28 Trauma

A Conservative Approach to Testicular Rupture in Adolescent Boys

Cubillos J, Reda EF, Gitlin J, et al (Cohen Children’s Med Ctr of New York-

Long Island Jewish Health System; Westchester Med Ctr, Valhalla, New York)

J Urol 184:1733-1738, 2010

Purpose.dManagement for blunt trauma with breach of the renalcapsule or bladder (extraperitoneal) has largely become nonsurgicalsince a conservative approach proved to be effective and safe. Currentlythe recommendation for managing testicular rupture is surgical explora-tion and debridement or orchiectomy. We report outcomes in boys diag-nosed with testicular rupture and treated without surgical intervention.

Materials and Methods.dIn the last year we conservatively treated 7consecutive boys with delayed presentation of testicular rupture afterblunt scrotal trauma. Patients were treated with scrotal support, antibi-otics to prevent abscess, rest, analgesics and serial ultrasound. We reportclinical information and outcomes.

Results.dThe 7 boys were 11 to 14 years old and presented 1 to 5 daysafter injury. Trauma was to the left testis in 3 cases and to the right testis in4. Patients presented with mild to moderate pain and similar scrotalswelling. Ultrasound findings consistently revealed hematocele andincreased echogenicity. Blood flow was present in the injured portion ofthe testes in 3 cases and to the remainder of the affected testicle in 6 ofthe 7 boys. In the remaining boy an adequate waveform was not seen ineither testicle, which the radiologist thought was secondary to prepubertalstatus. Other findings included scrotal edema, irregular contour and semi-niferous tubule extrusion. Followup was greater than 6 months in allcases. Five boys were seen at the office and the 2 remaining had telephonefollowup. In all cases hematocele resolved, testicular size stabilizedwithout atrophy and echogenicity normalized in the 5 patients with fol-lowup ultrasound. One patient required surgical repair of hydrocele4 months after trauma but no other patient needed surgical exploration.No abscess or infection developed.

Conclusions.dA conservative approach in a select group of adolescentboys with testicular rupture can result in resolution of the fracture andmaintenance of testicular architectural integrity.

:

Testicular rupture after blunt trauma has typically been deemed a relative

surgical emergency to decrease morbidity, expedite healing, and prevent testic-

ular loss. Surgical repair may also result in earlier recovery and a return to

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260 / Urology

normal activity. There is a small risk of orchiectomy and perhaps testicular injury

(atrophy) from the debridement and repair. The primary advantage of a nonop-

erative approach is avoiding unnecessary surgery. In the acute setting, the diag-

nosis of testicular rupture may not be clearly evident on ultrasound (US). There

is only a small hematocele and no definite disruption of the tunica or extrusion

of tubules. If the testicle is viable on US, then with appropriate parental coun-

seling expectant management is reasonable. Intractable discomfort, expanding

hematoma, and suspicion for infection/abscess formation are indications for

delayed exploration. If there is a delayed presentation and the patient is clini-

cally well, conservative treatment may be reasonable even when imaging is

conclusive.

D. E. Coplen, MD

Instituting a Conservative Management Protocol for Pediatric Blunt Renal

Trauma: Evaluation of a Prospectively Maintained Patient Registry

Fitzgerald CL, Tran P, Burnell J, et al (Detroit Med Ctr, MI)

J Urol 185:1058-1064, 2011

Purpose.dRetrospective studies show that even high grade pediatricrenal trauma can be safelymanaged conservatively.We evaluated a prospec-tive patient registry at our level 1 pediatric trauma center, where patientswith renal traumawere treatedwith an institutional review board approvedconservative blunt renal trauma protocol. Standardized treatment includeda trial of expectant management for all stable cases.Materials and Methods.dWe identified 39 children with blunt renal

trauma treated between 2003 and 2008. A strict conservative approachwas used, ie nonoperative management in cases that were hemodynami-cally stable or had a favorable response with up to 2 units of blood trans-fused and no operative renal lesion on imaging. Adult imaging protocolswere followed and exploratory laparotomy for nonrenal causes did notalter course of expectant renal management. Outcomes evaluated wereinjury grade, hematuria, operative management, length of stay and associ-ated injuries.Results.dBased on the American Association for the Surgery of Trauma

organ injury severity scale, 13 patients were considered to have grade Idisease, 8 grade II, 11 grade III, 6 grade IV and 1 grade V. Conservativemanagement resulted in a 97% nonoperative rate and a single renorrhaphy.Conclusions.dUsing a prospective patient registry, this study demon-

strates that conservative treatment of blunt pediatric renal trauma is safeand effective. Also, serious renal injuries are not missed by applyingadult diagnostic imaging protocols in children.

:

The authors prospectively evaluate a blunt renal traumamanagement algorithm

(Figure in the original article). They use an adult imaging protocol (gross hema-

turia, microscopic hematuria with shock, deceleration injury, or associated injury

requiring imaging). Because all patients did well with conservative management,