Operative, Angiographic and Nonoperative Treatment of the Severely Injured Kidney: 21st Century Upda

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Operative, Angiographic and Nonoperative
Treatment of the Severely Injured Kidney 21st
Century Update

• Richard A. Santucci
• Chief of Urology Detroit Receiving Hospital
• Professor, Michigan State College of Osteopathic
  Medicine
• Detroit Michigan USA

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• One is never or hardly ever presented with a
  renal (trauma) condition that calls for immediate
  scalpel treatment.
• Dr. A. Swersie
• Military Urologist, WWII
• Experiences and Lessons of Emergency
  Urological Surgery in War 1947

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Approaches

• Varies from very aggressive to very unaggressive
• Most older series operate on about 8
• Many modern series operate on 0
• Varies widely depending on relative number of
  high grade injuries in series and case mix

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McAninch operative rate

• 3 Grade III nephrectomy
• 76 Grade III surgery (nephrectomy/renorrhaphy)
• 9 Grade IV nephrectomy
• 78 Grade IV surgery (nephrectomy/renorrhaphy)
• N2467 renal trauma patients
• Reflects early series back to 1970s where
  operative therapy was more widely used
• Santucci et al, J Trauma. 2001 Feb50(2)195-200.
  Validation of the American Association for the
  Surgery of Trauma organ injury severity scale for
  the kidney.

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Operative Rates by Mechanism
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Expectant approach is underused

• About 100 citations support more conservative
  approach to renal trauma
• Not universally embraced
• N1360 renal trauma patients in the US
• 23 rate renal surgery
• Appalling 64 nephrectomy rate

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Data from other centers operative rate can be
lower than McAninch BLUNT I

• Matthews et al. 16 operative rate for BLUNT
  major injuries (Grade III-V) (n55)
• Compare to 63 McAninch, n93
• Nephrectomy rate 0 (McAninch 11)
• Few complications (stents in 4)
• Matthews, L. A., Smith, E. M., and Spirnak, J.
  P. Nonoperative treatment of major blunt renal
  lacerations with urinary extravasation. J Urol.
  157 2056-2058., 1997.

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Operative rates can be lower, and then lowered
further BLUNT II

• Danuser et al. Changed institutional policy to
  nonoperative
• Decrease OVERALL renal operative rate by about
  half
• 79 (n69) to 42 (n34)
• Total blood loss less with conservative treatment
• Complications Hypertension rate same
• Danuser, H., Wille, S., Zoscher, G., and Studer,
  U. How to treat blunt kidney ruptures primary
  open surgery or conservative treatment with
  deferred surgery when necessary? Eur Urol. 39
  9-14., 2001.

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Operative rates can be lower, and then lowered
further MIXED III

• Moudouni et al. 21 operative rate Grade III-V,
  n28 (compare McAninch 45 blunt, n135)
• Hospital length of stay lower with nonoperative
• 4 stent, 7 delayed renorrhaphy
• Moudouni, S. M., Hadj Slimen, M., Manunta, A.,
  Patard, J. J., Guiraud, P. H., Guille, F.,
  Bouchot, O., and Lobel, B. Management of major
  blunt renal lacerations is a nonoperative
  approach indicated? Eur Urol. 40 409-414., 2001.

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Overall Results Multi-institutional Nonoperative
Grade IV

• Meta Analysis of 16 papers
• N324 Grade IV renal injuries
• 90 managed nonoperatively
• 12.6 require delayed surgery
• 4.6 required nephrectomy
• Santucci RA and Fisher MB The literature
  increasingly supports expectant (conservative)
  management of renal trauma--a systematic review.
  J Trauma. 59 493-503, 2005.

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The Ultimate Test The Shattered Kidney
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Conservative Rx of Blunt Grade V Injury Study I

• 0 n6
• Compare to McAninch 95 (n21)
• Fewer intensive care unit days nonoperative (4 vs
  9, pNS)
• FAR less need for transfusion 3 vs 25 units
  p0.01
• Altman AL, Haas C, Dinchman KH, Spirnak JP.
  Selective nonoperative management of blunt grade
  5 renal injury. J Urol. 2000 Jul164(1)27-30

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Conservative Rx of Blunt Grade V Injury Study II

• N6 conservative compared to 6 historical
  nephrectomy (abstract only)
• Fewer transfusions (4 vs 16)
• Lower mortality rate (0 vs 67)
• Perego, K.L., Little, D. C. and Kirkpatrick, A.
  K. conservative nonoperative management of Grade
  5 blunt renal trauma. J Urol. 165 (supplement,
  abstract 61), pp 14-15, 2001

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Indications for Surgery BLUNT

• Absolute
• Grade V pedicle avulsion (nephrectomy)
• Exsanguinating injury (nephrectomy or
  renorrhaphy)
• Relative
• Persistent renal bleeding gt2 units day
• Extracapsular urine extravasation WITH
  devascularized parenchymal segment
• Associated enteric/pancreatic injury

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Data to support relative indications Blunt, with
devitalized

• Extracapsular urine extravasation WITH
  devascularized parenchymal segment
• n43 Grade IV injuries
• 38 complication rate when observed
• Husmann DA, Gilling PJ, Perry MO, Morris JS,
  Boone TB. Major renal lacerations with a
  devitalized fragment following blunt abdominal
  trauma a comparison between nonoperative
  (expectant) versus surgical management. J Urol
  1993 Dec150(6)1774-7

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Data to support relative indications Blunt with
devitalized cont

• Moudouni et al. 2001
• N11 Grade IV and V blunt injuries all managed
  conservatively
• Increased negative outcomes compared to no
  devitalized segment

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Data to support relative indications Blunt, with
enteric injury

• Operate on major renal lacerations and enteric or
  pancreatic injury (requiring laparotomy)
• N 14 treated conservatively
• 85 morbidity if associated enteric/pancreatic
  surgery
• Falls to 23 if renal injury treated at time of
  laparotomy (n13)
• Major renal lacerations with a devitalized
  fragment following blunt abdominal trauma a
  comparison between nonoperative (expectant)
  versus surgical management. Husmann DA, Gilling
  PJ, Perry MO, Morris JS, Boone TB. J Urol. 1993
  Dec150(6)1774-7.

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Reasonable Conclusion BLUNT

• All blunt Grade I-II injuries can be treated
  nonoperatively
• Most/all Grade III-IV injuries can be treated
  nonoperatively
• Even McAninch would agree in 2007
• Grade V? Not enough data (n14) but promising
  proof of principle for aggressive nonoperative
  treatment
• Think twice in cases of colon/pancreatic injury,
  or devitalized segment plus leakage

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Change Gears PENETRATING TRAUMA
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Conservative Management of Stab Wounds

• Well established in literature-South Africa
• N60, no shock, hematuria and stab
• 20 with complications (bleeding)
• 10 embolization
• 3 nephrectomy
• 2 heminephrectomy
• 2 ligation of arteriovenous malformation
• Heyns and Vollenvollen. Selective surgical
  management of renal stab wounds.Br J Urol. 1992
  Apr69(4)351-7.
• 20 complications confirmed (US series)
• Bernath et al.Stab wounds of the kidney
  conservative management in flank penetration. J
  Urol. 1983 Mar129(3)468-70.

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Penetrating Trauma The World is Changing

• General Surgery literature
• Well known USC study
• n1856 patients abdominal GSW
• 43 hemodynamically stable, - peritoneal signs
• 96 of these were observed WITHOUT LAPAROTOMY
  (total 38 all gsw patients)
• Velmahos et al. Ann Surg. 2001 Sep234(3)395-402
  Selective nonoperative management in 1,856
  patients with abdominal gunshot wounds should
  routine laparotomy still be the standard of care?

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Conservative Management of Gunshot Wounds

• Little data
• No touch approach at Detroit Receiving for
  Grade I-IV (n55)
• Only those exsanguinating from the kidney were
  operated nephrectomy (all grade V)
• Nephrectomy rate 75 Grade V, 0 all else
• Includes 2 Grade II and 3 Grade IV GSW injuries
• Low 4 complication rate (fever, hematuria)
• Hammer and Santucci. J Urol. 2003
  May169(5)1751-3. Effect of an institutional
  policy of nonoperative treatment of grades I to
  IV renal injuries.

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Conservative management low velocity renal gsw

• Serafetinides 2004
• N74
• 54 managed nonoperative
• Few complications
• Velmahos 1998
• N20
• 38 managed nonoperative

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What to do with Intraoperative consult
nonexpanding perirenal hematoma

• Consider One-shot intraoperative IVP
• 2 mg/kg iv contrast
• If normal, consider no exploration
• Realize that if you explore it you MAY end up
  taking it out unnecessarily!
• Ok to explore if you feel qualified, and you feel
  if necessary, but consider NOT exploring
• GSW consider making sure that renal pelvis and
  ureter are uninjured

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Conservatively treated Grade III shotgun injury
EASY
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Conservatively treated Grade IV GSW HARDER
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Conservatively treated Grade IV GSW HARDEST
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Pediatrics

• Nonoperative likely equally (or more) successful
  in peds
• Dozens of manuscripts support
• Complicating factor of renal abnormalities
  (congenital hydronephrosis, Wilms tumor)
• 1-19 incidence
• Be aware of potential major injury from minor
  trauma
• Nephrectomy rate as high as 33 in congenital
  hydronephrotic kidney
• May do well with perc nephrostomy, delayed repar
  of the congenital problem

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Pediatric Grade IV injury

• 17 patients with blunt Grade IV injury
• no renorrhaphy was required
• delayed problems developed in 3 (18)
• 1 required delayed nephrectomy
• 1 patient lost kidney function presumably due to
  the initial injury (6)
• 1 patient needed a decortication for late
  renovascular hypertension (6)
• Renal embolization was rarely required (6), but
  helpful.
• Stents were needed in 29, and percutaneous
  drains in 12.
• Cannon et. al. CT Findings in Pediatric Renal
  Trauma Indications for Early Intervention? J.
  Urol, 2008

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PEDIATRICS 13 year old hockey player who fell on
the skate of another player
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2 year old unrestrained passenger in a bus versus
car MVA
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Indications Published Renovascular

• Absolute
• Avulsion speedy nephrectomy
• Renovascular injury in a single kidney (repair)
• Expert opinion
• Bilateral injury (repair)
• Expert opinion

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Indications Published Renovascular

• Relative
• Renovascular injury (artery thrombosis) with 2
  kidneys
• Nephrectomy (conservative)
• Artery repair often fails
• 6-14 success (Clark et al, Surgery, 1982)
  (Carroll et al, J Trauma, 1990)
• 5 liters extra blood loss on average one series!
• Nephrectomy widely recommended (Ivatury et al, J
  Trauma, 1989) (Knudson et al, J Trauma, 2000)
• Repair
• 40 success in expert hands only (Brown, Graham,
  Mattox, FELICIANO, DeBakey American J Surgery,
  1980)

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Indications Published Renovascular

• Relative
• Contained hemorrhage (Grade IV) from partial
  vein/artery laceration. Watch or repair.
• Expert Opinion
• Do not operate Segmental injury--No treatment
• N24 patients, no complications
• Bertini et al. The natural history of traumatic
  branch renal artery injury.J Urol. 1986
  Feb135(2)228-30.
• Multiple other studies support

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Angiography

• Commonly done but published reports scarce
• Eastham, n16 stab wounds
• 11 angiography
• 9 successful
• 2 require open renorhaphy
• Nmany (pediatric, stab, iatrogenic, blunt), 100
  hemostasis in delayed bleeds

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Benefits of Renal Salvage

• No unnecessary surgery
• No iatrogenic nephrectomy
• 6 fold reduction in one study
• 2 fold reduction in another
• 0 nephrectomy in some series!
• PROBABLY true that saving nephrons saves patients
• Trauma nephrectomy patients have half the
  creatinine clearance
• 4 higher need for dialysis in those who have
  trauma nephrectomy (7 v 11)
• One study shows no acute outcomes difference
  between renorrhaphy and nephrectomy

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A final word

• Do NOT treat ureteric or renal pelvis injuries
  nonoperatively!
• Watch out for MEDIAL extravasation on CT scan

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Summary

• Blunt parenchymal
• I-IV Manage conservatively
• V consider conservative but watch closely
• Stab
• I-IV Manage conservatively but watch for 20
  complication rate requiring surgery
• V Operate
• Gunshot
• Little data
• Consider conservative management if not
  exsanguinating
• Monitor closely

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Summary

• Renovascular
• Avulsion speedy nephrectomy
• Partial avulsion of artery consider observation
  versus nephrectomy or (rarely) repair
• Thrombosis of artery nephrectomy (repair if
  single kidney or bilateral injury)
• Partial avulsion of vein consider repair or
  close observation if contained
• Segmental no need to operate

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RememberConservatively treated Grade IV GSW
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