VoL Copyright © l9Tl by The ·1NHhams l:?1 VVilkirrn Co.
ATIVE APPROACH THE MANAGElVIEJ~T OF BLUNT RENAL TRAUNIA ALAN J. WEIN, JOHN J. MURPHY, S. GRANT MULHOLLAND, ARNOLD W. CHAIT AND PETER H. ARGER From the Divisions of Urology and Radiology, Hospital of the University of Pennsylvania Veterans Administration Hospital, Philadelphia, Pennsylvania
ABSTRACT
A review of 85 cases of blunt renal trauma confirms that management is best guided by clinical radiologic demonstration of renal injury. A conservative non-operative findings and not solely approach is advocated in the clinically stable patient if renal pedicle injury can be ruled out. Management of all but the minor forms of renal injury caused by blunt trauma is still somewhat controversial. A generally aggressive early operative approach is advocated in some centers, i-,; while a more watchful conservative approach is endorsed in others. 7- 10 We report our experience with a conservative approach to non-penetrating renal trauma and relate our conclusions to those drawn from similar studies. MATERIALS AND METHODS
cases of radiologically studied blunt renal trauma were evaluated between 1964 and 1974. Pertinent data are shown in table 1. were retrospectively grouped on the basis of findings present on the initial radiologic examination (table 2). Presently, this consists of early infusion urography with nephrotomography. This classification is similar to that proposed initially by Sargent and Marquardt 7 and adopted by others. HHz, 1,; Group I includes patients with no or negligible radiologic abnormalities. Group III includes patients with evidence of severe renal fragmentation or renal pedicle injury. A variety of radiogTaphic findings is encompassed by patients categorized in group II- delayed or decreased function, intrarenal or subcapsular hematoma or extravasation, extrarenal hematoma or extravasation, blood clots within the renal pelvis or collecting system and frank visible laceration of the renal parenchyma. Further evaluation and subsequent management were guided close clinical observation and frequent rerather than by the initial alone. Hi Indications for an or RESULTS
Of the 38 patients in group I all were clinically stable and remained so. None had angiography. patients were treated with bed rest alone until the symptoms and signs disappeared. None has had complications. All 3 µ1.1,,n,J,n,:; in group III had shattered kidneys. Tvm of these patients were in shock when they were hospitalized. Both patients had evidence of persistent blood loss and required transabdominal exploration and nephrectomy within 24 hours of hospitalization. Angiography performed in 1 case revealed a splenic laceration in addition to permitting a more precise anatomic description of the renal injury. The remaining patient in group III was able to be clinically stabilized Accepted for publication July 23, 1976. Read at annual meeting of American Urological Association, Las Vegas, Nevada, May 16-20, 1976.
425
initially, and an attempt was made to manage him conservatively. Clinical deterioration necessitated transabdominal exploration 3 days after hospitalization and a nephrectomy was performed. Preoperative angiography confirmed the diagnosis of a shattered kidney and ruled out concomitant hepatic and splenic damage. In our opinion, earlier surgical intervention would not have resulted in renal salvage. Of the 44 patients in group II 2 underwent exploration within 24 hours of hospitalization because of clinical deterioration. In 1 of these patients the initial cw,orot,w-u urogTam (IVP) showed poor parenchymal visualization extrarenal extravasation. Angiography demonstrated a cortical laceration that was oversewn with no sequelae. The other patient was explored primarily for a symptomatic splenic laceration, which was documented on angiography. At the operation a stable retroperitoneal hematoma was present and inadvisedly explored and drained, although the arteriogram had revealed no source of active renal bleeding. No complications resulted. There were 42 patients in group II who vvere able to be clinically stabilized initially and vvere managed conservatively. For the purposes of discussion they are divided into subgroups based on their predominant findings on the initial IVP (table 3). One of the 13 patients in group Ha underwent a subsequent operation only because of findings suggestive of possible neoplastic disease on the rvP and arteriography. The other 12 patients recovered nr,,rn,or,n, with no sequelae. Arteriograms in 3 a more exact anatomic definition rm-m,m·· management was and no known cations have Four ograms, all of which were Of the 8 0ena;oc,rvc;h treated patients in group He 2 reIncreasing flank and fever rn and a IVP demonstrated a retroperito:neal c.u.ur.uA11J1 Iary laceration. Successful repair and plished via a flank approach 5 days after was hospitalized. Flank exploration was done in the second patient because of a suspected fracture of the lateral kidney border with continued extravasation on a repeat IVP. Arteriography was not done. At the operation no renal abnormality could be found and retroperitoneal drainage was performed. This patient was clinically stable and, in retrospect, an operation was unnecessary at that time. The other 6 patients in group He remained clinically stable and recovered without sequelae. None had arteriograms. A followup IVP revealed no further extravasation and a return towards normal in all cases. Four of the 7 patients in group IId underwent delayed flar1k exploration. In 3 of these 4 patients an operation was required because of clinical deterioration. A nephrectomy was neces-
WEIN AND ASSOCIATES
426 1. Patient data
with nephrotomograms, if possible, should be performed as soon as possible after the initial clinical evaluation of the patients. 5 • "· 10• 12 • 14 • 15 • 17 Delay in obtaining the study can re85 Total patients: sult in misleading information, since a relatively minor subMale, 60 Female, 25 capsular or perirenal hematoma may cause apparent lack of Age (yrs.): function or poor function on a delayed IVP. 17• 18 Hessel and 8 2-10 Smith, in an exhaustive review of the literature, cite the 38 11-30 average diagnostic accuracy of early high volume urography 34 31-50 5 51-70 in blunt renal trauma as 91 per cent. 17 With routine tomograEtiology of trauma: phy the accuracy may be as high as 95 per cent. 19 ~5 (29) Automobile accident It is difficult to draw additional consistent and generally 24 (28) Fall accepted conclusions regarding the further management of 23 (27) Sports 13 (15) Beating blunt renal trauma from the many such series in the literature Clinical signs and symptoms: since no 2 authors present their data in exactly the same 83 (97) Hematuria manner. Formats of the classification of renal injuries have 75 (88) Abdominal or flank pain or tenderness varied from a simple categorization into mild and severe 13 to 24 (28) Abdominal guarding, rigidity or tenderness 8 (9) Mass placement into 1 of 15 subdivisions based on anatomic angiographic criteria. 20 The modification of the Sargent and Marquardt classification, which others as well as we have adopted, TABLE 2. Classification of injuries seems sufficiently descriptive and is applicable to all renal No. (%) Radiologic Abnormality Groups injuries. 7, 10-12, 15 38 (45) None I The place of angiography in the evaluation of the patient 44 (52) Intrarenal distortion, incomplete visualizaII with blunt renal trauma has not yet been settled. There is no tion, intrarenal or extrarenal extravasadoubt that arteriography is the procedure that can provide the tion, parenchymal fracture, caliceal or pelvic clots, perirenal hematoma most accurate anatomic diagnosis of renal injury. 5 • 6 • 18• 20 3 (3) Extensive fragmentation, pedicle injury III Whether this procedure is essential in all but a few cases is debatable. In cases of suspected pedicle injury angiography is mandatory to provide a prompt exact diagnosis.17 Routine TABLE 3. Initial urographic findings in 42 patients in group II who angiographic evaluation to triage all cases of blunt renal were managed conservatively trauma has been advocated by Lang. 20 If the patient's clinical Subgroup Finding No. condition is stable and if a reasonable, even though not ana13 Intrarenal hematoma, extravasation or a tomically precise, approximation of the extent of injury to a distortion functioning kidney can be made, we agree with Ceccarelli 15 Poor or incomplete visualization 10 b Extrarenal extravasation, no definite evi8 that arteriography will add no therapeutically useful informadence of fracture tion. If an operation is contemplated, if a pre-existent renal Parenchymal fracture with extravasation 7 d abnormality is suspected, or if injury to other intra-abdominal Collecting system, pelvic or ureteral clots 2 e organs such as the spleen and liver is suspected, angiography Perirenal hematoma 2 f is useful in evaluation and in planning a surgical approach. Of the 19 angiograms done in our 85 patients we consider only 7 to sary in 1 case, while partial nephrectomy was possible in 2. have been truly necessary. Similarly, Vermillion and associArteriography precisely defined the injury in the patient re- ates found angiography necessary only in 9 of their 92 patients quiring nephrectomy and in 1 of the patients who underwent with blunt renal trauma. 14 partial nephrectomy. The fourth operation was performed in a We have found the clinical and laboratory criteria previclinically stable patient solely because of continued evidence of ously described more reliable to decide upon the necessity for extravasation on IVP. A partial nephrectomy was done. It is surgical intervention than the radiologic appearance of the questionable whether exploration was necessary at that time. kidney alone. In some cases an operation was done primarily All 4 patients operated upon have done well subsequently. for treatment of associated injuries to other viscera. Although Of the 3 patients in group IId who were not operated upon no cases of suspected traumatic thrombosis of the renal pedicle arteriography was performed in 2 and confirmed the presence were present in our series, immediate angiographic evaluation of a transcapsular parenchymal laceration. These patients all and an attempt at surgical correction are obviously indicated remained clinically stable and recovered uneventfully. One in these cases even if the patient is clinically stable. has been lost to followup. The other 2 are well clinically but Patients with group I injuries will rarely, if ever, require show polar contraction and loss of renal substance on IVPs. angiography or an operation for reasons related to kidney However, we believe that it is doubtful whether these results injury alone. 5 • 10- 15 , 17• 18 Extensive kidney fragmentation can could have been improved upon by early surgical manage- be expected to produce clinical instability or deterioration and ment. require an immediate or delayed operation, usually nephrecBoth patients in groups Ile and Hf remained clinically stable tomy. 15, 11 and required no treatment other than conservative manageEarly operative intervention in group II patients can be ment. Arteriography was done in 1 patient in each group and shown statistically to have resulted in nephrectomy rates as revealed no source of bleeding. One patient in group Hf was high as 35 per cent. 14 • 17 Conservative management, on the hypertensive prior to the injury and has remained so. Other- other hand, has resulted in nephrectomy rates as low as 4is to wise, there have been no complications. 67 per cent. In our series only 6 surgical procedures were ultimately performed for reasons related to renal trauma in 42 DISCUSSION patients in group II who were managed conservatively. Only 1 Actual management of patients with blunt renal trauma nephrectomy and 3 partial nephrectomies resulted. We believe depends, to some extent, on the presence or absence of severe these results justify the conclusion that clinically stable group associated injuries and pre-existent abnormalities. If such le- II patients can be successfully managed conservatively. Desions can be excluded the primary objective in the treatment of layed complications, which eventually require treatment, such patients becomes the maximum preservation of function- such as hemorrhage, infection, hypertension, hydronephrosis ing renal tissue with minimal mortality and morbidity. 17 and segmental or total non-function or atrophy, do occur but It is generally agreed that high dose or infusion urography are uncommon. 17 Scott and Carlton and their associates 3• 5 ·" TABLE
No.(%)
427 have shown in their of many group II injuries can result renal salvage at least equal to that achieved by non-operative managernent with minimal delayed sequelae. However, we do not believe that enough evidence has accumulated at this time to recommend this approach in the clinically stable patient. Extravasation of sterile urine after renal injury is not necessarily harmful per se and most often resolves spontaneously.''' rn, 14 , 1"· 17 Increasing pain and/or fever may indicate continued massive extravasation or secondary infection and warrant surgical intervention, Serial urography or angiogTaphy may confirm the diagnosis and aid in planning an operation, Unless active bleeding or associated intra-abdominal injury is anticipated there does not seem to be any particular advantage of the transperitoneal over the retroperitoneal flank approach. 21 Severe renal fracture often will require an early operation for control of hemorrhage, t-tR, 21 An operation to control blood loss is best accomplished transperitoneally with preliminary control of the renal pedicle, as has been pointed out by Scott and Carlton and their associates 3 · "'" However, we do not consider this radiologic finding alone an indication for an operation if the patient is clinically stable, If segmental contraction or non-function occurs later accompanying hypertension is the exception rather than the rule, 13 If hypertension secondary to segmental or total ischemia does occur, a corrective operation can be done at a later date, 22 Likewise, the Page kidney effect in producing subsequent hypertension in patients with a subcapsular or perirenal hematoma does occur infrequently 17 but the rarity of this phenomenon does not, in our opinion, justify an operation to acutely correct all such abnormalities, SUMMARY
Eighty-five cases of radiologically evaluated blunt renal trauma and the relevant data in the literature have been discussed, A conservative non-operative approach is advocated in the clinically stable patient if renal pedicle injury can be ruled out, REFERENCES l,
2,
3,
4.
5.
6. 7,
McKay, H, W., Baird, H, H. and Lynch, K, IvL, Jr,: Management of the injured kidney, J.A,M.A., 141: 575, 1949, Hodges, C, V,, Gilbert, D. Rand Scott, W.W.: Renal trauma: a study of 71 cases. J, UroL, 66: 627, 1951, Scott, R, Jr,, Carlton, C, K, Ashmore, A, J, and Duke, H, H,: Initial management of non-penetrating renal injuries: clinical review of 111 cases, J, UroL, 90: 535, 1963. Morse, T. S., Smith, J, P., Hovmrd, W, H, Rand Rowe, IVL L: Kidney injuries in children. J, UroL, 98: 539, 1967. Carlton, C. E,, Jr,: Eady operation in the management of blunt renal trauma. In: Current Controversies in Urologic N[anagernent. Edited by R Scott, Jr, Philadelphia: W, B, Saunders Co., 109-111, 1972. Carlton, E,, Jr.: Surgery in renal trauma (editorial), Urology, 3: 671, 1974, Sargent, J, C, and Marquardt, C, R: Renal injuries, J, UroL, 63: 1, 1950,
8, Glenn, J, F, and Harvard, B, IvL: The injured kidney, J,A.M,A., 173: 1189, 1960, 9, Nation, E, F, and Massey, B, D,: Renal trauma: experience with 258 cases. J, UroL, 89: 775, 1963, 10, Waterhouse, K, and Gross, M,: Trauma to the genitourinary tract: a 5-year experience with 251 cases, J, UroL, 101: 241, 1969,
11, Morrow, J, W, and Mendez, R: Renal trauma, J, UroL, 104: 649, 1970,
12, Lucey, D. T., Sn'lith, NL J, V, and Koontz, W, W., Jr,: A plea for conservative treatment of renal injuries, , Trauma, 11: 306, 197L 13, Slade, N.: Management of closed renal injuries, Brit, J, UroL, 43: 639, 197L 14, Vermillion, C, D., McLaughlin, A. P., III and Pfister, R C.: Management of blunt renal trauma, J, UroL, 106: 478, 197L 15, Ceccarelli, F. K: Expectant treatment in the management of blunt renal trauma, In: Current Controversies in Urologic Management, Edited by R Scott, Jr, Philadephia: W, B. Saunders Co., pp, 112-126, 1972, 16. Murphy, J, J., Iozzi, L, and Schoenberg, H, W,: Principles of management of renal trauma, J, Trauma, 2: 327, 1962, 17, Hessel, S, J, and Smith, E, ff: Renal trauma: a comprehensive review and radiologic assessment, CRC Crit, Rev, Clin, Radio!, NucL Med., 5: 251, 1974, 18, Lucey, D. T., Smith, M. J, V, and Koontz, W, W., Jr,: Modern trends in the management of urologic trauma, J, UroL, 107: 641, 1972, 19, Mahoney, S, A. and Persky, L,: Intravenous drip nephrotomography as an adjunct in the evaluation of renal injury, J, UroL, 99: 513, 1968, 20. Lang, E, K.: Arteriography in the assessment of renal trauma. The impact of arteriographic diagnosis on preservation of renal function and parenchyma, J, Trauma, 15: 553, 1975, 2L Bogash, M., Pollack, H, and Cates, J, L,: Renal injuries caused by external blunt trauma. Moderate approach to serious injuries, Urology, 4: 509, 1974, 22, Grant, RP,, Jr,, Gifford, R W., Jr,, Pudvan, W, R, Meaney, T, F,, Straffon, RA. and McCormack, L, J.: Renal trauma and hypertension, Amer, J, CardioL, 27: 173, 1971, COMMENT Our experience indicates that 85 per cent of blunt renal injuries will be categorized as minor injuries, An additional 5 per cent will have shattered kidneys and the clinical course will dictate prompt nephrectomy, Approximately 10 per cent of patients will have major cortical lacerations, which by our definition are lacerations that extend as deep as the corticomedullary junction. It is in this 10 per cent of patients that some controversy exists in regard to immediate surgical versus conservative therapy, Ninety per cent of the serious complications of the non-surgical management of blunt renal injuries occurs in this 10 per cent of patients with major lacerations, Our experience indicates that these complications can be avoided by prompt definitive surgical repair of the injury, The patients categorized as group IId and 1 patient in group Hic would seem to fall into our categorization of major renal injuries and the authors describe significant complications of the non-operative management of these 8 patients, C, Eugene Carlton, Jr, Baylor College of Medicine Houston, Texas REPLY BY AUTHORS
If eventual nephrectomy, partial nephrectomy and loss of renal
substances are to be considered complications of the initial conservative management of group II patients, they also must be considered complications of early operative management of this group, Since the nephrectomy rate alone for group II patients managed with an immediate operation is approximately 35 per cent, a statistical case cannot be made to support this approach, We agree that certain patients will require an early operation. However, we can find no evidence to support the contention that less renal salvage is achieved over-all by initial conservative management when this is possible. Likewise, we can find no concrete evidence that patients in whom an operation does become necessary after a trial of non-operative management have less renal substance preserved over-all than those managed by early operative intervention,
ATIVE APPROACH THE MANAGElVIEJ~T OF BLUNT RENAL TRAUNIA ALAN J. WEIN, JOHN J. MURPHY, S. GRANT MULHOLLAND, ARNOLD W. CHAIT AND PETER H. ARGER From the Divisions of Urology and Radiology, Hospital of the University of Pennsylvania Veterans Administration Hospital, Philadelphia, Pennsylvania
ABSTRACT
A review of 85 cases of blunt renal trauma confirms that management is best guided by clinical radiologic demonstration of renal injury. A conservative non-operative findings and not solely approach is advocated in the clinically stable patient if renal pedicle injury can be ruled out. Management of all but the minor forms of renal injury caused by blunt trauma is still somewhat controversial. A generally aggressive early operative approach is advocated in some centers, i-,; while a more watchful conservative approach is endorsed in others. 7- 10 We report our experience with a conservative approach to non-penetrating renal trauma and relate our conclusions to those drawn from similar studies. MATERIALS AND METHODS
cases of radiologically studied blunt renal trauma were evaluated between 1964 and 1974. Pertinent data are shown in table 1. were retrospectively grouped on the basis of findings present on the initial radiologic examination (table 2). Presently, this consists of early infusion urography with nephrotomography. This classification is similar to that proposed initially by Sargent and Marquardt 7 and adopted by others. HHz, 1,; Group I includes patients with no or negligible radiologic abnormalities. Group III includes patients with evidence of severe renal fragmentation or renal pedicle injury. A variety of radiogTaphic findings is encompassed by patients categorized in group II- delayed or decreased function, intrarenal or subcapsular hematoma or extravasation, extrarenal hematoma or extravasation, blood clots within the renal pelvis or collecting system and frank visible laceration of the renal parenchyma. Further evaluation and subsequent management were guided close clinical observation and frequent rerather than by the initial alone. Hi Indications for an or RESULTS
Of the 38 patients in group I all were clinically stable and remained so. None had angiography. patients were treated with bed rest alone until the symptoms and signs disappeared. None has had complications. All 3 µ1.1,,n,J,n,:; in group III had shattered kidneys. Tvm of these patients were in shock when they were hospitalized. Both patients had evidence of persistent blood loss and required transabdominal exploration and nephrectomy within 24 hours of hospitalization. Angiography performed in 1 case revealed a splenic laceration in addition to permitting a more precise anatomic description of the renal injury. The remaining patient in group III was able to be clinically stabilized Accepted for publication July 23, 1976. Read at annual meeting of American Urological Association, Las Vegas, Nevada, May 16-20, 1976.
425
initially, and an attempt was made to manage him conservatively. Clinical deterioration necessitated transabdominal exploration 3 days after hospitalization and a nephrectomy was performed. Preoperative angiography confirmed the diagnosis of a shattered kidney and ruled out concomitant hepatic and splenic damage. In our opinion, earlier surgical intervention would not have resulted in renal salvage. Of the 44 patients in group II 2 underwent exploration within 24 hours of hospitalization because of clinical deterioration. In 1 of these patients the initial cw,orot,w-u urogTam (IVP) showed poor parenchymal visualization extrarenal extravasation. Angiography demonstrated a cortical laceration that was oversewn with no sequelae. The other patient was explored primarily for a symptomatic splenic laceration, which was documented on angiography. At the operation a stable retroperitoneal hematoma was present and inadvisedly explored and drained, although the arteriogram had revealed no source of active renal bleeding. No complications resulted. There were 42 patients in group II who vvere able to be clinically stabilized initially and vvere managed conservatively. For the purposes of discussion they are divided into subgroups based on their predominant findings on the initial IVP (table 3). One of the 13 patients in group Ha underwent a subsequent operation only because of findings suggestive of possible neoplastic disease on the rvP and arteriography. The other 12 patients recovered nr,,rn,or,n, with no sequelae. Arteriograms in 3 a more exact anatomic definition rm-m,m·· management was and no known cations have Four ograms, all of which were Of the 8 0ena;oc,rvc;h treated patients in group He 2 reIncreasing flank and fever rn and a IVP demonstrated a retroperito:neal c.u.ur.uA11J1 Iary laceration. Successful repair and plished via a flank approach 5 days after was hospitalized. Flank exploration was done in the second patient because of a suspected fracture of the lateral kidney border with continued extravasation on a repeat IVP. Arteriography was not done. At the operation no renal abnormality could be found and retroperitoneal drainage was performed. This patient was clinically stable and, in retrospect, an operation was unnecessary at that time. The other 6 patients in group He remained clinically stable and recovered without sequelae. None had arteriograms. A followup IVP revealed no further extravasation and a return towards normal in all cases. Four of the 7 patients in group IId underwent delayed flar1k exploration. In 3 of these 4 patients an operation was required because of clinical deterioration. A nephrectomy was neces-
WEIN AND ASSOCIATES
426 1. Patient data
with nephrotomograms, if possible, should be performed as soon as possible after the initial clinical evaluation of the patients. 5 • "· 10• 12 • 14 • 15 • 17 Delay in obtaining the study can re85 Total patients: sult in misleading information, since a relatively minor subMale, 60 Female, 25 capsular or perirenal hematoma may cause apparent lack of Age (yrs.): function or poor function on a delayed IVP. 17• 18 Hessel and 8 2-10 Smith, in an exhaustive review of the literature, cite the 38 11-30 average diagnostic accuracy of early high volume urography 34 31-50 5 51-70 in blunt renal trauma as 91 per cent. 17 With routine tomograEtiology of trauma: phy the accuracy may be as high as 95 per cent. 19 ~5 (29) Automobile accident It is difficult to draw additional consistent and generally 24 (28) Fall accepted conclusions regarding the further management of 23 (27) Sports 13 (15) Beating blunt renal trauma from the many such series in the literature Clinical signs and symptoms: since no 2 authors present their data in exactly the same 83 (97) Hematuria manner. Formats of the classification of renal injuries have 75 (88) Abdominal or flank pain or tenderness varied from a simple categorization into mild and severe 13 to 24 (28) Abdominal guarding, rigidity or tenderness 8 (9) Mass placement into 1 of 15 subdivisions based on anatomic angiographic criteria. 20 The modification of the Sargent and Marquardt classification, which others as well as we have adopted, TABLE 2. Classification of injuries seems sufficiently descriptive and is applicable to all renal No. (%) Radiologic Abnormality Groups injuries. 7, 10-12, 15 38 (45) None I The place of angiography in the evaluation of the patient 44 (52) Intrarenal distortion, incomplete visualizaII with blunt renal trauma has not yet been settled. There is no tion, intrarenal or extrarenal extravasadoubt that arteriography is the procedure that can provide the tion, parenchymal fracture, caliceal or pelvic clots, perirenal hematoma most accurate anatomic diagnosis of renal injury. 5 • 6 • 18• 20 3 (3) Extensive fragmentation, pedicle injury III Whether this procedure is essential in all but a few cases is debatable. In cases of suspected pedicle injury angiography is mandatory to provide a prompt exact diagnosis.17 Routine TABLE 3. Initial urographic findings in 42 patients in group II who angiographic evaluation to triage all cases of blunt renal were managed conservatively trauma has been advocated by Lang. 20 If the patient's clinical Subgroup Finding No. condition is stable and if a reasonable, even though not ana13 Intrarenal hematoma, extravasation or a tomically precise, approximation of the extent of injury to a distortion functioning kidney can be made, we agree with Ceccarelli 15 Poor or incomplete visualization 10 b Extrarenal extravasation, no definite evi8 that arteriography will add no therapeutically useful informadence of fracture tion. If an operation is contemplated, if a pre-existent renal Parenchymal fracture with extravasation 7 d abnormality is suspected, or if injury to other intra-abdominal Collecting system, pelvic or ureteral clots 2 e organs such as the spleen and liver is suspected, angiography Perirenal hematoma 2 f is useful in evaluation and in planning a surgical approach. Of the 19 angiograms done in our 85 patients we consider only 7 to sary in 1 case, while partial nephrectomy was possible in 2. have been truly necessary. Similarly, Vermillion and associArteriography precisely defined the injury in the patient re- ates found angiography necessary only in 9 of their 92 patients quiring nephrectomy and in 1 of the patients who underwent with blunt renal trauma. 14 partial nephrectomy. The fourth operation was performed in a We have found the clinical and laboratory criteria previclinically stable patient solely because of continued evidence of ously described more reliable to decide upon the necessity for extravasation on IVP. A partial nephrectomy was done. It is surgical intervention than the radiologic appearance of the questionable whether exploration was necessary at that time. kidney alone. In some cases an operation was done primarily All 4 patients operated upon have done well subsequently. for treatment of associated injuries to other viscera. Although Of the 3 patients in group IId who were not operated upon no cases of suspected traumatic thrombosis of the renal pedicle arteriography was performed in 2 and confirmed the presence were present in our series, immediate angiographic evaluation of a transcapsular parenchymal laceration. These patients all and an attempt at surgical correction are obviously indicated remained clinically stable and recovered uneventfully. One in these cases even if the patient is clinically stable. has been lost to followup. The other 2 are well clinically but Patients with group I injuries will rarely, if ever, require show polar contraction and loss of renal substance on IVPs. angiography or an operation for reasons related to kidney However, we believe that it is doubtful whether these results injury alone. 5 • 10- 15 , 17• 18 Extensive kidney fragmentation can could have been improved upon by early surgical manage- be expected to produce clinical instability or deterioration and ment. require an immediate or delayed operation, usually nephrecBoth patients in groups Ile and Hf remained clinically stable tomy. 15, 11 and required no treatment other than conservative manageEarly operative intervention in group II patients can be ment. Arteriography was done in 1 patient in each group and shown statistically to have resulted in nephrectomy rates as revealed no source of bleeding. One patient in group Hf was high as 35 per cent. 14 • 17 Conservative management, on the hypertensive prior to the injury and has remained so. Other- other hand, has resulted in nephrectomy rates as low as 4is to wise, there have been no complications. 67 per cent. In our series only 6 surgical procedures were ultimately performed for reasons related to renal trauma in 42 DISCUSSION patients in group II who were managed conservatively. Only 1 Actual management of patients with blunt renal trauma nephrectomy and 3 partial nephrectomies resulted. We believe depends, to some extent, on the presence or absence of severe these results justify the conclusion that clinically stable group associated injuries and pre-existent abnormalities. If such le- II patients can be successfully managed conservatively. Desions can be excluded the primary objective in the treatment of layed complications, which eventually require treatment, such patients becomes the maximum preservation of function- such as hemorrhage, infection, hypertension, hydronephrosis ing renal tissue with minimal mortality and morbidity. 17 and segmental or total non-function or atrophy, do occur but It is generally agreed that high dose or infusion urography are uncommon. 17 Scott and Carlton and their associates 3• 5 ·" TABLE
No.(%)
427 have shown in their of many group II injuries can result renal salvage at least equal to that achieved by non-operative managernent with minimal delayed sequelae. However, we do not believe that enough evidence has accumulated at this time to recommend this approach in the clinically stable patient. Extravasation of sterile urine after renal injury is not necessarily harmful per se and most often resolves spontaneously.''' rn, 14 , 1"· 17 Increasing pain and/or fever may indicate continued massive extravasation or secondary infection and warrant surgical intervention, Serial urography or angiogTaphy may confirm the diagnosis and aid in planning an operation, Unless active bleeding or associated intra-abdominal injury is anticipated there does not seem to be any particular advantage of the transperitoneal over the retroperitoneal flank approach. 21 Severe renal fracture often will require an early operation for control of hemorrhage, t-tR, 21 An operation to control blood loss is best accomplished transperitoneally with preliminary control of the renal pedicle, as has been pointed out by Scott and Carlton and their associates 3 · "'" However, we do not consider this radiologic finding alone an indication for an operation if the patient is clinically stable, If segmental contraction or non-function occurs later accompanying hypertension is the exception rather than the rule, 13 If hypertension secondary to segmental or total ischemia does occur, a corrective operation can be done at a later date, 22 Likewise, the Page kidney effect in producing subsequent hypertension in patients with a subcapsular or perirenal hematoma does occur infrequently 17 but the rarity of this phenomenon does not, in our opinion, justify an operation to acutely correct all such abnormalities, SUMMARY
Eighty-five cases of radiologically evaluated blunt renal trauma and the relevant data in the literature have been discussed, A conservative non-operative approach is advocated in the clinically stable patient if renal pedicle injury can be ruled out, REFERENCES l,
2,
3,
4.
5.
6. 7,
McKay, H, W., Baird, H, H. and Lynch, K, IvL, Jr,: Management of the injured kidney, J.A,M.A., 141: 575, 1949, Hodges, C, V,, Gilbert, D. Rand Scott, W.W.: Renal trauma: a study of 71 cases. J, UroL, 66: 627, 1951, Scott, R, Jr,, Carlton, C, K, Ashmore, A, J, and Duke, H, H,: Initial management of non-penetrating renal injuries: clinical review of 111 cases, J, UroL, 90: 535, 1963. Morse, T. S., Smith, J, P., Hovmrd, W, H, Rand Rowe, IVL L: Kidney injuries in children. J, UroL, 98: 539, 1967. Carlton, C. E,, Jr,: Eady operation in the management of blunt renal trauma. In: Current Controversies in Urologic N[anagernent. Edited by R Scott, Jr, Philadelphia: W, B, Saunders Co., 109-111, 1972. Carlton, E,, Jr.: Surgery in renal trauma (editorial), Urology, 3: 671, 1974, Sargent, J, C, and Marquardt, C, R: Renal injuries, J, UroL, 63: 1, 1950,
8, Glenn, J, F, and Harvard, B, IvL: The injured kidney, J,A.M,A., 173: 1189, 1960, 9, Nation, E, F, and Massey, B, D,: Renal trauma: experience with 258 cases. J, UroL, 89: 775, 1963, 10, Waterhouse, K, and Gross, M,: Trauma to the genitourinary tract: a 5-year experience with 251 cases, J, UroL, 101: 241, 1969,
11, Morrow, J, W, and Mendez, R: Renal trauma, J, UroL, 104: 649, 1970,
12, Lucey, D. T., Sn'lith, NL J, V, and Koontz, W, W., Jr,: A plea for conservative treatment of renal injuries, , Trauma, 11: 306, 197L 13, Slade, N.: Management of closed renal injuries, Brit, J, UroL, 43: 639, 197L 14, Vermillion, C, D., McLaughlin, A. P., III and Pfister, R C.: Management of blunt renal trauma, J, UroL, 106: 478, 197L 15, Ceccarelli, F. K: Expectant treatment in the management of blunt renal trauma, In: Current Controversies in Urologic Management, Edited by R Scott, Jr, Philadephia: W, B. Saunders Co., pp, 112-126, 1972, 16. Murphy, J, J., Iozzi, L, and Schoenberg, H, W,: Principles of management of renal trauma, J, Trauma, 2: 327, 1962, 17, Hessel, S, J, and Smith, E, ff: Renal trauma: a comprehensive review and radiologic assessment, CRC Crit, Rev, Clin, Radio!, NucL Med., 5: 251, 1974, 18, Lucey, D. T., Smith, M. J, V, and Koontz, W, W., Jr,: Modern trends in the management of urologic trauma, J, UroL, 107: 641, 1972, 19, Mahoney, S, A. and Persky, L,: Intravenous drip nephrotomography as an adjunct in the evaluation of renal injury, J, UroL, 99: 513, 1968, 20. Lang, E, K.: Arteriography in the assessment of renal trauma. The impact of arteriographic diagnosis on preservation of renal function and parenchyma, J, Trauma, 15: 553, 1975, 2L Bogash, M., Pollack, H, and Cates, J, L,: Renal injuries caused by external blunt trauma. Moderate approach to serious injuries, Urology, 4: 509, 1974, 22, Grant, RP,, Jr,, Gifford, R W., Jr,, Pudvan, W, R, Meaney, T, F,, Straffon, RA. and McCormack, L, J.: Renal trauma and hypertension, Amer, J, CardioL, 27: 173, 1971, COMMENT Our experience indicates that 85 per cent of blunt renal injuries will be categorized as minor injuries, An additional 5 per cent will have shattered kidneys and the clinical course will dictate prompt nephrectomy, Approximately 10 per cent of patients will have major cortical lacerations, which by our definition are lacerations that extend as deep as the corticomedullary junction. It is in this 10 per cent of patients that some controversy exists in regard to immediate surgical versus conservative therapy, Ninety per cent of the serious complications of the non-surgical management of blunt renal injuries occurs in this 10 per cent of patients with major lacerations, Our experience indicates that these complications can be avoided by prompt definitive surgical repair of the injury, The patients categorized as group IId and 1 patient in group Hic would seem to fall into our categorization of major renal injuries and the authors describe significant complications of the non-operative management of these 8 patients, C, Eugene Carlton, Jr, Baylor College of Medicine Houston, Texas REPLY BY AUTHORS
If eventual nephrectomy, partial nephrectomy and loss of renal
substances are to be considered complications of the initial conservative management of group II patients, they also must be considered complications of early operative management of this group, Since the nephrectomy rate alone for group II patients managed with an immediate operation is approximately 35 per cent, a statistical case cannot be made to support this approach, We agree that certain patients will require an early operation. However, we can find no evidence to support the contention that less renal salvage is achieved over-all by initial conservative management when this is possible. Likewise, we can find no concrete evidence that patients in whom an operation does become necessary after a trial of non-operative management have less renal substance preserved over-all than those managed by early operative intervention,
