|Year : 2004 | Volume
| Issue : 2 | Page : 113-117
Review of 48 consecutive cases of renal injury: Outcome of management by conservative vs operative approach
RS Rai, SK Singh, AK Mandal, UK Mete, AK Goswami, SK Sharma
Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
S K Singh
Department of Urology, PGIMER, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : To analyse the outcome of conservative and surgical management of renal injuries in terms of renal salvage and complications.
Methods: Medical records of 48 consecutive patients of renal injury occurring in isolation or in association with polytrauma, managed during January 2000 to April 2002 were reviewed. After initial clinical evaluation and resuscitation, patients were evaluated by abdominal ultrasound followed by computerized tomography to stage the injury. The patients were classified into group 1 comprising of 29 patients having renal injuries of grade 1-III and group 2 consisting of 19 patients of grade IV, V and penetrating injuries. Initially, all patients in group 1 and 9 of group 2 were managed conservatively. Follow up evaluation included blood pressure monitoring, urinalysis and estimation of serum creatinine at each visit and intravenous urography after 6-8 weeks. Outcome in terms of renal salvage was evaluated in two subsets of patients in accordance with management adopted for renal injury (conservative vs operative) as well as severity of renal injure and the significance of difference between two patient groups was assessed statistically by Chi-square test.
Results : There were 37 males and 11 females in the age group of 11-70 years (mean 28 years). Blunt abdominal trauma accounted for renal injury in 85.4% (41/48) patients. Flank pain (43/48; 89.5%) and haematuria (40/ 48; 85.4%) were the common presenting symptoms. Thirty four (70.8%) patients had associated one or more organ injuries. In group 1, all renal units were salvaged except one, who underwent nephrectomy for massive secondary haemorrhage. In group 2, half of the patients (5/10) managed surgically (]for haemodynamic instability, 3 for nonsalvageable kidney and ]for secondary haemorrhage after repair of renal laceration) lost their injured kidney. During follow-up, 2 patients in group 2 managed conservatively lost their kidney. In one patient, the kidney became non-functioning due to renovascular injury and one patient of stab injury managed earlier by angioembolisation underwent nephrectomy for recurrent haematuria due to pseudoaneurysm of intrarenal artery. The renal loss was significantly more in cases with severe renal injury (7/19 vs 1/29, χ2 = 9.22, p < 0.01) and in cases who underwent operative management (5/10 vs 3/38, χ2 = 10.105, p < 0.01).
Conclusions : The data in this study suggest that conservative management of renal injuries yields more favourable results with high renal salvage rate, low morbidity and minimal complications when compared with immediate renal exploration. However, in this retrospective study, the decision of conservativs vs operative management was influenced by several factors. Therefore, a randomized prospective study including those cases in whom both the options are feasible would be helpful to derive a definite conclusion.
Keywords: Renal trauma, renal injury, haematuria, lacerations, pseudo-aneurysm, angioembolisation.
|How to cite this article:|
Rai R S, Singh S K, Mandal A K, Mete U K, Goswami A K, Sharma S K. Review of 48 consecutive cases of renal injury: Outcome of management by conservative vs operative approach. Indian J Urol 2004;20:113-7
|How to cite this URL:|
Rai R S, Singh S K, Mandal A K, Mete U K, Goswami A K, Sharma S K. Review of 48 consecutive cases of renal injury: Outcome of management by conservative vs operative approach. Indian J Urol [serial online] 2004 [cited 2020 May 28];20:113-7. Available from: http://www.indianjurol.com/text.asp?2004/20/2/113/21524
| Introduction|| |
Renal injury accounts for approximately 50% of all cases of genitourinary trauma and more than 50% of cases involve patients under the age of 30.  Until recently blunt trauma comprised 90% of all renal injuries, the remaining 10% being penetrating. With increased access to weapons and small arms, there is a trend towards open injury.  Common causes of blunt trauma are motor vehicle accidents, falls, sports accidents and assaults. Rapid deceleration, which commonly occurs in motor vehicle accidents or falls, may cause intimal tears in the renal artery or even complete avulsion of renal pedicle. Penetrating injury to the kidney is usually caused by knife and bullet wounds. Approximately, 85% of instances of penetrating trauma involving the kidney are associated with injury to other abdominal organs.
Management of renal injury by non-operative versus operative methods has been a subject of controversy for more than 2 decades. The goal of either treatment regimen is preservation of renal function while minimizing morbidity. We analyzed our observations on management of renal injuries to evaluate the outcome of conservative and surgical management in terms of renal salvage and complications.
| Patients and Methods|| |
Medical records of all cases of renal injury managed during January 2000 to April 2002 were reviewed. All patients were evaluated by ultrasonography of the abdomen after initial clinical evaluation and resuscitation. A computerized tomography of the abdomen was performed to stage the injury. The renal and associated organ system injuries were addressed accordingly. For the purpose of management, patients were classified into group 1 comprising of renal injuries grade 1-111 and group 2 comprising of grade IV, V and penetrating injuries. All stabilized patients of group l and 2 were managed conservatively with supportive intravenous fluids, blood transfusions, prophylactic antibiotics, bed rest and close observation.
Surgical intervention was done in the presence of haemodynamic instability, enlarging or pulsating perirenal/retroperitoneal haematoma, penetrating injuries and in cases when abdomen was explored for other associated intra-abdominal injuries. The abdomen was explored through midline approach with an intent to achieve the vascular control first. The procedure for renal reconstruction included control on renal pedicle, complete renal exposure, debridement of necrotic tissue, haemostasis by figure-of-eight suture ligation of bleeding vessels and approximation of the parenchymal defect with deep horizontal mattress 2-0 chromic catgut over crushed muscle to prevent cut through and invariably a perinephric drain was left behind.
Follow up evaluation included recording of blood pressure, microscopic examination of urine, estimation of serum creatinine and an intravenous urography (IVU) at 6-8 weeks visit. Outcome in terms of renal salvage was evaluated in two subsets of patients in accordance with management adopted for renal injury (conservative vs operative) as well as severity of renal injury and the significance of difference between two patient groups was assessed statistically by Chi-square test.
| Results|| |
Forty-eight consecutive patients (37 males and 11 females) of renal injury in the range of 11-70 years (mean 28 years) with majority (30 patients) belonging to 3rd and 4th decades of life were managed during January 2000 to April 2002. Blunt abdominal trauma in road traffic accident and penetrating injury due to stabbing incidents accounted for 85.4% (41 patients) and 12.5% (6 patients) of cases, respectively [Table - 1]. Flank pain and macroscopic haematuria were the common presenting symptoms and were present in 89.6% (43 patients) and 83.3% (40 patients) of cases. Fourteen patients had isolated renal injury whereas the remaining 34 patients suffered one or more associated injuries. Hepatic injury followed by injuries of chest and upper limbs were the common associated injuries [Table - 2]. Nine patients with multiple injuries were in hypovolumic shock at the time of presentation, requiring more than 4 units of blood transfusion.
In group l, there were 29 patients (9, 7 and 13 patients with grade I, II and III injuries respectively) [Table - 3]. Blunt abdominal trauma (road traffic accidents in 27 and fall from height in 2) accounted for renal injuries in this group. All patients were managed conservatively. One of them subsequently underwent exploration and nephrectomy due to infected perinephric haematoma and massive secondary haemorrhage on 9 th day following injury.
Among the 19 patients of group 2. 15 had grade IV and 4 had grade V injuries [Table - 3]. These injuries were caused by blunt trauma abdomen due to road traffic accidents in 12, stab injury in 6 and gunshot in 1 patient. Nine patients (7 with blunt trauma abdomen, I stab injury and I gunshot injury) were managed by conservative approach (2 underwent angioembolisation). Four out of 10 patients. who were explored surgically, needed nephrectomy (haemodynamic instability in 1, non-salvageable kidney in 3) and remaining one of them also underwent nephrectomy for massive secondary haemorrhage after repair of renal laceration [Figure - 1] and associated hepatic and bowel injuries. Among the 9 patients of group 2, who were managed conservatively, 2 patients lost their kidney during follow-up; in one patient, the kidney became nonfunctioning due to renovascular injury [Figure - 2] and the other patient of stab injury managed earlier by angioembolisation underwent nephrectomy for recurrent haematuria due to pseudoaneurysm of intrarenal artery. One patient among these 9 patients had associated avulsion of pelviureteric junction. Due to associated chest injury and fracture of bony pelvis, he was initially managed by percutaneous nephrostomy and an elective pelviureteric junction reconstruction was carried out after 12 weeks. The renal loss was significantly higher in cases with severe renal injury (7/19 vs 1/29, χ 2 = 9.22. p < 0.01) and in cases who underwent operative management (5/10 vs 3/38, χ 2 = 10.105, p < 0.01). In group 2, half of the patients (5110) managed surgically lost their kidney, whereas 22.2% (2/9) renal units were lost in patients managed conservatively.
Follow-up ranged from 7-35 months (average 22 months). Microscopic haematuria subsided by 3-4 weeks and IVU demonstrated satisfactory function and drainage in all salvaged renal unit. As per data at the time of last follow up, all patients were well and symptom free. Their serum creatinine levels were normal (normal value 0.61.2 mg/dl). None developed hypertension. The patient with reconstructed pelviureteric junction avulsion had normal function and drainage of the reno-ureteral unit on IVU at 6 months.
| Discussion|| |
Renal injury from external trauma is the most common of all injuries of the genitourinary system. Most of the renal injuries are of low grade and are managed conservatively. The key to successful management of patients with renal trauma is an accurate assessment of the extent of renal injury. McAninch and Federle  demonstrated the usefulness of computerized tomography in differentiating minor from major renal injuries and subsequently Bretan et al  documented its superior sensitivity and specificity over excretory urography. Computerized tomography has the advantage of identifying associated intra-abdominal injuries, which would modify the initial and subsequent management.  Even high grade injuries and penetrating trauma from gunshot or stab wounds to the kidney can be managed non-operatively if they are carefully staged and selected. , Nash et al examined the reasons for nephrectomy in cases of renal injuries and found that 23% required nephrectomy in otherwise reconstructable kidneys because of intraoperative haemodynamic instability. 
The management of renal lacerations by conservative Vs operative methods has been a subject of controversy for more than 2 decades. ,,, Proponents of conservative management argue that immediate surgical exploration may result in an increased nephrectomy rate and the injured kidney has the potential for spontaneous recovery with few significant complications. , Furthermore, many of the potential complications are amenable to endoscopic or percutaneous procedures without increasing the risk for delayed sequelae. Those who advocate immediate surgery believe that a conservative approach increased the likelihood of significant morbidity from persistent urinary extravasations with urinoma formation, sepsis and delayed hemorrhage. On the other hand, Mathews et al observed that urinary extravasations from grade IV parenchymal laceration or forniceal rupture could be managed nonoperatively with an expectation of spontaneous resolution in 87% of patients.  Perinephric abscess following renal trauma is very uncommon and can be managed by percutaneous drainage.
Patients with major renal lacerations and fragmentation with or without urinary extravasations have traditionally been managed by immediate surgical exploration and repair. Mendez stated that such injuries required surgery.  This approach however is associated with a high rate of nephrectomy. Cass and Ireland reported 15 nephrectomies in 22 patients who underwent immediate surgical exploration.  Saglowsky et al reported nephrectomy rates of 28%, 15% and 33% for patients with gunshots wound, stab wound and blunt trauma respectively.  Dobrowolski et al  reported complications in 9% of patients who were managed conservatively and in 5% of patients after surgery.
Renal salvage depends on the severity of injury. In patients with low-grade renal injuries management, by and large is conservative. In our study, only one of the patients in group 1 lost his kidney due to infection of perinephric haematoma. The kidney loss was significantly higher (p < 0.01) in patients with higher grade injury. It was also seen that loss of renal units was significantly higher in those who were managed surgically (5/10 Vs 3/38). Even in patients of higher grade injury, 50% of those managed surgically underwent nephrectomy, whereas, only 22.2% (2/9) patients lost their renal units following conservative management.
| Conclusions|| |
The data in this study favours nonoperative management of major renal lacerations whenever the patient is haemodynamically stable. This approach ensures a high renal salvage rate, low morbidity and minimal complications. However, in this retrospective study, the decision of conservative vs operative management was influenced by several factors. Therefore, a randomized prospective study including only those cases in whom both the options are feasible, would be helpful to derive a definite conclusion.
| References|| |
|1.||McGoldrick R, Carpinito R. Management of genitourinary trauma. In: Siroky MB, Edelstein RA, Krane RJ, editors. Manual of Urology, Diagnosis and Therapy, 2"d ed. Philadelphia, Lippincott: Williams & Wilkins, 1999: Pp 269-79. |
|2.||Dobrowolski Z, Kusionowicz J, Drewniak T, Habrat W, Lipczynsky W, Jakubik P et al. Renal and ureteric trauma: diagnosis and management in Poland. BJU Int 2002; 89: 748-51. |
|3.||Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BW, Champion HR et al. Organ injury scaling: Spleen, liver and kidney. J Trauma 1989; 29: 1664-6. |
|4.||McAninch JW, Federle MP. Evaluation of renal injuries with computed tomography. J Urol 1982; 128: 456-9. [PUBMED] |
|5.||Bretan PN, McAninch JW, Federle MP, Brooke Jeffery R. Computerized tomographic staging of renal trauma: 85 cases. J Urol 1986: 136: 561-65. |
|6.||Lang EK. Intra-abdominal and retroperitoneal organ injuries diagnosed on dynamic computed tomogram obtained for assessment of renal trauma. J Trauma 1990; 30: 1161. [PUBMED] |
|7.||Santucci RA, McAninch JW. Diagnosis and management of renal trauma: Past, present and future. J Am Coll Surg 2000; 191: 443-51. [PUBMED] |
|8.||McAninch JW. Carrol PR, Klosterman PW. Dixon CM, Greenblatt MN. Renal construction after injury. J Urol 1991; 145: 932-7. |
|9.||Nash PA, Bruce JE, McAninch JW. Nephrectomy for traumatic renal injuries. J Urol 1995: 153: 609-11. |
|10.||Del Villar RG, Ireland GW. Cass AS. Management of renal injury in conjunction with the immediate surgical treatment of the acute severe trauma patients. J Urol 1972; 107: 208-11. |
|11.||Cass AS, Luxenberg M, Gleich P, Smith C. Long term results of conservative and surgical management of blunt renal lacerations. J Urol 1987; 59: 17-20. |
|12.||Thompson IM. Expectant management of blunt renal trauma. Urol Clin North Am 1977; 4: 29-32. [PUBMED] |
|13.||Deka PM, Rajeev TP. Blunt renal trauma - Is nonoperative treatment a viable option. Ind J Urol 2001; 18: 10-13. |
|14.||Peterson NE. Complications of renal truama. Urol Clin North Am 1989; 16: 221-36. [PUBMED] |
|15.||Maria P, Mazeman E. Immediate and delayed management of renal trauma. Eur Urol 2000: 17: 1-10. |
|16.||Mathews LA. Smith EM. Spirnak JP. Nonoperative treatment of major blunt renal lacerations with urinary extravasations. J Urol 1997; 157: 2056-8. |
|17.||Mendez R. Renal trauma. J Urol 1977; 118: 698-703. [PUBMED] |
|18.||Cass AS, Ireland GW. Comparison of the conservative and surgical management of the more severe degrees of renal trauma in multiple injured patients. J Urol 1973; 109: 8-10. [PUBMED] |
|19.||Saglowsky AO, McConnell JD, Peters PC. Renal trauma requiring surgery: An analysis of 185 cases. J Trauma 1983; 23: 128-31. |
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3]