Nonoperative Management of Grade 5 Renal Injury in Children: Does It Have a Place?

• Published in: European urology 2010-01, Vol.57 (1), p.154-163
• Main Authors: Eassa, Waleed, El-Ghar, M. Abo, Jednak, Roman, El-Sherbiny, Mohamed
• Format: Article
• Language: English
• Subjects: Adolescent; Biological and medical sciences; Blood Transfusion; Child; Child, Preschool; Contrast Media; Drainage; Embolization, Therapeutic; Feasibility Studies; Female; Hemodynamics; Hemorrhage - diagnosis; Hemorrhage - etiology; Hemorrhage - physiopathology; Hemorrhage - surgery; Hemorrhage - therapy; Hemostatic Techniques; Humans; Injuries of the urinary system. Foreign bodies. Diseases due to physical agents; Kidney - blood supply; Kidney - diagnostic imaging; Kidney - injuries; Kidney - surgery; Male; Medical sciences; Nephrectomy; Nephrology. Urinary tract diseases; Patient Selection; Radionuclide Imaging; Retrospective Studies; Severity of Illness Index; Stents; Succimer; Time Factors; Tomography, X-Ray Computed; Traumas. Diseases due to physical agents; Treatment Outcome; Urology; Wounds, Nonpenetrating - complications; Wounds, Nonpenetrating - diagnosis; Wounds, Nonpenetrating - physiopathology; Wounds, Nonpenetrating - surgery; Wounds, Nonpenetrating - therapy
• ISSN: 0302-2838; 1873-7560
• DOI: 10.1016/j.eururo.2009.02.001

Abstract Background Nonoperative treatment of blunt renal trauma in children is progressively gaining acceptance; grade 5 renal trauma is associated with a significant rate of complications. Objective To assess the feasibility and outcome of initial nonoperative management of grade 5 blunt renal trauma in children. Design, setting, and participants This retrospective study included 18 children (12 boys and 6 girls; mean age: 8.4 ± 3.4 yr) who presented to the authors’ institutes with grade 5 blunt renal trauma between 1990 and 2007. Measurements An intravenous contrast-enhanced computed tomography (CT) scan demonstrated grade 5 renal trauma in all patients. Associated major vascular injuries were suspected in four patients. All were initially managed conservatively. Indications for intervention included hemodynamic instability, progressive urinoma, or persistent bleeding. Dimercaptosuccinic acid (DMSA) scans were performed at a mean time of 3.1 yr (range: 1–17) following the injury in nine patients. Results and limitations Four patients (22%) with suspected major vascular injuries required nephrectomy 1–21 d following the trauma. Two patients with continuing hemorrhage required selective lower-pole arterial embolization (11%). Three patients (17%) had their progressive urinoma drained percutaneously, and two of them required delayed reparative surgery for ureteropelvic junction (UPJ) avulsion. Nine patients (50%) were successfully managed nonoperatively. Kidneys were salvaged in 78% of patients. DMSA scanning showed a split function >40% in 44% of evaluated kidneys. Two patients (22%) had split function