Management of high-grade renal injuries in children after blunt abdominal trauma: Experience of 40 cases

doi:10.1016/j.jpurol.2006.07.006

Journal of Pediatric Urology

Volume 3, Issue 3, June 2007, Pages 223-229

https://doi.org/10.1016/j.jpurol.2006.07.006 Get rights and content

Abstract

Objective

We present our experience of management of high-grade renal trauma in a pediatric population, including assessment of the long-term function and morphology of the ipsilateral kidney.

Patients and methods

From 1997 to 2005, 40 children with high-grade renal injury (III, IV, V) after blunt abdominal trauma were managed. Initial evaluation included vital signs, color of urine, hemoglobin (Hb%), hematocrit, serum creatinine and computed tomography (CT). Follow up included vital signs, urine analysis, Hb%, CT, ±intravenous pyelogram and renogram.

Results

One patient needed superselective embolization due to continuing hemorrhage in spite of conservative treatment. Internal stenting plus percutaneous tube drain was indicated in three cases due to progressive extravasation. Exploration was indicated in four cases, one at presentation due to hemodynamic instability which ended in nephrectomy; the other three were successfully repaired. Conservative treatment was successful in 32 cases (80%). Blood transfusion was indicated in 16 cases (40%). Length of hospital stay was 4–20 days (mean 12.1). At the last follow up (range 1–8 years, mean 3.5), scars were detected in 10 cases, while all showed normal levels of Hb% and creatinine. No patient developed hypertension. Apart from in the nephrectomy case, the ipsilateral kidney showed split function of 40–50%.

Conclusion

After exclusion of hemodynamic instability and continuing hemorrhage, conservative treatment is successful in 80% of patients. Internal stenting with or without percutaneous drainage is indicated if there is progressive urinoma. Angioembolization is successful in selected cases.

Introduction

The kidney is one of the most frequently injured visceral organs in pediatric blunt trauma [1], [2], with an injury occurring in 10–20% of cases [3], [4]. Ninety per cent of pediatric renal injuries are as a result of blunt renal trauma with the remainder due to penetrating injury [5], [6]. The majority of blunt pediatric renal injuries are minor and of little consequence to the patient, with no known long-term sequelae. Most series in the literature support selective non-operative management of grade IV renal injuries with a few extending to include grade V renal injuries, although follow-up data is limited and incomplete [7], [8], [9]. With prompt diagnosis, appropriate imaging and selective management, renal preservation should be the standard of care [7], [8]. We present our experience with the management of high-grade renal injuries after blunt abdominal trauma in a pediatric population. We also assess the long-term follow up of ipsilateral renal function and morphology.

Section snippets

Materials and methods

From 1997 to 2005, 40 children presented to our institution with renal injury due to blunt abdominal trauma. They comprised 33 boys and seven girls, 3–15 years old (mean 10.5, median 10). The cause of trauma was car accident in 30 cases and falling from a height in 10 cases. Thirty-six patients presented with gross hematuria and four with microscopic hematuria. None of our patients had main renal artery or vein injuries or thrombosis. All except one were graded by emergency abdominal CT

Results

Conservative treatment was successful in 32 cases with complete resolution of hematuria and stabilization of general condition. One case needed superselective embolization of a pseudoaneurysm in one of the segmental branches of the upper polar artery with polyvinyl alcohol particles because of continuing hemorrhage. Four cases required exploration: one due to instability from the start resulted in nephrectomy, and three due to failure of conservative treatment were successfully repaired

Discussion

The pediatric kidney is more susceptible to blunt trauma than the adult kidney due to its relatively large size, increased immobility of the renal unit and less perinephric fat [5]. Excluding patients with hemodynamic instability, grade V and progressive urinoma, most authors recommend conservative treatment [6]. In the present study, the success rate of conservative treatment (80%) is in accordance with the studies of Russell et al. and Margenthaler et al. [4], [7]. The advantages of

Conclusion

In a pediatric population with high-grade injuries after blunt abdominal trauma, and after exclusion of hemodynamic instability and continuing hemorrhage, conservative treatment is successful initially and after long-term follow up in 80% of patients. Internal stenting with or without a percutaneous tube drain is indicated if there is progressive urinoma. Angioembolization as a minimally invasive technique is successful in selected cases.

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Cited by (29)

Determination of the radiologic findings for predicting failure of conservative management with observation for blunt renal injury patients: A single-centre experience over 13 years
2021, Injury
Most blunt renal injuries (BRIs) are managed conservatively without complications. Because conservative management with observation (CMO) is widely conducted, failed CMO is frequent. Clarifying the role and indication of CMO is important to manage BRI patients. Therefore, this study was conducted to analyse factors related to failed CMO.
BRI patients (aged >13 years) who were admitted via the emergency department in Wonju Severance Christian Hospital were analysed retrospectively between January 2008 and July 2020. Patient characteristics, including clinical data, laboratory findings, transfusion requirements, injury grade, initial CT findings, length of hospital stay, intensive care unit stay, and mortality, were investigated for all enrolled patients.
Kidney injury grade ≥ 4, perinephric haematoma rim distance (PHD), length of main laceration, intravascular contrast extravasation (ICE), Gerota's fascia discontinuity, multiple lacerations, dissociated renal fragment and complexity of laceration were statistically significantly different between the successful CMO and failed CMO groups in the comparative analysis.
The multivariate analysis showed that perinephric haematoma rim distance [odds ratio (OR) 1.44 [95% confidence interval (CI) 1.09 – 1.90], p = 0.011] and ICE [OR 7.41 (95% CI 2.20 – 24.99), p = 0.001] were mutually independent risk factors associated with failed CMO.
When the ROC curve of PHD and ICE was generated to predict the failure of CMO, the area under the curve (AUC) was 0.884 (95% CI, 0.826 – 0.942), p < 0.001), and the optimal cut-off value for PHD was 2.9 cm, and for ICE was presence of ICE on CT [sensitivity: 90.5% (95% CI, 0.70 – 0.99), specificity: 78.0% (95% CI, 0.73 – 0.83)].
PHD and ICE may be useful factors to predict failed CMO for BRI patients. PHD > 2.9 cm and the presence of ICE may indicate who will require invasive procedures. Close observation is wise for patients with these risk factors.
“Functional outcome in pediatric grade IV renal injuries following blunt abdominal trauma salvaged with minimally invasive interventions”
2020, Journal of Pediatric Urology
Citation Excerpt :
However, since this was before the extensive usage of minimally invasive modalities and the fact that open exploration had more chances of nephrectomy, this loss of function was deemed acceptable. The later few studies on non-operative management which have mentioned about functional outcomes have shown that though the kidneys were salvaged, the kidneys were scarred and function was reduced to varying degrees [10,11,15–17,24,27,32]. However, even these values were derived mostly from kidneys which responded to non-operative interventions alone so it may not be representative of renal units that needed intervention [10,11,15–17,24,27,32].
Non-operative management of higher-grade renal injuries has gradually become accepted in pediatric circles following multiple studies over the past decade which showed good renal salvage rates. However, some children do fail this conservative approach and need interventions which are mostly minimally invasive. There is still paucity of studies on the functional outcomes in this unique subgroup of patients. In this study, we review our management and functional outcome of children with grade IV renal injury due to blunt trauma of abdomen managed with minimally invasive interventions (MII) in a tertiary referral center.
The present study seeks to summarize contemporary management of pediatric grade IV renal injury due to blunt trauma at our tertiary care center and to assess the functional outcomes in the subgroup who needed MII.
A retrospective review was performed on children≤18 years with abdominal blunt trauma managed at our tertiary care facility over the past 10 years (January 2008–January 2018) to identify those with grade IV renal injuries. Data collected included demographic data like age, sex, mechanism of injury, incidence of hematuria, incidence of pre-existing urologic conditions, associated non-renal injuries, transfusion requirements, imaging findings, type of interventions, length of hospital stay, complications and outcomes on follow up.
Review of our institutional database identified 10 children with grade IV renal injury. Mean age was 11.7 ± 3.6 years (range, 6–18) and majority (6/10) were male. Motor vehicle collision and fall from heights were the commonest mechanisms of injury. While one patient responded to non-operative management, one girl needed emergency renal exploration and later nephrectomy. Eight needed minimally invasive interventions following initial non-operative management. One patient needed nephrectomy due to delayed hemorrhage while three patients needed delayed open reconstruction. The salvage rate in the group which needed interventions was 87.5% (7 of 8) however, the functional outcome was good only in 50% (4 of 8) of patients. The outcomes were better in those who were managed with MII earlier (3/4) compared to those who underwent delayed intervention (1/4). The median hospital stay was 11.5 days (range 7–34 days).
Pediatric patients with non-exsanguinating grade IV renal injuries due to blunt trauma who fail non-operative management and need minimal invasive interventions have good renal salvage rates however, the functional outcomes are poorer. Judicious and early use of these minimally invasive interventions, instead of persisting with non-operative management can possibly improve these functional outcomes.
Nonoperative Management of Blunt Solid Organ Injury in Pediatric Surgery
2017, Surgical Clinics of North America
Predictive factors for conservative treatment failure in grade IV pediatric blunt renal trauma
2016, Journal of Pediatric Urology
Citation Excerpt :
In hemodynamically stable children with the American Association for the Surgery of Trauma (AAST) grade I to III injuries, success of conservative management has been well established [1,2,4,5,10–13]. In recent years, most children with grade IV renal injury, without life-threatening bleeding, have been treated using a conservative approach with a high success rate [3,13–18]. However, a small minority of grade IV renal injury patients require urological intervention (such as ureteral stenting, percutaneous drainage, percutaneous nephrostomy, or renorrhaphy) because of symptomatic urinomas.
Most children with grade IV renal injury are treated using a conservative approach with a high success rate. However, a small minority of patients with grade IV renal injury require urological intervention because of symptomatic urinomas. The challenge lies in predicting which of the patients receiving initial conservative treatment may require delayed interventional management because of urological complications.
To identify clinical factors and radiological features associated with the need for urological intervention in grade IV pediatric, blunt renal trauma patients who were initially treated with a conservative approach.
The medical records of consecutive 26 children presenting to our center between 1996 and 2014 with grade IV renal injury, were retrospectively reviewed. Clinical factors, radiological features on computed tomography (CT), use of urological intervention, and patient outcomes were analyzed.
The population algorithm of this study is shown in the figure. The patients who required urological intervention had a higher transfusion rate and larger perinephric hematomas (>2.2 cm) than those who did not require intervention. The main laceration was located in the antero-medial portion of the kidney, and intravascular contrast extravasation was observed more often in patients who underwent urological intervention compared with patients with successful conservative management.
The authors recommend the use of cautious observation and timely imaging studies for unresolved or expanding urinomas in children with grade IV renal trauma with predictive factors. Moreover, most patients received urological intervention 4–8 days after the trauma. Therefore, it is suggested that a follow-up image study for early detection of urological complications should be conducted 4–5 days after trauma in grade IV renal trauma children with predictive factors. If none of these factors are observed on the initial CT or during the clinical course, follow-up imaging study may be avoided during hospitalization.
The need for transfusion, and the presence of specific image features on initial CT, such as the main laceration location in the antero-medial portion of kidney, intravascular contrast extravasation, and a large perinephric hematoma, served as useful predictive factors for urological intervention in grade IV pediatric blunt renal trauma patients who were initially treated with a conservative approach. The findings indicate that early detection and appropriate intervention should be considered a priority in the conservative treatment of grade IV pediatric renal trauma with predictive factors.
Functional damages after blunt renal trauma in children
2011, Progres en Urologie
Le but de cette étude a été d’évaluer le devenir fonctionnel des reins après traumatisme.
Il s’agissait une étude rétrospective qui reprenait 66 dossiers de traumatismes rénaux chez l’enfant de moins de 16 ans entre 1990 et 2010. Ces patients ont été répartis selon la classification internationale de l’Association américaine de traumatologie. Trente-trois patients de grade I–III, 28 patients de grade IV et cinq de grade V. Quel que soit leur stade et leur traitement, ils ont eu un suivi incluant échographie ou tomodensitométrie abdominale. Après documentation de la cicatrisation complète, une scintigraphie rénale au technétium-99m était réalisée.
Il n’y avait pas de lésion bilatérale. Treize patients ont été laparotomisés avec trois néphrectomies totales et deux néphrectomies partielles d’hémostase. Les quatre lésions vasculaires ont été traitées par angioplastie. Neuf urohématomes ont été drainés par huit sondes double J et un drainage externe. Au total, 26 scintigraphies ont été réalisées : la fonction résiduelle du rein lésé était de 43,4 % (±6,2 %), 35,7 % (±5,3 %) et 30,3 % (±12,2 %), p non significatif, respectivement pour les stades I–III, IV et V.
Les séquelles fonctionnelles après traumatisme rénal semblaient reliées au grade du traumatisme. Il existait des cicatrices même pour des traumatismes minimes. Cela a justifié un suivi rapproché dans lequel la scintigraphie occupait un rôle essentiel.
The purpose of this study was to determine the long-term functional outcome of renal injuries.
We retrospectively reviewed the charts of patients under 16 sustaining renal trauma and admitted to our department between 1990 et 2010. There were 66 renal lesions categorized as follows: grade I to III, 33, grade IV, 28 and grade V, 5. Whatever their initial status, all children were followed using ultrasonography or computed tomography. After complete healing, data of technetium-99m-dimercaptosuccinic acid nuclear were collected.
There was no bilateral injury. Thirteen patients proceeded to laparotomy leading to nephrectomy in three cases, partial nephrectomy in two others cases. Four renovascular injuries required interventional radiologic management. Nine urinomas were managed with eight stentings and one percutaneous drainage. Percentage of renal function by technetium-99m-dimercaptosuccinic acid nuclear scanning concerning 26 patients was analysed. Split percentage of renal function was 43.4% (± 6.2%), 35.7% (± 5.3%) et 30.3% (± 12.2%) (mean ± SD); P = no significant, for grade I–III, IV and V, respectively.
Functional outcome after blunt renal trauma appeared influenced by injury grade. Functional sequelae existed even with low-grade traumas. In keeping with literature, these results justified a close follow-up in which radionuclide study was the essential element.
Management of major blunt pediatric renal trauma: Single-center experience
2010, Journal of Pediatric Urology
Citation Excerpt :
The reports have varied for the treatment of grade III and IV parenchymal injuries, but most favor a conservative approach, especially in the most recent series. Even some grade V parenchymal injuries have been managed non-operatively [4,7]. With prompt diagnosis, appropriate imaging and selective management, renal preservation should be attempted for all grades.
To review the impact of major pediatric renal trauma and its management on long-term function and morphology of the injured kidney.
Thirty-six blunt trauma patients (20 males, 16 females) presented in 2004–2007 (age range 2 days to 14 years; mean 6.2 years). Thirty-seven renal units were included: 13 grade III, 14 grade IV, and 10 grade V injuries. Follow up was for 3–38 (mean 14) months. Patients were managed non-operatively unless vitally unstable. The most common causes of trauma were motor vehicle accidents and falls. Fourteen patients had associated non-renal injuries. Four patients had pre-existing renal problems.
The surgical intervention group (13 patients, 36%) included 9/10 grade V and 4/14 grade IV renal injuries. Surgical repair of lacerations was performed in seven cases, partial nephrectomy in four cases and nephrectomy in two cases. Follow up showed no significant change in renal function, and none developed hypertension. The non-operative group (24 patients, 63.2%) included all grade III injuries, 10 grade IV injuries, and one grade V injury. There was an excellent outcome for 18/24 patients (75%) with kidney preservation, no complications from urinary extravasation and hematoma resolution. The remaining patients had lower polar infarction (1), renal atrophy (1), persistent subcapsular collection (2), recurrent hematuria requiring angioembolization (1), and there was one death related to central nervous system injury.
The outcome of our management of pediatric major renal trauma was favorable overall. Longer follow up is needed with regard to renal function and development of hypertension.

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Management of high-grade renal injuries in children after blunt abdominal trauma: Experience of 40 cases

Abstract

Objective

Patients and methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

J Pediatr Surg

J Urol

Urology

J Urol

J Urol

J Urol

J Urol

Urology

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