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Serafetinidis E, Campos-Juanatey F, Hallscheidt P, Mahmud H, Mayer E, Schouten N, Sharma DM, Waterloos M, Zimmermann K, Kitrey ND. Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma. Eur Urol Focus 2023:S2405-4569(23)00196-7. [PMID: 37968186 DOI: 10.1016/j.euf.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 11/17/2023]
Abstract
CONTEXT The European Association of Urology (EAU) Guidelines Panel for Urological Trauma has produced guidelines in order to assist medical professionals in the management of urological trauma in adults for the past 20 yr. It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients regarding other parameters such as experience and available facilities. Guidelines are not mandates and do not purport to be a legal standard of care. OBJECTIVE To present a summary of the 2023 version of the EAU guidelines on the management of urological trauma. EVIDENCE ACQUISITION A systematic literature search was conducted from 1966 to 2022, and articles with the highest certainty evidence were selected. It is important to note that due to its nature, genitourinary trauma literature still relies heavily on expert opinion and retrospective series. EVIDENCE SYNTHESIS Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 1, 2021 and April 29, 2022. A total of 1236 unique records were identified, retrieved, and screened for relevance. CONCLUSIONS The guidelines provide an evidence-based approach for the management of urological trauma. PATIENT SUMMARY Trauma is a serious public health problem with significant social and economic costs. Urological trauma is common; traffic accidents, falls, intrapersonal violence, and iatrogenic injuries are the main causes. Developments in technology, continuous training of medical professionals, and improved care of polytrauma patients reduce morbidity and maximise the opportunity for quick recovery.
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Affiliation(s)
| | | | | | - Husny Mahmud
- Department of Urology, Sheba Medical Centre, Tel-Hashomer, Israel
| | - Erik Mayer
- Department of Surgery & Cancer, Imperial College London, London, UK; Department of Urology, The Royal Marsden Hospital, London, UK
| | - Natasha Schouten
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | | | - Marjan Waterloos
- Division of Urology, Gent University Hospital, Gent, Belgium; Division of Urology, AZ Maria Middelares, Gent, Belgium
| | - Kristin Zimmermann
- Department of Urology, Federal Armed Services Hospital Koblenz, Koblenz, Germany
| | - Noam D Kitrey
- Department of Urology, Sheba Medical Centre, Tel-Hashomer, Israel.
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Marcou M, Hartmann A, Wullich B, Apel H, Hirsch-Koch K. Retrospective histological evaluation of orchiectomy specimens following testicular torsion reveals a 10% incidence of reversible injury. Is it time for a change of strategy? Andrology 2023; 11:1044-1049. [PMID: 36542416 DOI: 10.1111/andr.13368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/01/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND According to standard medical practice, immediate orchiectomy is advised in the case of a non-viable testis following testicular torsion. Because of the lack of objective criteria in the evaluation of testicular viability, the fate of the testis solely depends on the discretion and experience of the surgeon. OBJECTIVE In this study, we retrospectively reassess the management of patients with testicular torsion in our center, and we ask the question, from a retrospective point of view, of whether the decision to perform orchiectomy has always been correct. MATERIALS AND METHODS We retrospectively reviewed all cases of patients with testicular torsion who underwent surgery in our center between 2001 and 2021. All orchiectomy specimens were reevaluated and graded by an experienced pathologist using the Mikuz grading system. RESULTS Immediate orchiectomy was performed in 48 of the 136 patients (35%). Five (10.4%) of the 48 orchiectomy specimens were categorized as "grade 1," and 17 (35.4%) were categorized as "grade 2." The time between the onset of symptoms and surgical exploration exceeded 12 h in three of the five patients with a "grade 1" testicular injury, and in one case, it even exceeded 24 h. DISCUSSION "Grade 1" testicular injury is potentially reversible, whereas the fate of a testis with a "grade 2" testicular injury remains unknown. Whether and to what extent partial testicular tissue salvage in a "grade 2" injury is still possible remain unclear. CONCLUSIONS Our results indicate that at least 10% of the testicles removed in our center could, from a retrospective point of view, have been salvaged. Our study further demonstrated that the duration of symptoms is not an absolute indicator of testicular damage and that the decision of whether orchiectomy should be performed, based simply on the subjective macroscopic image of the affected testis, is not always correct.
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Affiliation(s)
- Marios Marcou
- Clinic of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Arndt Hartmann
- Institute of Pathology, University Hospital Erlangen, Erlangen, Germany
| | - Bernd Wullich
- Clinic of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Hendrik Apel
- Clinic of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Karin Hirsch-Koch
- Clinic of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
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Baboudjian M, Lebacle C, Gondran-Tellier B, Hutin M, Olivier J, Ruggiero M, Panayotopoulos P, Dominique I, Millet C, Bergerat S, Freton L, Betari R, Matillon X, Chebbi A, Caes T, Patard PM, Szabla N, Sabourin L, Dariane C, Rizk J, Madec FX, Nouhaud FX, Rod X, Fiard G, Pradere B, Peyronnet B. Who Is at Risk of Death after Renal Trauma? An Analysis of Thirty-Day Mortality after 1,799 Cases of Renal Trauma. Urol Int 2023; 107:165-170. [PMID: 35390797 DOI: 10.1159/000521554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of the study was to report the 30-day mortality (30DM) after renal trauma and identify the risk factors associated with death. METHODS The TRAUMAFUF project was a retrospective multi-institutional study including all patients with renal trauma admitted to 17 French hospitals between 2005 and 2015. The included population focused on patients of all age groups who underwent renal trauma during the study period. The primary outcome was death within 30 days following trauma. The multivariate logistic regression model with a stepwise backward elimination was used to identify predictive factors of 30DM. RESULTS Data on 1,799 renal trauma were recorded over the 10-year period. There were 59 deaths within 30 days of renal trauma, conferring a 30DM rate of 3.27%. Renal trauma was directly involved in 5 deaths (8.5% of all deaths, 0.3% of all renal trauma). Multivariate stepwise logistic regression analysis revealed that age >40 years (odds ratio [OR] 2.18; 95% confidence interval [CI]: 1.20-3.99; p = 0.01), hemodynamic instability (OR 4.67; 95% CI: 2.49-9; p < 0.001), anemia (OR 3.89; 95% CI: 1.94-8.37; p < 0.001), bilateral renal trauma (OR 6.77; 95% CI: 2.83-15.61; p < 0.001), arterial contrast extravasation (OR 2.09; 95% CI: 1.09-3.96; p = 0.02), and concomitant visceral and bone injuries (OR 6.57; 95% CI: 2.41-23.14; p < 0.001) were independent predictors of 30DM. CONCLUSION Our large multi-institutional study supports that the 30DM of 3.27% after renal trauma is due to the high degree of associated injuries and was rarely a consequence of renal trauma alone. Age >40 years, hemodynamic instability, anemia, bilateral renal trauma, arterial contrast extravasation, and concomitant visceral and bone lesions were predictors of death. These results can help clinicians to identify high-risk patients.
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Affiliation(s)
- Michael Baboudjian
- Department of Urology and Kidney Transplantation, Aix-Marseille University, APHM, Conception Academic Hospital, Marseille, France
| | - Cedric Lebacle
- Department of Urology, University of Paris Sud, CHU Bicetre, Paris, France
| | - Bastien Gondran-Tellier
- Department of Urology and Kidney Transplantation, Aix-Marseille University, APHM, Conception Academic Hospital, Marseille, France
| | - Marine Hutin
- Department of Urology, University of Montpellier, Montpellier, France
| | | | - Marina Ruggiero
- Department of Urology, University of Paris Sud, CHU Bicetre, Paris, France
| | | | | | - Clémentine Millet
- Department of Urology, University of Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Lucas Freton
- Department of Urology, University of Rennes, Rennes, France
| | - Reem Betari
- Department of Urology, University of Amiens, Amiens, France
| | | | - Ala Chebbi
- Department of Urology, University of Rouen, Rouen, France
| | - Thomas Caes
- Department of Urology, University of Lille, Lille, France
| | | | | | - Laura Sabourin
- Department of Urology, University of Clermont-Ferrand, Clermont-Ferrand, France
| | - Charles Dariane
- Department of Urology, University of Paris Descartes, Paris, France
| | - Jerome Rizk
- Department of Urology, University of Lille, Lille, France
| | | | | | - Xavier Rod
- Department of Urology, University of Nantes, Nantes, France
| | - Gaelle Fiard
- Department of Urology, University of Grenoble, Grenoble, France
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Bowles DC. Is a trauma surgeon always a trauma specialist? Injury 2023; 54:3-4. [PMID: 36587957 DOI: 10.1016/j.injury.2022.11.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Tae BS, Jang HA, Yu J, Oh KJ, Moon KH, Park JY. Epidemiology and Management Trend of Renal Trauma: Results of a Nationwide Population-Based Study. J Korean Med Sci 2022; 37:e333. [PMID: 36472084 PMCID: PMC9723188 DOI: 10.3346/jkms.2022.37.e333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To analyze the incidence of renal trauma using the National Health Insurance Service Database (NHISD). METHODS Using the NHISD, representative of all upper urinary tract injuries in Korea, data regarding renal trauma were analyzed. The International Classification of Diseases, Tenth Revision Clinical Modification codes were used to identify the diagnoses. The incidence estimates of renal traumas were analyzed using Poisson regression analysis. Risk factors for high-grade renal trauma were estimated using multivariable logistic regression analyses. RESULTS Patients with renal trauma were identified from a nationwide database collected by the National Health Insurance Service of Korea between 2012 and 2016. Among 37,683 individuals with renal trauma, 1,293 (3.4%) were diagnosed with high-grade renal trauma. Surgical therapy was performed in 995 (2.6%) patients with renal trauma and 184 (14.2%) patients with high-grade renal trauma. Renal trauma occurred in all age groups, and the ratio between men and women was approximately 3:1. Men and women experienced 8,000 (31.82/100,000) and 2,365 (9.52/100,000) renal trauma in 2013 (total 10,365, 20.73/100,000) and 5,243 (20.56/100.000) and 2,168 (8.58/100,000) in 2016 (total 7,411, 14.60/100,000), respectively. In multivariable analysis, female sex, age (age; 41-60 and 61-80 years), and comorbidity of peripheral vascular disease, renal disease, and malignancy were revealed as risk factors for high-grade renal trauma. CONCLUSION Annual incidence of renal trauma is 17.33 per 100,000 population from 2012 to 2016. The incidence of kidney damage decreased gradually from 2013 to 2016, and the majority of renal trauma cases were low-grade. Conservative management was the preferred treatment modality in most patients with renal trauma, including those with high-grade renal trauma.
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Affiliation(s)
- Bum Sik Tae
- Department of Urology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | | | - Jihyeong Yu
- Department of Urology, Sanggye Paik Hospital, Inje University, Seoul, Korea
| | - Kyung-Jin Oh
- Department of Urology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Kyung Hyun Moon
- Department of Urology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jae Young Park
- Department of Urology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea.
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Denning Ho R, Shrivastava V, Mokhtari A, Lakshminarayan R. The Role of Renal Artery Embolisation in the Management of Blunt Renal Injuries: A Review. Vascular and Endovascular Review 2022. [DOI: 10.15420/ver.2022.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Renal injuries are the most common urinary tract injury secondary to external abdominal trauma. They are caused by blunt, penetrating and iatrogenic mechanisms. Despite the high number of blunt renal injuries, little evidence is available to guide management, especially with the evolution of embolisation as a minimally invasive treatment. Consequently, clinical practice is driven by results of observational studies and anecdote. We have reviewed the current trends in practice when using renal artery embolisation in the management of blunt renal injuries. Three key principles are highlighted. First, high-grade blunt renal injuries can be successfully managed with embolisation. Second, embolisation should be considered when there is radiological evidence of active contrast extravasation, pseudoaneurysm or arteriovenous fistula. Third, embolisation can be used to manage blunt renal injuries in haemodynamically unstable patients. Beyond this, evidence regarding optimal technique, CT indications, clinical status, comorbidities and complications are inconclusive. We discuss the implications for clinical practice and how these findings should define the agenda for future clinical research.
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Lindner AK, Luger AK, Fritz J, Stäblein J, Radmayr C, Aigner F, Rehder P, Tulchiner G, Horninger W, Pichler R. Do we need repeated CT imaging in uncomplicated blunt renal injuries? Experiences of a high-volume urological trauma centre. World J Emerg Surg 2022; 17:38. [PMID: 35799209 PMCID: PMC9264658 DOI: 10.1186/s13017-022-00445-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Current guidelines recommend repeat computed tomography (CT) imaging in high-grade blunt renal injury within 48–96 h, yet diagnostic value and clinical significance remain controversial. The aim of this work was to determine the possible gain of CT re-imaging in uncomplicated patients with blunt renal trauma at 48 h after injury, presenting one of the largest case series. Methods A retrospective database of patients admitted to our centre with isolated blunt renal trauma due to sporting injuries was analysed for a period of 20 years (2000–2020). We included only patients who underwent repeat imaging at 48 h after trauma irrespective of AAST renal injury grading (grade 1–5) and initial management. The primary outcome was intervention rates after CT imaging at 48 h in uncomplicated patients versus CT scan at the time of clinical symptoms. Results A total of 280 patients (mean age: 37.8 years; 244 (87.1%) male) with repeat CT after 48 h were included. 150 (53.6%) patients were classified as low-grade (grade 1–3) and 130 (46.4%) as high-grade (grade 4–5) trauma. Immediate intervention at trauma was necessary in 59 (21.1%) patients with high-grade injuries: minimally invasive therapy in 48 (81.4%) and open surgery in 11 (18.6%) patients, respectively. In only 16 (5.7%) cases, intervention was performed based on CT re-imaging at 48 h (low-grade vs. high-grade: 3.3% vs. 8.5%; p = 0.075). On the contrary, intervention rate due to clinical symptoms was 12.5% (n = 35). Onset of clinical progress was on average (range) 5.3 (1–17) days post trauma. High-grade trauma (odds ratio [OR]grade 4 vs. grade 3, 14.62; p < 0.001; ORgrade 5 vs. grade 3, 22.88, p = 0.004) and intervention performed at the day of trauma (OR 3.22; p = 0.014) were powerful predictors of occurrence of clinical progress. Conclusion Our data suggest that routine CT imaging 48 h post trauma can be safely omitted for patients with low- and high-grade blunt renal injury as long as they remain clinically stable. Patients with high-grade renal injury have the highest risk for clinical progress; thus, close surveillance should be considered especially in this group.
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Affiliation(s)
- Andrea Katharina Lindner
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | | | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Stäblein
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Friedrich Aigner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Rehder
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Gennadi Tulchiner
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Wolfgang Horninger
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Renate Pichler
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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Kelly CE, Bowers KE, Holton AE, Van Embden D. Non-operatively managed blunt and penetrating renal trauma: Does early follow up CT scan change management? A systematic review. Injury 2022; 53:69-75. [PMID: 34392984 DOI: 10.1016/j.injury.2021.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 07/11/2021] [Accepted: 07/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Renal injury accounts for 1-5% of all traumatic injuries. Non-operative management (NOM) of renal trauma has demonstrated higher renal salvage rates and reduced morbidity. AIMS The aim of this review is to clarify the indications of early follow up CT scan for adult patients, with NOM, renal trauma, with a view to avoiding unnecessary CT scanning and radiation exposure in this cohort of patients. METHODS A systematic search was conducted using PubMed (MEDLINE), Web of Science, Embase, and Cochrane library, with references from relevant articles also evaluated. Inclusion criteria were defined as studies reporting outcomes of patients ≥12 years of age, with NOM, renal trauma and early CT re-imaging. The outcomes of interest were renal complications requiring intervention, specifically collecting system and vascular complications. RESULTS Five studies met the inclusion criteria. In total, 542 patients were included in this analysis; study sizes ranged from 48 to 207 patients. Early re-imaging was performed for 510 patients, including 489 CTs and 31 Ultrasounds (US). Mean time to re-imaging ranged from 1 - 35.9 days. Twenty three patients required intervention following re-imaging, all of which were for injuries grade ≥ 3 and presented with clinical deterioration prior to re-imaging, had a collecting system injury identified on initial CT scan or both. The number needed to re-image, in order to change the management of one patient, was 22. CONCLUSIONS Although the findings of this review are based on retrospective data, they suggest routine early re-imaging can be safely omitted for all NOM, renal injuries which remain asymptomatic, with no collecting system injury diagnosed on initial CT, provided appropriate delayed phase imaging is available. Future prospective studies are required to further clarify the indications of early re-imaging, specifically for NOM penetrating injuries, and the appropriate modality and timing of early re-imaging for all NOM renal trauma.
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Affiliation(s)
- Caroline E Kelly
- Blizard Institute, Queen Mary University of London, United Kingdom.
| | - Kevin E Bowers
- James Connolly Memorial Hospital, Blanchardstown, Mill Rd, Abbotstown D15, X40D, Dublin, Ireland
| | - Alice E Holton
- RCSI School of Pharmacy and Bio Molecular Sciences, 111 St. Stephen's Green, Saint Peter's D02 VN51, Dublin, Ireland
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Smith TA, Eastaway A, Hartt D, Quencer KB. Endovascular embolization in renal trauma: a narrative review. Ann Transl Med 2021; 9:1198. [PMID: 34430639 PMCID: PMC8350687 DOI: 10.21037/atm-20-4310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/19/2020] [Indexed: 11/20/2022]
Abstract
Approximately 1–3% of all trauma patients have a renal injury. Eighty percent of renal trauma is due to blunt injury, with the remainder due to penetrating trauma which is most often iatrogenic. Contrast enhanced computed tomography is used to triage patients and offers a quick and accurate assessment of any potential organ injury. If injury is present, The American Association for the Surgery of Trauma grading system can both grade renal injuries and be used to help guide management and intervention. Grades are assigned based on imaging and clinical features of renal trauma, and have prognostic and treatment implications for patients. The objective of this narrative review is to identify optimal management of patients with renal trauma, specifically which patients can be treated with endovascular interventions following renal trauma, which can be observed, and which would be best managed surgically. For hemodynamically stable patients with renal trauma, endovascular angiography and embolization is a non-invasive approach that can be used to control bleeding and potentially avoid surgery or nephrectomy in select cases. Future research is needed to determine if a specific antibiotic regimen is needed prior to or following embolization. Further research is needed to evaluate the effectiveness of endovascular management of high-grade renal trauma (grade V). Complications of renal embolization include short-term hypertension, long term hypertension in cases of significant ischemia, acute kidney injury, and infection.
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Affiliation(s)
- Tyler Andrew Smith
- Department of Interventional Radiology, University of Utah, Salt Lake City, UT, USA
| | - Adriene Eastaway
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Duncan Hartt
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
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Simonit F, Marcuzzi G, Desinan L. A bizarre case of fatal main renal artery partial laceration without primary kidney injury due to a single stab wound in the chest. Leg Med (Tokyo) 2021; 51:101892. [PMID: 33910129 DOI: 10.1016/j.legalmed.2021.101892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 11/29/2022]
Abstract
Reno-vascular injuries are a rare type of renal injury, and their second most frequent cause is penetrating wounds. The majority of the reports and of the studies are present in the urological and radiological literature and they focus on the clinical approach to such injuries. In the case here presented, an 18-year-old male died after being stabbed in the left hemithorax. During body examination, thoracic organs were found to be unremarkable (except for a small peripheral laceration of the left lung), but the diaphragm was transfixed and the upper wall of the left main renal artery was lacerated. The adjacent renal vein, the kidney, the aorta, the vena cava and the surrounding internal structures were not damaged (except for a small laceration of the pancreatic tail). A massive haemothorax and a large retroperitoneal haematoma in the left kidney area were observed. The cause of death was attributed to haemorrhagic shock following a partial laceration of the left main renal artery due to the stab wound to the chest. No other cases of similar fatal renovascular injuries due to stab wounds have been published in the current forensic literature.
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Affiliation(s)
- Francesco Simonit
- Dipartimento di Area Medica, Medicina Legale, Università degli Studi di Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy.
| | - Gabriella Marcuzzi
- Dipartimento di Area Medica, Medicina Legale, Università degli Studi di Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy.
| | - Lorenzo Desinan
- Dipartimento di Area Medica, Medicina Legale, Università degli Studi di Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy.
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Baboudjian M, Gondran-Tellier B, Panayotopoulos P, Hutin M, Olivier J, Ruggiero M, Dominique I, Millet C, Bergerat S, Freton L, Betari R, Matillon X, Chebbi A, Caes T, Patard PM, Szabla N, Sabourin L, Dariane C, Lebacle C, Rizk J, Madec FX, Nouhaud FX, Rod X, Fiard G, Pradere B, Peyronnet B; TRAUMAFUF Collaborative Group. Factors Predictive of Selective Angioembolization Failure for Moderate- to High-grade Renal Trauma: A French Multi-institutional Study. Eur Urol Focus 2021:S2405-4569(21)00009-2. [PMID: 33509672 DOI: 10.1016/j.euf.2021.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/21/2020] [Accepted: 01/08/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Angiography with selective angioembolization (SAE) is safe and effective in addressing bleeding in patients with renal trauma. However, there are no validated criteria to predict SAE efficacy. OBJECTIVE To evaluate factors predictive of SAE failure after moderate- to high-grade renal trauma. DESIGN, SETTING, AND PARTICIPANTS TRAUMAFUF was a retrospective multi-institutional study including all patients who underwent upfront SAE for renal trauma in 17 French hospitals between 2005 and 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was SAE efficacy, defined as the absence of repeat SAE, salvage nephrectomy, and/or death for each patient. RESULTS AND LIMITATIONS Out of 1770 consecutive patients with renal trauma, 170 (9.6%) with moderate- to high-grade renal trauma underwent SAE. Overall upfront SAE was successful in 131 patients (77%) and failed in 39 patients: six patients died after the embolization, ten underwent repeat SAE, 22 underwent open nephrectomy, and one underwent open surgical exploration. In multivariate logistic regression analysis, gross hematuria (odds ratio [OR] 3.16, 95% confidence interval [CI] 1.29-8.49; p=0.015), hemodynamic instability (OR 3.29, 95% CI 1.37-8.22; p=0.009), grade V trauma (OR 2.86, 95% CI 1.06-7.72; p=0.036), and urinary extravasation (OR 3.49, 95% CI 1.42-8.83; p=0.007) were predictors of SAE failure. The success rate was 64.7% (22/34) for patients with grade V trauma and 59.6% (31/52) for those with hemodynamic instability. The study was limited by its retrospective design and the lack of a control group managed with either surgery or surveillance. CONCLUSIONS We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure. However, success rates in these subgroups remained relatively high, suggesting that SAE might be appropriate for those patients as well. PATIENT SUMMARY Selective angioembolization (SAE) is a useful alternative to nephrectomy to address bleeding in patients with renal trauma. Currently, there are no validated criteria to predict SAE efficacy. We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure.
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Choudhury S, Ray P, Pal DK. Changing paradigms of management of isolated blunt renal trauma. Trauma 2020. [DOI: 10.1177/1460408620965446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction The last thirty years has seen a change in management of renal trauma with progression more towards nonoperative management; however there is lack of guidelines of many practical aspects for conservative management of renal trauma. Here we are sharing our experience of managing isolated renal trauma over a period of five years. Materials and methods The study was conducted in a tertiary care centre of eastern part of India from April 2015–March 2020. It was a retro-prospective study and included cases of isolated blunt renal trauma managed in our hospital. Results A total of 61 cases of isolated blunt renal trauma were treated in the mentioned time period. Seventeen (28%) cases were of AAST Grade IV and five (8%) Grade V injury. Blood transfusion was required in eighteen (29%) cases during management. In eight (47%) cases of Grade IV injury and two (40%) cases of Grade V injury angioembolization was done. In two (11.7%) cases of Grade IV injury ureteral stenting was performed. Delayed surgical exploration and nephrectomy was required in one case of Grade V injury because of failed angioembolization and one Grade IV injury due to sepsis. One death was encountered in Grade V injury who had delayed presentation with haemorrhagic shock and underwent immediate surgical exploration. On follow up four patients (23%) of Grade IV injury and one patient of Grade III injury and two patients (40%) of Grade IV injury developed hypertension. The remaining patients were found to be normal. Conclusion Conservative management of renal trauma is the norm nowadays. Angioembolisation was found to be one of the strongest armamentarium when patient needs intervention. Surgery is rarely contemplated, mostly in hemodynamically unstable high grade trauma patients.
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Affiliation(s)
- Sunirmal Choudhury
- Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Pinaki Ray
- Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Dilip Kumar Pal
- Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India
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Chen J, Cai W, Li L. Profile of renal artery embolization (RAE) for renal trauma: A comparison of data from two major trauma center. Int Braz J Urol 2020; 46:194-202. [PMID: 32022507 PMCID: PMC7025829 DOI: 10.1590/s1677-5538.ibju.2019.0506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/06/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate usage of renal artery embolization (RAE) for renal injuries and discuss the indications for this treatment. MATERIALS AND METHODS A retrospective study was performed evaluating the electronic medical records of all patients with renal trauma admitted to two major comprehensive hospitals in Shantou city from January 2006 to December 2015. RESULTS There were 264 and 304 renal traumatic patients admitted to hospital A and B, respectively. LGRT was the reason for presentation in the majority of patients (522, 91.9%). A total of 534 (94.0%) patients were treated conservatively. RAE was performed in 9 patients from 2012 to 2015 at hospital A, including in 6 patients (6/9, 66.7%) with LGRT, and 3 patients (3/9, 33.3%) with HGRT. No patient underwent interventional therapy (RAE) at hospital B during the same period. No significant differences in the operative rate of hospital A were observed between the two time periods (2006-2011 and 2012-2015). The operative rate for LGRT between the two hospitals from 2006 to 2011 and 2012 to 2015 was not significantly different. Hospital A showed a significant decrease in the rate of conservative treatment for patients with LGRT. In the univariate and multivariate analyses, the AAST renal grade both were significantly associated with undergoing RAE. CONCLUSIONS LGRT was present in the majority of patients, and most cases of renal trauma could be treated with conservative treatment. RAE was well utilized for the treatment of renal trauma. However, some patients with LGRT were treated with unnecessary interventional therapy.
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Affiliation(s)
- Jie Chen
- Injury Prevention Research CenterShantou UniversityMedical CollegeShantouGuangdongChinaInjury Prevention Research Center, Shantou University Medical College, Shantou, Guangdong, P.R. China;
- Second Affiliated HospitalShantou UniversityMedical CollegeShantouGuangdongChina Department of Urology, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, P.R. China;
| | - Weicong Cai
- Injury Prevention Research CenterShantou UniversityMedical CollegeShantouGuangdongChinaInjury Prevention Research Center, Shantou University Medical College, Shantou, Guangdong, P.R. China;
- Department of Non-communicable Disease Control and PreventionShenzhen Center for Chronic Disease ControlShenzhenGuangdongChinaDepartment of Non-communicable Disease Control and Prevention, Shenzhen Center for Chronic Disease Control, Shenzhen, Guangdong, P.R. China
| | - Liping Li
- Injury Prevention Research CenterShantou UniversityMedical CollegeShantouGuangdongChinaInjury Prevention Research Center, Shantou University Medical College, Shantou, Guangdong, P.R. China;
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Abstract
BACKGROUND Training in trauma forms a fundamental component of general surgical training in Australia. It faces a number of challenges, including the limitations of working hours and increasing use of non-operative management techniques. Adjustment of rosters to encompass a "swing shift" (12pm-midnight) is one proposed solution to maximise exposure of junior surgical doctors to trauma. This proposal prompted a review of the timing of major trauma presentations and interventions at a Level 1 trauma centre. METHODS A retrospective observational study was performed of all major trauma presentations to Westmead Hospital, Australia over ten-years (2008-2017). Trauma operative procedures and major resuscitations were reviewed across three potential shifts: day shift (0730-1930), night shift (1930-0730) and "swing shift" (1200-midnight). Operative interventions included: laparotomy, thoracotomy/sternotomy, re-look laparotomy, rib fixation and tracheostomy. Descriptive statistics were obtained for between-shift comparisons. RESULTS Over the ten-years there were 3745 full trauma team activations (FTTAs). The "swing shift" had the highest number of FTTAs, patients with injury severity scores >15, patients requiring resuscitation and emergency operations (laparotomies, sternotomies/thoracotomies). CONCLUSIONS More major trauma calls, laparotomies and thoracotomies occurred during a theoretical "swing shift" rather than the standard day and night shifts. Changing trauma rostering for junior doctors to reflect this peak in clinical and operative demand could change exposure to trauma training.
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Affiliation(s)
- Amy Hort
- Department of Surgery, Westmead Hospital, Darcy Road, Westmead, 2145, Sydney NSW Australia; Trauma Service, Westmead Hospital, Darcy Road, Westmead, 2145, Sydney NSW Australia
| | - Annelise Cocco
- Department of Surgery, Westmead Hospital, Darcy Road, Westmead, 2145, Sydney NSW Australia
| | - Jeremy M Hsu
- Department of Surgery, Westmead Hospital, Darcy Road, Westmead, 2145, Sydney NSW Australia; Trauma Service, Westmead Hospital, Darcy Road, Westmead, 2145, Sydney NSW Australia; Discipline of Surgery, University of Sydney, Darcy Road, Westmead, 2145, NSW Australia.
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El Hechi MW, Nederpelt C, Kongkaewpaisan N, Bonde A, Kokoroskos N, Breen K, Nasser A, Saillant NN, Kaafarani HMA, Velmahos GC, Mendoza AE. Contemporary management of penetrating renal trauma - A national analysis. Injury 2020; 51:32-38. [PMID: 31540800 DOI: 10.1016/j.injury.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/26/2019] [Accepted: 09/05/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Indications for nonoperative management (NOM) after penetrating renal injury remain ill-defined. Using a national database, we sought to describe the experience of operative and nonoperative management in the United States and retrospectively examine risk factors for failure of NOM. MATERIALS AND METHODS The TQIP database 2010-2016 was used to identify patients with penetrating renal trauma. Outcomes of patients treated with an immediate operation (IO) and NOM are described. Failure of NOM was defined as the need for a renal operation after 4 h from arrival. Univariate then multivariable regression analyses were performed to identify predictors of NOM failure. RESULTS Out of 8139 patients with kidney trauma, 1,842 had a penetrating mechanism of injury and were included. Of those, 89% were male, median age was 28 years, and 330 (18%) were offered NOM. Compared to IO, NOM patients were less likely to have gunshot wound (59% vs 89% p < 0.001) or high-grade renal injuries [AAST 4-5] (48% vs 76%, p < 0.001). Lower rates of in-hospital complications and shorter ICU and hospital stays were observed in the NOM group. NOM failed in 26 patients (8%). Independent predictors of NOM failure included a concomitant abdominal injury (OR = 3.99, 95% CI 1.03-23.23, p = 0.044), and every point increase in AAST grade (OR = 2.43, 95% CI 1.27-5.21, p = 0.005). CONCLUSIONS NOM is highly successful in selected patients. Concomitant abdominal injuries and higher grade AAST injuries predict NOM failure and should be considered when selecting patients for IO or NOM.
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Affiliation(s)
- Majed W El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Charlie Nederpelt
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Alexander Bonde
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Kerry Breen
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Ahmed Nasser
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States.
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16
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Coccolini F, Moore EE, Kluger Y, Biffl W, Leppaniemi A, Matsumura Y, Kim F, Peitzman AB, Fraga GP, Sartelli M, Ansaloni L, Augustin G, Kirkpatrick A, Abu-Zidan F, Wani I, Weber D, Pikoulis E, Larrea M, Arvieux C, Manchev V, Reva V, Coimbra R, Khokha V, Mefire AC, Ordonez C, Chiarugi M, Machado F, Sakakushev B, Matsumoto J, Maier R, di Carlo I, Catena F. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:54. [PMID: 31827593 PMCID: PMC6886230 DOI: 10.1186/s13017-019-0274-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/23/2019] [Indexed: 12/22/2022] Open
Abstract
Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia, 56124 Pisa, Italy
| | | | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Trauma Surgery Dept., Scripps Memorial Hospital, La Jolla, California USA
| | - Ari Leppaniemi
- General Surgery Dept., Mehilati Hospital, Helsinki, Finland
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Hospital, Chiba, Japan
| | - Fernando Kim
- Urology Department, University of Colorado, Denver, USA
| | | | - Gustavo P. Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Imitiaz Wani
- Department of Surgery, DHS Hospitals, Srinagar, Kashmir India
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Emmanouil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Martha Larrea
- General Surgery, “General Calixto García”, Habana Medicine University, Havana, Cuba
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics and Gynecology, University of Buea, Buea, Cameroon
| | - Carlos Ordonez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia, 56124 Pisa, Italy
| | - Fernando Machado
- General and Emergency Surgery Department, Montevideo Hospital, Montevideo, Paraguay
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Isidoro di Carlo
- Department of Surgical Sciences and Advanced Technologies “GF Ingrassia”, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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Abstract
OBJECTIVE To characterize national trends in procedural management of renal trauma. BACKGROUND Management of renal trauma has evolved to favor a more conservative approach. For patients requiring intervention, there is a paucity of information to characterize the nature of procedural therapy administered. METHODS A retrospective cross-sectional analysis was performed using data contained within the National Trauma Data Bank. The National Trauma Data Bank is a voluntary data repository managed by the American College of Surgeons, containing data regarding trauma admissions at 747 level I to V trauma centers throughout the United States and Canada. Participants included any patient with renal trauma requiring intervention from 2002 to 2012. They were identified according to International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, with codes 866.00 through 866.03 for blunt renal trauma, and codes 866.10 through 866.13 for penetrating trauma. Cases were separated into those requiring nephrectomy, renorrhaphy, or endovascular repair based on ICD-9 procedure code. The number of cases performed each year and yearly trends as measured by linear regression. RESULTS A total of 4296 cases were reported during the study period. Of these cases, 2635 involved blunt trauma and 1661 involved penetrating injury. There was a significant increase in the percentage of cases managed by endovascular means for both blunt and penetrating trauma (R = 0.92, P < 0.01; and R = 0.86, P < 0.01, respectively). This was primarily at the expense of nephrectomy, with cases showing significant decline in both groups. CONCLUSIONS National trends for procedural management of renal trauma are toward less invasive interventions. These trends suggest favorable change towards renal preservation and decreased morbidity, potentially facilitated, in part, by improved radiographic staging and endovascular techniques, and also increased provider awareness of the safety and value of conservative management.
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18
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Abstract
Background: Management of renal trauma injuries is shifting towards more conservative approaches in hemodynamically stable adult patients, even for high grade and/or penetrating trauma. The objective of this study was to analyze the patterns of injury, management and complications in renal trauma patients at a Danish university hospital with a level 1 trauma center.Method: Patients diagnosed with renal trauma at Rigshospitalet, Copenhagen, Denmark, between January 2010 and December 2015 were identified retrospectively by the ICD-10 code. Data were collected from electronic patient records. Imaging was classified by radiologists.Results: Out of 107 patients identified, blunt injuries comprised 93%. Median age was 28. The distribution of injury grade according to AAST was 20% grade I, 4% grade II, 33% grade III, 33% grade IV and 10% grade V. All patients with grade I-III were managed conservatively. Two patients were treated with angioembolization (1 with grade IV and 1 with grade V). Five patients with grade IV were treated with an internal ureteral stent and one patient with grade IV blunt trauma had an emergency nephrectomy performed. Overall complication rate was 7%. No patient died due to their renal injury. Renal function was normal in all patients at discharge, assessed by eGFR measurement. Of the 50% of patients who were followed up with a renography, none developed obstruction due to the renal trauma.Conclusion: The vast majority of renal injuries were due to blunt trauma. Hemodynamically stable patients, even with penetrating and/or high-grade blunt trauma, were managed non-operatively and there was a low rate of complications.
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Affiliation(s)
| | | | | | - Ulla Germer
- Department of Radiology, Rigshospitalet, Copenhagen, Denmark
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Aldiwani M, Georgiades F, Omar I, Angel-Scott H, Tharakan T, Vale J, Mayer E. Traumatic renal injury in a UK major trauma centre - current management strategies and the role of early re-imaging. BJU Int 2019; 124:672-678. [PMID: 30903729 DOI: 10.1111/bju.14752] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To analyse the contemporary management of renal injuries in a UK major trauma centre and to evaluate the utility and value of re-imaging. PATIENTS AND METHODS The prospectively maintained 'Trauma Audit and Research Network' database was interrogated to identify patients with urinary tract injuries between January 2014 and December 2017. Patients' records and imaging were reviewed to identify injury grades, interventions, outcomes, and follow-up. RESULTS Renal injury was identified in 90 patients (79 males and 11 females). The mean (sd; range) age was 35.5 (17.4; 1.5-94) years. Most of the renal traumas were caused by blunt mechanisms (74%). The overall severity of injuries was: 18 (20%) Grade I, 19 (21%) Grade II, 27 (30%) Grade III, 22 (24%) Grade IV, and four (4%) Grade V. Most patients (84%) were managed conservatively. Early intervention (<24 h) was performed in 14 patients (16%) for renal injuries. Most of these patients were managed by interventional radiology techniques (nine of 14). Only two patients required an emergency nephrectomy, both of whom died from extensive polytrauma. In all, 19 patients underwent laparotomy for other injuries and did not require renal exploration. The overall 30-day mortality was 13%. Re-imaging was performed in 66% of patients at an average time of 3.4 days from initial scan. The majority of re-imaging was planned (49 patients) and 12% of these scans demonstrated a relevant finding (urinoma, pseudoaneurysm) that altered management in three of the 49 patients (6.1%). CONCLUSION Non-operative management is the mainstay for all grades of injury. Haemodynamic instability and persistent urine leak are primary indications for intervention. Open surgical management is uncommon. Repeat imaging after injury is advocated for stable patients with high-grade renal injuries (Grade III-V), although more research is needed to determine the optimal timing.
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Affiliation(s)
- Mohammed Aldiwani
- Department of Urology, St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Fanourios Georgiades
- Department of Urology, St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Ismail Omar
- Department of Urology, St Mary's Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Helena Angel-Scott
- Department of Urology, St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Tharu Tharakan
- Department of Urology, St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Justin Vale
- Department of Urology, St Mary's Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Erik Mayer
- Department of Urology, St Mary's Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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Clements W, Moriarty HK. Blunt renal vascular trauma resulting in arterial avulsion injury with a nephron‐sparing outcome. J Med Imaging Radiat Oncol 2019; 63:795-798. [DOI: 10.1111/1754-9485.12907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/15/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Warren Clements
- Department of Radiology Alfred Hospital Melbourne Victoria Australia
- Department of Surgery Monash University Melbourne Victoria Australia
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21
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Wang SY, Lin KJ, Chen SW, Cheng CT, Chang CH, Wu YT, Liao CA, Liao CH, Fu CY, Lin JR, Hsieh CH. Long-term renal outcomes in patients with traumatic renal injury after nephrectomy: A nationwide cohort study. Int J Surg 2019; 65:140-146. [DOI: 10.1016/j.ijsu.2019.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/30/2019] [Accepted: 04/03/2019] [Indexed: 11/29/2022]
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Abstract
The purpose of this study was to determine the need of repeat follow-up computed tomography imaging in patients with renal trauma.All patients who were admitted in the trauma center of the Military Institute of Medicine with a diagnosis of kidney injury from January 2008 to December 2017 were identified. A retrospective review of all patients' medical records and radiologic imaging was conducted.Data on the following factors were collected - patients' demographics, mechanism of trauma, American Association for the Surgery of Trauma renal injury scale, injury severity score, laboratory examinations, multiorgan injuries, transfusion of fresh frozen plasma and packed red blood cells, time of surgical procedure in multiorgan injuries, length of hospital stay, and acute kidney injury.This group consisted of 37 patients with left renal injuries, 32 with right renal injuries, and 5 with bilateral renal injuries. Renal trauma due to blunt injury secondary to a motor vehicle accident was noted in 45 patients, falling from a height in 14 patients, injury from battery in 4 patients, sports-related activities in 1 patient, and other factors in 10 patients.Of the 63 patients treated conservatively due to multiorgan trauma or isolated trauma, values of morphology, serum creatinine and blood urea nitrogen, and ultrasonography in all patients did not reveal any pathological changes within earlier kidney damage.The conservative treatment of grade I-IV renal injury in the American Association for the Surgery of Trauma scale provided good outcome and only involved noninvasive ultrasonography.This study confirms that routine follow-up computed tomography imaging can be safely omitted in renal injuries graded I-IV providing that the patient remains in good clinical state.
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Affiliation(s)
| | | | | | - Saracyn Marek
- Department of Endocrinology and Radioisotope Therapy, Military Institute of Medicine, Warsaw, Poland
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Sujenthiran A, Elshout PJ, Veskimae E, MacLennan S, Yuan Y, Serafetinidis E, Sharma DM, Kitrey ND, Djakovic N, Lumen N, Kuehhas FE, Summerton DJ. Is Nonoperative Management the Best First-line Option for High-grade Renal trauma? A Systematic Review. Eur Urol Focus 2019; 5:290-300. [DOI: 10.1016/j.euf.2017.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/10/2017] [Accepted: 04/29/2017] [Indexed: 10/19/2022]
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Mansbridge MM, Ryan J, Hill DC, Wullschleger M. Renal trauma: a 3-year audit from a Gold Coast trauma centre. ANZ J Surg 2019; 89:339-344. [PMID: 30699462 DOI: 10.1111/ans.15026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 11/15/2018] [Accepted: 11/20/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Limited data Exists ? on the Australian epidemiology of renal trauma, with very few studies published in the literature. The authors aim to detail the trends of renal trauma in the coastal city of the Gold Coast. METHODS Retrospective data collection yielded 81 patients who sustained renal trauma from our 3-year period. Data included information on demographics, mechanism, American Association for the Surgery of Trauma (AAST) grade, presence of haematuria, associated injuries, management, and complications. RESULTS Male patients accounted for 83% (n = 67) of cases, and the average age of all injuries was 36 years. Low-grade AAST Grade I-III injuries comprised of 76% (n = 62) of injuries, AAST Grade IV contributed to 20% (n = 16) and 4% (n = 3) of injuries were AAST Grade V. The most common mechanism of injury was road accidents accounting for 35% (n = 28) followed by fall-related injuries (26%, n = 21). Other mechanisms included sport-related (13.5%, n = 11), non-motorized bicycle injuries (8.5%, n = 7), alleged assault (8.5%, n = 7), pedestrian injuries (5%, n = 4) and horse-related injuries (2%, n = 2). Ninety-six percent (n = 78) of kidney injuries were managed conservatively. Of the patients requiring intervention, all were AAST Grade V kidney injuries. CONCLUSION Males accounted for the majority of renal trauma cases, similar to the 3:1 ratio of male-to-female injuries found in other studies. In line with other studies, renal trauma reviewed on the Gold Coast also revealed road trauma as the leading cause, closely followed by falls. The majority of high-grade renal trauma was managed conservatively.
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Affiliation(s)
- Margaret M Mansbridge
- Department of Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - James Ryan
- Department of Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - David C Hill
- Department of Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Martin Wullschleger
- Department of Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Yanagi M, Suzuki Y, Hamasaki T, Mizunuma K, Arai M, Yokota H, Murata S, Kondo Y, Nishimura T. Early Transcatheter Arterial Embolization for the American Association for the Surgery of Trauma Grade 4 Blunt Renal Trauma in Two Institutions. J NIPPON MED SCH 2018; 85:204-207. [PMID: 30259888 DOI: 10.1272/jnms.jnms.2018_85-31] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the efficacy of early transcatheter arterial embolization for hemodynamically stable patients with The American Association for the Surgery of Trauma (AAST) grade 4 blunt renal trauma. MATERIALS AND METHODS The medical records of consecutive patients with grade 4 blunt renal trauma who were transported to our two critical care centers in Japan and treated with early transcatheter arterial embolization (TAE) between 2001 and 2013 were retrospectively reviewed. Treatment failure was defined as the need for further surgical intervention or re-embolization after initial embolization. We divided these cases into two groups, a group who survived and a group who died, investigating the factors that led to death. RESULTS Seventeen patients underwent early TAE, with an average time between presentation and embolization for renal trauma of 125 minutes (66-214 minutes). There was no case of treatment failure. Three of the patients died, but none solely because of renal injury. Significant factors associated with patient death were the number of concomitant injured organs (p=0.04), the presence of pelvic fractures (p<0.01), and the presence of visceral injuries (p<0.01). The presence of lumber fractures (p=0.09) also tended to be associated with patient death. CONCLUSIONS Early TAE is an effective treatment and should be actively performed for hemodynamically stable patients with grade 4 blunt renal injuries without multiple concomitant organ injuries.
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Affiliation(s)
- Masato Yanagi
- Department of Urology (Chief: Y. Suzuki), Nippon Medical School Chiba Hokusoh Hospital.,Department of Urology (Chairman and Professor: Y. Kondo), Nippon Medical School
| | - Yasutomo Suzuki
- Department of Urology (Chief: Y. Suzuki), Nippon Medical School Chiba Hokusoh Hospital.,Department of Urology (Chairman and Professor: Y. Kondo), Nippon Medical School
| | - Tsutomu Hamasaki
- Department of Urology (Chairman and Professor: Y. Kondo), Nippon Medical School
| | | | - Masatoku Arai
- Department of Emergency and Critical Care Medicine, (Chairman and Professor: H. Yokota), Nippon Medical School
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, (Chairman and Professor: H. Yokota), Nippon Medical School
| | - Satoru Murata
- Department of Radiology (Chairman and Professor: S. Kumita), Nippon Medical School
| | - Yukihiro Kondo
- Department of Urology (Chairman and Professor: Y. Kondo), Nippon Medical School
| | - Taiji Nishimura
- Department of Urology (Chief: S. Kurita), Tachikawa Sogo Hospital
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Bjurlin MA, Renson A, Fantus RJ, Fantus RJ. Impact of Trauma Center Designation and Interfacility Transfer on Renal Trauma Outcomes: Evidence for Universal Management. Eur Urol Focus 2018; 5:1135-1142. [PMID: 29934273 DOI: 10.1016/j.euf.2018.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/29/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Renal trauma may be managed differently in tiered trauma systems and among those who requireinterfaculty transfer. OBJECTIVE To evaluate the initial management of renal trauma, assess patterns of management based on hospital trauma level designation and interfacility transfer status, and analyze management trends over time. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of renal trauma from the National Trauma Data Bank 2010-2015. INTERVENTION Nephrectomy, angioembolization, or nonoperative management. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS We used generalized estimating equations to compare odds of each management outcome in patients transferred and directly admitted to a level I center, versus those directly admitted to a non-level I center, adjusting for vital signs, injury, demographic, and facility characteristics. We also used generalized estimating equations to examine linear time trends in management outcome, adjusting for injury characteristics. RESULTS AND LIMITATIONS A total of 51798 renal trauma records were included: 44 838 low-grade (American Association for the Surgery of Trauma I-III) and 6359 high grade (IV-V) injuries. After adjusting for comorbidities, demographics, and hospital characteristics, odds of nephrectomy, angioembolization, and nonoperative management were similar in patients transferred or directly admitted to a level I center compared with those treated at a non-level I center. Changes in management over time demonstrated a decreased rate of nephrectomy (p=0.007) in high-grade injuries, while the rate of angioembolization remained constant (p=0.33). Study limitations include mortality prior to hospital transfer or arrival, and its retrospective nature. CONCLUSIONS In this contemporary trauma analysis, outcomes of both low- and high-grade renal trauma are similar across patients managed in tiered trauma centers and those undergoing transfer, signifying dissemination of collective renal trauma management. The rate of nephrectomy has decreased for high-grade renal injury over our study period, suggesting new adoption of kidney-sparing management. PATIENT SUMMARY Renal trauma is now managed similarly in tiered trauma centers and in patients requiring interfacility transfer. The rate of nephrectomy for high-grade renal injuries has decreased over time.
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Affiliation(s)
- Marc A Bjurlin
- Department of Urology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA.
| | - Audrey Renson
- Department of Population Health, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA; Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, The City University of New York, New York, NY, USA
| | - Richard Jacob Fantus
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL, USA
| | - Richard Joseph Fantus
- Department of Surgery, Section of Trauma, and Surgical Critical Care, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
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Barras M, Pearson E, Cousin I, Le Rouzic C, Thepaut M, Gentric JC, Roue JM, Yevich S, de Vries P. Renal artery embolization in a child with delayed hemodynamic instability from penetrating knife wound. Arch Pediatr 2018; 25:S0929-693X(18)30113-1. [PMID: 29909939 DOI: 10.1016/j.arcped.2018.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 02/22/2018] [Accepted: 05/20/2018] [Indexed: 11/24/2022]
Abstract
Penetrating laceration injury in the pediatric population may present as an acute or delayed life-threatening injury. Although emergent intra-arterial embolization is commonly utilized in adults, few cases have been reported for children. Surgical treatment for severe renal laceration injuries may require complete nephrectomy; an unfortunate outcome for a pediatric patient if a renal-preserving alternative is feasible. We present a case of penetrating renal laceration in a 10-year-old boy treated with intra-arterial embolization of the lacerated dominant renal artery and subsequent renal perfusion by an uninjured accessory renal artery allowing for renal preservation.
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Affiliation(s)
- M Barras
- Pediatric surgery department, CHU de Brest, 2, avenue Foch, 29609 Brest cedex, France.
| | - E Pearson
- Interventional Radiology department, CHU de Brest, boulevard Tanguy-Prigent, 29000 Brest, France
| | - I Cousin
- Pediatric surgery department, CHU de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - C Le Rouzic
- Pediatric surgery department, CHU de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - M Thepaut
- Pediatric surgery department, CHU de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - J-C Gentric
- Interventional Radiology department, CHU de Brest, boulevard Tanguy-Prigent, 29000 Brest, France
| | - J-M Roue
- Pediatric department, CHU de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - S Yevich
- Gustave Roussy Cancer Campus Grand Paris, Interventional Radiology department, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - P de Vries
- Pediatric surgery department, CHU de Brest, 2, avenue Foch, 29609 Brest cedex, France
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Petrone P, Magadán Álvarez C, Joseph D, Cartagena L, Ali F, E M Brathwaite C. Approach and Management of Traumatic Retroperitoneal Injuries. Cir Esp 2018; 96:250-9. [PMID: 29656797 DOI: 10.1016/j.ciresp.2018.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 11/23/2022]
Abstract
Traumatic retroperitoneal injuries constitute a challenge for trauma surgeons. They usually occur in the context of a trauma patient with multiple associated injuries, in whom invasive procedures have an important role in the diagnosis of these injuries. The retroperitoneum is the anatomical region with the highest mortality rates, therefore early diagnosis and treatment of these lesions acquire special relevance. The aim of this study is to present current published scientific evidence regarding incidence, mechanism of injury, diagnostic methods and treatment through a review of the international literature from the last 70 years. In conclusion, this systematic review showed an increasing trend towards non-surgical management of retroperitoneal injuries.
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Hadjipavlou M, Grouse E, Gray R, Sri D, Huang D, Brown C, Sharma D. Managing penetrating renal trauma: experience from two major trauma centres in the UK. BJU Int 2018; 121:928-934. [DOI: 10.1111/bju.14165] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Edmund Grouse
- Department of Urology; St George's Hospital; London UK
| | - Robert Gray
- Department of Urology; King's College Hospital; London UK
| | - Denosshan Sri
- Department of Urology; King's College Hospital; London UK
| | - Dean Huang
- Department of Radiology; King's College Hospital; London UK
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30
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Mingoli A, La Torre M, Migliori E, Cirillo B, Zambon M, Sapienza P, Brachini G. Operative and nonoperative management for renal trauma: comparison of outcomes. A systematic review and meta-analysis. Ther Clin Risk Manag 2017; 13:1127-1138. [PMID: 28894376 PMCID: PMC5584778 DOI: 10.2147/tcrm.s139194] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Preservation of kidney and renal function is the goal of nonoperative management (NOM) of renal trauma (RT). The advantages of NOM for minor blunt RT have already been clearly described, but its value for major blunt and penetrating RT is still under debate. We present a systematic review and meta-analysis on NOM for RT, which was compared with the operative management (OM) with respect to mortality, morbidity, and length of hospital stay (LOS). Methods The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed for this study. A systematic search was performed on Embase, Medline, Cochrane, and PubMed for studies published up to December 2015, without language restrictions, which compared NOM versus OM for renal injuries. Results Twenty nonrandomized retrospective cohort studies comprising 13,824 patients with blunt (2,998) or penetrating (10,826) RT were identified. When all RT were considered (American Association for the Surgery of Trauma grades 1–5), NOM was associated with lower mortality and morbidity rates compared to OM (8.3% vs 17.1%, odds ratio [OR] 0.471; 95% confidence interval [CI] 0.404–0.548; P<0.001 and 2% vs 53.3%, OR 0.0484; 95% CI 0.0279–0.0839, P<0.001). Likewise, NOM represented the gold standard treatment resulting in a lower mortality rate compared to OM even when only high-grade RT was considered (9.1% vs 17.9%, OR 0.332; 95% CI 0.155–0.708; P=0.004), be they blunt (4.1% vs 8.1%, OR 0.275; 95% CI 0.0957–0.788; P=0.016) or penetrating (9.1% vs 18.1%, OR 0.468; 95% CI 0.398–0.0552; P<0.001). Conclusion Our meta-analysis demonstrated that NOM for RT is the treatment of choice not only for AAST grades 1 and 2, but also for higher grade blunt and penetrating RT.
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Affiliation(s)
- Andrea Mingoli
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Marco La Torre
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Emanuele Migliori
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Bruno Cirillo
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Martina Zambon
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Paolo Sapienza
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Gioia Brachini
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
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31
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Abstract
Severe renal injuries are usually associated with multisystem injuries, may require interventional radiology to control hemorrhage and improve the chances for renal salvage, and are more likely to fail nonoperative management. However, most renal injuries are mild in severity and successfully managed conservatively. The AAST classification is the most widely used system to describe renal injuries and carries management and prognostic implications. CT with intravenous contrast is the imaging test of choice to assess for renal injuries. Contrast extravasation indicating active bleeding should be mentioned as its presence is predictive for failure of nonoperative management. Radiologists play a critical role in identifying renal injuries and should make every effort to describe renal injuries according to the AAST grading scheme to better inform the surgeon's management decisions.
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32
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Affiliation(s)
- A N Smolyar
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
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33
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McPhee M, Arumainayagam N, Clark M, Burfitt N, DasGupta R. Renal injury management in an urban trauma centre and implications for urological training. Ann R Coll Surg Engl 2015; 97:194-7. [PMID: 26263803 DOI: 10.1308/003588414x14055925061117] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this study was to analyse the treatment and management of renal injury patients presenting to our major trauma unit to determine the likelihood of patients needing immediate nephrectomy. METHODS The Trauma Audit and Research Network (TARN) database was used to review trauma cases presenting to our department between February 2009 and September 2013. Demographic data, mechanism and severity of injury, grade of renal trauma, management and 30-day outcome were determined from TARN data, electronic patient records and imaging. RESULTS There were a total of 1,856 trauma cases, of which 36 patients (1.9%) had a renal injury. In this group, the median age was 28 years (range: 16-92 years), with 28 patients (78%) having blunt renal trauma and 8 (22%) penetrating renal trauma. The most common cause for blunt renal trauma was road traffic accidents. Renal trauma cases were stratified into American Association for the Surgery of Trauma (AAST) grades (grade I: 19%, grade II: 22%, grade III: 28%, grade IV: 28%, grade V: 0%). All patients with grade I and II injuries were treated conservatively. There were three patients (1 with grade III and 2 with grade IV renal injuries) who underwent radiological embolisation. One of these patients went on to have a delayed nephrectomy owing to unsuccessful embolisation. CONCLUSIONS Trauma patients rarely require emergency nephrectomy. Radiological selective embolisation provides a good interventional option in cases of active bleeding from renal injury in haemodynamically stable patients. This has implications for trauma care and how surgical cover is provided for the rare event of nephrectomy.
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Affiliation(s)
| | | | - M Clark
- Imperial College Healthcare NHS Trust , UK
| | - N Burfitt
- Imperial College Healthcare NHS Trust , UK
| | - R DasGupta
- Imperial College Healthcare NHS Trust , UK
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34
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Kautza B, Zuckerbraun B, Peitzman AB. "Management of blunt renal injury: what is new?". Eur J Trauma Emerg Surg 2015; 41:251-8. [PMID: 26038034 DOI: 10.1007/s00068-015-0516-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/11/2015] [Indexed: 11/24/2022]
Abstract
The diagnosis, workup and management of blunt renal injury have evolved greatly over the past decades. Evaluation and management of blunt renal injury echoes the increasing success of nonoperative management in other blunt abdominal solid organ injury, such as liver and spleen. Decision-making difficulties still remain regarding the optimal imaging, grading and degree of interventional or operative exploration used. Increasingly, initial nonoperative management has gained acceptance and appears to be applicable even high-grade injuries. Emerging techniques in highly sensitive imaging as well as interventional angiography have allowed safe nonoperative management in the appropriate patient. This review will focus on the contemporary workup and management of blunt renal injury while focusing on some of the emerging literatures in regard to refined imaging and grading of injuries as well as techniques to increase the success of nonoperative management.
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Affiliation(s)
- B Kautza
- Department of Surgery, University of Pittsburgh, F1200 PUH 200 Lothrop St, Pittsburgh, PA, 15213, USA
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35
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McCombie SP, Thyer I, Corcoran NM, Rowling C, Dyer J, Le Roux A, Kuan M, Wallace DMA, Hayne D. The conservative management of renal trauma: a literature review and practical clinical guideline from Australia and New Zealand. BJU Int 2014; 114 Suppl 1:13-21. [DOI: 10.1111/bju.12902] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Steve P. McCombie
- School of Surgery; University of Western Australia; Crawley WA Australia
- Department of Urology; Fremantle Hospital; Fremantle WA Australia
| | - Isaac Thyer
- Department of Urology; Fremantle Hospital; Fremantle WA Australia
| | - Niall M. Corcoran
- Departments of Urology and Surgery; Royal Melbourne Hospital and University of Melbourne; Parkville VIC Australia
| | | | - John Dyer
- Department of Infectious Diseases; Fremantle Hospital; Fremantle WA Australia
| | - Anton Le Roux
- Department of Radiology; Fremantle Hospital; Fremantle WA Australia
| | - Melvyn Kuan
- Department of Urology; Fremantle Hospital; Fremantle WA Australia
| | | | - Dickon Hayne
- School of Surgery; University of Western Australia; Crawley WA Australia
- Department of Urology; Fremantle Hospital; Fremantle WA Australia
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36
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Breen KJ, Sweeney P, Nicholson PJ, Kiely EA, O'Brien MF. Adult blunt renal trauma: routine follow-up imaging is excessive. Urology 2014; 84:62-7. [PMID: 24821469 DOI: 10.1016/j.urology.2014.03.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 03/06/2014] [Accepted: 03/08/2014] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine the yield of follow-up imaging in patients sustaining renal trauma at our level-1 trauma center and hence, whether the 2013 European Association of Urology guidelines are clinically applicable. METHODS All patients who attended Cork University Hospital with a diagnosis of renal injury from 2000-2012 were identified. Review of all medical records and radiologic imaging was undertaken. Injuries were graded using the American Association for the Surgery of Trauma Organ Injury Scale and were grouped as low-grade injuries (I, II, and III) or high-grade injuries (IV and V). RESULTS One hundred and two patients (105 renal units) were identified with a median age of 23 years (interquartile range, 18-39 years). The mechanism of injury was blunt force in 98 of 102 cases (96%). Injuries were diagnosed at the time of admission using contrast-enhanced computed tomography (CT) imaging. Low-grade injuries accounted for 78 of 102 cases (77%); all were managed conservatively with a complication rate of 2 of 78 (3%). Twenty-four patients (23%) had high-grade injuries; 2 cases required nephrectomy, 22 of 24 (92%) were managed conservatively with a complication rate of 5 of 24 (21%). All patients with complications were symptomatic, prompting repeat imaging. Overall, 38 of 102 patients (37%) underwent at least 1 follow-up CT: 20 of 78 (25%) of low-grade injuries and 18 of 24 (75%) of high-grade injuries. Concurrent thoracoabdominal injuries mandated the need for repeat CT evaluation in 21 of 38 patients (55%). Thirty-one (30%) patients were reimaged by renal ultrasonography. CONCLUSION Selective reimaging of renal injuries based on clinical and laboratory criteria would have detected all complications. The 2013 European Association of Urology guidelines on urologic trauma are clinically appropriate in a major tertiary-trauma unit.
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Affiliation(s)
- Kieran J Breen
- Department of Urology, Cork University Hospital, Cork, Ireland.
| | - Paul Sweeney
- Department of Urology, Cork University Hospital, Cork, Ireland
| | | | - Eamonn A Kiely
- Department of Urology, Cork University Hospital, Cork, Ireland
| | - M F O'Brien
- Department of Urology, Cork University Hospital, Cork, Ireland
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