UROLOGICAL SURVEY
Davis KA, Reed RL 2nd, Santaniello J, Abodeely A, Esposito TJ, Poulakidas SJ, Luchette FA
Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL, USA
J Trauma. 2006; 60: 164-9; discussion 169-70
BACKGROUND: Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma.
METHODS: This is a retrospective review of renal injuries admitted over a 12-year period to a Level I trauma center.
RESULTS: Ninety-seven patients (73% male) sustained a kidney injury (mean age, 27 +/- 16; mean Injury Severity Score, 13 +/- 10). Of the 72 blunt trauma patients, 5 patients (7%) underwent urgent nephrectomy, 3 (4%) had repair and/or stenting, and 89% were observed despite a 29% laparotomy rate for associated intraabdominal injuries in this group. Twenty-five patients with penetrating trauma underwent eight nephrectomies (31%), one partial nephrectomy, and two renal repairs. Regardless of the mechanism of injury, patients requiring nephrectomy were in shock, had a higher 24-hour transfusion requirement, and were more likely to have a high-grade renal laceration (all p < 0.05). Bluntly injured patients requiring nephrectomy had more concurrent intraabdominal injuries (p < 0.0001). Overall, patients after penetrating trauma were more severely injured, had higher 24-hour transfusion requirements, and a higher nephrectomy rate (all p < 0.05). Despite a higher injury severity in the penetrating group, however, mortality was higher in the bluntly injured group (p < 0.0001). Univariate predictors for nephrectomy included: revised trauma score, injury severity score, Glasgow Coma Scale score, shock on presentation, renal injury grade, and 24-hour transfusion requirement. No patient with a mild or moderate renal injury required nephrectomy, whereas 6 of 12 (50%) grade 4 injuries and 7 of 8 (88%) grade 5 injuries required nephrectomy. Multiple logistic regression analysis confirmed penetrating injury, renal injury grade, and Glasgow Coma Scale score as predictive of nephrectomy.
CONCLUSION: Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.
Editorial Comment
This study confirms the well-established concept that most renal injuries are AAST grade 1-3, and can be safely managed non-operatively. Predictors for nephrectomy were shock, higher AAST grade of renal injury (4 - 5), ongoing transfusion requirement, and associated intraabdominal injuries. Grade 5 injuries, by definition are potentially life-threatening with avulsion of the renal hilum or a completely shattered kidney. That the nephrectomy rate in this study for Grade 5 kidney injuries approached 90% is not surprising. In unstable kidney trauma patients with ongoing blood loss, nephrectomy is part of a "damage control" approach to stabilize the patient, get them off the OR stable, and quickly into the ICU for resuscitation.
Clearly, opening up Gerota's fascia and releasing the tamponade effect of the retroperitoneal hematoma may result in uncontrollable bleeding and subsequent nephrectomy. Thus, there are 2 main ways to avoid unnecessary nephrectomy: 1) For the stable trauma patient, image the abdomen with CT with delayed images in order to properly stage the kidney injury. With an accurate kidney injury stage and location of the retroperitoneal hematoma, patients can then be selected for surgery or expectant management. 2) Retroperitoneal hematomas that are not zone 1, stable, non-expanding, non-pulsatile, and contained do not demand exploration. Zone 1 hematomas, namely midline supramesocolic or midline inframesocolic, from a blunt or penetrating mechanism demand exploration. Zone 2, lateral perinephric hematomas should be selectively explored for penetrating trauma, and typically observed for blunt trauma (1).
In Davis et al, half of Grade 4 injuries ended up with nephrectomy. This is higher then prior reports, but again nephrectomy may have been performed as "damage control" in the face of instability and associated injuries. Prior reports, however, have demonstrated that most Grade 4 renal injuries can be managed expectantly, with the kidney being re-imaged by CT with intravenous contrast and delayed images (3 to 5 days after initial injury) to assess for persistent urinary leakage. Worsened or unimproved leak warrants ureteral stent placement of urinoma drain placement.
Reference
1. Brandes SB: Trauma to the Genitourinary Tract. In: Rakel RE, Bope ET (eds.), Conn's Current Therapy. 57th ed., Philadelphia, WB Saunders, 2005.
Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
Damage Control Management of Experimental Grade 5 Renal Injuries: Further Evaluation of FloSeal Gelatin Matrix
Pursifull NF, Morris MS, Harris RA, Morey AF
Urology Service, Brooke Army Medical Center, Fort Sam Houston, Texas 78324, USA
J Trauma. 2006; 60: 346-50
BACKGROUND: We developed a porcine grade 5 renal laceration damage control model to evaluate the hemostatic efficacy of FloSeal gelatin matrix (Baxter Healthcare, Corp., Deerfield, Ill).
METHODS: Ten commercial swine underwent celiotomy, contralateral nephrectomy, and cooling to 32 degrees C after a well-established hypothermia protocol to simulate a damage control scenario. Following prospective randomization, a complex grade 5 renal injury was uniformly produced on the remaining kidney. Control animals (group 1, n = 5) were treated with direct manual compression with a gelatin sponge. Experimental animals (group 2, n = 5) were treated by application of FloSeal gelatin matrix followed by direct compression with a gelatin sponge. Operative blood loss and efficacy of hemostasis were compared. Creatinine levels were obtained daily until postoperative day 7. Abdominal computed tomography was performed at 10 days.
RESULTS: Use of FloSeal gelatin matrix hemostatic sealant resulted in significantly less mean blood loss than gelatin sponge bolster compression alone (202.4 mL vs. 540.4 mL, respectively, p = 0.016). Hemostasis was complete in 60% (three out of five) of experimental animals after 2 minutes, but was incomplete in all control animals. After an initial increase, serum creatinine approached baseline by postoperative day 7 in all animals. Axial imaging 10 days postoperatively revealed no evidence of significant delayed perirenal hemorrhage.
CONCLUSIONS: FloSeal gelatin matrix performed well as a rapidly deployable, effective hemostatic agent in a hypothermic grade 5 renal injury damage control model. The absence of delayed bleeding and nephrotoxicity suggests a possible increased role for FloSeal in the treatment of devastating renal injuries in damage control surgery.
Editorial Comment
This article illustrates nicely the concept of damage control and the use of a pig model. Damage control is the concept that an abdominal trauma surgery is abbreviated to control hemorrhage and fecal and urinary contamination, to not perform the definitive repair until a planned staged re-operation improves survival, and to resuscitate the patient in the ICU before any prolonged reconstructive surgery. Such a policy of staged, abbreviated operations, has clearly been shown to improve overall survival, and helps the avoid the lethal triad of cold (body temperature), coagulopathy and acidosis.
The use of fibrin sealants in urology has been particularly popular recently, due to its use in laparoscopic kidney surgery. With the expanding role of laparoscopy for partial nephrectomy, methods to better control urinary leak or bleeding have been explored. Aside from direct suturing of the collecting system and vessels, fibrin sealants have been the "suspenders" to the "belts" of suturing. The current commercially available sealants are Tisseel "fibrin sealant", (by Baxter, a mix of fibrinogen aprotonin solution, Factor XIII, and human derived thrombin), FloSeal "gelatin matrix" (by Baxter, a mix of human derived thrombin and bovine derived gelatin matrix), and BioGlue "surgical adhesive" (by Cryolife, a mix of bovine serum albumin and gluteraldehyde).
Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
Urogenital trauma
Publication Dates
-
Publication in this collection
16 Aug 2006 -
Date of issue
June 2006
