renal trauma blunt

Wichien Sirithanaphol, MD

Management of Blunt Renal trauma

in Srinagarind Hospital: 10-year experience

• Urogenital system injuries are seen in 10% of traumatic patients and mostly in patients with multiple trauma and severe trauma of lower parts of abdomen or pelvis

• The prevalence of urogenital injuries has been reported between 10 and 30% in adults and less than 3% in children

MC Aninch JW. Genitourinary trauma. World Urol 1999.17: 95-96.

Introduction

• Renal injury is the most common injury in urogenital system

• The prevalence of Renal Injury in Abdomonal Traumatic Patients has reported 8 – 10%1 and 13.6 % in Siriraj Hospital2

1Peterson NE. complications of renal trauma. Urol Clin North Am 1989; 16: 221-36.

2 เกษียร ภงัคานนท,์ สิงหพนัธ์ ทองสวสัด์ิ ใน: เกษียร ภงัคานนท,์ บรรณาธิการ.บาดเจ็บท่ีทอ้ง. กรุงเทพมหานคร: โครงการต าราศิริราช, 2522: 1-13.

Introduction

• Blunt trauma is the cause of more than 90% of Renal Injuries1

– Accidents, falling and being hit are the most frequent of blunt injury

• Bullet and stab wounds are the most common cause for penetrating injuries2

1Dreitlein AA, Snner S, Basler J. Genitourinary trauma.Emery med clin North Am 2001 19(3): 599-90.

2Palmer LS, Rosenbaum RR, Gershbaum MD. Penetrating ureteral trauma at an urban trauma center.

Urology 1999 54(1): 34-36.

Introduction

• Grading of renal injuries is performed using the American Association for the Surgery of Trauma organ injury severity scale

Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: spleen, liver, and kidney. J Trauma 29: 1664–1666, 1989.

Introduction

• Nonoperative management of renal injuries has gained much support in past decades

• A trial of Nonoperative management has been advocated for most adult blunt renal injuries1, many renal stab wounds2, and selective renal gunshot wounds3

1Danuser H, Wille S, Zoscher G, et al: How to treat blunt kidney ruptures: primary open surgery or

conservative treatment with deferred surgery when necessary? Eur Urol 39: 9–14, 2001.

2Bernath AS, Schutte H, Fernandez RR, et al: Stab wounds of the kidney: conservative management in

flank penetration. J Urol 129: 468–470, 19833

Serafetinides E, Mitropoulos D, Constantinedes C, et al: Management of renal gunshot injuries (RGI). J Urol 171: 20, 2004.

Introduction

Patient & Method

• Retrospective review : case review

• Srinagarind hospital, university hospital in Khon-Kaen

• Period of study : 1 Jan 1999 - 31 Dec 2008

• Retrieve data from ICD10 code– Renal trauma

– Renal injury

Research methodology

Inclusion & Exclusion criteria

Inclusion criteria

• Blunt renal Trauma

• Referred patients with Renal Injury related complication

Exclusion criteria

• Penetrating injury

• Iatrogenic Renal injury

• Referred patients with Non-Renal Injury related complication

Group of Study

• Non Operative Management (NOM) group

(+Interventional Treatment)

- Successful NOM

- Failed NOM

• Operative Management group

- Renal exploration

• The absolute indications for renal exploration– Life-threatening hemorrhage from a renal source

– Pulsatile perirenal hematoma (suggestive of a grade V vascular injury)

– Active extravasation of intravenous contrast

Management

• The patients who were considered non-operative treatment– Absolute bed rest until gross hematuria resolves

– Regular & frequent vital sign measurement

– Serial abdominal examination

– Serial Hct checked

• Surgical procedures were performed in operative group, depended on intra-operative finding

Management

• This study have proved by The Khon Kaen University Ethics Committee for Human Research

• No : HE 521112

Ethical Consideration

Results

Renal trauma (80 pt)

Renal trauma (77 pt)

Missing data (3 pt = 3.89%)

Exclude (8 pt = 10.4 %)

Penetrating injury 5 pt Iatrogenic injury 3 pt (kidney biopsy)

Blunt renal trauma (69 pt)

Blunt renal trauma (69 pt)

Abdominal trauma (1,693 pt)

4.07 % of Abdominal trauma

Characteristic

MaleFemale

Mean age

Underlying disease

Blunt injury 69 pt

56 pt (82%)

13 pt (18%)

29.8 yr (1-68 yr)

No 55 pt (80%)

Mechanism of injury

Blunt Renal injury 69 pt

Management

NOM Group 55 pt (80%)

Operative Group 14 pt (20%)

Renal Exploration 7 pt (10%)

Other intraabdominal injury 7 pt (10%)

Blunt Renal injury 69 pt


Renal Exploration 7 pt (10%)

Mean SBP

Mean Hct (at ER)

113 (0-179mmHg) 78 (0-139 mmHg)

35% (15-48%) 30% (20-44%)


Patients with shock on arrival

5/55 pt

6/7 pt

Injury severity score (ISS)

78%

22%

14%

86%

Revised Trauma Score (RTS)

Trauma Score - Injury Severity Score (TRISS)

Grading of injuryBlunt Renal injury

69 pt

33%

23%

21%14%

9%

Non operative group 55 pt

Operative group 7 pt

Associated injury

Head injury 23

Hemo/pneumothorax 22

Rib fracture 18

ExtremitylowerUpper

128

Facial bone 6

Spine 5

Extra-abdominal injury Pt

Spleen 13

Liver 8

Small bowel 2

Colon 1

Pancreas 1

IVC 1

Intra-abdominal injury pt

Mean hospital stay

Mean ICU stay

Mean PRC used

Non operative group(55 pt)

Operative group(7 pt)

11.8 days (1-54) 19 days (1-74)

0.5 days (0-9 ) 5.14 days (0-23)

1.6 units (0-16) 5.14 units (0-9 )

Management outcome

Management outcome

Non-operative Group (55 Pt)

Successful NOM

48/55 pt (87.2%)

Failed NOM

4/55 pt (7.3%)

Peritonitis : 1 pt

- Avulsion of upper pole of kidney

Complication : 3 pt

- Pseudoaneurysm : 1 pt

- Infected urinoma : 1 pt

- Delayed bleeding : 1 pt

Death

3/55 pt (5.5%)

Severe head injury : 2 pt

Massive hemothorax : 1 pt

Management outcome

Operative Group (7 Pt)

Death

1/7 pt (14%)

Severe head injury

Procedure

EL c nephrectomy 6 pt

EL c ureteropyeloplasty 1 pt

Non specific complication



Pneumonia 1UTI 7

Pneumonia 6

Wound infection 2

ARF 2

ARDS 1

Specific complication


Perinephric abscess 2

Infected urinoma 1

Delayed bleeding 1

Pseudoaneurysm 1


Compartmental syndrome

1

Specific complication treatment


Perinephric abscess 2

Infected urinoma 1

Delayed bleeding 1

Pseudoaneurysm 1

ATB

Percutaneous drainage EL c nephrectomy

Embolization EL c left lower pole nephrectomy

EL c nephrectomy

failed

failed

ATB

Specific complication treatment


Compartmental syndrome

1EL c temporaryabdominal closure

• According to the obtained results from this study, Renal Injury develops in a little portion of abdominal traumatic patients – 4.07%

– This is quite less than findings of other studies

• However, these injuries may lead to mortality, urogenital dysfunction, neglecting them could cause serious sequelae

Discussion

• 20 – 30 years are the most common age group, may be because of traumatic pattern which mostly affect the youth

• Regarding gender, Male were enrolled 4.5 times more than female in this study

• Blunt trauma is the cause of more than 90% of Renal Injuries

Which are almost similar to other studies

Discussion

• NOM Groups– NOM is the treatment of choice in stable patients

– Most of blunt renal injury can be managed conservatively

• Grade 5 is only 1 pt

• Failed NOM– 3 pt : Death due to serious associated injury

– 2 pt : due to late sequale (Infected urinoma, Delayed bleeding)

– 1 pt : due to immediated sequale (Developed peritonitis)

Discussion

• Mortality in operative group is higher than NOM group– 5% vs. 36%

– Severe Renal Injury

– Severe associated injury

• Conservative Management have also been applied to penetrating renal injuries, who were hemodynamically stable and without peritoneal signs– In this study can't be manage due to contraindication

Discussion

• Most of blunt renal injury can be managed conservatively

• Penetrating renal injuries can be managed nonoperatively in selected patients

• Multimodality of Treatment– Procedure should be suited for individual

Conclusion

Thank You

renal trauma blunt

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