|Year : 2001 | Volume
| Issue : 1 | Page : 10-13
Blunt renal trauma - is non-operative management a viable option
PM Deka, TP Rajeev
Department of Urology, Guwahati Medical College Hospital, Guwahati, India
P M Deka
Department of Urology, Manik Nagar, Near Rajdhani Nursery, Zoo Road, Guwahati (Assam) - 781 005
| Abstract|| |
Deep cortical lacerations with or without urinary extravasations have traditionally been managed by exploration and surgical repair. With improved and readily available radiologic imaging modalities like computed tomography and intravenous pyelography, we propose that the majority of these injuries can be followed expectantly with delayed intervention if needed. 30 patients with blunt abdominal trauma with significant renal injuries were reviewed. 9 patients had Gr II, 16 patients had Gr III, 2 had Gr IV renal injuries. 26 (86.7%) patients responded to conservative management. 4 patients required operative intervention. 6 patients had associated injuries. There was loss of I renal unit in 2 cases. With the aid of computed tomography, conservative therapy for severely injured kidneys can yield favourable results and save patients from unnecessary exploration and possible renal loss.
Keywords: Blunt Trauma; Renal Injury; Haematuria: Conservative Management.
|How to cite this article:|
Deka P M, Rajeev T P. Blunt renal trauma - is non-operative management a viable option. Indian J Urol 2001;18:10-3
| Introduction|| |
Renal trauma occurs in 8-10% of all blunt and penetrating abdominal injuries. Renal trauma is classified into 4 types. Type I injury includes minor contusion. Type II injury consists of minor lacerations without involvement of collecting systems; type III injury includes major lacerations and fragmentation, with or without extravasation. Type IV injury involves pedicle injuries.,,
Successful management of renal injury depends upon accurate assessment of their extent. In type I and II injuries conservative approach has been advocated,, but type III and IV injuries have been traditionally managed by exploration and surgical repair., With the advancement in radiologic imaging modalities and the ready availability of computed tomography, we believe that the majority of patients with type III renal trauma can be followed expectantly with delayed intervention only if needed. We report our experience of management of blunt renal trauma.
| Materials and Methods|| |
We reviewed 30 consecutive patients with blunt abdominal trauma with suspected significant renal injuries during the period Jan. '97 to Dec. 2000. Male:Female ratio was 6:1. Age- ranged from 4-42 years. All patients were initially managed by fluid resuscitation and radiographic screening. Radiographic screening included intravenous urography, ultrasound scan and or an abdominal computerized tomography scan with contrast medium. All stabilized patients were managed by careful continuous observation, bed rest, appropriate fluid resuscitation and prophylactic antibiotic coverage. Operative intervention for urological injury was not done unless complications developed. The indications for immediate exploratory laparotomy were acute abdomen, rapidly dropping hematocrit or associated injuries as determined by radiographic evaluation. Conservative management consisted of monitoring vital signs, repeated abdominal examinations and serial measurement of hematocrit.
Patients were followed routinely at intervals of 1, 3, 6 and 12 months after the injury and then yearly thereafter. Follow-up evaluations involved blood pressure monitoring and urinalysis on each visit. Intravenous urography was obtained at 1 and 1'/z months after injury. Any patient with an abnormal urinalysis or elevated blood pressure was evaluated at shorter intervals.
| Results|| |
Of the 30 patients evaluated, 3 (10%) had minor contusions. 9 (30%) had only minor lacerations. There were 16 (53.3%) patients with major lacerations, type III. 2 (6.6%) patients had shattered kidney or pedicle injury.
In our series, the mechanism of injury was motor vehicle crash (6), pedestrian struck by car (5), motor cycle crash (3), assault (11). 5 patients suffered falls [Table - 1]. 24 patients initially had gross haematuria. 6 patients had only microhaematuria.
Abdominal computerized tomography (CT) with contrast was performed in 17 patients, intravenous urography (IVU) in 24, combined IVU + CT in 12, combined IVU + Ultrasound scan in 11.
Associated injuries were found in 6 patients, These included pneumothorax (1), bowel injury (2), liver lacerations (2), and splenic rupture (1) [Table - 2]. The patient who had pneumothorax and pelvic fracture died in the emergency, 6 hours after he was brought. 3 patients underwent immediate exploratory laparotomy due to acute abdomen. Of these 3 patients, 2 had repair of bowel injury and liver laceration and 1 underwent splenectomy.
3 patients with gross haematuria who had unstable vital signs and dropping haematocrit inspite of adequate fluid resuscitation and blood transfusions needed renal exploration. Of these patients, 2 lost one renal unit due to shattered kidney and 1 underwent partial nephrectomy for non-viable lower polar parenchyma.
The average haematocrit decrease in patients was 8% (absolute value, range 0-13.6%). 24 patients with blunt trauma required blood transfusion (average 3 units of packed red cells; range 2-6 units).
26 patients (86.6%) responded to conservative protocol. The hospital stay ranged from 9 to 22 days (average 14.5 days). Majority 17 (65.3%) patients with initial gross haematuria had clear urine by hospital day 10. In this series, two renal units were lost. One had partial nephrectomy.
All the 29 patients, 26 conservatively managed and 3 with renal exploration, had normal blood urea nitrogen and serum creatinine levels. No patient developed hypertension during their hospital stays.
Majority of our surviving patients, 21 out of 29 had been followed up for more than 9 months. Long-term follow-up examination is difficult to obtain because of transient nature of our city hospital population.
| Discussion|| |
The management of renal lacerations by non-operative versus operative methods has been a subject of controversy for more than 2 decades.,, Patients with major renal laceration and fragmentation with or without urinary extravasation have traditionally been managed by immediate surgical exploration and repair. Mendez stated that such injuries required mandatory surgery. This approach however is associated with a high rate of nephrectomy. Cass & Ireland reported 15 nephrectomies in 22 patients who underwent immediate surgery. Sagalowsky et al reported nephrectomy rates of 28%, 15% and 33% for patients with gunshot wounds, stab wounds and blunt trauma respectively. In our series, only two of 30 (6.6%) renal units were lost, and this occurred in a patient who was initially explored. Thus, expectant management of type III injuries yield more favourable results when compared with immediate renal exploration where one can expect a higher nephrectomy rate.
Given the high rate of renal loss and the improved results with expectant treatment, the decision to perform immediate surgery must be weighed carefully. In decisionmaking process, accurate assessment of the extent of injury is invaluable. Computed tomography has emerged in recent years as an effective means of providing such needed information., In the present series, CT-scanning was used to effectively stage the renal injuries. It also has the advantages of identifying associated injuries which would modify the initial and subsequent management. The data in this study demonstrate that conservative treatment of major renal lacerations are associated with low morbidity.
All of the patients had normal blood urea and serum creatinine levels at the time of discharge. No patient developed hypertension. Watts & Hoffbrand reported an increased incidence of hypertension especially in patients treated expectantly. According to that study, hypertension could develop after many years. In our limited follow-up examinations, this appears not to be the case, but we agree with Watts & Hoffbrand that these patients need to be followed with regular blood pressure recordings.
Immediate radiologic evaluation gives valuable information in treating patients with renal trauma. The criteria for study have been well established by McAninch. Using these criteria of scanning all trauma patients with gross haematuria, microhaematuria plus shock, rapidly dropping haematocrits or peritoneal signs the present study shows that no urologic or intra-abdominal injuries were missed. Use of CT staging of renal trauma is superior to IVP and is sufficiently accurate to allow the majority of the patients with major renal injuries to be treated expectantly and to avoid unnecessary exploration with its high risk of renal loss. Unless immediate exploratory laparotomy is indicated because of associated injuries or shock, most major renal injuries can be managed by non-surgical treatment with delayed intervention as needed.
In conclusion, we believe that non-operative management of major renal lacerations with vascularised fragments is a viable and proper method of treatment. However, in an individual with a major renal maceration associated with a devitalized fragment a heightened awareness of probable complications must exist. If these additional risks would adversely affect survival we believe that immediate exploration and repair are indicated.
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[Table - 1], [Table - 2]