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.