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No . 031. Renal trauma management in the new millennium. Rick L Catterwell , Mark Sparnon , Donna Clifford, Nicholas R Brook The Royal Adelaide Hospital, South Australia. Posters Proudly Supported by: . Results. Introduction

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No. 031

Renal trauma management in the new millennium

Rick L Catterwell, Mark Sparnon, Donna Clifford, Nicholas R Brook

The Royal Adelaide Hospital, South Australia

Posters Proudly Supported by:

Results

Introduction

Trauma is the highest cause of mortality in Australian males and females between 1 and 44 years of age1. Renal injury occurs in up to 5% of major trauma; the kidney is the most commonly injured genito-urinary organ. The majority of renal trauma has historically been managed conservatively2, 4.

Advances in imaging and treatment modalities, and an emphasis on nephron preservation, has expanded conservative management options in high grade renal trauma2. However, conservative management of high grade injuries may be associated with complications and late surgery5.

  • A total of 226 renal injuries in 222 patients were identified. Blunt injury accounted for the majority of cases (94%)
  • 52% of injuries were AAST
  • Grade III or greater, and
  • considered high grade.
  • 26% Grade III
  • 18% Grade IV
  • 8.0% Grade V.

Mechanism of Renal Injuries (All and High Grade)

Aim

To examine the incidence, aetiologyand outcomes of contemporary management of renal trauma at South Australia’s major tertiary referral trauma hospital over a ten-year period.

Motor vehicle accidents (37%) and motor bike accidents (21%) were the most common cause of injury.

The majority of patients (74%) had multiple injuries; most commonly rib fractures (38%), liver (24%) or splenic (22%) lacerations. Isolated renal injuries were commonly sport related (48%) secondary to Australian Football (32%).

Methods

All patients admitted to The Royal Adelaide Hospital between 1st July 2002 and 30th June 2012 with traumatic renal injuries were identified using the hospital coding system.

Imaging was reviewed and assessed as per the American Association for the Surgery of Trauma (AAST) grading of renal injury3.

  • Required Interventions:
  • Immediate surgical exploration
  • - Trauma nephrectomy (1.4%)
  • - Nephron-preserving repair (0.9%)
  • Renal embolisation (4.1%)
  • Ureteric stent insertion (5.4%)
  • Nephrostomy insertion (1.4%)
  • Peri-nephric collection drainage (1.4%)

Angiography and successful lower pole embolization of a Grade IV renal injury

Complications occurred in ten patients (5.4%). One patient had a non-perfused kidney post embolization with persistent hypertension requiring delayed nephrectomy. One had a non-perfused kidney following nephron preserving surgery. Eight patients had a persistent urinoma (4.3%), of these 75% had not been appropriately imaged and 87% had not been stented. Three developed a peri-nephric abscess.

A delayed phase CT within 72 hours of injury is recommended in high grade injuries. This ensures adequate assessment of the collecting system5. In this cohort appropriate imaging was more likely to be performed in isolated injuries and those admitted under urological care.

There is controversy over stent or nephrostomy insertion to reduce risk of persistent urinoma1, 5. In this cohort persistent or infected urinoma was more common with incomplete staging or significant collecting system injuries not managed with early ureteric stent insertion.

Retrospective case and surgical note review was undertaken assessing for aetiology of injury, accompanying injuries, duration of stay, intervention required and complications.

  • Conclusions
  • Renal injury in the Australian population is predominantly secondary to blunt trauma.
  • Accompanying significant injuries are common and hospital management frequently shared between units
  • Surgical exploration has a high likelihood of nephrectomy.
  • Most renal trauma, including high grade injuries, can be successfully managed conservatively but adequate evaluation of the injury is important.
  • Prolonged urinary extravasation and urinoma formation are the most common complications of conservative management. In high grade injuries ureteric stent insertion may reduce such complications

Delayed contrast enhanced CT demonstrating a persistent urine leak in a Grade IV injury

References

Shoobridge JJ, Corcoran N M, et al. Contemporary Management of Renal Trauma. Rev Urol. 2011; 13(2): 65–72.

SantucciRA, Fisher MB. The literature increasingly supports expectant (conservative) management of renal trauma-a systematic review. J Trauma. 2005;59:493–503.

SantucciRA, McAninch JW, Safir M, et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma. 2001;50:195–200.

 Davis KA, Reed RL , 2nd, Santaniello J, et al. Predictors of the need for nephrectomy after renal trauma. J Trauma. 2006;60:164–169

AlsikafiNF, Rosenstein DI. Staging, evaluation, and nonoperative management of renal injuries. UrolClin North Am. 2006;33:13–19.