Elsevier

Urology

Volume 64, Issue 3, September 2004, Pages 574-579
Urology

Pediatric urology
High-grade renal injuries in children—is conservative management possible?

https://doi.org/10.1016/j.urology.2004.04.069Get rights and content

Abstract

Objectives

To review our experience with the management of high-grade (grade IV and V) renal injuries to clarify the role of conservative management.

Methods

From 1991 to 2003, 79 consecutive patients (age range 2 to 14 years) with renal injuries were treated in an urban level I pediatric trauma center. Twenty children were identified as having high-grade renal injury (grade IV, 10 children and grade V, 10 children). The mechanism of injury was blunt trauma in 17 patients (85%) and penetrating trauma in 3 (15%).

Results

Of the 10 patients with grade IV injury, 8 (80%) were successfully treated conservatively with bedrest and catheter drainage. Two patients with persistent urine leaks required ureteral stenting, and one subsequently required open operative repair. The initial radiographic findings in both patients demonstrated complete renal fracture with retained vasculature to both renal segments. All 10 patients with grade V injury required open operative management and only 3 (30%) achieved long-term renal salvage.

Conclusions

Most children with grade IV renal injury can be treated conservatively. Patients with complete renal fracture or significant urinary extravasation on initial radiographic imaging may be less likely to undergo spontaneous resolution. Patients with a persistent urinary leak can be successfully treated with internal drainage. Grade V injuries are associated with an increased risk of requiring open operative intervention, and the renal preservation rates are low.

Section snippets

Material and methods

From 1991 to 2003, 79 consecutive patients (age range 2 to 16 years) with renal injuries were treated in an urban level I pediatric trauma center. The diagnosis of renal injury was confirmed in all patients by abdominal computed tomography (CT) scan with intravenous contrast. The grade of renal injury was classified by an independent radiologist according to the kidney injury scale of the American Association for the Surgery of Trauma organ injury severity scale.8 Grade IV renal injury was

Results

Twenty children (age range 2 to 14 years) were identified as having high-grade renal injury (10 each with grade IV and V renal injury). The characteristics of the children with high-grade injury are listed in Table I. Blunt trauma was the predominant mechanism of injury in 17 patients (85%) and was most often caused by falls (n = 11), motor vehicle accidents (n = 2), and bicycle accidents (n = 2). Children with grade V renal injuries had a greater mean injury severity score (P = 0.004) and

Comment

The incidence of renal injuries in children is difficult to define. Blunt abdominal trauma is reported to involve renal injury in 10% to 20% of cases, with 10% of those high-grade injuries.1, 3 A search of the National Pediatric Trauma Registry showed that renal trauma comprised 1.6% of total injuries.9 High-grade renal trauma was diagnosed in 20 (39%) of the 79 patients in our study. High-grade renal trauma may have been more common in our study owing to the small study size and selection

Conclusions

Children with grade IV renal injury can usually be treated conservatively. Patients with significant urinary extravasation or renal fracture should undergo a trial of urinary drainage with early ureteral stenting and bladder catheterization. Grade V injury is associated with an increased risk of requiring open operative intervention and the renal preservation rates are low.

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    Citation Excerpt :

    Given the lack of long-term sequelae from grade I-II injuries and almost universal non-operative management of these injuries, it could be argued that diagnosing every grade I-II renal injury with CT scan may be clinically unnecessary. The use of non-operative management of higher grade injuries (IV–V) has also been reported with successful outcomes in the literature [[9,10]], further justifying the need to re-evaluate the use of routine CT scans for every pediatric renal trauma patient. Renal ultrasound is a common imaging study used in pediatric hospitals and is quickly obtained and very familiar as a diagnostic modality to pediatric urologists and radiologists.

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