0022-534 7/92/1482-0267$03.00/0 Vol. 148, 266-267, August 1992
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
Original Articles RADIOGRAPHIC EVALUATION OF ADULT PATIENTS WITH BLUNT RENAL TRAUMA JAMES A. EASTHAM, TIMOTHY G. WILSON
AND
THOMAS E. AHLERING
From the Department of Urology, University of Southern California Medical Center, Los Angeles, California
ABSTRACT
Recent reports in the literature suggest that radiographic evaluation of the normotensive blunt trauma patient with microscopic hematuria is no longer necessary. Several facilities, however, including ours, continue to perform excretory urography (IVP) routinely in this setting. To evaluate further whether this practice is indicated, we retrospectively reviewed the records of 317 adults who presented to our facility between May 1986 and December 1989 after blunt trauma with resultant microscopic hematuria but no shock. All patients were radiographically assessed with an IVP. Of the 317 studies 29 (9%) had an abnormal result, including 28 with renal contusion and 1 with a nonfunctioning kidney (in which case further evaluation revealed a congenitally absent kidney). No significant urological injury was identified. Thus, no injury would have been missed if a policy of observation had been followed in these patients. Our data support other reports in the literature that radiographic staging is not necessary in the adult blunt trauma patient with microscopic hematuria but no shock. KEY WORDS: kidney, wounds and injuries, radiography
The proposed management of patients who have sustained blunt abdominal trauma with resultant microscopic hematuria but no shock has changed during the last several years. Before 1985 complete radiographic evaluation of the urinary tract with an excretory urogram (IVP) or computerized tomography (CT) scan with or without a cystogram was the routine. However, with the report by Nicolaisen et al this policy was questioned. 1 It was concluded that these patients could be safely managed without any radiographic studies with little chance of missing a significant renal injury. We retrospectively reviewed a large group of adults who had sustained blunt abdominal trauma with resultant microscopic hematuria but no shock to determine if this policy is warranted. MATERIALS AND METHODS
We reviewed the charts of 317 consecutive adults with microscopic hematuria but no shock secondary to blunt trauma who presented to our medical center between May 1986 and December 1989. Initial evaluation included vital signs, a thorough history and physical examination. Shock was defined as any systolic blood pressure of less than 90 mm. Hg recorded in the field by paramedics or at any time in the emergency area. The first urine sample collected was examined by dipstick analysis and microscopically. Patients with microscopic hematuria but no shock were subsequently referred for radiographic assessment. All of the patients had an IVP with nephrotomography as the initial imaging test. CT scans were used to assess abnormal IVP findings. Angiography was used in cases of suspected vascular injury. RESULTS
A total of 317 patients presented to our facility with blunt trauma, microscopic hematuria and no shock. There were 237 Accepted for publication September 13, 1991.
men and 80 women between 21 and 80 years old. The trauma included 161 motor vehicle accidents, 56 pedestrian accidents, 35 falls, 35 motorcycle accidents and 30 assaults. All 317 patients initially underwent an IVP. An abnormal study was found in 29 patients (9%), including 28 renal contusions and 1 nonvisualized kidney. A total of 14 patients with an abnormal IVP finding underwent CT scans and 1 underwent angiography. All CT scans confirmed renal contusions and angiography revealed a congenitally absent kidney. All contusions were managed nonoperatively without sequelae. DISCUSSION
Despite recent reports in the urological literature concluding that radiographic evaluation is not needed in the normotensive blunt trauma patient with microscopic hematuria, several in stitutions, including our own, routinely perform IVPs in this setting. We retrospectively reviewed 317 adults to assess this policy. No injury would have been missed if a policy of observation had been followed in these patients. These results compare favorably with other reported data. Mee et al recently reported a combined retrospective/prospective study of 812 blunt trauma patients with microscopic hematuria but no shock. 2 None of the 404 patients who had or the 408 patients who did not have complete radiographic assessment had a significant injury. Hardeman et al evaluated 365 patients who had microscopic hematuria but no shock after blunt trauma. 3 All patients were radiographically assessed with an IVP. No patient with a significant renal injury was identified. Cass et al reported a retrospective review of 494 patients with blunt trauma, microscopic hematuria and no shock. 4 All 494 patients had an IVP and 6 major renal injuries were identified. However, 5 injuries occurred in patients with associated injuries that would probably have required further radiographic assessment. Thus, if patients who are normotensive with microscopic hematuria following blunt trauma are not
266
RADIOGRAPHIC EVALUATION OF ADULTS WITH BLUNT RENAL TRAUMA
radiographically assessed solely for urological purposes, only 1 major urological injury in 1,988 patients (0.05%) would have been missed. We support a policy that routine radiographic assessment of urological injuries in the normotensive adult with blunt trauma and microscopic hematuria is not indicated. However, we do continue to investigate radiographically patients with gross hematuria, microscopic hematuria and shock, those with suspected intra-abdominal injuries and children with any degree of hematuria after blunt trauma.
267
of fall from an extreme height) or other history that would make one highly suspicious, may be safely observed and not subjected to an IVP. We agree completely with the findings reported. This study is representative of the more recent approach to the blunt trauma patient. We should emphasize, however, that these findings do not apply to the patient with penetrating trauma, in whom a high incidence of associated injuries makes exploration mandatory. Paul C. Peters Division of Urology University of Texas Dallas, Texas
REFERENCES 1. Nicolaisen, G. S., McAninch, J. W., Marshall, G. A., Bluth, R. F.,
Jr. and Carroll, P. R.: Renal trauma: re-evaluation of the indications for radiographic assessment. J. Urol., 133: 183, 1985. 2. Mee, 8. L., McAninch, J. W., Robinson, A. L., Auerbach, P. S. and Carroll, P. R.: Radiographic assessment of renal trauma: a 10year prospective study of patient selection. J. Urol., 141: 1095, 1989. 3. Hardeman, S. W., Husmann, D. A., Chinn, H. K. W. and Peters, P. C.: Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. J. Urol., 138: 99, 1987. 4. Cass, A. S., Luxenberg, M., Gleich, P. and Smith, C. S.: Clinical indications for radiographic evaluation of blunt renal trauma. J. Urol., 136: 370, 1986. EDITORIAL COMMENTS This is a retrospective study of 317 consecutive adults with microscopic hematuria but no shock, defined as a systolic pressure of less than 90 mm. Hg. These patients were seen between May 1986 and December 1989. The question was whether a significant renal injury would have been missed had the patients been simply observed and not had an IVP. The authors found that 29 of 317 patients who had an IVP had abnormal findings. One kidney that was not visualized was absent by angiography, explaining the nonvisualization. A total of 14 patients underwent a CT scan, confirming the impression from the IVP that contusion was present. All contusions were managed nonoperatively and no injury would have been missed if a policy of observation had been followed in these patients. These data compare favorably with 2,066 cases collected from the literature in studies by various groups, including 1 reference from the Southwestern group (reference 3 in article). This incidence of patients missed by observation is less than 1 % if one considers significant injuries only. We believe that patients with microscopic hematuria only and no history of shock, who do not have an unusual history of trauma (that is sudden deceleration
Another respected large metropolitan urological center supports the study from San Francisco General Hospital published in 1985 in this Journal (reference 1 in article). It is obvious now that microscopic hematuria found in association with blunt trauma without shock is rarely due to significant renal injury, particularly ifthere are no obvious signs of associated injuries. The risks to the physician's medicolegal health and the health of the patient with missed renal injury when no studies are performed is 100%. Policy decisions that may be rational at a trauma center, where residents and staff have the support of the school and hospital, may be irrational when applied to the individual practitioner in solo practice. How can we adopt a compromise position that minimizes the risks of missed injury and maximizes the economic savings while minimizing the risk of contrast medium allergy? One must tell the patient that he has microscopic hematuria, reassure him that it is unlikely that significant injury is present and then follow the patient. Repeat the urinalysis in 3 to 5 days. The urine in 60 to 70% of the patients should be free of blood at that time. If hematuria persists then repeat the examination in 2 to 3 weeks. If it still persists the urinary tract should be imaged. Remember that the old urological adage "hematuria is hematuria" still applies. The patient might have cancer. Cystoscopy may be necessary. With this policy there may be a nasty surprise but it is unlikely. Remember that most emergency room patients do not keep followup emergency room appointments. Be sure to document your instructions to the patient and the fact that you told him of the presence of blood in the urine. These suggested guidelines apply only to the patient with no associated injury. If multi-organ trauma or great force was applied to the body then diagnostic evaluation should be done. We rarely can fix arterial disruptions successfully even when we identify this injury in the emergency room. I do not believe that the practice I have outlined here will make any difference to our success rate in treating that injury. W. Graham Guerriero Department of Urology Baylor College of Medicine Houston, Texas
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
Original Articles RADIOGRAPHIC EVALUATION OF ADULT PATIENTS WITH BLUNT RENAL TRAUMA JAMES A. EASTHAM, TIMOTHY G. WILSON
AND
THOMAS E. AHLERING
From the Department of Urology, University of Southern California Medical Center, Los Angeles, California
ABSTRACT
Recent reports in the literature suggest that radiographic evaluation of the normotensive blunt trauma patient with microscopic hematuria is no longer necessary. Several facilities, however, including ours, continue to perform excretory urography (IVP) routinely in this setting. To evaluate further whether this practice is indicated, we retrospectively reviewed the records of 317 adults who presented to our facility between May 1986 and December 1989 after blunt trauma with resultant microscopic hematuria but no shock. All patients were radiographically assessed with an IVP. Of the 317 studies 29 (9%) had an abnormal result, including 28 with renal contusion and 1 with a nonfunctioning kidney (in which case further evaluation revealed a congenitally absent kidney). No significant urological injury was identified. Thus, no injury would have been missed if a policy of observation had been followed in these patients. Our data support other reports in the literature that radiographic staging is not necessary in the adult blunt trauma patient with microscopic hematuria but no shock. KEY WORDS: kidney, wounds and injuries, radiography
The proposed management of patients who have sustained blunt abdominal trauma with resultant microscopic hematuria but no shock has changed during the last several years. Before 1985 complete radiographic evaluation of the urinary tract with an excretory urogram (IVP) or computerized tomography (CT) scan with or without a cystogram was the routine. However, with the report by Nicolaisen et al this policy was questioned. 1 It was concluded that these patients could be safely managed without any radiographic studies with little chance of missing a significant renal injury. We retrospectively reviewed a large group of adults who had sustained blunt abdominal trauma with resultant microscopic hematuria but no shock to determine if this policy is warranted. MATERIALS AND METHODS
We reviewed the charts of 317 consecutive adults with microscopic hematuria but no shock secondary to blunt trauma who presented to our medical center between May 1986 and December 1989. Initial evaluation included vital signs, a thorough history and physical examination. Shock was defined as any systolic blood pressure of less than 90 mm. Hg recorded in the field by paramedics or at any time in the emergency area. The first urine sample collected was examined by dipstick analysis and microscopically. Patients with microscopic hematuria but no shock were subsequently referred for radiographic assessment. All of the patients had an IVP with nephrotomography as the initial imaging test. CT scans were used to assess abnormal IVP findings. Angiography was used in cases of suspected vascular injury. RESULTS
A total of 317 patients presented to our facility with blunt trauma, microscopic hematuria and no shock. There were 237 Accepted for publication September 13, 1991.
men and 80 women between 21 and 80 years old. The trauma included 161 motor vehicle accidents, 56 pedestrian accidents, 35 falls, 35 motorcycle accidents and 30 assaults. All 317 patients initially underwent an IVP. An abnormal study was found in 29 patients (9%), including 28 renal contusions and 1 nonvisualized kidney. A total of 14 patients with an abnormal IVP finding underwent CT scans and 1 underwent angiography. All CT scans confirmed renal contusions and angiography revealed a congenitally absent kidney. All contusions were managed nonoperatively without sequelae. DISCUSSION
Despite recent reports in the urological literature concluding that radiographic evaluation is not needed in the normotensive blunt trauma patient with microscopic hematuria, several in stitutions, including our own, routinely perform IVPs in this setting. We retrospectively reviewed 317 adults to assess this policy. No injury would have been missed if a policy of observation had been followed in these patients. These results compare favorably with other reported data. Mee et al recently reported a combined retrospective/prospective study of 812 blunt trauma patients with microscopic hematuria but no shock. 2 None of the 404 patients who had or the 408 patients who did not have complete radiographic assessment had a significant injury. Hardeman et al evaluated 365 patients who had microscopic hematuria but no shock after blunt trauma. 3 All patients were radiographically assessed with an IVP. No patient with a significant renal injury was identified. Cass et al reported a retrospective review of 494 patients with blunt trauma, microscopic hematuria and no shock. 4 All 494 patients had an IVP and 6 major renal injuries were identified. However, 5 injuries occurred in patients with associated injuries that would probably have required further radiographic assessment. Thus, if patients who are normotensive with microscopic hematuria following blunt trauma are not
266
RADIOGRAPHIC EVALUATION OF ADULTS WITH BLUNT RENAL TRAUMA
radiographically assessed solely for urological purposes, only 1 major urological injury in 1,988 patients (0.05%) would have been missed. We support a policy that routine radiographic assessment of urological injuries in the normotensive adult with blunt trauma and microscopic hematuria is not indicated. However, we do continue to investigate radiographically patients with gross hematuria, microscopic hematuria and shock, those with suspected intra-abdominal injuries and children with any degree of hematuria after blunt trauma.
267
of fall from an extreme height) or other history that would make one highly suspicious, may be safely observed and not subjected to an IVP. We agree completely with the findings reported. This study is representative of the more recent approach to the blunt trauma patient. We should emphasize, however, that these findings do not apply to the patient with penetrating trauma, in whom a high incidence of associated injuries makes exploration mandatory. Paul C. Peters Division of Urology University of Texas Dallas, Texas
REFERENCES 1. Nicolaisen, G. S., McAninch, J. W., Marshall, G. A., Bluth, R. F.,
Jr. and Carroll, P. R.: Renal trauma: re-evaluation of the indications for radiographic assessment. J. Urol., 133: 183, 1985. 2. Mee, 8. L., McAninch, J. W., Robinson, A. L., Auerbach, P. S. and Carroll, P. R.: Radiographic assessment of renal trauma: a 10year prospective study of patient selection. J. Urol., 141: 1095, 1989. 3. Hardeman, S. W., Husmann, D. A., Chinn, H. K. W. and Peters, P. C.: Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. J. Urol., 138: 99, 1987. 4. Cass, A. S., Luxenberg, M., Gleich, P. and Smith, C. S.: Clinical indications for radiographic evaluation of blunt renal trauma. J. Urol., 136: 370, 1986. EDITORIAL COMMENTS This is a retrospective study of 317 consecutive adults with microscopic hematuria but no shock, defined as a systolic pressure of less than 90 mm. Hg. These patients were seen between May 1986 and December 1989. The question was whether a significant renal injury would have been missed had the patients been simply observed and not had an IVP. The authors found that 29 of 317 patients who had an IVP had abnormal findings. One kidney that was not visualized was absent by angiography, explaining the nonvisualization. A total of 14 patients underwent a CT scan, confirming the impression from the IVP that contusion was present. All contusions were managed nonoperatively and no injury would have been missed if a policy of observation had been followed in these patients. These data compare favorably with 2,066 cases collected from the literature in studies by various groups, including 1 reference from the Southwestern group (reference 3 in article). This incidence of patients missed by observation is less than 1 % if one considers significant injuries only. We believe that patients with microscopic hematuria only and no history of shock, who do not have an unusual history of trauma (that is sudden deceleration
Another respected large metropolitan urological center supports the study from San Francisco General Hospital published in 1985 in this Journal (reference 1 in article). It is obvious now that microscopic hematuria found in association with blunt trauma without shock is rarely due to significant renal injury, particularly ifthere are no obvious signs of associated injuries. The risks to the physician's medicolegal health and the health of the patient with missed renal injury when no studies are performed is 100%. Policy decisions that may be rational at a trauma center, where residents and staff have the support of the school and hospital, may be irrational when applied to the individual practitioner in solo practice. How can we adopt a compromise position that minimizes the risks of missed injury and maximizes the economic savings while minimizing the risk of contrast medium allergy? One must tell the patient that he has microscopic hematuria, reassure him that it is unlikely that significant injury is present and then follow the patient. Repeat the urinalysis in 3 to 5 days. The urine in 60 to 70% of the patients should be free of blood at that time. If hematuria persists then repeat the examination in 2 to 3 weeks. If it still persists the urinary tract should be imaged. Remember that the old urological adage "hematuria is hematuria" still applies. The patient might have cancer. Cystoscopy may be necessary. With this policy there may be a nasty surprise but it is unlikely. Remember that most emergency room patients do not keep followup emergency room appointments. Be sure to document your instructions to the patient and the fact that you told him of the presence of blood in the urine. These suggested guidelines apply only to the patient with no associated injury. If multi-organ trauma or great force was applied to the body then diagnostic evaluation should be done. We rarely can fix arterial disruptions successfully even when we identify this injury in the emergency room. I do not believe that the practice I have outlined here will make any difference to our success rate in treating that injury. W. Graham Guerriero Department of Urology Baylor College of Medicine Houston, Texas
