Management of Blunt Renal trauma in Srinagarind Hospital

: 10-year experience
Wichien Sirithanaphol, MD

Introduction
Urogenital system injuries are seen in 10% of traumatic patients and mostly in patients with multiple trauma and severe trauma of lower parts of abdomen or pelvis The prevalence of urogenital injuries has been reported between 10 and 30% in adults and less than 3% in children
MC Aninch JW. Genitourinary trauma. World Urol 1999.17: 95-96.

Introduction
Renal injury is the most common injury in urogenital system
The prevalence of Renal Injury in Abdomonal Traumatic Patients has reported 8 10%1 and 13.6 % in Siriraj Hospital2
1 Peterson NE. complications of renal trauma. Urol Clin North Am 1989; 16: 221-36. 2 , : , .. : , 2522: 1-13.

Introduction
Blunt trauma is the cause of more than 90% of Renal Injuries1
Accidents, falling and being hit are the most frequent of blunt injury

Bullet and stab wounds are the most common cause for penetrating injuries2
1 Dreitlein AA, Snner S, Basler J. Genitourinary trauma.Emery med clin North Am 2001 19(3): 599-90. 2 Palmer LS, Rosenbaum RR, Gershbaum MD. Penetrating ureteral trauma at an urban trauma center.
Urology 1999 54(1): 34-36.

Introduction
Grading of renal injuries is performed using the American Association for the Surgery of Trauma organ injury severity scale

Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: spleen, liver, and kidney. 29: 16641666, 1989.

J Trauma

Introduction
Nonoperative management of renal injuries has gained much support in past decades
A trial of Nonoperative management has been advocated for most adult blunt renal injuries1, many renal stab wounds2, and selective renal gunshot wounds3
1 Danuser H, Wille S, Zoscher G, et al: How to treat blunt kidney ruptures: primary open surgery or
conservative treatment with deferred surgery when necessary? Eur Urol 39: 914, 2001.

2 Bernath AS, Schutte H, Fernandez RR, et al: Stab wounds of the kidney: conservative management in
flank penetration. J Urol 129: 468470, 1983 Urol 171: 20, 2004.

3 Serafetinides E, Mitropoulos D, Constantinedes C, et al: Management of renal gunshot injuries (RGI).

Patient & Method

Research methodology
Retrospective review : case review
Srinagarind hospital, university hospital in Khon-Kaen Period of study : 1 Jan 1999 - 31 Dec 2008 Retrieve data from ICD10 code
Renal trauma Renal injury

Inclusion & Exclusion criteria

Inclusion criteria Blunt renal Trauma Referred patients with Renal Injury related complication

Exclusion criteria Penetrating injury Iatrogenic Renal injury Referred patients with Non-Renal Injury related complication

Group of Study
Non Operative Management (NOM) group (+Interventional Treatment) - Successful NOM - Failed NOM Operative Management group - Renal exploration

Management
The absolute indications for renal exploration
Life-threatening hemorrhage from a renal source

Pulsatile perirenal hematoma (suggestive of a grade V vascular injury) Active extravasation of intravenous contrast

Management
The patients who were considered non-operative treatment
Absolute bed rest until gross hematuria resolves Regular & frequent vital sign measurement Serial abdominal examination Serial Hct checked

Surgical procedures were performed in operative group, depended on intra-operative finding

Ethical Consideration
This study have proved by The Khon Kaen University Ethics Committee for Human Research No : HE 521112

Results

Renal trauma (80 pt)

Missing data (3 pt = 3.89%)

Renal trauma (77 pt)

Exclude (8 pt = 10.4 %) Penetrating injury 5 pt Iatrogenic injury 3 pt (kidney biopsy)

Blunt renal trauma (69 pt)

Abdominal trauma (1,693 pt)

Blunt renal trauma (69 pt)

4.07 % of Abdominal trauma

Characteristic

Blunt injury 69 pt
56 pt (82%) 13 pt (18%)

Male Female

Mean age

29.8 yr (1-68 yr)

Underlying disease

No 55 pt (80%)

Mechanism of injury
Blunt Renal injury 69 pt

Management
Blunt Renal injury 69 pt

NOM Group 55 pt (80%)

Operative Group 14 pt (20%)

Renal Exploration 7 pt (10%)

Other intraabdominal injury 7 pt (10%)

NOM Group 55 pt (80%)

Mean SBP
113 (0-179mmHg)

Renal Exploration 7 pt (10%)

78 (0-139 mmHg)

NOM Group Mean Hct (at ER) 55 pt (80%)

35% (15-48%)

30% (20-44%)

Patients with shock on arrival

6/7 pt

5/55 pt

Injury severity score (ISS)

86% 78%

22% 14%

Revised Trauma Score (RTS)

Trauma Score - Injury Severity Score (TRISS)

Grading of injury
Blunt Renal injury 69 pt

9%

33% 23%

14%

21%

Non operative group 55 pt

Operative group 7 pt

Associated injury
Extra-abdominal injury
Head injury

Pt
23

Intra-abdominal injury
Spleen Liver

pt
13 8

Hemo/pneumothorax
Rib fracture

22
18 12 8 6 5

Small bowel
Colon Pancreas

2
1 1

Extremity lower Upper

Facial bone Spine

IVC

Management outcome

Non operative group (55 pt)

Operative group (7 pt) 19 days (1-74)

Mean hospital stay

11.8 days (1-54)

Mean ICU stay Mean PRC used

0.5 days (0-9 )

1.6 units (0-16)

5.14 days (0-23)

5.14 units (0-9 )

Management outcome
Non-operative Group (55 Pt)

Successful NOM 48/55 pt (87.2%)

Death 3/55 pt (5.5%) Severe head injury : 2 pt Massive hemothorax : 1 pt

Failed NOM 4/55 pt (7.3%) Peritonitis : 1 pt - Avulsion of upper pole of kidney Complication : 3 pt - Pseudoaneurysm : 1 pt - Infected urinoma : 1 pt - Delayed bleeding : 1 pt

Management outcome
Operative Group (7 Pt)
Procedure EL c nephrectomy 6 pt EL c ureteropyeloplasty 1 pt

Death 1/7 pt (14%) Severe head injury

Non specific complication

Non operative group (55 pt) UTI 7 Pneumonia 6

Operative group (7 pt) Pneumonia 1

Wound infection ARF

ARDS

2 2
1

Specific complication

Non operative group (55 pt) Perinephric abscess Infected urinoma 2 1

Operative group (7 pt) Compartmental syndrome 1

Delayed bleeding Pseudoaneurysm

1 1

Specific complication treatment

Non operative group (55 pt) Perinephric abscess Infected urinoma 2 1

ATB Percutaneous drainage

failed

EL c nephrectomy
EL c left lower pole nephrectomy

Delayed bleeding Pseudoaneurysm

1 1

Embolization

failed

EL c nephrectomy

Specific complication treatment

Operative group (7 pt)

EL c temporary abdominal closure

Compartmental syndrome

Discussion
According to the obtained results from this study, Renal Injury develops in a little portion of abdominal traumatic patients
4.07% This is quite less than findings of other studies

However, these injuries may lead to mortality, urogenital dysfunction, neglecting them could cause serious sequelae

Discussion
20 30 years are the most common age group, may be because of traumatic pattern which mostly affect the youth

Regarding gender, Male were enrolled 4.5 times more than female in this study
Blunt trauma is the cause of more than 90% of Renal Injuries

Which are almost similar to other studies

Discussion
NOM Groups
NOM is the treatment of choice in stable patients Most of blunt renal injury can be managed conservatively
Grade 5 is only 1 pt

Failed NOM
3 pt : Death due to serious associated injury 2 pt : due to late sequale (Infected urinoma, Delayed bleeding) 1 pt : due to immediated sequale (Developed peritonitis)

Discussion
Mortality in operative group is higher than NOM group
5% vs. 36% Severe Renal Injury Severe associated injury

Conservative Management have also been applied to penetrating renal injuries, who were hemodynamically stable and without peritoneal signs
In this study can't be manage due to contraindication

Conclusion
Most of blunt renal injury can be managed conservatively Penetrating renal injuries can be managed nonoperatively in selected patients
Multimodality of Treatment
Procedure should be suited for individual

Thank You