined. However, the management of renal injuries after blunt trauma, particularly with a PERL and in clinically stable patients, remains controversial. Obstructed kidneys are generally very prone for blunt abdominal trauma. Congenital PUJ (12 cases) and urinary stones (14 cases) topped the list in our study. Associated obstruction to the urinary outflow and extravasation of urine pose a significant problem in management.
Patients with persistent extravasation of urine from an obstructed kidney can benefit from endoscopic or minimally invasive techniques in controlling the urinary leak.  Stenting of the ureter is a treatment method for infected fornix rupture with upper ureteral and ureteropelvic junction stones.
Russell et al  described their experience with endoscopic treatment of urinary extravasation in five patients with a grade IV renal injury. Two patients were successfully managed with percutaneous tube drains alone, while internal stents were necessary in three.
Henderson et al  used combined percutaneous and endoscopic drainage in one patient with a grade IV injury with persistent urinary drainage, which resulted in the resolution of the drainage and preservation of the kidney. Laurin et al  reviewed 71 TPND procedures in 59 patients with congenital or postoperative obstructions, stones, renal cystic diseases and traumas. The mean duration of drainage was 60 days with maximum 11 months. They reported no complications, for example, infection or hemorrhage, which required intervention. In two large series, , there was a 98% success rate for TPND, with a 5.6%-6% complication rate in patients with urinary obstruction or urinary fistulae in an emergency setting.
Although urinary extravasation and urinomas have been a relative indication for surgical approach, we do not consider that urinary extravasation alone, without hemodynamic instability, obstruction, or expanding urinomas, warrants initial surgery in these patients.
In our study, four patients had nonopacified ureters with UPJ partial disruption, all patients were managed initially with ureteral stents followed by delayed surgical repair after 2-3 months. We believe that this approach optimizes the conditions for satisfactory lesions repair and renal salvage.
In our study, the follow-up was >4 years. All seven patients who underwent delayed exploration or conservative management recovered completely with no complication. In addition, the functional outcome of the kidneys with TPND was better. These results need to be confirmed in more patients, especially in children.
In summary, the frequency of PERL is high (16.6%) with blunt renal trauma. PERL, even with no evidence of hydronephrosis, can predispose to kidney injury with minor trauma. In selected patients, ureteral stenting may decrease the length of hospital stay and improve the outcome of the injured kidney. The ultimate goal of conservative management is to minimize the incidence of negative explorations and unnecessary repairs and decrease iatrogenic nephrectomy rates, without increasing morbidity or mortality. In our study, the conservative treatment was possible in 73% of cases. To date, no randomized controlled trial of conservative versus operative intervention for renal trauma with PERL has been performed. However, we believe the published data support increasing conservative attempts in the hemodynamically stable patients.
| References|| |
|1.||McAleer IM, Kaplan G, Sherz HC, et al. Genitourinary trauma in the pediatric patient. Urol 1993;42:563-8. |
|2.||Cass AS. Renal trauma in multiple-injured child. Urol 1983;21:487-92. |
|3.||Giannopoulos A, Serafetinides E, Alamanis C, et al. Lesions urogenitales diagnostiquees par hasard au cours du bilan pour des contusions fermees renales. Progres en Urol 1999;9:464-9. |
|4.||Sorgman JA, Langevin E, Banks PA. Urinoma masquerding as pancreatic pseudocyst. Int J Pancreatol 1992;11:195-8. |
|5.||Cormio G, Cormio L, Di Gesu'G, Loverro G, Selvaggi L. Calyceal rupture and perirenal urinoma as presenting sign of recurrent ovarian cancer. Gynecol Oncol 2001;83:415-7. |
|6.||Gayer G, Zissin R, Apter S, et al. Urinomas caused by ureteral injuries: CT appearance. Abdom Imaging 2002;27:88-92. |
|7.||Gore RM, Balfe DM, Aizenstien RI, Silverman PM. The great escape: interfascial decompression planes of the retroperitoneum. AJR Am J Roentgenol 2000;175:363-70. |
|8.||Kalafatis P, Zougkas K, Petas A. Primary ureterocopic treatment for obstructive ureteral stone-causing fornix rupture. Int J Urol 2004;11:1058-64. |
|9.||Titton RL, Gervais DA, Hahn PF, Harisinghani MG, Arellano RS, Mueller PR. Urine leaks and urinoma: diagnosis and imaging guided intervention. Radiographics 2003;23:1133- 47. |
|10.||Ertugrul A, Yucel S, Ilker Y, Akdas A. Use of double J stent in case of spontaneous ureteral extravasation of urine. Arch Esp Urol 2000; 53:491-3. |
|11.||Santucci RA, Fisher MB. The literature increasingly supports expectant (conservative management of renal trauma: a systematic review. J Trauma 2005;59:493-503. |
|12.||Russell RS, Gomelsky A, McMahon DR, et al. Management of grade IV renal injury in children. J Urol 2001;166:1049-50. |
|13.||Henderson CG, Sedberry-Ross S, Pickard R, et al. Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center. J Urol 2007;178:246-50 . |
|14.||Laurin S, Sandstrom S, Ivarsson H. Percutaneous nephrostomy in infants and children. Acad Radiol 2000;7:526-9. |
|15.||Gupta S, Gulati M, Uday Shankar K, Rungta U, Suri S. Percutaneous nephrostomy with realtime sonographic guidance. Acta Radiol 1997;38:454-7. |
|16.||Lee WJ, Patel U, Patel S, Pillari GP. Emergency percutaneous nephrostomy, results and complications. J Vasc Interv Radiol 1994;5: 135-9. |
13, Rue de Grenade, Immeuble Ambassadeur, A3, Manar 2 Tunis
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]