management of pediatric blunt renal trauma a systematic review

Management of pediatric blunt renal trauma: A systematic review

Elyse LeeVan, MD, Osnat Zmora, MD, Francesca Cazzulino, Rita V. Burke, PhD, MPH, Jessica Zagory, MD,and Jeffrey Scott Upperman, MD, Los Angeles, California

BACKGROUND: Blunt trauma remains a significant cause of morbidity and mortality in the pediatric population. The use of conservativemanagement for blunt renal trauma is widely accepted in adult trauma literature and is now increasingly accepted for use in thepediatric patient population. This study aimed to review current practices in pediatric blunt renal trauma management and tohighlight current practices in conservative protocols, success rates of conservative management strategies, as well as short- andlong-term outcomes of blunt renal trauma management.

METHODS: This is a systematic review of PubMed, Ovid, and the Cochrane Library. The following search was performed in each ofthe three databases: (Renal or Kidney) AND (Pediatric or Children) AND Trauma AND Management. Publications werelimited to publish date after January 1, 2000. Inclusion criteria were (1) original research articles regarding managementof pediatric blunt renal trauma, (2) involvement of cases of high-grade renal (Grades IVand V) trauma, and (3) more than onepatient presented per study. Literature reviews and meta-analyses were excluded.

RESULTS: Titles and abstracts (n = 308) were screened to identify scientific articles reporting original research findings. A total of32 articles met the selection criteria and were included in the review.

CONCLUSION: The literature supports application of conservative management protocols to high-grade blunt pediatric renal trauma. Criteriafor early operative intervention are not well understood. At this time, emergent operative intervention only for hemody-namic instability is recommended. Minimally invasive interventions including angioembolization, stenting, and percutaneousdrainage should be used when indicated. Short- and long-term outcomes are favorable when using conservative manage-ment approaches to Grade IV and V renal injuries. Further studies including prospective studies and randomized controltrials are necessary. Cost analyses of current treatment protocols are also necessary to guide efficient management strategies.(J Trauma Acute Care Surg. 2016;80: 519Y528. Copyright * 2016 Wolters Kluwer Health, Inc. All rights reserved.)

LEVEL OF EVIDENCE: Systematic review, level III.KEY WORDS: Renal; kidney; pediatric; blunt; trauma.

B lunt trauma remains a significant cause of morbidity andmortality in the pediatric population.1Y4 Compared with the

adult kidney, the pediatric kidney is more susceptible totrauma-induced injury due to anatomic factors.5,6 According tothe National Trauma Data Bank, greater than 18,000 pediatricrenal units experienced injury from 2002 to 2007.7 Renal in-juries are graded based on computed tomography (CT) imagingas classified by the American Association for the Surgery ofTrauma Organ Injury Scale and are ranked as Grade I (leastsevere) to V (most severe) (Table 1).8

The use of conservative management for blunt renaltrauma is widely accepted in adult urologic trauma literatureand is now increasingly accepted for use in the pediatric pa-tient population.5,9Y13 This strategy aims to preserve renalunits by using careful monitoring and minimally invasive tech-niques such as percutaneous drainage, endourologic stenting,and angioembolization. Multiple studies and meta-analysis of

these data support conservative management protocols in pa-tients with low-grade injuries; however, consensus regardingmanagement of high-grade injuries has not been achieved.14

Furthermore, many questions remain regarding what an opti-mal protocol for conservative management should include, whatthe threshold for implementation of operative managementshould be, and what is the ultimate impact of conservativemanagement on the patient and health care system. Even thedefinition of ‘‘conservative management’’ varies throughout theliterature, with minimally invasive procedures being variablydefined as conservative or operative/interventional manage-ment. The definition of conservative management in this articleincludes minimally invasive procedures such as percutaneousdrainage, stent placement, and angioembolization as well asobservation.

Operative intervention will refer to laparotomy and moreextensive renal exploration or resection. As more studies onpatients with high-grade renal trauma emerge, it is important tounderstand differences between Grade IV and Grade V injurythatmay impact treatment regimens. In this systematic review,wehighlight current practices in conservative protocols, successrates of conservativemanagement strategies, aswell as short- andlong-term outcomes of blunt renal trauma management.

PATIENTS AND METHODS

A search of all original research studies was conductedusing PubMed, Ovid, and the Cochrane Library. The following

SYSTEMATIC REVIEW

J Trauma Acute Care SurgVolume 80, Number 3 519

Submitted: September 8, 2015, Revised: November 10, 2015, Accepted: November24, 2015, Published online: December 26, 2015.

From the Department of General Surgery (E.L.V.), Huntington Hospital, Pasadena;Division of Pediatric Surgery (F.C., R.V.B., J.Z., J.S.U.), Children’s Hospital LosAngeles; and Keck School of Medicine (R.V.B., J.S.U.), University of SouthernCalifornia, Los Angeles, California; and Tel Aviv Sourasky Medical Center(O.Z.), Tel Aviv, Israel.

Address for reprints: Jeffrey S. Upperman, MD, Division of Pediatric Surgery,Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, CA90027; email: [email protected].

DOI: 10.1097/TA.0000000000000950

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

mailto:[email protected]

search was performed in PubMed: (Renal or Kidney) AND(Pediatric or Children) AND Trauma AND Management.Publications were limited to publish date after January 1, 2000.Patient population was limited to patients age 0 to 18 years.Language was limited to English. Search was limited to fulltext. Species was limited to humans. The search was repeatedin Ovid and Cochrane library. Abstracts were reviewed, andthose that met the selection criteria specified later were importedinto Endnote, a bibliographic management program. If the fullabstract was unavailable or it remained ambiguous whetherthe article complied with the selection criteria, the full articlewas obtained and reviewed for inclusion.15 Inclusion criteriawere (1) original research articles regarding management ofpediatric blunt renal trauma, (2) involvement of cases of high-grade renal (Grades IV and V) trauma, and (3) more than one

patient presented per study. Literature reviews and meta-analyses were excluded as well as all articles not written inEnglish or written before the year 2000.

Studies that reported blunt abdominal trauma manage-ment overall were only included if renal data were presentedindependently. Articles were included if the treatments ren-dered were broken down by grade of injury or grouped intohigh- or low-grade injury.

Treatment protocols, intervention type, outcome mea-sures including percent success of conservative protocols, andrenal salvage rates were recorded. Bias was assessed using theCochrane risk of bias assessment tool (Fig. 1).

RESULTS

Three hundred eight titles and abstracts were screenedto identify scientific articles reporting original research find-ings. A total of 32 articles met the selection criteria and wereincluded in the review (Table 2).5Y7,9,12,16Y42

Protocol for Conservative TherapyAlthough conservative management is discussed as a

cohesive entity, the protocol for conservative management isinconsistent throughout the literature. The articles reviewedin this study used diverse nonoperative measures in the sup-port of acutely injured patients. All studies advocated forsome combination of frequent vital sign evaluation, hemoglobin/hematocrit measurement, serial abdominal examination, andintravenous fluid resuscitation.5,6,9,18Y22,25,26,29,30,33,34,36,38Y40

Among the articles that clearly delineated their conservative pro-tocol, bed rest remained a common measure.5,6,9,12,18Y21,23,25,30,38

Although most studies did not report the duration of bed rest,typically, bed rest was maintained until resolution of grosshematuria.5,9,12,20,21,23,30

The study of Graziano et al.22 challenged the need forbed rest and instead applied an ‘‘abbreviated’’ protocol in-volving early mobilization; no urinary catheter, antibiotics, or

TABLE 1. American Association for the Surgery of TraumaOrgan Injury Scale for Renal Injury

Grade Type Injury Description

I Contusion Microscopic or gross hematuria, urologicstudies normal

Hematoma Subcapsular, nonexpanding withoutparenchymal laceration

II Hematoma Nonexpanding perirenal hematoma confinedto renal retroperitoneum

Laceration G1-cm parenchymal depth of renal cortexwithout urinary extravasation

III Laceration 91-cm parenchymal depth of renal cortex withoutcollecting system rupture or urinary extravasation

IV Laceration Parenchymal laceration extending through renalcortex, medulla, and collecting system

Vascular Main renal artery or vein injury with containedhemorrhage

V Laceration Completely shattered kidney

Vascular Avulsion of renal hilum, which devascularizesthe kidney

Figure 1. Cochrane risk of bias assessment toolVarticle bias.

J Trauma Acute Care SurgVolume 80, Number 3LeeVan et al.

520 * 2016 Wolters Kluwer Health, Inc. All rights reserved.


greenoa

Highlight

TABLE

2.Cha

racteristic

sof

Stud

iesInclud

edin

theRe

view

Author

Journal

Year

No.

Subjects

Age

Ran

ge(M

ean)

[Median]

Location

Study

Typ

eHospital

Stay,d

Transfusion

(No.

Patients)

Barsnesset

al.16

Journa

lof

Trau

ma

2004

47Not

recorded

Singlecenter,Denver,

UnitedStates

Retrospectiv

ereview

Not

recorded

Not

recorded

Bartleyet

al.9

Urology

2012

611Y

16(8)

Singlecenter,Detroit,

UnitedStates

Retrospectiv

ereview

Bygrade:

I=7.7,

II=7.9,

III=5.9,

IV=8.6,

V=9

10

Brogham

meretal.5

Urology

2006

631Y16

IVandV:(8.3)


UnitedStates

Retrospectiv

ereview

7.7

11

Buckley

etal.12

Journa

lof

Urology

2004

374

G18

Singlecenter,San

Francisco,

UnitedStates

Retrospectiv

ereview

Non

operative=14

.1,

operative=11.5

Not

recorded

Ceylanet

al.17

Pediatric

Surgery

Internationa

l20

0320

51Y

14(7.4)

Singlecenter,Izmir,Tu

rkey

Retrospectiv

ereview

Not

recorded

Not

recorded

Eassa

etal.18

Europ

eanUrology

2009

183Y

14(8.4)

Multicenter,Egy

ptandMontreal,Canada

Retrospectiv

ereview

11.5

15

Eeg

etal.19

Journa

lof

Urology

2009

73(10.5)

Singlecenter,To

ronto,

Canada

Retrospectiv

ereview

Not

recorded

Not

recorded

El-S

herbinyetal.20

British

Journa

lof

Urology

International

2004

131Y

15(8.4)

Singlecenter,

Mansoura,Egy

ptRetrospectiv

ecase

control

97

Fitzgerald

etal.21

Journa

lof

Urology

2011

810Y

19(9.7)


UnitedStates

Prospectiv

ecoho

rtBygrade:

I=5,

II=6,

III=12

,IV

=7,

V=10

Not

recorded

Gerstenbluthetal.42

Journa

lof

Urology

2002

685Y

15(10.1)

Multicenter,Cleveland,

andCleveland,U

nitedStates

Retrospectiv

ereview

Not

recorded

Not

recorded

Grazianoet

al.22

Journa

lof

Pediatric

Surgery

2014

703Y

17(11.8)

Singlecenter,KansasCity,

UnitedStates

Prospectiv

estud

y2.9

6

Heet

al.23

InternationalUrology

andNephrology

2011

831Y

16(7.2)

Singlecenter,Chonq

uing

,China

Retrospectiv

ereview

Bygrade:lowgrade=14.8,

high

grade=18.2

15

Henderson

etal.24

Journa

lof

Urology

2006

126

0Y17

(9)

Singlecenter,Districtof

Colum

bia,UnitedStates

Retrospectiv

ereview

Not

recorded

Not

recorded

Impellizzerietal.2

5Minerva

Pediatrica

2012

153Y

15(6.3)

Singlecenter,Messina,Italy

Retrospectiv

ereview

10.5

(3Y11)

3

Jacobs

etal.7

Journa

lof

Urology

2012

419

1Y18

NationalTraum

aDataBank

Retrospectiv

ecohort

Not

recorded

Not

recorded

Kelleret

al.26

Journa

lof

Trau

ma

2004

172Y

16(10.4)

Multicenter,Burlin

gton

and

St.Lou

is,U

nitedStates

Retrospectiv

ereview

Not

recorded

7

Kelleret

al.27

Journa

lof

Pediatric

Surgery

2009

163Y

16(10)

Singlecenter,StLou

is,

UnitedStates

Retrospectiv

ereview

Not

recorded

4

Kiankho

oyet

al.28

Journa

lof

Trau

ma

2010

266Y

16(12.3)

Singlecenter,Burlin

gton

,UnitedStates

Retrospectiv

ereview

Renal

specificinform

ation,

notrecorded

0

Manikandanetal.29

InternationalUrology

andNephrology

2009

212

(12)

Singlecenter,

Pond

icherry,India

Caseseries

Not

recorded

1

Margenthaleretal.30

Journa

lof

Trau

ma

2002

550Y

17(9.1)

Singlecenter,St.Louis,

UnitedStates

Retrospectiv

ereview

Not

recorded

11

Moham

edet

al.31

Journa

lof

Pediatric

Urology

2009

360Y

14(6.2

Singlecenter,Cairo,E

gypt

Retrospectiv

ereview

12.5

(5Y35)

Not

recorded

Mooget

al.32

Journa

lof

Urology

2003

200Y

16(9.7)

Singlecenter,

Strasbourg,

France

Retrospectivereview

with

control

Not

recorded

Not

recorded

Nance

etal.33

Journa

lof

Trau

ma

2004

950Y

18(10)

Singlecenter,Philadelphia,

UnitedStates

Retrospectiv

ereview

623

(Con

tinu

edon

next

page)

J Trauma Acute Care SurgVolume 80, Number 3 LeeVan et al.

* 2016 Wolters Kluwer Health, Inc. All rights reserved. 521


routine imaging; and discharge when patient tolerated a dietregardless of hematuria. Although authors reported a reductionin length of stay from a mean of 6.6 days to 2.9 days after theprotocol was applied, it is notable that this study addressed apopulation with greater than 50% low-grade injuries with fewerthan four patients (5%) with Grade V injury. In addition, fivepatients (7%) required readmission, although follow-up ultra-sound results were normal.

Admission to and duration of observation in the inten-sive care unit (ICU) varied considerably. ICU admissionwas recommended for all blunt renal traumas by severalauthors.12,30,31,33,35 Duration of ICU stay was recommendedas 24 hours to 1 week.12,31,33,35 Of note, Buckley andMcAninch12 as well as Mohamed et al.,31 who recommended48 hours and 1 week, respectively, had high length of stayscompared with other study populations. Nance et al.33 hadshorter average length of stay but a study population that washighly skewed to low-grade injury.

Empiric antibiotic therapy was used in six studies.6,18,20,31,34,39 Neither the rate of urinary tract infection nor the rateof infected hematoma was reported in the majority of studies;thus, the necessity and efficacy of this intervention are notknown, and further study is required to clarify this issue. The useof urinary catheter for bladder decompression was recommendedby two studies30,38 and specifically not used in one study.22

Guidelines for serial imaging remain a controversial topicin conservative management protocols. Several studies recom-mend routine serial imaging protocols.12,18,19,25,30,39 Four stud-ies recommend repeat imagingwithin the first 24-hour to72-hourwindow.12,18,19,25 Eassa et al.18 recommended daily bedsideultrasounds throughout the hospitalization in his population ofGrade V injury patients. The study by Eeg et al.19 specificallyaimed to apply the ‘‘as low as reasonably achievable’’ conceptto renal trauma imaging. After initial CT, the study teamused ultrasound for the evaluation of clinical changes and onlyused repeat CT if ultrasound was inconclusive. Only two pa-tients required repeat CT for urologic reasons including oneangioembolization and one patient with expanding urinoma.There were no complications caused by delayed diagnosis. Im-aging of all patients before discharge to confirm resolution ofextravasation was performed in one study.30 No intervention asa result of this imaging was described.

Indications for Operative InterventionThe criteria for operative management of blunt renal

trauma in children have not been fully delineated. This con-tributes to the discrepancy in the success rates seen for con-servative management throughout the literature.

One area of agreement throughout the literature is thathemodynamic instability, despite adequate resuscitation, is anabsolute indication for operative intervention or angiography.Several authors provided specific criteria for blood loss as anindication for surgery.12,21,34,35,37 Recommendations varyfrom a 3-U decrement in hematocrit12 to requirement of 2 Uof blood21,37 to transfusion of greater than 50% of bloodvolume.34,35 Ten studies list hemodynamic instability as thesole indication for operative intervention when consideringtreatment of isolated blunt renal trauma.5,9,16,19,20,23,25,30,34,35TA

BLE

2.(Con

tinued)

Author

Journal

Year

No.

Subjects

Age

Ran

ge(M

ean)

[Median]

Location

Study

Typ

eHospital

Stay,d

Transfusion

(No.

Patients)

Nerliet

al.34

Pediatric

Surgery

International

2011

43Not

recorded

Singlecenter,B

elgaum

,India

Retrospectiv

ereview

Conservativelymanaged

patientsG2wk

Not

recorded

Ozturket

al.35

Europ

eanJournalof

Pediatric

Surgery

2003

451Y15

[7]

Singlecenter,

Diyarbakır,Tu

rkey

Retrospectiv

ereview

Renal

specificinform

ation,

notrecorded

Renal

specific

inform

ation,

notrecorded

Philpottet

al.36

Journalof

Pediatric

Surgery

2003

213Y16(14.5)

Singlecenter,Philadelphia,

UnitedStates

Caseseries

9.5

0

Reese

etal.37

Journalof

Urology

2014

264Y16

(11.2)

Singlecenter,Pittsburgh,

UnitedStates

Retrospectiv

ereview

Early

interventio

n=7.4,

nonoperativ

e=5.4,

failedconservativ

emanagem

ent=7.9

2

Rogerset

al.38

Urology

2004

202Y14

(8.9)

Singlecenter,Baltim

ore,

UnitedStates

Retrospectiv

ereview

Bygrade:

IV=11

,V

=16

5

Russellet

al.39

Journalof

Urology

2001

154Y16

(11.5)

[11]

Singlecenter,Akron

,UnitedStates

Retrospectiv

ereview

11.1

6

Tsuiet

al.40

Injury

2011

151Y11

(6.5)

Singlecenter,CapeTown,

Sou

thAfrica

Retrospectiv

ereview

16.5

Not

recorded

Wan

etal.41

Journalof

Urology

2003

168Y17

(13.4)

[14]

Singlecenter,Buffalo,

UnitedStates

Retrospectiv

ereview

Not

recorded

3

Wesselet

al.6

JournalofPediatricSurgery

2000

671Y14

Singlecenter,M

annheim,G

ermany

Retrospectiv

ereview

Not

recorded

Not

recorded




greenoa

Highlight

Renal salvage rates with these operative criteria ranged from0% to 100% for both Grade IV and V injury.

Nine studies identified characteristic CT findings as anabsolute or relative indication for operative intervention.12,18,21,24,28,37Y40 Injury to the renal artery was a cause for operativeintervention in three studies.12,22,33 In two additional studies,operative management was reserved for more severe vascularinjury, specifically, unstable vascular Grade V injury21,33 andvascular pedicle injury.28 Nonvisualized renal units or evidenceof nonviable tissue was identified in three studies as an indi-cation to bypass a trial of conservative management.12,38,39

Despite implementing broader criteria for operative interven-tion, within the nine studies that list CT findings as a causeto intervene surgically, renal salvage rates remained high at86.7% to 100% and 30% to 100% in Grade IV and V injuries,respectively.12,18,21,24,28,37Y40

Urinoma and/or extravasation of urine represent a spe-cific area of controversy in the management of blunt renaltrauma. Overall, most patients with urinoma and/or extrava-sation of urine were managed effectively with conservativemeasures. Several authors specifically advocated a trial ofnonoperative management in this population.18,30,38 Despitethis, there is evidence that expanding urinoma or activeextravasation of urine has a role as an absolute or relative in-dication for surgery.12,18,24,26,30,31 Extravasation of urine wasidentified as the cause of failure of conservative managementfor individuals in eight studies.5,17,18,24,30,34,37,38

Although some patients with urinoma or extravasationof urine went on to require surgery, total nephrectomy wasrarely required after a trial of conservative management. Fol-lowing a trial of conservative management, at least one patientin each of eight studies (total of 12 patients) went on to receiverenorrhaphy or partial nephrectomy,5,17,18,24,30,34,38,39 whileonly one patient in each of three studies ultimately requirednephrectomy.5,30,37

Four patients who underwent surgical intervention werefound to have ureteropelvic disruption.5,18,30 Patients with ure-teropelvic junction injury may be a group that warrants specificmanagement strategies. Eassa et al.18 described four patients(22%) with suspected ureteropelvic junction avulsion based onnonopacifying ipsilateral ureters. Two required early interventionand received nephrectomies, whereas the remaining two under-went initial conservative management with percutaneous drain-age and successful delayed surgical repair.

Patients with complete renal fracture with retained bloodsupply to each segment and concomitant perinephric extrava-sation was suggested by Rogers et al.38 as a subpopulation ofpatients who are more likely to fail conservative therapy andmay benefit from early surgical intervention, but this was basedon two individuals with this finding. Reese et al.37 corroboratedthat this CT finding was a good predictor of a need for inter-vention but recommended endourologic management.

Medial extravasation of contrast was identified by twostudies as a predictor of conservative management failure.9,18

Of four individuals (22%) found to have medial extravasationof contrast in the study of Eassa et al., one required immediatenephrectomy and three required delayed nephrectomies. Ofthe two patients requiring delayed surgical intervention in thepopulation of Bartley and Santucci, both demonstrated medial

contrast extravasation on CT. Given these findings, it seemsthat medial extravasation of contrast may portend extensiverenal injury, which is not amenable to conservative therapy.

Grade IV InjuryTwenty-seven studies reported information specific to

patients with Grade IV injury. In these studies, 0% to 38.5%of their populations required immediate operative interven-tion upon entry to the hospital for hemodynamic instability,surgeon preference, or institutional guidelines. Seventeenstudies required emergent intervention in less than 15% of thepopulation with a mode of 0 patients who required interven-tion.5,9,20Y22,24Y27,29,30,33,36,38Y41 In the remainder of the stud-ies, patients were initially treated using conservative measures.Twenty-two of these studies had a success rate of at least 80%when treating patients conservatively.5,9,16,20Y24,26Y31,33,36Y42

The studies with the three largest patient populations accom-plished success rates of 88.6%, 93.8%, and 100%, respec-tively.22,24,37 Two studies that present as outliers with successrates less than or equal to 50% had small patient populations,and one did not discuss operative indications.6,25 Overall, renalsalvage rate was high with a conservative approach. Eighteenstudies reported renal salvage rates greater than 90%, withsixteen studies reporting renal salvage rates greater than 95%(Table 3).9,12,20Y22,24Y29,31,33,36Y38,40,41

Grade V InjuryIndications for the use of conservative management

in the patient population with Grade V injury remain highlycontroversial. The reviewed data show a wide range of successrates when using conservative management with renal salvageof 0% to 100%. Only 5 of the 15 studies for which successrates of conservative management could be calculated hadsuccess rates of 50% or less.6,17,23,31,42 Overall, renal salvagerate for 10 of the 20 studies that reported this informationwas greater than 80%. One challenge in interpreting this in-formation is the small patient population size. Few patientspresented with Grade V injuries, and even fewer were hemo-dynamically stable and eligible for conservative therapy. Eassaet al.18 had the largest analysis with 18 patients. This study usedhemodynamic instability, progressive urinoma, and persistentbleeding as operative criteria. Conservative management suc-cess rate was 70.6%, and overall renal salvage rate was 78%.Of the six studies that presented Grade IV and V injuries inaggregate, success of conservative management was overallhigh, 79.7% to 100%, with overall renal salvage rates of 69%to 100% (Table 4).7,16,19,32,34,42

Minimally Invasive TherapyAdjunct therapies including stent placement, percuta-

neous drainage, and angioembolization serve as minimallyinvasive alternatives to operative intervention. In the reviewedstudies, these three interventions were largely successful inobviating the need for surgery. Indications for these proceduresare as yet without consensus.

Seventeen studies used stenting and/or drainage pro-cedures as adjunct measures for the treatment of urinaryextravasation or expanding urinoma.5,7,9,17Y20,24,29,31Y34,36Y39

Nearly all studies cited ongoing urinary extravasation or




expanding urinoma as cause for stenting. Urinomas associatedwith fever, tachycardia, ileus, nausea, or flank pain are de-scribed indications.29,31,36,39 Eight studies reported 100%success rate at avoiding laparotomy with these measures.17,20,24,29,31Y33,36,39 Patients in three studies required ureteral stentingafter percutaneous drainage for persistent collection, with sub-sequent resolution of symptoms.24,29,39

Timing of drainage remains controversial. In the studypopulations, drainage and/or stenting was performed as earlyas 48 hours and as late as 5 weeks after injury. Two studiesspecifically commented on timing of stenting and/or percuta-neous drainage. In the study of Rogers et al.,38 where patientswere stented after 20 days of nonresolving urinoma, sponta-neous resolution was not seen after 14 days. Reese et al.37

described 16 patients initially managed conservatively, 7 ofwhom required stenting or percutaneous drainage, which wasperformed at a mean of 11 days. Reese et al. additionally ex-amined initial radiographic findings associated with patientswho required stenting and/or percutaneous drainage versusthose who did not. Statistically significant predictors of needfor minimally invasive therapy were renal pelvic hematomaand large urinoma. Average urinoma sizes for the failed and

successful conservatively managed groups were 4.29 cm and1.45 cm, respectively.

Angioembolization was used in seven studies.18Y20,22,28,31,37 Six studies report successful management of ongoinghemorrhage or pseudoaneurysm with angioembolization andno further intervention.18Y20,28,31,37 One patient with a hilarbleed eventually required nephrectomy due to devasculariza-tion after embolization.22

OutcomesPreservation of renal function after hospitalization

was investigated in seven studies using Technetium-99m-dimercaptosuccinic acid (DMSA) scans.18,19,24Y26,32,34 Nerliet al. reported good renal function in all individuals who re-ceived follow-up. The remaining six studies reported variablesuccess at function preservation. Eassa et al.,18 Impellizzeriet al.,25 and Keller and Green27 reported follow-up DMSA dataon 9, 9, and 17 patients, respectively, and found that greaterthan 40% of patients retained normal renal function in thetraumatized kidney. In four studies, a moderate dysfunctionwas reported in 22% to 56% of study participants.18,24Y26

Severe to complete dysfunction was detected in 11%, 24%,

TABLE 3. Management of Grade IV Injury

Author

Grade IVInjury

(No. Patients)

PatientsRequiringEmergent

Surgery, n (%)

Patients WithInitial Attemptat Nonoperative

Management, n (%)

Success ofConservative,NonoperativeTherapy, n (%)

Patients RequiringMinimally InvasiveIntervention, n (%)

Success of MinimallyInvasive Intervention atAvoiding Surgery, n (%)

RenalSalvage,n (%)

Barsness16 7 2 (28.6) 5 (71.4) 5 (100) 0 (0) na Unknown

Bartley9 10 0 (0) 10 (100) 8 (80) 2 (20) 1 (50) 9 (90)

Broghammer5 10 0 (0) 10 (100) 8 (80) 2 (25) 0 (0) 8 (80)

Buckley12 11 Unknown Unknown 8 (72.7) Unknown na 11 (100)

Ceylan17 7 Unknown Unknown 4 (57.1) 1 (14.3) 1 (100) 6 (85.7)

El-Sherbiny20 4 0 (0) 4 (100) 4 (100) 2 (50) 2 (100) 4 (100)

Fitzgerald21 6 0 (0) 6 (100) 5 (83.3) 1 (16.7) 0 (0) 6 (100)

Gerstenbluth42 17 Unknown Unknown 16 (94.1) Unknown na Unknown

Graziano22 21Y24 0 (0) 21Y24 21Y24 (100%) 0 (0) na 21Y24 (100)

He23 10 2 (20) 8 (80) 7 (88) 0 (0) na 7 (70)

Henderson24 35 0 (0) 35 (100) 31 (88.6) 1 (3.2) 1 (100) 34 (97.1)

Impellizzeri25 2 0 (0) 2 (100) 1 (50) 0 (0) na 2 (100)

Keller26 9 0 (0) 9 (100) 9 (100) 0 (0) na 9 (100)

Keller27 9 0 (0) 9 (0) 9 (100) Unknown Unknown 9 (100)

Kiankhooy28 Unknown Unknown Unknown Unknown (100) 3 (Unknown) 3 (100) Unknown (100)

Manikandan29 2 0 (0) 2 (100) 2 (100) 2 (100) 2 (100) 2 (100)

Margenthaler30 14 2 (14.3) 12 (85.7) 10 (83.3) 0 (0) na 11 (78.6)

Mohamed31 14 4 (28.6) 10 (71.4) 10 (100) 5 (50) 5 (100) 14 (100)

Moog32 5

Nance33 11 1 (9.1) 10 (90.9) 10 (100) 4 (40) 4 (100) 10 (90.9)

Ozturk35 2 2 (100) 0 (0) na 0 (0) na 0 (0)

Philpott36 2 0 (0) 2 (100) 2 (100) 2 (100) 2 (100) 2 (100)

Reese37 26 10 (38.5) 16 (61.5) 15 (93.8) 7 (43.8) 6 (85.7) 25 (96.1)

Rogers38 10 0 (0) 10 (100) 9 (90.0) 2 (25) 1 (50) 10 (100)

Russell39 15 1 (0.6) 14 (93.3) 13 (92.9) 5 (38.5) 4 (80) 13 (86.7)

Tsui40 2 0 (0) 2 (100) 2 (100) 0 (0) na 2 (100)

Wan41 3 0 (0) 3 (100) 3 (100) 0 (0) na 3 (100)

Wessel6 5 1 (20) 4 (80) 0 (0) 0 (0) na 3 (75)

Operations performed for nonrenal trauma or nontraumatic reasons were not included as ‘‘surgery.’’




TABLE

4.Man

agem

entof

Grade

VInjury

andAgg

rega

teGrade

IV/V

Injury

Author

Typ

eV

Injury

(No.

Patients)

Patients

Requiring

Emergent

Surgery,

n(%

)

Patients

WithInitial

Attem

ptat

Non

operative

Man

agem

ent,

n(%

)

Successof

Con

servative,

Non

operative

Therap

y,n(%

)

Patients

Requiring

Minim

ally

Invasive

Intervention

,n(%

)

Successof

Minim

ally

Invasive

Intervention

atAvoiding

Surgery,

n(%

)

Renal

Salvage,

n(%

)

Com

bined

Typ

eIV

andV,

(No.

Patients)

Patients

Requiring

Emergent

Surgery,

n(%

)

Patients

WithInitial

Attem

ptat

Non

operative

Man

agem

ent,

n(%

)

Successof

Con

servative,

Non

operative

Therap

y,n(%

)

Patients

Requiring

Minim

ally

Invasive

Intervention

,n(%

)

Successof

Minim

ally

Invasive

Intervention

atAvoiding

Surgery,

n(%

)

Renal

Salvage,

n(%

)

Barsness1

66

5(83)

1(20)

1(100)

0(0)

naUnknown

137(53.8)

6(46.1)

6(100)

0(0)

na9(69)

Bartley

91

1(100)

0(0)

na0(0)

na0(0)

Brogham

mer

52

Buckley

12

1Unknown

Unknown

Unknown

1(100)

Ceylan1

75

3(60)

2(40)

0(0)

0(0)

na1(20)

Eassa

18

181(5.6)

17(94.4)

12(70.6)

5(27.8)

3(60)

14(78)

Eeg

19

222(10)

20(90.9)

19(95)

4(20)

3(75)

19(86.3)

El-Sherbiny2

03

0(0)

3(100)

3(100)

2(66.6)

2(100)

3(100)

Fitzgerald

21

10(0)

1(100)

1(100)

0(0)

na1(100)

Gerstenbluth4

28

Unknown

Unknown

4(50)

Unknown

naUnknown

25Unknown

Unknown

20(80)

Unknown

na22

(88)

Graziano2

22Y3

1(30Y

50%)

Unknown

Unknown

1(30Y

50%)

1(100)

Unknown

He2

38

3(37.5)

5(62.5)

0(0)

0(0)

na0(0)

Henderson

24

152(13.3)

13(86.7)

11(84.6)

0(0)

na12

(80)

Impellizzeri25

0

Jacobs

7419

81(19.3)

338(80.6)

334(79.7)

47(13.9)

Unknown

373(89)

Keller26

40(0)

4(100)

4(100)

0(0)

4(100)

Keller27

30(0)

3(100)

3(100)

Unknown

Unknown

3(100)

Kiankhooy

28

Unknown

Unknown

Unknown

Unknown

0(0)

naUnknown

(100)

Manikandan2

90

Margenthaler30

53(60)

2(40)

2(100)

0(0)

na2(40)

Moham

ed31

107(70)

3(30)

1(33.3)

0(0)

na8(80)

Moog3

25

100(0)

10(100)

9(90)

4(40)

4(100)

10(100)

Nance

33

20(0)

2(100)

2(100)

1(50)

1(100)

2(100)

Nerli34

4310

(23.3)

33(76.7)

29(87.9)

6(18.2)

4(66.7)

41(95.3)

Ozturk3

51

1(100)

0(0)

na0(0)

na0(0)

Philpott36

0

Reese

37

21(50)

1(50)

Not

stated

0(0)

na1(50)

Rogers3

810

10(100)

0(0)

na3(30)

Tsui40

10(0)

1(100)

1(100)

0(0)

0(0)

1(100)

Wan

41

11(100)

0(0)

na0(0)

na0(0)

Wessel6

10(0)

1(1)

0(0)

0(0)

na0(0)

*Operatio

nsperformed

fornonrenal

traumaor

nontraum

atic

reasonswerenotincluded

as‘‘surgery.’’




and 15% of scanned patients in the studies performed byImpellizzeri et al.,25 Keller and Green,27 and Henderson et al.,24

respectively. At 6 months after trauma, Moog et al.32 calculatedan average 48% loss of function in the injured kidney.

Both Keller and Green and Henderson et al. describedworse functional outcomes in those with Grade V injury. Kellerand Green27 demonstrated severe dysfunction in 50% ofchildren with Grade V injury compared with 20% of childrenwith Grade IV injury (p G 0.05). Henderson et al.24 reportedless than 23% function in 3 (15%) of 20 with Grade IV injuryand 3 (50%) of 6 with Grade V injury. Of note, on repeat scan at1 year for eight patients, the study of Keller and Green27

demonstrated equivalent results at the time of radiographichealing.

Secondary hypertension is a feared complication of re-nal trauma; there is concern that conservative managementmay increase the likelihood of this adverse outcome. Our re-view of the recent literature does not find evidence to stronglysubstantiate this fear. Ten studies reported no hypertensiondiscovered in the follow-up of their patient population.16,20,25Y27,30,31,34,36,40 Nine studies list 5% to 15% of patients withtransient or long-term hypertension.17Y19,21,23,24,28,32,39 Ceylanet al., Fitzgerald et al., and Kiankhooy et al. presented 1 (0.5%),2 (5%), and 2 (66%) patients, respectively, with self-limitedhypertension. He et al. presented three patients (3.6%) withhypertension that was treated medically. Eeg et al. reportedfive patients (7%) who developed hypertension, but treatmentregimen was not discussed. Five studies report hyperten-sion cured by subsequent operation.17,18,24,32 These includedthe studies of Eassa et al. with one (5%), Henderson et al.with one (3%), Moog et al. with one (5%), and Russell et al.with one (6.6%).

Length of StayThe effect of conservative management on length of stay

is not well understood. The six studies that analyzed length ofstay reach differing conclusions, and there is no evidence tosuggest that any particular management course is associatedwith reduced length of stay.5,12,21,37,38 Rogers et al.38 reportedan increased length of stay in patients undergoing conserva-tive therapy compared with operative therapy of 23 days versus11 days, respectively. Reese et al.37 reported no statisticallysignificant difference between early and late interventiongroups but found that patients who had successful conserva-tive management required the shortest stay. Buckley andMcAninch12 reported longer stay for operatively managedpatients compared with nonoperatively managed patients. In-cluded studies do report that presence of nonrenal injury sub-stantially affects length of stay.5,21 In studies that compared gradeof renal injury, they determined it had no significant effect onlength of stay.5,33

DISCUSSION

As management of high-grade renal injury trends to-ward conservative protocols, it is increasingly important todevise a pathway that optimizes recovery and minimizes lengthof stay and unnecessary intervention. There are currently norandomized control trials that assess the utility of ICU

admission, urinary catheter drainage, antibiotics, bed rest, orroutine imaging. Based on the findings of this review, there isminimal evidence to support routine ICU care for high-graderenal trauma patients. Patients should be maintained in theICU based on daily assessment of monitoring needs. Althoughno studies directly compare outcomes for patients cared for inthe ICU versus the floor, the five studies that reported routineICU admission based on the presence of high-grade renal in-jury did not demonstrate improved renal salvage rates com-pared with studies that did not use this criterion.12,30,31,33,35

Although prospective comparative studies are lacking,indicating the need for urinary catheter placement, prophylac-tic antibiotics, and mandatory bed rest, there is insufficient evi-dence to recommend the routine use of these measures. Studiesthat did not routinely use these measures as part of a conserva-tive protocol did not have worse outcomes.5,6,9,12,18Y21,23,25,30,38

Given that catheter drainage increases risk of infection, we donot recommend routine placement.12 Antibiotic therapy mayhave a role after minimally invasive intervention but shouldotherwise be reserved for use when signs or symptoms of in-fection emerge. Failure of compliance with bed rest may berelated to recurrence of gross hematuria,23 but studies that didnot use this measure did not demonstrate inferior therapeuticsuccess.22

In addition, there is minimal evidence to support the useof routine imaging, especially in patients with Grade IV injury,as part of a conservative protocol. Ultrasound is an adequatetool for the assessment of signs and symptoms of injury pro-gression.19 CT should be considered if ultrasound is equivocalor demonstrates worsening injury or is necessary for thera-peutic intervention.18 Reducing routine CT use will help re-duce cost and radiation exposure.

The initial use of a conservative protocol should beused for all patients, and immediate surgical intervention forboth Grade IV and V injury should be based exclusively onhemodynamic stability, as studies demonstrate that immediatesurgical intervention is associated with higher nephrectomyrates.7 Although several studies identified findings includingmedial extravasation of contrast, nonopacification of ureter,and interpolar contrast extravasation as associated with higherrates of surgical intervention, many patients with these in-jury patterns were successfully treated with conservative man-agement with or without minimally invasive therapy.9,18,37,38

These patients merit close monitoring, and further studies arenecessary to identify optimal timing of surgical interventionwhen indicated.

Minimally invasive therapy including percutaneous drain-age, stenting, and angioembolization are often successful atpreventing the need for more extensive surgical intervention.Because up to two thirds of urinomas resolve spontaneously,39

intervention should be reserved for urinomas that are symp-tomatic, are large, or persist for an excessive amount of time.Although there are very limited data to suggest optimal sizecriteria, we recommend intervention for urinoma greater than4 cm.37 Several studies reported failure of isolated percuta-neous drainage alone, with subsequent success with ureteralstenting.24,29,39 This finding in addition to practical consider-ations including the cumbersome nature of external drain-age systems and potential for dislodgement leads to the




recommendation of stenting as the initial choice of urinomamanagement. Therapeutic intervention should not be delayed forgreater than 2 weeks because urinoma is likely to resolve afterthis time point. Angioembolization is a very useful tool and,where available, should be used for renal artery pseudoaneurysmand hemorrhage amenable to intervention.

Although resolution of gross hematuria was commonlyused in conservative protocols as a criterion for discharge,there are limited data to support this claim. As a result, werecommend discharge on the basis of symptomatic control andassessment of stability. Patients require follow-up in the out-patient setting with special attention paid to worsening symp-toms, but routine use of imaging is not recommended. Overallfunctional outcomes are good with most individuals experi-encing only mild-to-moderate ipsilateral renal dysfunction.18,19,24Y26,32,34 Although monitoring is required for the developmentof hypertension, it is a relatively uncommon sequelae of renaltrauma.16,20,25Y27,30,31,34,36,40

LIMITATIONS

The review was limited by the retrospective nature ofthe studies included and the relatively small sample size be-cause of the infrequency with which pediatric renal traumaoccurs. Further limitations include the lack of uniformity inreporting timing of intervention, definition of failure of con-servative therapy, and reasoning behind operative intervention.

CONCLUSION

This review synthesizes the past 15 years of literatureregarding blunt pediatric renal trauma. The primary limitationto the analysis is the small size and the retrospective natureof the available literature. Based on the analysis of the avail-able literature, we recommend implementation of conservativemanagement protocols to treat high-grade blunt pediatric renaltrauma. It is not recommended that protocols routinely re-quire bed rest, serial imaging, and ICU admission, althoughprospective comparative data are lacking to support specificmanagement strategies. Early operative intervention shouldbe implemented for hemodynamic instability. Intervention dueto CT findings alone is not recommended. Minimally invasiveinterventions including angioembolization, stenting, and per-cutaneous drainage should be used when indicated and donot qualify as a failure of conservative therapy. Short- and long-term outcomes are favorable when using conservative manage-ment approaches to high-grade renal injuries. Further studiesincluding prospective, randomized studies and cost-benefitanalyses are essential to develop a comprehensive, standard-ized approach to the management of pediatric renal trauma,which will improve outcomes and maximize resource use.

AUTHORSHIP

E.L.V., O.Z., F.C., R.V.B., and J.S.U. designed this study. E.L.V., O.Z., andF.C. conducted the literature search. E.L.V., F.C., and R.V.B. contributedto the data collection. E.L.V. performed the data analysis and wrote themanuscript. R.V.B., J.Z., and J.S.U. participated in the critical revision.

DISCLOSURE

The authors declare no conflicts of interest.

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management of pediatric blunt renal trauma a systematic review

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