Our experience in the treatment of grade 4 renal injuries

Dimitrios Moschotzopoulos; Charalampos Fragkoulis; Georgios Theoxaris; Ioannis Glykas; Miltiadis Gravanis; Georgios Karydas; Georgios Stathouros; Georgios Papadopoulos; Konstantinos Ntoumas

doi:10.4103/HUAJ.HUAJ_3_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 32 | Issue : 2 | Page : 80-83

Our experience in the treatment of grade 4 renal injuries

Dimitrios Moschotzopoulos¹, Charalampos Fragkoulis¹, Georgios Theoxaris¹, Ioannis Glykas¹, Miltiadis Gravanis², Georgios Karydas², Georgios Stathouros¹, Georgios Papadopoulos¹, Konstantinos Ntoumas¹
¹ Department of Urology, General Hospital of Athens G.N.A. “G. Gennimatas”, Athens, Greece
² Department of Interventional Radiology, General Hospital of Athens G.N.A. “G. Gennimatas”, Athens, Greece

Date of Submission	13-Mar-2020
Date of Decision	14-Apr-2020
Date of Acceptance	16-Apr-2020
Date of Web Publication	30-Nov-2020

Correspondence Address:
Charalampos Fragkoulis
Department of Urology, General Hospital of Athens G.N.A. “G. Gennimatas,” Athens
Greece
Ioannis Glykas
Department of Urology, General Hospital of Athens G.N.A. “G. Gennimatas,” Athens
Greece

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HUAJ.HUAJ_3_20

Abstract

Introduction: The aim of this study is to evaluate treatment modalities in patients with Grade 4 renal injury. Materials and Methods: In this retrospective study, we included a total of 64 patients who were diagnosed with Grade 4 renal injury at our trauma center hospital from 2015 to 2019. Patients who underwent immediate laparotomy due to concomitant injuries or penetrating wounds were excluded from the study. Hemodynamic instability was the absolute indication for nephrectomy as well as failure to respond to conservative treatment. Results: In our study, 10 patients (15.6%) underwent immediate nephrectomy due to hemodynamic instability. In 15 out of 54 remaining patients, arterial embolization was performed. Twelve patients presented with urinoma which required intervention. In this subgroup of patients, a double J stent was inserted in four of the patients and a nephrostomy tube was placed in the remaining eight patients for perinephric space drainage. Nephrectomy was performed in four of the patients in the urinoma group. From the patients treated totally conservative, two presented with perirenal abscess, but only one underwent computed tomography-guided abscess drainage. Conclusion: Patients with Grade 4 renal injuries may be treated conservatively or in a minimally invasive way, and immediate nephrectomy should be performed only in case of hemodynamic instability.

Keywords: Conservative management, Grade 4 renal injuries, renal trauma

How to cite this article:
Moschotzopoulos D, Fragkoulis C, Theoxaris G, Glykas I, Gravanis M, Karydas G, Stathouros G, Papadopoulos G, Ntoumas K. Our experience in the treatment of grade 4 renal injuries. Hellenic Urology 2020;32:80-3

How to cite this URL:
Moschotzopoulos D, Fragkoulis C, Theoxaris G, Glykas I, Gravanis M, Karydas G, Stathouros G, Papadopoulos G, Ntoumas K. Our experience in the treatment of grade 4 renal injuries. Hellenic Urology [serial online] 2020 [cited 2021 Jan 28];32:80-3. Available from: http://www.hellenicurologyjournal.com/text.asp?2020/32/2/80/301820

Introduction

Renal injuries are a major cause of admission to urological clinics, and their treatment is often a challenge. The kidney is the third most common organ that is affected by multitraumatic injury after the spleen and the liver.^[1] These injuries are mainly attributable to young people, with an average age of 31 years, and the vast majority is due to road accidents (63%).

Assessment of the overall renal injury severity is classified according to the American Association for the Surgery of Trauma (AAST) grading scale. This classification is based on the degree of renal parenchyma and blood vessel rupture and the extent of the subcapsular or perirenal hemorrhage [Figure 1] and [Table 1].^[2] Grade 4 injuries account for 19% of the total of renal injuries.^[3] Since invasive radiology and endourology have allowed conservative treatment of such lesions either by arterial embolization or double J stent or nephrostomy insertion, urologists nowadays have many options apart from radical nephrectomy in the treatment of Grade 4 trauma, and in most cases, the organ may be preserved.^[4] In this study, we present our departments' experience in the treatment of Grade 4 renal trauma focusing on totally conservative or minimally invasive modalities based on incidents that occurred at our trauma center hospital between 2015 and 2019.

Figure 1: American Association for the Surgery of Trauma kidney injury scale (published under license by freepick.com)

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Table 1: American Association for the Surgery of Trauma kidney injury scale

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Materials and Methods

In this retrospective study, we collected data from a total of 64 trauma patients diagnosed with Grade 4 renal injury in our department from 2015 to 2019. Diagnosis was based on CT scan which was performed in all patients. All patients with renal trauma due to penetrating organs were excluded from the study. Patients who underwent immediate laparotomy due to concomitant injuries were also excluded. Absolute indication for immediate nephrectomy was hemodynamic instability. All hemodynamic stable patients were treated conservatively with blood transfusions if necessary, and a minimally invasive approach with arterial embolization was performed in patients with continuous renal bleeding. Grade 4 renal injuries also include patients with trauma to the renal collective system with subsequent urine leak and urinoma formation. A double J stent was not inserted in all patients with urine leak but only in patients with severe urinoma or fever. Decision was based on the urologist experience in the management of such trauma. In cases of large perirenal urinoma or abscess, a nephrostomy tube was inserted.

Results

A total of 64 patients diagnosed with Grade 4 renal trauma were treated in our department between 2015 and 2019. All patients managed to undergo computed tomography (CT) scan in the emergency department, and patients with severe hemodynamic instability requiring immediate surgical exploration were excluded from the study. Vital signs were recorded throughout the initial evaluation giving the most reliable indication of the urgency of the situation as immediate nephrectomy should be performed only in patients with hemodynamic instability. The median age was 34 years, and most patients were males (58 males, 6 females). The most common cause was road accident (50 patients), followed by falls (10 patients) and work accidents (4 patients). The left kidney was most usually injured (40 patients), and visible hematuria was present in 32 patients. Concomitant injuries not requiring surgical interventions were present in 48 patients including fractured ribs, splenic trauma, or liver trauma.

As far as it concerns trauma management, 10 patients (15.6%) underwent immediate nephrectomy due to hemodynamic instability after the diagnosis of a Grade 4 renal injury. From the remaining 54 patients, 15 (23.4%) presented continuous renal bleeding, and an arterial embolization was performed. All patients were stable after the embolization, and no further embolization or surgical exploration was necessary. In addition, a double J stent was inserted in 4 (6.3%) patients due to severe urine leak, and a nephrostomy tube was placed in 8 (12.5%) patients in order to drain severe urinoma. During hospitalization, an abscess was diagnosed in 2 patients, but only in one, drainage was performed under CT guidance.

Discussion

Renal injury is characterized as blunt (90%), or acute penetrating (10%), depending on the mechanism of injury and the type of renal damage. Assessment of the overall renal injury severity is classified according to the AAST grading scale. This classification is based on the degree of renal parenchymal and blood vessel rupture and the extent of the subcapsular or perirenal hemorrhage. Grade 4 traumas are diagnosed in cases of either parenchymal laceration through the corticomedullary junction into the collecting system or in cases of vascular trauma involving segmental renal artery or vein injury with contained hematoma, or partial vessel laceration, or vessel thrombosis.^[2] Grade 4 injuries account for 19% of the total of renal injuries.^[3] The absolute indication of immediate surgical exploration and nephrectomy if necessary is the hemodynamic instability regardless of the grade of injury.^[5] As a result, Grade 1–3 renal injuries are treated in a preservative way, and in Grade 4 patients, the approach should be individualized.^[4],[6] As far as it concerns Grade 5 renal injury, surgical exploration is usually mandatory, although in some trauma centers with experience in renal injuries, an initial conservative approach may be applied, provided that the patient is hemodynamically stable.^[7],[8]

As far as it concerns acute penetrating traumas (stab wounds and gunshot wounds), in the past years, the recommendation was in favor of surgical exploration and subsequent nephrectomy when necessary. Nowadays, based on modern imaging techniques and growing experience in the conservative management of renal trauma, the trend is toward a more conservative approach even in penetrating trauma. Thus, nephrectomy is only recommended for wounds from high-velocity gun bullets that cause extensive damage.^[9],[10] We must also underline that whenever surgical exploration is performed either for blunt or penetrating renal trauma, if the bleeding can be controlled and sufficient renal tissue is present, efforts should be made to preserve the kidney.^[11]

In Buckley's et al. study, 153 Grade 4 renal lesions were studied, of which 43 were cases in which there was isolated kidney injury without concomitant injury. In this study, 25 (58%) of these patients were initially treated conservatively, and eventually, 22 (88%) maintained their kidneys. The remaining 18 patients underwent surgical exploration and 15 managed to retain their kidneys.^[9] Moreover, Santucci and McAninch have evaluated the management of 2047 patients with Grade 4 kidney injury. The kidney was retained in 91% of the cases, while 22% of the patients were treated totally conservatively.^[12] In another study by Kuo et al. involving 95 patients, the kidney was preserved in 75% of the cases.^[13] In a similar study by Wright et al., a rate of 77.6% of kidney preservation in such injuries was reported.^[14]

Conservative management of hemodynamic stable patients with Grade 4 renal trauma is not without complications. Early complications include bleeding, infection, abscess formation, and urinary extravasation with urinoma formation. Bleeding is a major complication which often is life-threatening and should be managed by arterial embolization.^[15] As far as it concerns the formation of urinoma, it can also be managed in a minimally invasive way by ureteral stent or nephrostomy placement.^[16]

Conclusion

Grade 4 renal trauma can be treated conservatively in most cases. In cases of continuous bleeding, arterial embolization must be performed, and in cases of urinoma, a ureteral stent or a nephrostomy tube may be placed. Absolute indication for surgical intervention and nephrectomy if necessary is hemodynamic instability, failure of conservative or minimally invasive efforts, or laparotomy for concomitant injuries. As a result, surgical exploration is limited to a minority of cases with Grade 4 renal trauma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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