UROLOGICAL SURVEY
Urogenital trauma
Renovascular injury: an argument for renal preservation
Barsness KA, Bensard DD, Partrick D, Hendrickson R, Koyle M, Calkins CM, Karrer F
Division of Pediatric Surgery, Department of Surgery, The Children's Hospital, University of Colorado Health Sciences Center, Denver, Colorado, USA
J Trauma. 2004; 57: 310-5
BACKGROUND: Renovascular injury is uncommon among children. This study hypothesized that preservation of the severely injured kidney can be achieved safely without renal insufficiency, postinjury hypertension, or the need for hemodialysis.
METHODS: Retrospective chart review of renal injuries seen between 1997 and 2001 at a level 1 pediatric trauma center was conducted. Severity of injury was graded by the American Association for the Surgery of Trauma Organ Injury Severity Scale. The outcome variables included the need for hemodialysis, impaired renal function (creatinine), and postinjury hypertension.
RESULTS: In this study, 34 children presented with grade 1, 2, or 3 injury (74%), whereas 13 children presented with grade 4 or 5 renovascular injury (28%). The children with unilateral renovascular injury who underwent either nephrectomy or renal preservation had comparable outcomes with no hypertension, hemodialysis, or renal insufficiency in either group.
CONCLUSIONS: The treatment outcomes were not different between the patients who underwent renal preservation and those who had immediate nephrectomy. The authors conclude that renal preservation should be attempted for all children with grade 4 or 5 renovascular injury.
Editorial Comment
In adults the consensus seems to be that major renovascular injury is probably going to result in nephrectomy (see article below). Those with complete avulsion are usually bleeding briskly and need speedy vascular control to save their life; those with renal artery thrombosis nearly always eventually require nephrectomy even if revascularization is attempted (see paper below) and it is starting to be seen that even venous lacerations have a high nephrectomy rate even in the best hands (1). This pediatric series of 13 patients with grade IV (7 patients) or grade V (6 patients) renovascular injury, supports observing these patients without nephrectomy if possible. Six children in this series who had no treatment seemed to do as well as 4 that had nephrectomy for their injury. Even one child with bilateral hilar injuries (usually listed as a reason to attempt vascular repair) was observed without vessel repair (although he later developed renovascular hypertension). Unfortunately, the authors do not specify the outcomes of those with grade IV injuries compared to grade V. Obviously those with grade V avulsions should be expected to do much worse! In any case, this paper is further evidence that you should at least initially consider expectant management of renal trauma - in a pediatric subset with nonexsanguinating renovascular trauma.
Reference
1. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW, Nash P, Schmidlin F: Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int. 2004; 93: 937-54.
Dr. Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA
Outcome after major renovascular injuries: a Western trauma association multicenter report
Knudson MM, Harrison PB, Hoyt DB, Shatz DV, Zietlow SP, Bergstein JM, Mario LA, McAninch JW
San Francisco General Hospital of the University of California, USA
J Trauma. 2000; 49: 1116-22
BACKGROUND: Major renal vascular injuries are uncommon and are frequently associated with a poor outcome. In addition to renal dysfunction, posttraumatic renovascular hypertension may result, although the true incidence of this complication is unknown. The objective of this study was to describe the factors contributing to outcome after major renovascular trauma. We hypothesized that the highest percentage of renal salvage would be achieved by minimizing the time from injury to repair.
METHODS: This was a retrospective chart review over a 16-year period conducted at six university trauma centers of patients with American Association for the Surgery of Trauma grade IV/V renal injuries surviving longer than 24 hours. Postinjury renal function with poor outcome was defined as renal failure requiring dialysis, serum creatinine greater than or equal to 2 mg/dL, renal scan showing less than 25% function of the injured kidney, postinjury hypertension requiring treatment, or delayed nephrectomy. Data collected for analysis included demographics, mechanism of injury, presence of shock, presence of hematuria, associated injuries, type of renal injury (major artery, renal vein, segmental artery), type of repair (primary vascular repair, revascularization, observation, nephrectomy), time from injury to definitive renal surgery, and type of surgeon performing the operation (urologist, vascular surgeon, trauma surgeon).
RESULTS: Eighty-nine patients met inclusion criteria; 49% were injured from blunt mechanisms. Patients with blunt injuries were 2.29 times more likely to have a poor outcome compared with those with penetrating injuries. Similarly, the odds ratio of having a poor outcome with a grade V injury (n = 32) versus grade IV (n = 57) was 2.2 (p = 0.085). Arterial repairs had significantly worse outcomes than vein repairs (p = 0.005). Neither the time to definitive surgery nor the operating surgeon's specialty significantly affected outcome. Ten percent (nine patients) developed hypertension or renal failure postoperatively: three had immediate nephrectomies, four had arterial repairs with one intraoperative failure requiring nephrectomy, and two were observed. Of the 20 good outcomes for grade V injuries, 15 had immediate nephrectomy, 1 had a renal artery repair, 1 had a bypass graft, 1 underwent a partial nephrectomy, and 2 were observed.
CONCLUSION: Factors associated with a poor outcome following renovascular injuries include blunt trauma, the presence of a grade V injury, and an attempted arterial repair. Patients with blunt major vascular injuries (grade V) are likely to have associated major parenchymal disruption, which contributes to the poor function of the revascularized kidney. These patients may be best served by immediate nephrectomy, provided that there is a functioning contralateral kidney.
Editorial Comment
This is not the newest paper, but it is one of the best. It establishes that "conservative" management of adult renovascular injury probably means "nephrectomy instead of vascular repair". In a multicenter series of 89 patients with renovascular injuries, 3 of 4 patients that had a primary repair had a "poor" result, while only 3 of 18 of those with a primary nephrectomy had a poor result. In general, an attempted bypass graft was 15 times more likely to result in a poor result for the patient than nephrectomy. These data again support at least a trial of nonoperative treatment of the patient, and failing that, a "conservative" approach by performing nephrectomy instead of vascular repair. In this dataset, some patients who were initially observed eventually needed the kidney to be removed, but this could be achieved after a few days when the patient was stable. Two patients developed renovascular hypertension, but these patients had vascular repair instead of kidney removal.
Dr. Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA
Publication Dates
-
Publication in this collection
04 May 2005 -
Date of issue
Feb 2005
