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

Transcription

1 EUROPEAN UROLOGY 57 (2010) available at journal homepage: Pediatric Urology Nonoperative Management of Grade 5 Renal Injury in Children: Does It Have a Place? Waleed Eassa a, *, M. Abo El-Ghar a, Roman Jednak b, Mohamed El-Sherbiny b a Pediatric Urology Unit, Urology and Nephrology Center, Mansoura, Egypt b Division of Pediatric Urology, Montreal Children s Hospital and McGill University Health Center, Montreal, Quebec, Canada Article info Article history: Accepted February 2, 2009 Published online ahead of print on February 10, 2009 Keywords: Renal trauma Shattered kidney Nonoperative management Children 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: yr) who presented to the authors institutes with grade 5 blunt renal trauma between 1990 and 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 <30%. At last follow-up, none of the children were hypertensive or had any abnormality on urine analysis. Conclusions: Nonoperative management of grade 5 renal trauma is feasible. Prompt surgical intervention is required for those with major vascular injuries. Superselective arterial embolization can be an excellent option in patients with continuing hemorrhage and who have pseudoaneurysms. Patients with UPJ disruption can be salvaged by initial drainage of the urinoma followed by deferred correction. # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Montreal Children s Hospital, 2300 Rue Tupper Room C5.27, Montreal, Quebec, Canada H3H 1P3. Tel ; Fax: address: ped.urology@inbox.com, ped.urology@gmail.com (W. Eassa) /$ see back matter # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 EUROPEAN UROLOGY 57 (2010) Introduction The nonoperative treatment of blunt renal trauma in children is progressively gaining acceptance by clinicians, with published reports demonstrating effectiveness in >85% of patients [1,2]. Nonoperative treatment should be considered in patients without continuing hemorrhage and hemodynamic instability. Delayed bleeding from a renal artery pseudoaneurysm can be successfully managed with selective angiographic embolization [3,4]. When blunt trauma is accompanied by significant urinary extravasation, percutaneous drainage, sometimes with ureteric stenting, can result in the complete resolution of persistent urine leakage [2,5]. The function of such nonoperatively treated kidneys can be preserved despite morphologic scaring [6]. Grade 5 renal trauma (shattered kidney or major vascular injury) is associated with a significant rate of complications that include persistent bleeding, progressive urinoma formation, fever, and infection. Surgical intervention is more frequently required and often results in significant ipsilateral renal functional loss or an inevitable nephrectomy [7 11]. Recently, there have been reports of successful nonoperative management of grade 5 renal injuries [12,13]. In this paper, we present the short- and long-term outcomes following initial nonoperative management in 18 children sustaining a grade 5 renal injury. 2. Materials and methods The charts of all children who presented to the authors institutions with blunt renal trauma between 1990 and 2007 were identified. Only those presenting with a grade 5 renal injury (shattered kidney or major vascular injury) for whom urology service was consulted were included in this study. Trauma was graded according to the renal injury scale developed by the Organ Injury Scaling Committee of the American Association for Surgery of Trauma [14]. Grading was based on a contrastenhanced (1.5 2 ml/kg) abdominal computed tomography (CT) scan performed at the time of injury. A total of 102 patients were identified, of whom 18 (17.6%) presented with grade 5 renal injury and constituted the subject matter of this study. Initial treatment included intravenous fluids, broad-spectrum antibiotics, bed rest, and close clinical observation with monitoring of vital signs and serial hematocrits. Patients were transfused for hemodynamic instability or a hematocrit of <20%. Patients with gross hematuria were kept on bed rest until the urine was grossly clear. Daily clinical examinations and portable bedside abdominal ultrasounds were used to monitor the size of the /urinoma. CT scan was repeated in patients with persistent bleeding or an increasing /urinoma as detected clinically or by ultrasound at any time during the course of initial management. The findings on repeated CT scans were compared to the initial studies, and data were used for planning of subsequent interventions. Patients with hemodynamic instability (refractory to blood transfusion) or those with persistent bleeding (hematuria and/or increasing size) underwent either surgical exploration or angioembolization (based on CT findings). Patients with progressively increasing urinoma were treated by percutaneous drainage (PCD) with or without ureteral stenting. Data were collected with respect to the type of injury, symptoms at presentation, complications and their treatment, duration of hospital stay, initial radiologic evaluation, and radiologic evaluation prior to any intervention. Patients were evaluated at follow-up visits by clinical examination, serial blood pressure measurements, urine analysis, serum creatinine, and CT scan. Dimercaptosuccinic acid (DMSA) scanning was reserved for those patients with salvaged kidneys. Hypertension was defined as a systolic and diastolic blood pressure above the 95th percentile for age, sex, and weight [15]. 3. Results There were 6 girls and 12 boys with mean age yr (range: 3 14). The cause of trauma was a motor vehicle accident in 3 children and a fall from a height in 15 children. The injured kidneys were on the right in 11 patients and on the left in 7 patients. Five patients had only microscopic hematuria on initial urine analysis and 13 had gross hematuria. All 18 kidneys showed variable degrees of renal perfusion and multiple lacerations at the initial CT scan. A main renal pedicle injury was suspected in four patients due to the presence of a medially located with active extravasation and pooling of contrast-enhanced blood in the arterial phase of the scan, an indication of active bleeding from a major renal vessel (Fig. 1). A nonopacifying ipsilateral ureter was detected in four cases. Associated nonrenal injuries were reported in three patients, with two sustaining orthopedic injuries and one an ipsilateral hemothorax. Fifteen patients (83%) required blood transfusions. The four patients (22%) in whom a main renal pedicle injury was suspected required nephrectomy. All kidneys were on the right side and were explored via a right paramedian incision. One patient underwent nephrectomy on the first day of trauma due to hemodynamic instability. At the time of surgery, a partial injury of the main renal pedicle was found in all patients. The remaining three patients underwent a delayed nephrectomy as a result of a clinical course complicated by fever and a continuous drop in hemoglobin despite repeated blood transfusions. Serial ultrasound demonstrated the presence of a persistent. A repeat CT scan performed 7, 19, and 20 d following the trauma showed an increase in the size of the medially located /urinoma. Findings at the time Fig. 1 A contrast-enhanced arterial phase computed tomography (CT) image posttrauma showing active extravasation into the, indicating vigorous bleeding from the right kidney.

3 156 EUROPEAN UROLOGY 57 (2010) of nephrectomy included total disruption of the lower-pole parenchyma with ureteropelvic junction (UPJ) avulsion in two cases and multiple disruptive parenchymal injuries in one. Renal reconstruction or partial nephrectomy was judged as unsafe in those patients. There were no postoperative complications. Two patients (11%) required arterial embolization due to ongoing hemorrhage that required three transfusions over the course of a 2-d period. Both had repeat CT scans 9 and 10 d following the initial trauma. Posttraumatic pseudoaneurysms were demonstrated at the medial borders of completely shattered lower renal poles. These findings were not appreciated on the initial CT scans (Fig. 2a and b). Superselective embolization of the pseudoaneurysms with 0.5-mm platinum microcoils was successfully carried out (Fig. 2c e), and both patients subsequently had an uneventful recovery. Fig. 2 (a) Computed tomography (CT) scan showing a grade 5 traumatic injury of the left kidney; (b) a coronal reformatted image showing the shattered renal parenchyma and a lower-pole pseudoaneurysm; (c) selective angiography of the kidney prior to embolization identifies a pseudoaneurysm; (d) superselective angiography shows the pseudoaneurysm prior to embolization; (e) following embolization, the occluding microcoils can be seen, and there is nonfilling of the pseudoaneurysm.

4 EUROPEAN UROLOGY 57 (2010) Fig. 3 (a) A contrast-enhanced arterial phase computed tomography (CT) image showing an intact arterial supply with multiple deep parenchymal lacerations in the right kidney; (b) a follow-up image showing preserved perfusion of the kidney, contrast excretion, and approximation of the shattered parenchymal fragments; (c) dimercaptosuccinic acid (DMSA) scan of the same patient shows loss of perfusion of the ipsilateral upper pole with preserved function of the remaining part, with split function of 30%. Three patients (17%) developed an increasing urinoma detected by serial abdominal ultrasound 1 3 wk following the initial trauma. One patient was treated with simultaneous insertion of a percutaneous drainage tube and cystoscopic insertion of a double-j stent for 6 wk. The remaining two patients were managed only by insertion of a percutaneous drainage tube. Retrograde stenting failed in both of them due to UPJ avulsion. Extravasation continued despite the percutaneous drainage of the urinoma. Retrograde pyelography and successful repair were carried out at 10 and 12 wk later. A double-j stent was left in place for 6 wk following repair of the ureteropelvic junction. Hypertension developed in one patient and immediately resolved following the removal of a shattered left lower renal pole. There were no postoperative complications. Nine patients (50%) were successfully managed nonoperatively with no active intervention. All patients were discharged with stable vital signs and laboratory profiles as well as grossly clear urine. The mean hospital stay was d (range: 4 23). The mean follow-up was 4.6 yr (range: 1 17). At last follow-up, all patients were normotensive with a normal urine analysis and serum creatinine. The traumatized kidney was preserved in 14 of 18 patients (78%). A follow-up CT scan was carried out in 13 of 14 patients in whom the kidney was salvaged. The scan was performed at mean time of 8 mo (range: 6 18) following the injury. The initially shattered kidneys demonstrated reapproximation of the parenchymal fragments with separation of the individual fragments by thin hypoperfused scars. The fragments actively excreted contrast, thus demonstrating reasonable function. There were no vascular abnormalities or hydronephrosis apart from asymptomatic localized upper hydrocalycosis in one patient (Fig. 3a and b). A DMSA scan was performed in 9 of 14 patients in whom the kidney was salvaged. The scan was performed at a mean

5 158 Table 1 Summary of patient management No. Age, yr Sex Cause of trauma Side Initial CT Blood tx Serial US Delayed CT findings Management Hospital stay, d Hypertension Kidney salvage M Fall L Shattered kidney Yes Stable Not done Nonoperative 4.0 No Yes M Fall R Shattered kidney Yes Stable Not done Nonoperative 5.0 No Yes F Fall R Shattered kidney Yes Stable Not done Nonoperative 4.0 No Yes M Fall R Shattered kidney Yes Stable Not done Nonoperative 15.0 No Yes M MVA L Shattered kidney Yes Pseudoaneurysms Angioembolization 12.0 No Yes M Fall R Shattered kidney No Stable Not done Nonoperative 14.0 No Yes M Fall R Shattered kidney, suspicion of major vascular injury Yes Nephrectomy (delayed) 7.0 No No F Fall L Shattered kidney Yes Stable Not done Nonoperative 5.0 No Yes F Fall R Shattered kidney, Yes Not done PC drainage, retrograde, 21.0 No Yes nonvisualized distal ureter. urinoma deferred repair F MVA R Shattered kidney Yes Stable Not done Nonoperative 7.0 No Yes F MVA R Shattered kidney, Yes Not done Not done Nephrectomy (immediate) 6.0 No No nonvisualized distal ureter, suspicion of major vascular injury M Fall R Shattered kidney Yes Stable Not done Nonoperative 23.0 No Yes M Fall L Shattered kidney No Stable Not done Nonoperative 7.0 No Yes M Fall R Shattered kidney, suspicion of major vascular injury Yes M Fall L Shattered kidney Yes F Fall R Shattered kidney, nonvisualized distal ureter, suspicion of major vascular injury Yes M Fall L Shattered kidney No urinoma M Fall L Shattered kidney, nonvisualized distal ureter Yes urinoma Nephrectomy (delayed, avulsed ureter detected intraoperatively) 19.0 No No Pseudoaneurysms Angioembolization 18.0 No Yes Not done Not done Nephrectomy (delayed, avulsed ureter detected intraoperatively) PC drainage, retrograde plus double-j stent for 6 wk PC drainage, retrograde, deferred repair, partial nephrectomy 20.0 No No 8.0 No Yes 12.0 Yes, cured by partial nephrectomy Yes EUROPEAN UROLOGY 57 (2010) CT = computed tomography; tx = treatment; US = ultrasound; M = male; F = female; MVA = motor vehicle accident; L = left; R = right; PC = percutaneous.

6 EUROPEAN UROLOGY 57 (2010) of 3.1 yr (range: 1 17) following the initial trauma. Four patients (44%) showed preserved renal function with split function >40% on the affected side. Five patients showed variable degrees of renal dysfunction. One patient treated entirely nonoperatively demonstrated a split function of 29% (Fig. 3c). The two patients for whom arterial embolization was carried out were left with split renal functions of 30% and 27%. The two patients who underwent deferred renal reconstructions had split functions of 37% and 32%. The latter patient had a small portion of the lower renal pole excised. Table 1 summarizes patients management. 4. Discussion A growing body of literature supports primary nonoperative management of renal trauma in children. In a review by Buckley and McAninch, they demonstrated that 98.2% of blunt renal injuries (327 of 333) in children were successfully managed nonoperatively [11]. Renal exploration was required in only 1.8% of the cases, and all renal units were salvaged. Only one case with grade 5 blunt renal trauma was included in this series, however. Traditionally, grade 5 injury has been managed surgically, and little is known about the outcome of nonoperative management in such a group of patients [7 11]. Recently, there have been isolated reports of successful nonoperative management of grade 5 renal injuries [12]. Henderson et al reviewed their experience with renal trauma in 126 children, of whom 15 had sustained a grade 5 renal trauma [13]. Two patients died of associated head injuries. Four patients (30%) underwent surgery related to the renal injury. Two patients had an immediate nephrectomy, one required a delayed nephrectomy, and one underwent a delayed evacuation and drainage of a. The kidney was salvaged in 11 patients (73%). Six patients (33%) in our study required surgery for their renal injury (one immediate nephrectomy, three delayed nephrectomies, and two delayed reconstructive renal surgeries following initial percutaneous drainage). Of note, the four patients in whom major vascular injuries were suspected at the time of the initial CT scan required nephrectomy. Active extravasation and pooling of contrastenhanced blood in the arterial phase of the CT scan was noted in all four patients and should be considered an indication for prompt surgical intervention. The kidney was salvaged in 14 (78%) of our cases. To our knowledge, our study represents the largest series of patients managed nonoperatively for grade 5 blunt renal trauma and demonstrates the potential for excellent renal salvage rates. Selective arterial embolization has been used successfully for the treatment of delayed bleeding from renalartery pseudoaneurysms [4]. Dinkel et al showed the effectiveness and safety of superselective embolization in the primary control of active renovascular bleeding from severe blunt renal trauma in a series of nine consecutive patients, of whom three had grade 5 blunt renal trauma [3]. Superselective embolization in our series was used in two patients with continued bleeding who required repeated blood transfusions. Although some might consider surgical exploration more appropriate for those patients, our nonoperative approach permitted salvage of the traumatized kidney with a minimally invasive procedure. Patients with persistent extravasation of urine from a grade 4 or 5 injury can benefit from endoscopic or minimally invasive techniques in controlling the urinary leak [16]. Russell et al described their experience with endoscopic treatment of urinary extravasation in five patients with a grade 4 renal injury. Two patients were successfully managed with a percutaneous tube drain alone, while an internal stent was necessary in three [2]. Henderson et al used combined percutaneous and endoscopic drainage in one patient with a grade 4 injury with persistent urinary drainage, which resulted in resolution of the drainage and preservation of the kidney [13]. Similarly, one patient in our series was successfully treated with simultaneous insertion of a percutaneous tube drain and cystoscopic insertion of a double-j stent for 6 wk. Traditionally, management of isolated traumatic UPJ avulsion depends on time of diagnosis. Surgical exploration and reconstruction is recommended for those diagnosed early, while those with delayed diagnosis could benefit from initial drainage and deferred reconstruction. UPJ avulsion associated with high-grade renal trauma is rarely reported [1,13]. The classic signs of isolated UPJ avulsion, including nonopacifying ipsilateral ureter and medial extravasation in the absence of parenchymal laceration, are usually obscured in cases with high-grade renal trauma, especially in those who have a large /urinoma compressing the ureter. Diagnosis is usually made late, and early surgical exploration in these patients carries a high risk of nephrectomy [1,13]. In our series, four patients had nonopacifying ureter with suspected UPJ avulsion; two of them were explored due to complicated posttraumatic course, and UPJ avulsion was confirmed intraoperatively. In both cases, surgical reconstruction was not feasible and nephrectomy was inevitable. The remaining two were managed initially with a percutaneous tube drain followed by delayed surgical repair after wk. We feel this approach optimizes the conditions for a satisfactory repair and renal salvage. A delayed CT scan (24 48 h after the injury) has been shown in the literature to be useful in confirming urinary extravasation in those children with grade 4 injuries in whom extravasation has not been conclusively demonstrated on the initial scan [17]. The delayed extravasation may result from the development of a urinoma, completion of an initially partial disruption, or lack of adequate delayed images on the initial CT scan. Although routine follow-up imaging is not performed for hepatic or splenic injuries, delayed imaging of higher-grade renal injuries may be useful, particularly in cases of persistent bleeding, fever, or pain. We found that repeating the CT scan was helpful for those who did not improve during the initial period of nonoperative management. We repeated a CT scan 1 3 wk after the initial trauma due to continued bleeding (increasing ) in five patients. In two of them (40%), newly developed lower-pole renal posttraumatic pseudoaneurysms were demonstrated

7 160 EUROPEAN UROLOGY 57 (2010) Fig. 4 An algorithm for the management of a grade 5 renal injury. PCD = percutaneous drainage. and subsequently treated with superselective arterial embolization. Surgical exploration and possible nephrectomy were thereby avoided. In the remaining three patients (60%), CT documented increased size of medially located s without evidence of a vascular abnormality suitable for selective embolization. Angioembolization would have required embolization of the entire renal vascular supply. Consequently, surgical exploration was decided on; however, nephrectomy was inevitable. Our study highlights the importance of repeat CT scanning in patients with ongoing hemorrhage. The true risk of developing hypertension as a result of renal trauma is unclear. The reported incidence of posttraumatic hypertension ranges from 0% to 6.6% in the pediatric literature [1,2,14,17]. Surgical intervention can be considered if there is no response to medical treatment [13]. One child in our series developed hypertension (5.5%), necessitating medical treatment in the early posttraumatic period. The hypertension was subsequently cured with partial nephrectomy at the time of delayed reconstructive surgery. Long-term evaluation of our group of patients with salvaged kidneys has not revealed any to have developed hypertension; however, because of the relatively high reported risk of hypertension in these patients, we believe that long-term follow-up is still warranted. The ability of the kidney to heal satisfactorily and the infrequent occurrence of complications are the basis of nonoperative management. The short-term follow-up of such children shows normal total renal function, but little has been reported with respect to late renal function and morphology of salvaged kidneys. Henderson et al reported on the functional outcome of five patients with grade 5 blunt renal trauma who underwent isotope imaging 1 14 mo after injury [13]. All five renal units lost function, with two providing 30% of total renal function and three providing 17% to 21% of total renal function. Keller et al studied the late functional outcome in five children with grade 5 renal injuries using DMSA scanning [10]. Overall, 50% of the children with grade 5 injuries were left with severe dysfunction (split function <30%). Although morphological abnormalities were detected in all patients in our study, 44% of evaluated kidneys had preserved renal function. Two patients (22%) had split renal function <30%. We feel that such successful preservation of renal function in our series provides an objective support for the nonoperative treatment of grade 5 renal injuries. This study is retrospective by design and therefore has limitations. Data were collected by chart review of patients managed by multiple surgeons at two different institutions over an extended period of time. Nevertheless, a similar management (ie, nonoperative) approach was used. Extracting the important observations from our experience in the management of pediatric grade 5 blunt renal trauma has led us to propose the management algorithm shown in Fig Conclusions Nonoperative management of grade 5 renal trauma in children is feasible and should be considered as first-line treatment provided the patient is hemodynamically stable. Prompt surgical intervention is required for those with major vascular injuries as suspected by the presence of a medially located with active extravasation and pooling of contrast-enhanced blood in the arterial phase of the scan. Repeating the CT can be advantageous for those

8 EUROPEAN UROLOGY 57 (2010) patients with continuous or delayed bleeding. Superselective arterial embolization can be an excellent therapeutic option in certain patients with continuing hemorrhage and who have pseudoaneurysms. Patients with ureteropelvic junction disruption can be salvaged by initial drainage of the urinoma followed by delayed surgical intervention. Renal preservation can be anticipated in >75% of cases. Author contributions: Waleed Eassa had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Eassa, El-Sherbiny. Acquisition of data: Eassa, El-Ghar. Analysis and interpretation of data: Eassa, El-Ghar, El-Sherbiny. Drafting of the manuscript: Eassa, El-Sherbiny, Jednak. Critical revision of the manuscript for important intellectual content: El- Sherbiny, Jednak. Statistical analysis: Eassa, El-Sherbiny. Obtaining funding: None. Administrative, technical, or material support: None. Supervision: El-Sherbiny. Other (specify): None. Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None. Acknowledgement statement: The authors extend their thanks to the medical, paramedical and nursing staff in both Mansoura Urology and Nephrology Center and Montréal Children s Hospital who shared in providing state of art care for these group of patients. References [1] Margenthaler JA, Weber TR, Keller MS. Blunt renal trauma in children: experience with conservative management at a pediatric trauma center. J Trauma 2002;52: [2] Russell RS, Gomelsky A, McMahon DR, et al. Management of grade IV renal injury in children. J Urol 2001;166: [3] Dinkel HP, Danuser H, Triller J. Blunt renal trauma: minimally invasive management with microcatheter embolization experience in nine patients. Radiology 2002;223: [4] Halachmi S, Chait P, Hodapp J, et al. Renal pseudoaneurysm after blunt renal trauma in a pediatric patient: management by angiographic embolization. Urology 2003;61:224. [5] Gill B, Palmer LS, Reda E, et al. Optimal renal preservation with timely percutaneous intervention: a changing concept in the management of blunt renal trauma in children in the 1990s. Br J Urol 1994;74: [6] El-Sherbiny MT, Aboul-Ghar ME, Hafez AT, et al. Late renal functional and morphological evaluation after non-operative treatment of high-grade renal injuries in children. BJU Int 2004;93: [7] Cass AS, Luxenberg M, Gleich P, et al. Long-term results of conservative and surgical management of blunt renal lacerations. Br J Urol 1987;59: [8] Kristjansson A, Pedersen J. Management of blunt renal trauma. Br J Urol 1993;72: [9] Hammer CC, Santucci RA. Effect of an institutional policy of nonoperative treatment of grades I to IV renal injuries. J Urol 2003;169: [10] Keller MS, Eric Coln C, Garza JJ, et al. Functional outcome of nonoperatively managed renal injuries in children. J Trauma 2004;57:108 10, discussion 110. [11] Buckley JC, McAninch JW. Pediatric renal injuries: management guidelines from a 25-year experience. J Urol 2004;172:687 90, discussion 690. [12] Altman AL, Haas C, Dinchman KH, et al. Selective nonoperative management of blunt grade 5 renal injury. J Urol 2000;164:27 30, discussion 31. [13] Henderson CG, Sedberry-Ross S, Pickard R, et al. Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center. J Urol 2007;178:246 50, discussion 250. [14] Radmayr C, Oswald J, Müller E, Höltl L, Bartsch G. Blunt renal trauma in children: 26 years clinical experience in an Alpine region. Eur Urol 2002;42: [15] Report of the Second Task Force on Blood Pressure Control in Children Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics 1987;79:1 25. [16] Santucci RA, Fisher MB. The literature increasingly supports expectant (conservative) management of renal trauma a systematic review. J Trauma 2005;59: [17] Nance ML, Lutz N, Carr MC, et al. Blunt renal injuries in children can be managed nonoperatively: outcome in a consecutive series of patients. J Trauma 2004;57:474 8, discussion 478. Editorial Comment on: Nonoperative Management of Grade 5 Renal Injury in Children: Does It Have a Place? Arianna Lesma Department of Urology, Vita-Salute University, Milan, Italy lesma.arianna@hsr.it The goals of nonoperative management of blunt renal injury are to avoid unnecessary nephrectomy, to limit renal function loss, and to manage associated complications such as urinary extravasation, infection, and, of course, bleeding. Accurate staging of urinary injuries provided by excellent imaging and the recognition that many patients can be successfully managed with observation alone have expanded the nonoperative approach, but official guidelines are not available yet. In the present article [1], the authors reviewed their 17-yr experience with initial nonoperative management of 18 paediatric cases with isolated grade 5 renal blunt trauma. The authors preserved >75% (14 of 18) of the grade 5 traumatised kidney units, with a split function at long-term dimercaptosuccinic acid (DMSA) scan of >40% in 44% of evaluated kidneys (4 of 9) and with no case of late hypertension. In accordance with their experience, the authors suggest prompt surgical exploration only in

9 162 EUROPEAN UROLOGY 57 (2010) haemodynamically unstable children refractory to blood transfusion or in case of suspected renal pedicle injury. In all haemodynamically stable children, even in those with suspected ureteropelvic avulsion, nonoperative management is recommended. Deferred open surgery is reserved for children with persistent bleeding without evidence of aneurysm. Minimally invasive procedures such as angioembolisation and percutaneous drainage are indicated in case of aneurysm and progressive urinoma, respectively. The results of the present study [1] are convincing as far as the effectiveness in renal salvage is concerned, with literature-reported data of 40 87% salvaged kidneys [2]. Weaknesses of this study [1] include its retrospective design and its study population collected from two different institutions. A prospective study with the proposed algorithm will confirm the authors conclusions. Furthermore, the authors do not have long-term DMSA data for many patients in their population (5 of 14), so we are unable to completely evaluate the impact of nonoperative management on long-term renal function of this large but restricted cohort of patients. The study confirms the more and more limited indication for open surgery in case of isolated renal blunt trauma [3], even of high grade. The issue of severe associated injuries, such as liver, spleen, or lung injury [4], and their influence on the management of ipsilateral renal injury needs to be addressed. References [1] Eassa W, El-Ghar MA, Jednak R, El-Sherbiny M. Nonoperative management of grade 5 renal injury in children: does it have a place? Eur Urol 2010;57: [2] Henderson CG, Sedberry-Ross S, Pickard R, et al. Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center. J Urol 2007;178: [3] Buckley JC, McAninch JW. The diagnosis, management, and outcomes of pediatric renal injuries. Urol Clin North Am 2006;33:33 40, vi. [4] Broghammer JA, Langenburg SE, Smith SJ, Santucci RA. Pediatric blunt renal trauma: its conservative management and patterns of associated injuries. Urology 2006;67: DOI: /j.eururo DOI of original article: /j.eururo Editorial Comment on: Nonoperative Management of Grade 5 Renal Injury in Children: Does It Have a Place? Jack S. Elder Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA jelder1@hfhs.org In this issue of European Urology, Eassa et al retrospectively review the results of nonoperative management of grade 5 renal trauma in 18 children from two large medical centers dating back to 1990 [1]. Two-thirds of the patients were <10 yr old. Nonoperative management of children with grade 5 injuries (shattered kidney or major vascular injury) exemplifies the trend used in an increasing number of pediatric centers. Rogers et al recently reported 10 children with grade 5 injuries, all of whom required open operative repair, and only three kidneys were salvaged [2]. In contrast, Henderson et al described 15 pediatric patients, of whom 11 were managed nonoperatively; in that series, operative indications included hemodynamic instability in 2 and severe urinary extravasation with fever in 2 [3]. In addition to these early complications, there are several other major potential risks of which clinicians must be aware: arteriovenous fistula, pseudoaneurysm, delayed bleeding, and hypertension. Although nonoperative management of grade 5 renal trauma has been advocated for several years in adults [4], the pediatric kidney is more susceptible to renal trauma [5]. Children with grade 3, 4, or 5 renal injuries, for example, have a lower injury severity score compared with adults with similar renal injuries, indicating that less severe trauma can cause significant renal injury in a child. Furthermore, the source of injury often allows one to predict whether nonoperative management is safe [6]. Eassa et al assessed their patients initially with a computed tomography scan and managed them with vigorous hydration, broad spectrum antibiotics, bed rest, and careful monitoring of blood pressure and serial hematocrits [1]. Patients were transfused as necessary. The authors performed daily renal sonograms at the bedside. Children underwent renal exploration for hemodynamic instability, persistent hematuria, or increasing size of. urinoma size was managed by percutaneous drainage with or without ureteral stenting. Those with suspected major vascular injuries underwent delayed nephrectomy, while two with continuing bleeding underwent selective arterial embolization and two underwent delayed repair of a ureteropelvic junction avulsion. Overall, 50% required no intervention. The authors critical analysis of their data allows several important lessons to be learned from these pediatric patients. First, if there is a shattered kidney and a suspected pedicle injury with a medially located and active extravasation, the kidney cannot be salvaged and nephrectomy is advised. Second, if ureteropelvic junction disruption is suspected because the distal

10 EUROPEAN UROLOGY 57 (2010) ureter is not visualized, percutaneous drainage of the urinoma with delayed pyeloplasty may yield a satisfactory result, although prompt repair seems preferable if the patient is stable. Third, with expertise in pediatric interventional radiology, percutaneous management of arterial injuries is feasible. Finally, and most important, there is no algorithm or standard care path for these difficult cases. As seen in Table 1, care must be highly individualized to allow for a favorable result. The authors are to be congratulated for their success. [2] Rogers CG, Knight V, MacUra KJ, et al. High-grade renal injuries in children is conservative management possible? Urology 2004; 64: [3] Henderson CG, Sedberry-Ross S, Pickard R, et al. Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center. J Urol 2007;178: [4] Altman AL, Haas C, Dinchman KH, Spirnak JP. Selective nonoperative management of blunt grade 5 renal injury. J Urol 2000;164: [5] Brown SL, Elder JS, Spirnak JP. Are pediatric patients more susceptible to major renal injury from blunt trauma? A comparative study. J Urol 1998;160: [6] Gerstenbluth RE, Spirnak JP, Elder JS. Sports participation and high grade renal injuries in children. J Urol 2002;168: References [1] Eassa W, El-Ghar MA, Jednak R, El-Sherbiny M. Nonoperative management of grade 5 renal injury in children: does it have a place? Eur Urol 2010;57: DOI: /j.eururo DOI of original article: /j.eururo