complication following renal trauma

8/12/2019 Complication Following Renal Trauma

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ORIGINAL ARTICLE

Complications Following Renal Trauma

Margaret Starnes, MD; Demetrios Demetriades, MD, PhD; Pantelis Hadjizacharia, MD;Kenji Inaba, MD; Charles Best, MD; Linda Chan, PhD

Objectives: To evaluate and compare the incidence andtype of kidney-related complications among differentmodes of management for kidney injuries.

Design: Trauma registry andmedical record reviewstudy.

Setting:Level I trauma center in Los Angeles, Califor-nia.

Patients:

All patients with renal trauma injuries treatedfrom January 1, 1993, through December 31, 2006.

Main Outcome Measures:Severity of kidney injury,method of renal treatment, and kidney-related compli-cations.

Results: During the study period, 889 patients hadkidney injuries, 227 of whom (25.5%) had severe kid-ney injuries. In 568 patients (63.9%), the kidney wasnot explored; 173 patients (19.5%) underwent totalnephrectomy, 53 (6.0%) underwent partial nephrec-tomy, and 95 (10.7%) underwent kidney repair. Of the227 patients with severe kidney injuries, 89 (39.2%)

received no exploration, 105 (46.3%) underwent total

nephrectomy, 25 (11.0%) underwent partial nephrec-tomy, and 8 (3.5%) underwent nephrorrhaphy. Theoverall incidence of kidney-related complicationsexcluding renal failure was 5.2%. The kidney repairgroup was significantly more likely to develop localkidney-related complications than the total nephrec-tomy, partial nephrectomy, and no kidney explorationgroups, even though the nephrorrhaphy group had lesssevere kidney injuries. Patients with minor or moderate

kidney injuries who underwent kidney exploration hadmore than twice the local complication rate thanpatients with no kidney exploration (7.1% vs 3.3%,P=.05).

Conclusions: Selective nonoperative management is safefor blunt and penetrating kidney injuries. Patients man-aged with nephrorrhaphy are at higher risk for local kid-ney-related complications than other therapeutic mo-dalities. Patients with minor or moderate kidney injuriestreated with exploration of the kidney are more likely todevelop local complications than those treated withoutexploration.

Arch Surg. 2010;145(4):377-381

THE EVALUATION AND MAN-agement of renal traumahave undergone signifi-cant changes during thepast decade. The liberal use

of computed tomographic evaluation inblunt and penetrating trauma has im-proved the diagnosis and grading of theseverity of kidney injuries. More than90%of blunt trauma renal injuries can safelybe managed nonoperatively.1-3 The safety

of nonoperative management, even insevere grade IV injuries, is well docu-mented in the literature.4 The introduc-tion of nonoperative management in pen-etrating solid organ injuries has added anew method to our armamentarium in the

treatment of kidney injuries.5-7 To ourknowledge, the effect of the different meth-ods of management of kidney injuries onrenal-related complications has not beenstudied in the literature. The present studyevaluates the various therapeutic ap-proaches practicedin a large level I traumacenter and compares the type and inci-dence of kidney-related complicationsamong the different methods of kidneymanagement.

METHODS

This trauma registry andarchivedmedical rec-ordreview study includes all patients with re-nal trauma injuries admitted to the Los Ange-les County and University of SouthernCaliforniatrauma center from January 1, 1993,through December 31, 2006. The trauma reg-istry is maintained by 7 full-time nurses, andthe quality of data entry is monitored by the

See Invited Critiqueat end of article

Author Affiliations:Department of Surgery,Los Angeles County/Universityof Southern CaliforniaMedical Center, Los Angeles.

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including 292 of 582 patients with penetrating injuries(50.2%) and 276 of 307 patients with blunt injuries(89.9%) (P.001). In severe kidney injuries, 89 of 227patients (39.2%) did not undergo kidney exploration orlaparotomy, including 54 of 172 (31.4%) with penetrat-ing trauma and 35 of 55 (63.6%) with blunt trauma

(P.001). For minor or moderate kidney injuries, 238patients with penetrating trauma (58.0%) and 241 pa-tients with blunt trauma (96.0%) did not undergo kid-ney exploration.

Of the 889 patients, a nephrectomy was performed in173 patients (19.5%), including 146 of 582 patients withpenetrating trauma (25.1%) and 27 of 307 patients withblunt trauma (8.8%;P.001). Kidney repair was per-formed in 95 of 889 (10.7%) patients, including 93 of582 patients with penetrating trauma (16.0%) and 2 of307 patients with blunt trauma (0.7%;P .001). Partial

nephrectomy was performed in only 53 of 889 patientswith kidney injuries (6.0%), including 51 of 582 pa-tients with penetrating trauma (8.8%) and 2 of 307 pa-tients with blunt trauma (0.7%;P .001) (Table 3).

KIDNEY-RELATED COMPLICATIONS

Overall, 46 patients (5.2%) developed 1 or more kidney-related local complications: 36 of 582 patients with pen-etrating injuries (6.2%) and 10 of 307 with blunt trauma(3.3%; P =.08). The types of kidney-related complica-tions by management modality are given in Table 4.Ne-phrectomy was associated with a significantly higher in-cidence of renal failure than the other therapeuticmodalities (4.6% vs 0.6%, P .001). The overall inci-dence of kidney-related complications other than renalfailure was significantly higher in patients undergoing

Table 3. Frequency of Specific Therapeutic Interventions According to Mechanism of Injury and Kidney Injury Severitya

Mechanism and Severity of Injury

No. (%) of Patients b

Laparotomy WithNephrectomy

Laparotomy WithPartial Nephrectomy

Laparotomy WithKidney Repair

Laparotomy WithNo Kidney Exploration No Laparotomy

All mechanisms 173/889 (19.5) 53/889 (6.0) 95/889 (10.7) 207/889 (23.3) 361/889 (40.6)

Severe injury 105/227 (46.3) 25/227 (11.0) 8/227 (3.5) 39/227 (17.2) 50/227 (22.0)

Minor or moderate injury 68/662 (10.3) 28/662 (4.2) 87/662 (13.1) 168/662 (25.4) 311/662 (47.0)

Penetrating trauma 146/582 (25.1) 51/582 (8.8) 93/582 (16.0) 150/582 (25.8) 142/582 (24.4)

Severe injury 88/172 (51.2) 23/172 (13.4) 7/172 (4.1) 27/172 (15.7) 27/172 (15.7)Minor or moderate injury 58/410 (14.2) 28/410 (6.8) 86/410 (21.0) 123/410 (30.0) 115/410 (28.1)

Blunt trauma 27/307 (8.8) 2/307 (0.7) 2/307 (0.7) 57/307 (18.6) 219/307 (71.3)

Severe injury 17/55 (30.9) 2/55 (3.6) 1/55 (1.8) 12/55 (21.8) 23/55 (41.8)

Minor or moderate injury 10/251 (4.0) 0 1/251 (0.4) 45/251 (17.9) 196/251 (78.1)

a P .001 for comparing the distribution of cases by management method between severe and minor or moderate injury based on the Fisher exact test.b Percentages do not total 100 because of rounding.

Table 4. Comparison of Kidney-Related Complications Among Management Methods for Patients With Renal Trauma

Kidney-Related Complicationa

No. (%) of Patients

P

Valueb

All Patients

(N=889)

Laparotomy WithNephrectomy

(n=173)

Laparotomy WithPartial Nephrectomy

(n=53)

Laparotomy WithKidney Repair

(n=95)

Laparotomy WithNo Exploration

(n=207)

NoLaparotomy

(n=361)

Renal failure 12 (1.3) 8 (4.6) 0 1 (1.1) 2 (1.0) 1 (0.3) .004

Renal failure excludingextra-abdominalAIS-90 score 3

9 (1.0) 6 (3.5) 0 1 (1.1) 1 (0.5) 1 (0.3) .01

Any complication excludingrenal failure

46 (5.2) 11 (6.4) 2 (3.8) 10 (10.5) 14 (6.8) 9 (2.5) .001

UTI or pyelonephritis 20 (2.3) 7 (4.1) 2 (3.8) 4 (4.2) 4 (1.9) 3 (0.8) .04

Urine leak or fistula 11 (1.2) 3 (1.7) 1 (1.9) 2 (2.1) 3 (1.5) 2 (0.6) .36

Urinoma 4 (0.5) 0 1 (1.9) 2 (2.1) 1 (0.5) 0 .02

Abscess 3 (0.3) 1 (0.6) 0 0 0 2 (0.6) .77

False aneurysm 3 (0.3) 1 (0.6) 0 0 1 (0.5) 1 (0.3) .88

Arteriovenous fistula 1 (0.1) 0 0 0 1 (0.5) 0 .59

Vascular thrombosis 4 (0.5) 0 0 0 2 (1.0) 2 (0.6) .86

Persistent bleeding 11 (1.2) 1 (0.6) 0 2 (2.1) 5 (2.4) 2 (0.6) .27

Incomplete repair 3 (0.3) 1 (0.6) 0 1 (1.1) 1 (0.5) 0 .24

Infarct or parenchymal loss 2 (0.2) 0 1 (1.9) 1 (1.1) 0 0 .36Renal dysfunction 2 (0.2) 0 0 0 1 (0.5) 1 (0.3) .74

Abbreviations: AIS-90, Abbreviated Injury Scale 1990 Revision; UTI, urinary tract infection.a Kidney-related complications included renal failure, urine leak or fistula, urinoma, abscess, false aneurysm, arteriovenous fistula, vascular thrombosis,

persistent bleeding, incomplete repair, and renal insufficiency.b Pvalues were derived from the 2-sided Fisher exact test.





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nephrorrhaphy than in patients undergoing nephrec-tomy, partial nephrectomy, or no exploration of the kid-ney (Table 4), even though the nephrectomy group wasless likely to have severe kidney injuries than the othergroups. Further analysis of kidney-related complica-tions showed the incidence of complications after se-vere renal trauma was similar in patients who did andthose who did not undergo kidney exploration (7.3% [10of 138] vs 7.9% [7 of 89];P.99, 2-sided Fisher exact

test). However, in patients with minor or moderatetrauma, patients who underwent exploration of the kid-ney had more than twice the complication rate com-pared with patients who did not undergo exploration(7.1% [13 of 183] vs 3.3% [16 of 479], P =.05).

COMMENT

Thekidney is thethirdmostcommonly injuredsolidorganafter blunt traumaandthesecondmostcommon after pen-etrating trauma. The International Society of Urology esti-mates thatapproximately245 000renalinjuriesoccureachyear worldwide, approximately 80% of which areowingto

blunttrauma.12

Althoughlesscommoninmostinstitutions,penetrating trauma is more likely to cause severe renal in-juryrequiringnephrectomy.13,14 Inthis study,582 patients(65.5%)experiencedrenal traumafrom penetratingmecha-nisms.Also,inthepresentstudy,172patientswithpenetrat-ingtrauma (29.6%) and55 with blunttrauma (17.9%) hadsevere kidney injuries (grades IV and V).

The management of blunt renal trauma has not un-dergone significant change in the past decade. Nonop-erative management has remained the standard of carein most cases, with some pediatric series up to 95%.1 Inthepresent study,276 patients with blunt trauma(89.9%)were treated with no surgical exploration of the kidneyinjury. However, the management of penetrating inju-

ries has undergone major changes.5-7

Traditionally, pen-etrating renal injuriesweremanaged withexploration andnephrorrhaphy (61%), partial nephrectomy (48%), or noexploration of the kidney or nephrectomy. Small seriesof successful nonoperative management of renal stabwounds were reported as long ago as 1985.5 More re-cently, Wessells et al15 suggested that many grade II pen-etrating renal injuries can be managed nonoperatively.The approach to gunshot wounds to the kidney re-mained much more cautious,andoperation is widely con-sidered the procedure of choice. Thissurgical dogma waschallenged by a recent study,6 which showed that in ap-proximately 40% of renal gunshot wounds, there was noneed for exploration of the kidney. In a more recent pro-

spective study, 50% of isolated penetrating kidney inju-riesweresuccessfully managed nonoperatively. One caseof urinoma wasmanaged without operation.7 The presentstudy showedthat 142penetrating kidneyinjuries (24.4%)were successfully managed nonoperatively. Overall, 292patients with penetrating kidney injuries (50.2%) did notundergo kidney exploration. More than 30% of patientswith penetrating kidney injuries do not have any otherserious associated intra-abdominal injuries.7 These pa-tients are good candidates for nonoperative treatment.More than 26% of grade I or II penetrating kidney inju-

ries can safely be managed nonoperatively. The combi-nation of careful initial and serial clinical examinationsand computed tomographic evaluation is highly reli-able in identifying patients with associated hollow vis-cus injuries.7,16

The management of kidney injuries during lapa-rotomy may include no exploration of the kidney, an ap-proach followed in 207 patients (23.3%) in this series.No exploration of kidney hematomas owing to penetrat-

ing trauma should be considered in stable hematomasaway from the hilum.6,7 However, expanding hemato-mas or those involving the hilum should always be ex-plored because of the possibility of underlying signifi-cant vascular injuries.17 Routine exploration of kidneyinjuries, especially after blunt trauma, increases the riskof kidney loss.18 The safety of nonoperative manage-ment, even in grade IV renal injuries or injuries with uri-nary extravasation, is well documented in the litera-ture.4,19 In the present study, patients with minor ormoderate injuries undergoing kidney exploration weresignificantly more likely to develop local complicationsthan those without exploration. No difference was foundin the complication rates between exploration or no ex-

ploration in patients with severe injuries.Nephrectomy is the most commonly used surgical in-tervention for kidney injury, especially after penetrat-ingtrauma, andit was performed in 27 patients with blunttrauma (8.8%) and 146 patients with penetrating trauma(25.1% ). In a National Trauma Data Bank study, Wrightet al14 reported nephrectomy rates of 4% and 21% for pa-tients with blunt trauma and penetrating trauma, respec-tively. Removal of one of the kidneys in a patient withmajor associatedinjuries or other riskfactorsis more likelyto result in renal failure, as clearly shown in the presentstudy. The next most common surgical intervention wasnephrorrhaphy. This repair should be performed me-ticulously, with attention to precise suturing of any caly-

ceal injury andgood hemostasis.This procedurewasusedfrequently in penetrating trauma but rarely in blunttrauma. It is the procedure with the highest incidence ofkidney-related complications, even though its group hadless severe kidney injuries. The high incidence of localcomplications with this method might result from inad-equate debridement of devitalized tissues, failure to re-pair any calyceal injuries, or poor hemostasis. Of pa-tients treated with kidney repair, 10 (10.5%) developed1 or more local complications. However, almost all thesecomplications can safely be managed with percutane-ous drainage, stenting of the ureter, or angioemboliza-tion. In patients with hemodynamic stability, it might beappropriate to involve an experienced urologist for me-

ticulous repair of the calyceal system. The least-used sur-gical intervention was partial nephrectomy. It was per-formed in 51 patients with penetrating trauma (8.8%)undergoing a laparotomy butin only 2 patients with blunttrauma (0.7%). The procedure is associated with signifi-cantly lower local kidney-related complications com-pared with kidney repair.

In conclusion, selective nonoperative management ofpenetrating kidney injuries can safely be used in a sig-nificant number of patients, including those with severetrauma. Nephrectomy is associated with a higher inci-





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dence of renal failure than other therapeutic modalities.Nephrorrhaphy is associated with a higher incidence ofkidney-related local complications than the rest of theinterventions. Exploration of minor- or moderate-severity kidney injuries increases the risk for kidney-related local complications.

Accepted for Publication:May 26, 2009.Correspondence: Demetrios Demetriades, MD, PhD, Los

Angeles County/University of Southern California Medi-calCenter, 1200 N State St, Room 1105, Los Angeles, CA90033 ([email protected]).Author Contributions: Drs Starnes, Demetriades, andInaba had full access to all the data in the study and takeresponsibility for the integrity of the data and the accu-racy of the data analysis. Study concept and design: Starnesand Demetriades. Acquisition of data: Starnes andHadjizacharia.Analysis and interpretation of data: Starnes,Demetriades, Hadjizacharia, Inaba, Best, and Chan.Draft-ing of the manuscript: Starnes, Demetriades, and Hadji-zacharia.Critical revision of the manuscript for importantintellectual content:Demetriades, Inaba, Best, and Chan.Statistical analysis: Hadjizacharia and Chan.Administra-

tive, technical, and material support: Starnes, Demetria-des, Inaba, and Best. Study supervision: Demetriades andBest.Financial Disclosure:None reported.

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INVITED CRITIQUE

Renal Trauma

Open With Care

Starnes et al report a 14-year, single-center expe-rience of various treatment options for renaltrauma. They identified 889 patients with trau-

matic kidney injuries, of which 227 (25.5%) were high-grade (ie, AmericanAssociation for theSurgery of Traumagrades IV and V) injuries. Overall, roughly 63.9% of all

renal injuries were managed nonoperatively with mostowing to blunt mechanisms. This nonoperative groupincludes many patients with known renal injuries whounderwent a laparotomy for other reasons but hadno ex-ploration of the renal injury. For the most part, nonop-erative management of renal injuries was successful; how-ever, owing to the retrospective nature of the data, it isnot known how many patients who were initially man-aged nonoperatively required a subsequent operation orthe complication rate of those patients whose condi-tions failed to improve with nonoperative management.

If these data were available, the clinical usefulness of thisdata set would be greatly enhanced. Nevertheless, thisarticle provides invaluable data about the likely successof nonoperative management of renal trauma and thenatural history of attempted renal salvage surgery.

In patients who underwent renal exploration, sev-

eral important findings were noted. Patients who re-quired a nephrectomy had an 8-fold increase in postop-erative renal failure compared with those who did notundergo nephrectomy (4.6% vs 0.6%). Postoperative re-nal failure was the most common complication follow-ing nephrectomy. Once again, the surgical dictum thatrenal exploration is associated with a higher nephrec-tomy rate is confirmed by the authors. Partial nephrec-tomy was an infrequent procedure and was undertakenmuch less often than, but seemed better tolerated than,nephrorrhaphy. Patientsundergoing nephrorrhaphy had



complication following renal trauma

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