conservative management of penetrating renal injuries aaron smith, do efraim serafetinides, md...

Conservative Management of Penetrating Renal Injuries

Aaron Smith, DOEfraim Serafetinides, MDRichard A. Santucci, MD

Introduction• Penetrating renal trauma had traditionally been treated by renal

exploration.1

• Renal exploration is associated with nephrectomy rates ranging from 11-64%. 2

• Nephrectomy can lead to increased morbidity, mortality, renal failure rates. 3-,4

• Currently, non-operative management has gained acceptance for management of renal stab wounds. 5

• Expectant management has an increasing role in the management of abdominal gunshot wounds (GSW). 6,7

1. Scott, R., Jr., Carlton, C., et al. Penetrating injuries of the kidney: an analysis of 181 patients. J. Urol., 101: 247, 1969.2. Wessells H, Suh D, Parker Jr, et al. Renal injury and operative management in the United States: results of a population-based

study. J. Trauma, 2003; 54: 423-430.3. McGonigal MD, Lucas CE, Ledgerwood AM. The effects of treatment of renal trauma on renal function. J Trauma. 1987; 27:

471-476.4. Narrod JA, Moore EE, Posner M, et al. Nephrectomy following trauma-impact on patient outcome. J Trauma. 1985; 25: 842-

844.5. Armenakas NA, Duckett CP, McAninch JW. Indications for nonoperative management of renal stab wounds. J Urol. 1999; 161:

768-771.6. Hammer CC, Santucci RA. Effect of an institutional policy of nonoperative treatment of grade I-IV renal injuries. J Urol. 2003;

169: 1751-17537. Wessells H, McAninch JW, Meyer A, et al. Criteria for nonoperative treatment of significant penetrating renal lacerations. J Urol.

1997; 157. 24-27.

Purpose

• Review our experience in penetrating renal trauma when employing principles of expectant management

• Bolster current literature on expectant management of penetrating renal injury

• Reduce iatrogenic nephrectomy rates

Study Design

• IRB approved• Multi-institutional

– Detroit Medical Center (DMC)– Athens, Greece

• Retrospective analysis• 1990-2004 (Greece)• 2000-2007 (DMC)

Patients

• Greece– AAST Grade II-III– 85 stab wounds– 41 GSWs

• 30 low-velocity gunshot wounds (LVGSW)• 11 high-velocity gunshot wounds (HVGSW)

• DMC– AAST Grade III-IV– 2 stab wounds– 11 GSWs (LVGSW)

Materials & Methods

• 139 charts were reviewed from two trauma databases

• Injury type (stab, GSW), AAST Grade, physical and radiographic findings, associated injuries, management and follow-up was noted

• Initial evaluation included physical exam, lab tests and radiographic staging

• All hemodynamically stable patients were selected for conservative management of their GU injuries

Materials & Methods

• Patients with hemodynamic instability or injury to renal pelvis/ureter on imaging were taken for renal exploration

• Those selected for expectant management were treated with:– Serial physical exams by experienced teams– Hematocrit monitoring– Hemodynamic monitoring– Antibiotics– Bed rest

Materials & Methods

• The GSW, stab wound subgroups were compared with regard to:– Mean associated injuries/patient– Transfusion requirement– Need for nephrectomy– Delayed complications– Mean Length of Stay (LOS)– Death

Results

Outcome Status Stab (N=87) GSW (N=52) P-value

Transfusion Yes 14 (16%) 40 (77%) <.0001

No 73 (84%) 12 (23%)

Nephrectomy Yes 0 (0%) 16 (31%) <.0001

No 87 (100%) 36 (69%)

Delayed Complication

Yes 9 (10%) 4 (8%) 0.767

No 78 (90%) 48 (92%)

Results

Outcome Stab (N=87) GSW (N=52)

Mean associated injuries/patient

0.53 2.1

Mean days of hospitalization

6.8 17.6

Death 0 1

Results

Surgical Intervention

Stab (N=87)

LVGSW (N=41)

HVGSW (N=11)

Drainage/ stent

1 (1.1%) 3 (7.3%) 0 (0%)

Renorrhaphy 2 (2.3%) 8 (19.5%) 0 (0%)

Partial Nephrectomy

1 (1.1%) 5 (12.2%) 0 (0%)

Nephrectomy 0 (0%) 5 (12.2%) 11 (100%)

Results

• 83/87 (95.2%) of patients with stab wounds were successfully treated expectantly. Number of lost renal units=0

• 20/41 (48.8%) of LVGSW patients did not require GU-specific surgical intervention (51% operative rate). Number of lost renal units= 5

• 11/11 (100%) of HVGSW patients underwent nephrectomy

• 16/52 (30.8%) total GSW patients underwent nephrectomy

Conclusions

• Expectant management is a reasonable option for the treatment of renal stab wounds

• Approximately 50% of patients with LVGSW will require GU-specific surgical intervention

• HVGSW mandated more aggressive treatment • A renal salvage rate of 88.5% (123/139) for

penetrating trauma was achieved with selected exploration and an organ preserving strategy for grades II-IV renal injury.