Vol. ll8, October Printed in U .SA.
The Journal of Urology Copyright © 1977 by The Williams & Wilkins Co.
RESULTS OF NON-OPERATIVE MANAGEMENT OF BLUNT RENAL TRAUMA IAN M. THOMPSON,* HARRY LATOURETTE, JOSEPH E. MONTIE
AND
GILBERT ROSS, JR.
From the Section of Urology, University of Missouri School of Medicine, Columbia, Missouri
ABSTRACT
A study of 84 patients with blunt renal trauma has revealed that expectant, non-operative management of the clinically stable patient with either minor or more severe injuries (excluding vascular pedicle trauma) gives satisfactory results and entails few subsequent complications. The nephrectomy rate with expectant management is markedly lower than that reported after an immediate operation. The salvage of functioning renal tissue appears to be commensurate with angiographic delineation of devascularized tissue and would seem to be comparable to that of patients afforded immediate surgical intervention, without the threat of loss of the renal unit that appears to be entailed by early operation. The use of arteriography in the investigation of trauma to the kidney had its initial impetus in circumstances when vascular pedicle injuries or extensive parenchymal destruction was suggested by incomplete or absent visualization of contrast medium on excretory urography (IVP). The success of angiographic delineation of traumatic pedicle occlusions and devascularizing parenchymal fragmentations engendered its more widespread use in all categories of renal trauma and, to an extent, instigated a recycling of interest in immediate surgical exploration of the more than minimally traumatized kidney. Early intervention has been predicated on the assumption that more renal tissue could be preserved by debridement, repair and drainage than could be achieved with an expectant, non-operative initial approach to these patients. Controversy has arisen again as to which therapeutic philosophy has, in fact, been associated with greater salvage of functioning renal tissue. Proponents of expectant management point to a higher nephrectomy rate in the reports by advocates of an immediate operation, while the interventionists decry the prolonged hospitalization and increased incidence of complications arising from expectant or non-operative management. As is so often the case the issue is clouded on both sides by patient selection and the admixture of assumptions insecurely based on imprecise categorizations of extent and type of trauma, lumping of penetrating and blunt injuries, and the imponderables addended by concomitant trauma to other systems. Comparisons of results, even in the exclusively renal injuries of blunt and non-pedicle derivation, are made difficult if on the one hand immediate intervention is promulgated by the appearance of the angiogram without consideration of the stability or instability of the clinical condition of the patient and on the other hand if angiography is not performed on the stable patient who is to be managed expectantly. Since we have secured angiograms in the majority of instances in which vascular pedicle trauma has been suspected or urography has indicated a severe renal injury and have managed all clinically stable patients expectantly, a review of our results appeared to be germane to this disputation. CLINICAL EXPERIENCE
We have classified the type of injuries as follows: group 1patients construed to have a contusion or superficial laceration Accepted for publication January 14, 1977. * Died February 11, 1977.
of the renal parenchyma; group 2 - patients with renal injuries in which an IVP demonstrated transcapsular fracture of the parenchyma with or without extension into the collecting system and with or without urinary extravasation and perirenal hematoma, and group 3-patients with extensive fragmentation of the renal parenchyma or vascular pedicle injuries. Patients were included in group 2 or 3 if there was urographic and arteriographic delineation of significant renal injury. The majority of patients in group 1 did not have angiographic evaluation. There were 36 patients in group 1, 43 patients in group 2 and 5 patients in group 3, or a total of 84 patients. All patients had careful monitoring of vital signs, temperature, hemoglobin and hematocrit, and were kept at bed rest until their clinical condition warranted ambulation. Patients with renal trauma alone averaged 10 days in the hospital and patients with concomitant injuries averaged 18 days. Followup ranged from 4 months to 10 years, with an average of 18 months. In our series no patients in group 1 required an operation, 2 patients in group 2 were operated upon and 4 of 5 patients in group 3 underwent an operation. RESULTS
There were no deaths secondary to renal injury. In group 1 no surgical intervention was required and no complications or hypertension was noted at followup. In group 2 surgical exploration was necessary in 2 patients, 3 and 6 weeks after injury. In 1 patient a nephrectomy was done eventually, after 2 surgical procedures had failed to obviate a persistent extravasation. The other patient required a heminephrectomy after pyelonephritis developed secondary to ureteral catheterization for persistent urinary extravasation. This intervention might not have been necessary if ureteral catheterization had been avoided. In the other 41 patients no operation was performed and any parenchymal loss has appeared to be commensurate with the areas of devascularization seen on the angiogram (fig. 1). No complications or hypertension has ensued in these patients. In group 3 immediate surgical intervention and nephrectomy for extensive fragmentational renal injuries were necessary in 3 clinically unstable patients. One patient with a rupture of the intima of the renal artery underwent nephrectomy after an attempt at revascularization had failed. The fifth patient had sustained multiple trauma and a severely lacerated kidney, which was managed non-operatively with salvage of all but the devascularized area of parenchyma 522
NON-OPERATIVE MANAGEMENT OF BLUNT RENAL TRAUMA
apparent on the initial angiogram (fig. 2). Fourteen months after injury the patient was normotensive and asymptomatic. DISCUSSION
A review of the reported series of cases from the proponents of an immediate operation and those who advocate an expectant approach reveals that a retrospective analysis is necessarimprecise. There are no data from the active interventionists as to whether clinical instability of the patient or the angiographic findings instigated the operative approach and certainly no paired controls of clinically stable patients with similar injuries managed alternatively with immediate exploration or an expectant non-operative approach. For the non-interventionist it is perhaps simpler. The clinical course (other than in pedicle injuries) and further serial radiographic and laboratory studies dictate whether an operative approach is to be entertained, either immediately or at a later date. The experience of Sargent and Marquardt, who reported on 72 cases of blunt trauma of the group 2 type managed expectantly, demonstrated that the nephrectomy rate (2 patients) and late sequelae (3 per cent) were small.' Glenn and Har-
523
vard, 2 Morrow and Mendez, 3 Cecarrelli4 and others have found nephrectomy rates ranging from 4 to 16 per cent and the incidence of post-traumatic complications with expectant management has been less than 5 per cent. In contradistinction Hodges and associates, advocates of an early operation, had 23 patients who could be classified in our group 2 category in whom 9 nephrectomies were performed. 5 Their report of an 85 per cent incidence of late sequelae with non-operative management might be attributed to the number of patients referred at a later date specifically for a complication. Similarly, among the more ardent advocates of an immediate operation Scott and associates tabulated their results in 56 major injuries and reported a 60 per cent nephrectomy rate, which may have some relation to their depiction of a 5 per cent incidence of post-surgical complications versus the 17 per cent incidence they annotated in those managed non-operatively." The more recent report of Cass on 471 renal injuries of alI types emphasizes an over-all 5 per cent nephrectomy rate.' However 373 patients were in the minor injury or group category. In a tabulation of the 57 patients described by him who would have been included in group 2 or 3, 9 died in the
Fm. 1. A, hematoma owing to upper pole parenchymal avulsion displaces collecting system. B, nephrographic phase of angiogram shows area of avulsion in upper pole. C, IVP 1 year later. Right renal shadow appears normal.
Fm. 2. A, late angiographic selective study shows parenchymal lacerations. B, nephrographic phase shows areas of parenchymal devitalization. C, IVP 14 months later demonstrates parenchymal loss consistent with initial angiographic area of devascularization.
524
THOMPSON AND ASSOCIATES
early postoperative period of other causes. In this numerically confusing list of patients subjected to an immediate operation who also had subsequent operations there were 20 nephrectomies, 15 heminephrectomies, 17 lacerations sutured, 10 drainage procedures and 1 nephrostomy. Although the correlation of the surgical results relative to either the initial 57 patients or the 48 survivors is unclear a combined nephrectomy-heminephrectomy total of 35 patients makes the contention that the 24 patients from an earlier group managed non-operatively fared worse because 6 of them required delayed operations and 4 patients with pedicle injuries had nephrectomy, a less than forceful argument for the superiority of immediate intervention. Granting that the series of Cass, and Scott and associates are a mixture of penetrating, blunt and pedicle injuries and acknowledging the fact that the unstable patient or the patient with a pedicle injury must and will be operated upon by even the most adamant non-interventionist, the evidence from the data of both camps would appear to imply that an expectant approach diminishes the nephrectomy rate in the patient who can be stabilized clinically. We have had no compunction about performing an immediate operation upon the patient with a pedicle injury or the patient who cannot be stabilized readily with conservative measures but our data would reinforce that of others, suggesting that kidneys often can heal themselves with as much, if not more, preservation of functioning tissue if left alone and followed expectantly. In our 43 patients in group 2, 1½ kidneys were removed but not, in fact, as a consequence of failure to operate immediately. Severely traumatized kidneys in the unstable patient or pedicle injuries often will result in nephrectomy, as the results in our group 3 indicate. Although we have not included our cases of penetrating trauma (and a more recent pedicle injury patient who again could not be revascularized) because of the relatively small numbers our expectant management of these penetrating injuries has been equally satisfactory to us. CONCLUSION
We believe that the patient with a renal injury who is or can be stabilized clinically can be managed expectantly and that repeated evaluations and radiographic studies can reveal readily any deleterious sequelae that can be attended to at an appropriate time, which often may coincide with a more salubrious over-all condition of the patient.
We have not had any incidence of renal function loss or secondary complications that would cause us to retreat from an expectant approach and we believe that immediate exploration on the basis of the angiogram or urogram rather than on the clinical and radiographic course of the patient may produce an unnecessary harvest of operative complications and loss of renal tissue that might have survived if left alone. REFERENCES
1. Sargent, J. C. and Marquardt, C.R.: Renal injuries. J. Urol., 63:
1, 1950. 2. Glenn, J. F. and Harvard, B. M.: The injured kidney. J.A.M.A., 173: 1189, 1960. 3. Morrow, J. W. and Mendez, R.: Renal trauma. J. Urol., 104: 649, 1970. 4. Ceccarelli, F. E.: Expectant treatment in the management of blunt renal trauma. In: Current Controversies in Urologic Management. Edited by R. Scott, Jr. Philadelphia: W. B. Saunders Co., pp. 112-126, 1972. 5. Hodges, C. V., Gilbert, D.R. and Scott, W.W.: Renal trauma: a study of71 cases. J. Urol., 66: 627, 1951. 6. Scott, R., Jr., Carlton, C. E., Jr. and Goldman, M.: Penetrating injuries of the kidney: an analysis of 181 patients. J. Urol., 101: 247, 1969. 7. Cass, A. S.: Renal trauma in the multiple injured patient. J. Urol., 114: 495, 1975.
COMMENT We agree with the authors' classification and urge a very aggressive and precise radiographic diagnostic evaluation in the early postinjury phase in order that these patients may be accurately staged and intelligent treatment decisions made. In our experience 80 per cent of patients with blunt renal injury will have class I injuries and there is little disagreement with the non-operative management of this group of patients. Less than 10 per cent of the complications of non-operative management of renal trauma occur in this class I extent of injury. At the other end of the spectrum the type III injury is almost invariably seen in an unstable patient and surgery is usually required as a lifesaving matter. The controversy that exists relative to the management of blunt renal injuries is in the class II injury, making up no more than 10 per cent of patients with renal trauma. It is in this group of class II injuries that 90 per cent of the complications of non-operative management occur. It is in this group that early surgical repair will result in an increased renal salvage. C. Eugene Carlton, Jr. Division of Urology Baylor College of Medicine Houston, Texas
The Journal of Urology Copyright © 1977 by The Williams & Wilkins Co.
RESULTS OF NON-OPERATIVE MANAGEMENT OF BLUNT RENAL TRAUMA IAN M. THOMPSON,* HARRY LATOURETTE, JOSEPH E. MONTIE
AND
GILBERT ROSS, JR.
From the Section of Urology, University of Missouri School of Medicine, Columbia, Missouri
ABSTRACT
A study of 84 patients with blunt renal trauma has revealed that expectant, non-operative management of the clinically stable patient with either minor or more severe injuries (excluding vascular pedicle trauma) gives satisfactory results and entails few subsequent complications. The nephrectomy rate with expectant management is markedly lower than that reported after an immediate operation. The salvage of functioning renal tissue appears to be commensurate with angiographic delineation of devascularized tissue and would seem to be comparable to that of patients afforded immediate surgical intervention, without the threat of loss of the renal unit that appears to be entailed by early operation. The use of arteriography in the investigation of trauma to the kidney had its initial impetus in circumstances when vascular pedicle injuries or extensive parenchymal destruction was suggested by incomplete or absent visualization of contrast medium on excretory urography (IVP). The success of angiographic delineation of traumatic pedicle occlusions and devascularizing parenchymal fragmentations engendered its more widespread use in all categories of renal trauma and, to an extent, instigated a recycling of interest in immediate surgical exploration of the more than minimally traumatized kidney. Early intervention has been predicated on the assumption that more renal tissue could be preserved by debridement, repair and drainage than could be achieved with an expectant, non-operative initial approach to these patients. Controversy has arisen again as to which therapeutic philosophy has, in fact, been associated with greater salvage of functioning renal tissue. Proponents of expectant management point to a higher nephrectomy rate in the reports by advocates of an immediate operation, while the interventionists decry the prolonged hospitalization and increased incidence of complications arising from expectant or non-operative management. As is so often the case the issue is clouded on both sides by patient selection and the admixture of assumptions insecurely based on imprecise categorizations of extent and type of trauma, lumping of penetrating and blunt injuries, and the imponderables addended by concomitant trauma to other systems. Comparisons of results, even in the exclusively renal injuries of blunt and non-pedicle derivation, are made difficult if on the one hand immediate intervention is promulgated by the appearance of the angiogram without consideration of the stability or instability of the clinical condition of the patient and on the other hand if angiography is not performed on the stable patient who is to be managed expectantly. Since we have secured angiograms in the majority of instances in which vascular pedicle trauma has been suspected or urography has indicated a severe renal injury and have managed all clinically stable patients expectantly, a review of our results appeared to be germane to this disputation. CLINICAL EXPERIENCE
We have classified the type of injuries as follows: group 1patients construed to have a contusion or superficial laceration Accepted for publication January 14, 1977. * Died February 11, 1977.
of the renal parenchyma; group 2 - patients with renal injuries in which an IVP demonstrated transcapsular fracture of the parenchyma with or without extension into the collecting system and with or without urinary extravasation and perirenal hematoma, and group 3-patients with extensive fragmentation of the renal parenchyma or vascular pedicle injuries. Patients were included in group 2 or 3 if there was urographic and arteriographic delineation of significant renal injury. The majority of patients in group 1 did not have angiographic evaluation. There were 36 patients in group 1, 43 patients in group 2 and 5 patients in group 3, or a total of 84 patients. All patients had careful monitoring of vital signs, temperature, hemoglobin and hematocrit, and were kept at bed rest until their clinical condition warranted ambulation. Patients with renal trauma alone averaged 10 days in the hospital and patients with concomitant injuries averaged 18 days. Followup ranged from 4 months to 10 years, with an average of 18 months. In our series no patients in group 1 required an operation, 2 patients in group 2 were operated upon and 4 of 5 patients in group 3 underwent an operation. RESULTS
There were no deaths secondary to renal injury. In group 1 no surgical intervention was required and no complications or hypertension was noted at followup. In group 2 surgical exploration was necessary in 2 patients, 3 and 6 weeks after injury. In 1 patient a nephrectomy was done eventually, after 2 surgical procedures had failed to obviate a persistent extravasation. The other patient required a heminephrectomy after pyelonephritis developed secondary to ureteral catheterization for persistent urinary extravasation. This intervention might not have been necessary if ureteral catheterization had been avoided. In the other 41 patients no operation was performed and any parenchymal loss has appeared to be commensurate with the areas of devascularization seen on the angiogram (fig. 1). No complications or hypertension has ensued in these patients. In group 3 immediate surgical intervention and nephrectomy for extensive fragmentational renal injuries were necessary in 3 clinically unstable patients. One patient with a rupture of the intima of the renal artery underwent nephrectomy after an attempt at revascularization had failed. The fifth patient had sustained multiple trauma and a severely lacerated kidney, which was managed non-operatively with salvage of all but the devascularized area of parenchyma 522
NON-OPERATIVE MANAGEMENT OF BLUNT RENAL TRAUMA
apparent on the initial angiogram (fig. 2). Fourteen months after injury the patient was normotensive and asymptomatic. DISCUSSION
A review of the reported series of cases from the proponents of an immediate operation and those who advocate an expectant approach reveals that a retrospective analysis is necessarimprecise. There are no data from the active interventionists as to whether clinical instability of the patient or the angiographic findings instigated the operative approach and certainly no paired controls of clinically stable patients with similar injuries managed alternatively with immediate exploration or an expectant non-operative approach. For the non-interventionist it is perhaps simpler. The clinical course (other than in pedicle injuries) and further serial radiographic and laboratory studies dictate whether an operative approach is to be entertained, either immediately or at a later date. The experience of Sargent and Marquardt, who reported on 72 cases of blunt trauma of the group 2 type managed expectantly, demonstrated that the nephrectomy rate (2 patients) and late sequelae (3 per cent) were small.' Glenn and Har-
523
vard, 2 Morrow and Mendez, 3 Cecarrelli4 and others have found nephrectomy rates ranging from 4 to 16 per cent and the incidence of post-traumatic complications with expectant management has been less than 5 per cent. In contradistinction Hodges and associates, advocates of an early operation, had 23 patients who could be classified in our group 2 category in whom 9 nephrectomies were performed. 5 Their report of an 85 per cent incidence of late sequelae with non-operative management might be attributed to the number of patients referred at a later date specifically for a complication. Similarly, among the more ardent advocates of an immediate operation Scott and associates tabulated their results in 56 major injuries and reported a 60 per cent nephrectomy rate, which may have some relation to their depiction of a 5 per cent incidence of post-surgical complications versus the 17 per cent incidence they annotated in those managed non-operatively." The more recent report of Cass on 471 renal injuries of alI types emphasizes an over-all 5 per cent nephrectomy rate.' However 373 patients were in the minor injury or group category. In a tabulation of the 57 patients described by him who would have been included in group 2 or 3, 9 died in the
Fm. 1. A, hematoma owing to upper pole parenchymal avulsion displaces collecting system. B, nephrographic phase of angiogram shows area of avulsion in upper pole. C, IVP 1 year later. Right renal shadow appears normal.
Fm. 2. A, late angiographic selective study shows parenchymal lacerations. B, nephrographic phase shows areas of parenchymal devitalization. C, IVP 14 months later demonstrates parenchymal loss consistent with initial angiographic area of devascularization.
524
THOMPSON AND ASSOCIATES
early postoperative period of other causes. In this numerically confusing list of patients subjected to an immediate operation who also had subsequent operations there were 20 nephrectomies, 15 heminephrectomies, 17 lacerations sutured, 10 drainage procedures and 1 nephrostomy. Although the correlation of the surgical results relative to either the initial 57 patients or the 48 survivors is unclear a combined nephrectomy-heminephrectomy total of 35 patients makes the contention that the 24 patients from an earlier group managed non-operatively fared worse because 6 of them required delayed operations and 4 patients with pedicle injuries had nephrectomy, a less than forceful argument for the superiority of immediate intervention. Granting that the series of Cass, and Scott and associates are a mixture of penetrating, blunt and pedicle injuries and acknowledging the fact that the unstable patient or the patient with a pedicle injury must and will be operated upon by even the most adamant non-interventionist, the evidence from the data of both camps would appear to imply that an expectant approach diminishes the nephrectomy rate in the patient who can be stabilized clinically. We have had no compunction about performing an immediate operation upon the patient with a pedicle injury or the patient who cannot be stabilized readily with conservative measures but our data would reinforce that of others, suggesting that kidneys often can heal themselves with as much, if not more, preservation of functioning tissue if left alone and followed expectantly. In our 43 patients in group 2, 1½ kidneys were removed but not, in fact, as a consequence of failure to operate immediately. Severely traumatized kidneys in the unstable patient or pedicle injuries often will result in nephrectomy, as the results in our group 3 indicate. Although we have not included our cases of penetrating trauma (and a more recent pedicle injury patient who again could not be revascularized) because of the relatively small numbers our expectant management of these penetrating injuries has been equally satisfactory to us. CONCLUSION
We believe that the patient with a renal injury who is or can be stabilized clinically can be managed expectantly and that repeated evaluations and radiographic studies can reveal readily any deleterious sequelae that can be attended to at an appropriate time, which often may coincide with a more salubrious over-all condition of the patient.
We have not had any incidence of renal function loss or secondary complications that would cause us to retreat from an expectant approach and we believe that immediate exploration on the basis of the angiogram or urogram rather than on the clinical and radiographic course of the patient may produce an unnecessary harvest of operative complications and loss of renal tissue that might have survived if left alone. REFERENCES
1. Sargent, J. C. and Marquardt, C.R.: Renal injuries. J. Urol., 63:
1, 1950. 2. Glenn, J. F. and Harvard, B. M.: The injured kidney. J.A.M.A., 173: 1189, 1960. 3. Morrow, J. W. and Mendez, R.: Renal trauma. J. Urol., 104: 649, 1970. 4. Ceccarelli, F. E.: Expectant treatment in the management of blunt renal trauma. In: Current Controversies in Urologic Management. Edited by R. Scott, Jr. Philadelphia: W. B. Saunders Co., pp. 112-126, 1972. 5. Hodges, C. V., Gilbert, D.R. and Scott, W.W.: Renal trauma: a study of71 cases. J. Urol., 66: 627, 1951. 6. Scott, R., Jr., Carlton, C. E., Jr. and Goldman, M.: Penetrating injuries of the kidney: an analysis of 181 patients. J. Urol., 101: 247, 1969. 7. Cass, A. S.: Renal trauma in the multiple injured patient. J. Urol., 114: 495, 1975.
COMMENT We agree with the authors' classification and urge a very aggressive and precise radiographic diagnostic evaluation in the early postinjury phase in order that these patients may be accurately staged and intelligent treatment decisions made. In our experience 80 per cent of patients with blunt renal injury will have class I injuries and there is little disagreement with the non-operative management of this group of patients. Less than 10 per cent of the complications of non-operative management of renal trauma occur in this class I extent of injury. At the other end of the spectrum the type III injury is almost invariably seen in an unstable patient and surgery is usually required as a lifesaving matter. The controversy that exists relative to the management of blunt renal injuries is in the class II injury, making up no more than 10 per cent of patients with renal trauma. It is in this group of class II injuries that 90 per cent of the complications of non-operative management occur. It is in this group that early surgical repair will result in an increased renal salvage. C. Eugene Carlton, Jr. Division of Urology Baylor College of Medicine Houston, Texas
