Recommandé
Contenu connexe
Tendances
Tendances (20)
En vedette
Similaire à Management of pediatric blunt renal trauma a systematic review
Similaire à Management of pediatric blunt renal trauma a systematic review (20)
Plus de skrentz
Dernier
Dernier (20)
Management of pediatric blunt renal trauma a systematic review
- 1. 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 conservative management for blunt renal trauma is widely accepted in adult trauma literature and is now increasingly accepted for use in the pediatric patient population. This study aimed to review current practices in pediatric blunt renal trauma management and to highlight current practices in conservative protocols, success rates of conservative management strategies, as well as short- and long-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 of the three databases: (Renal or Kidney) AND (Pediatric or Children) AND Trauma AND Management. Publications were limited to publish date after January 1, 2000. Inclusion criteria were (1) original research articles regarding management of pediatric blunt renal trauma, (2) involvement of cases of high-grade renal (Grades IVand V) trauma, and (3) more than one patient 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 of 32 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. Criteria for 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 percutaneous drainage 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 control trials 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. Blunt trauma remains a significant cause of morbidity and mortality in the pediatric population.1Y4 Compared with the adult kidney, the pediatric kidney is more susceptible to trauma-induced injury due to anatomic factors.5,6 According to the National Trauma Data Bank, greater than 18,000 pediatric renal units experienced injury from 2002 to 2007.7 Renal in- juries are graded based on computed tomography (CT) imaging as classified by the American Association for the Surgery of Trauma Organ Injury Scale and are ranked as Grade I (least severe) to V (most severe) (Table 1).8 The use of conservative management for blunt renal trauma is widely accepted in adult urologic trauma literature and is now increasingly accepted for use in the pediatric pa- tient population.5,9Y13 This strategy aims to preserve renal units 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 regarding management of high-grade injuries has not been achieved.14 Furthermore, many questions remain regarding what an opti- mal protocol for conservative management should include, what the threshold for implementation of operative management should be, and what is the ultimate impact of conservative management on the patient and health care system. Even the definition of ‘‘conservative management’’ varies throughout the literature, with minimally invasive procedures being variably defined as conservative or operative/interventional manage- ment. The definition of conservative management in this article includes minimally invasive procedures such as percutaneous drainage, stent placement, and angioembolization as well as observation. Operative intervention will refer to laparotomy and more extensive renal exploration or resection. As more studies on patients with high-grade renal trauma emerge, it is important to understand differences between Grade IV and Grade V injury thatmayimpacttreatmentregimens.Inthissystematicreview,we highlight current practices in conservative protocols, success rates ofconservative managementstrategies, aswell as short- and long-term outcomes of blunt renal trauma management. PATIENTS AND METHODS A search of all original research studies was conducted using PubMed, Ovid, and the Cochrane Library. The following SYSTEMATIC REVIEW J Trauma Acute Care Surg Volume 80, Number 3 519 Submitted: September 8, 2015, Revised: November 10, 2015, Accepted: November 24, 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 Los Angeles; and Keck School of Medicine (R.V.B., J.S.U.), University of Southern California, 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, CA 90027; email: jupperman@chla.usc.edu. DOI: 10.1097/TA.0000000000000950 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
- 2. 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 full text. Species was limited to humans. The search was repeated in Ovid and Cochrane library. Abstracts were reviewed, and those that met the selection criteria specified later were imported into Endnote, a bibliographic management program. If the full abstract was unavailable or it remained ambiguous whether the article complied with the selection criteria, the full article was obtained and reviewed for inclusion.15 Inclusion criteria were (1) original research articles regarding management of pediatric 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 in English or written before the year 2000. Studies that reported blunt abdominal trauma manage- ment overall were only included if renal data were presented independently. Articles were included if the treatments ren- dered were broken down by grade of injury or grouped into high- or low-grade injury. Treatment protocols, intervention type, outcome mea- sures including percent success of conservative protocols, and renal salvage rates were recorded. Bias was assessed using the Cochrane risk of bias assessment tool (Fig. 1). RESULTS Three hundred eight titles and abstracts were screened to identify scientific articles reporting original research find- ings. A total of 32 articles met the selection criteria and were included in the review (Table 2).5Y7,9,12,16Y42 Protocol for Conservative Therapy Although conservative management is discussed as a cohesive entity, the protocol for conservative management is inconsistent throughout the literature. The articles reviewed in this study used diverse nonoperative measures in the sup- port of acutely injured patients. All studies advocated for some combination offrequent vital sign evaluation, hemoglobin/ hematocrit measurement, serial abdominal examination, and intravenous 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 gross hematuria.5,9,12,20,21,23,30 The study of Graziano et al.22 challenged the need for bed rest and instead applied an ‘‘abbreviated’’ protocol in- volving early mobilization; no urinary catheter, antibiotics, or TABLE 1. American Association for the Surgery of Trauma Organ Injury Scale for Renal Injury Grade Type Injury Description I Contusion Microscopic or gross hematuria, urologic studies normal Hematoma Subcapsular, nonexpanding without parenchymal laceration II Hematoma Nonexpanding perirenal hematoma confined to renal retroperitoneum Laceration G1-cm parenchymal depth of renal cortex without urinary extravasation III Laceration 91-cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation IV Laceration Parenchymal laceration extending through renal cortex, medulla, and collecting system Vascular Main renal artery or vein injury with contained hemorrhage V Laceration Completely shattered kidney Vascular Avulsion of renal hilum, which devascularizes the kidney Figure 1. Cochrane risk of bias assessment toolVarticle bias. J Trauma Acute Care Surg Volume 80, Number 3LeeVan et al. 520 * 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
- 4. routine imaging; and discharge when patient tolerated a diet regardless of hematuria. Although authors reported a reduction in length of stay from a mean of 6.6 days to 2.9 days after the protocol was applied, it is notable that this study addressed a population with greater than 50% low-grade injuries with fewer than four patients (5%) with Grade V injury. In addition, five patients (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 admission was recommended for all blunt renal traumas by several authors.12,30,31,33,35 Duration of ICU stay was recommended as 24 hours to 1 week.12,31,33,35 Of note, Buckley and McAninch12 as well as Mohamed et al.,31 who recommended 48 hours and 1 week, respectively, had high length of stays compared with other study populations. Nance et al.33 had shorter average length of stay but a study population that was highly 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 rate of infected hematoma was reported in the majority of studies; thus, the necessity and efficacy of this intervention are not known, and further study is required to clarify this issue. The use of urinary catheter for bladder decompression was recommended by two studies30,38 and specifically not used in one study.22 Guidelines for serial imaging remain a controversial topic in conservative management protocols. Several studies recom- mend routine serial imaging protocols.12,18,19,25,30,39 Four stud- iesrecommendrepeatimagingwithinthefirst24-hour to72-hour window.12,18,19,25 Eassa et al.18 recommended daily bedside ultrasounds throughout the hospitalization in his population of Grade V injury patients. The study by Eeg et al.19 specifically aimed to apply the ‘‘as low as reasonably achievable’’ concept to renal trauma imaging. After initial CT, the study team used ultrasound for the evaluation of clinical changes and only used repeat CT if ultrasound was inconclusive. Only two pa- tients required repeat CT for urologic reasons including one angioembolization and one patient with expanding urinoma. There were no complications caused by delayed diagnosis. Im- aging of all patients before discharge to confirm resolution of extravasation was performed in one study.30 No intervention as a result of this imaging was described. Indications for Operative Intervention The 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 that hemodynamic instability, despite adequate resuscitation, is an absolute indication for operative intervention or angiography. Several authors provided specific criteria for blood loss as an indication for surgery.12,21,34,35,37 Recommendations vary from a 3-U decrement in hematocrit12 to requirement of 2 U of blood21,37 to transfusion of greater than 50% of blood volume.34,35 Ten studies list hemodynamic instability as the sole indication for operative intervention when considering treatment of isolated blunt renal trauma.5,9,16,19,20,23,25,30,34,35 TABLE2.(Continued) AuthorJournalYear No. Subjects AgeRange(Mean) [Median]LocationStudyTypeHospitalStay,d Transfusion (No.Patients) Nerlietal.34 PediatricSurgery International 201143NotrecordedSinglecenter,Belgaum,IndiaRetrospectivereviewConservativelymanaged patientsG2wk Notrecorded Ozturketal.35 EuropeanJournalof PediatricSurgery 2003451Y15[7]Singlecenter, Diyarbakır,Turkey RetrospectivereviewRenalspecificinformation, notrecorded Renalspecific information, notrecorded Philpottetal.36 JournalofPediatric Surgery 2003213Y16(14.5)Singlecenter,Philadelphia, UnitedStates Caseseries9.50 Reeseetal.37 JournalofUrology2014264Y16(11.2)Singlecenter,Pittsburgh, UnitedStates RetrospectivereviewEarlyintervention=7.4, nonoperative=5.4, failedconservative management=7.9 2 Rogersetal.38 Urology2004202Y14(8.9)Singlecenter,Baltimore, UnitedStates RetrospectivereviewBygrade:IV=11, V=16 5 Russelletal.39 JournalofUrology2001154Y16(11.5)[11]Singlecenter,Akron, UnitedStates Retrospectivereview11.16 Tsuietal.40 Injury2011151Y11(6.5)Singlecenter,CapeTown, SouthAfrica Retrospectivereview16.5Notrecorded Wanetal.41 JournalofUrology2003168Y17(13.4)[14]Singlecenter,Buffalo, UnitedStates RetrospectivereviewNotrecorded3 Wesseletal.6 JournalofPediatricSurgery2000671Y14Singlecenter,Mannheim,GermanyRetrospectivereviewNotrecordedNotrecorded J Trauma Acute Care Surg Volume 80, Number 3LeeVan et al. 522 * 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
- 5. Renal salvage rates with these operative criteria ranged from 0% to 100% for both Grade IV and V injury. Nine studies identified characteristic CT findings as an absolute or relative indication for operative intervention.12,18, 21,24,28,37Y40 Injury to the renal artery was a cause for operative intervention in three studies.12,22,33 In two additional studies, operative management was reserved for more severe vascular injury, specifically, unstable vascular Grade V injury21,33 and vascular pedicle injury.28 Nonvisualized renal units or evidence of 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 cause to intervene surgically, renal salvage rates remained high at 86.7% 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 renal trauma. Overall, most patients with urinoma and/or extrava- sation of urine were managed effectively with conservative measures. Several authors specifically advocated a trial of nonoperative management in this population.18,30,38 Despite this, there is evidence that expanding urinoma or active extravasation of urine has a role as an absolute or relative in- dication for surgery.12,18,24,26,30,31 Extravasation of urine was identified as the cause of failure of conservative management for individuals in eight studies.5,17,18,24,30,34,37,38 Although some patients with urinoma or extravasation of urine went on to require surgery, total nephrectomy was rarely required after a trial of conservative management. Fol- lowing a trial of conservative management, at least one patient in each of eight studies (total of 12 patients) went on to receive renorrhaphy or partial nephrectomy,5,17,18,24,30,34,38,39 while only one patient in each of three studies ultimately required nephrectomy.5,30,37 Four patients who underwent surgical intervention were found to have ureteropelvic disruption.5,18,30 Patients with ure- teropelvic junction injury may be a group that warrants specific management strategies. Eassa et al.18 described four patients (22%) with suspected ureteropelvic junction avulsion based on nonopacifyingipsilateral ureters.Tworequiredearly intervention and 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 blood supply to each segment and concomitant perinephric extrava- sation was suggested by Rogers et al.38 as a subpopulation of patients who are more likely to fail conservative therapy and may benefit from early surgical intervention, but this was based on two individuals with this finding. Reese et al.37 corroborated that this CT finding was a good predictor of a need for inter- vention but recommended endourologic management. Medial extravasation of contrast was identified by two studies as a predictor of conservative management failure.9,18 Of four individuals (22%) found to have medial extravasation of contrast in the study of Eassa et al., one required immediate nephrectomy and three required delayed nephrectomies. Of the two patients requiring delayed surgical intervention in the population of Bartley and Santucci, both demonstrated medial contrast extravasation on CT. Given these findings, it seems that medial extravasation of contrast may portend extensive renal injury, which is not amenable to conservative therapy. Grade IV Injury Twenty-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. Seventeen studies required emergent intervention in less than 15% of the population 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 success rates less than or equal to 50% had small patient populations, and one did not discuss operative indications.6,25 Overall, renal salvage rate was high with a conservative approach. Eighteen studies reported renal salvage rates greater than 90%, with sixteen studies reporting renal salvage rates greater than 95% (Table 3).9,12,20Y22,24Y29,31,33,36Y38,40,41 Grade V Injury Indications for the use of conservative management in the patient population with Grade V injury remain highly controversial. The reviewed data show a wide range of success rates when using conservative management with renal salvage of 0% to 100%. Only 5 of the 15 studies for which success rates of conservative management could be calculated had success rates of 50% or less.6,17,23,31,42 Overall, renal salvage rate for 10 of the 20 studies that reported this information was greater than 80%. One challenge in interpreting this in- formation is the small patient population size. Few patients presented with Grade V injuries, and even fewer were hemo- dynamically stable and eligible for conservative therapy. Eassa et al.18 had the largest analysis with 18 patients. This study used hemodynamic instability, progressive urinoma, and persistent bleeding 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 in aggregate, success of conservative management was overall high, 79.7% to 100%, with overall renal salvage rates of 69% to 100% (Table 4).7,16,19,32,34,42 Minimally Invasive Therapy Adjunct therapies including stent placement, percuta- neous drainage, and angioembolization serve as minimally invasive alternatives to operative intervention. In the reviewed studies, these three interventions were largely successful in obviating the need for surgery. Indications for these procedures are as yet without consensus. Seventeen studies used stenting and/or drainage pro- cedures as adjunct measures for the treatment of urinary extravasation or expanding urinoma.5,7,9,17Y20,24,29,31Y34,36Y39 Nearly all studies cited ongoing urinary extravasation or J Trauma Acute Care Surg Volume 80, Number 3 LeeVan et al. * 2016 Wolters Kluwer Health, Inc. All rights reserved. 523 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
- 6. expanding urinoma as cause for stenting. Urinomas associated with 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 stenting after percutaneous drainage for persistent collection, with sub- sequent resolution of symptoms.24,29,39 Timing of drainage remains controversial. In the study populations, drainage and/or stenting was performed as early as 48 hours and as late as 5 weeks after injury. Two studies specifically commented on timing of stenting and/or percuta- neous drainage. In the study of Rogers et al.,38 where patients were 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 of whom required stenting or percutaneous drainage, which was performed at a mean of 11 days. Reese et al. additionally ex- amined initial radiographic findings associated with patients who required stenting and/or percutaneous drainage versus those who did not. Statistically significant predictors of need for minimally invasive therapy were renal pelvic hematoma and large urinoma. Average urinoma sizes for the failed and successful conservatively managed groups were 4.29 cm and 1.45 cm, respectively. Angioembolization was used in seven studies.18Y20,22, 28,31,37 Six studies report successful management of ongoing hemorrhage or pseudoaneurysm with angioembolization and no further intervention.18Y20,28,31,37 One patient with a hilar bleed eventually required nephrectomy due to devasculariza- tion after embolization.22 Outcomes Preservation of renal function after hospitalization was investigated in seven studies using Technetium-99m- dimercaptosuccinic acid (DMSA) scans.18,19,24Y26,32,34 Nerli et al. reported good renal function in all individuals who re- ceived follow-up. The remaining six studies reported variable success at function preservation. Eassa et al.,18 Impellizzeri et al.,25 and Keller and Green27 reported follow-up DMSA data on 9, 9, and 17 patients, respectively, and found that greater than 40% of patients retained normal renal function in the traumatized kidney. In four studies, a moderate dysfunction was 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 IV Injury (No. Patients) Patients Requiring Emergent Surgery, n (%) Patients With Initial Attempt at Nonoperative Management, n (%) Success of Conservative, Nonoperative Therapy, n (%) Patients Requiring Minimally Invasive Intervention, n (%) Success of Minimally Invasive Intervention at Avoiding Surgery, n (%) Renal Salvage, 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.’’ J Trauma Acute Care Surg Volume 80, Number 3LeeVan et al. 524 * 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
- 8. and 15% of scanned patients in the studies performed by Impellizzeri et al.,25 Keller and Green,27 and Henderson et al.,24 respectively. At 6 months after trauma, Moog et al.32 calculated an average 48% loss of function in the injured kidney. Both Keller and Green and Henderson et al. described worse functional outcomes in those with Grade V injury. Keller and Green27 demonstrated severe dysfunction in 50% of children with Grade V injury compared with 20% of children with Grade IV injury (p G 0.05). Henderson et al.24 reported less than 23% function in 3 (15%) of 20 with Grade IV injury and 3 (50%) of 6 with Grade V injury. Of note, on repeat scan at 1 year for eight patients, the study of Keller and Green27 demonstrated equivalent results at the time of radiographic healing. Secondary hypertension is a feared complication of re- nal trauma; there is concern that conservative management may increase the likelihood of this adverse outcome. Our re- view of the recent literature does not find evidence to strongly substantiate this fear. Ten studies reported no hypertension discovered in the follow-up of their patient population.16,20, 25Y27,30,31,34,36,40 Nine studies list 5% to 15% of patients with transient or long-term hypertension.17Y19,21,23,24,28,32,39 Ceylan et al., Fitzgerald et al., and Kiankhooy et al. presented 1 (0.5%), 2 (5%), and 2 (66%) patients, respectively, with self-limited hypertension. He et al. presented three patients (3.6%) with hypertension that was treated medically. Eeg et al. reported five patients (7%) who developed hypertension, but treatment regimen was not discussed. Five studies report hyperten- sion cured by subsequent operation.17,18,24,32 These included the 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 Stay The effect of conservative management on length of stay is not well understood. The six studies that analyzed length of stay reach differing conclusions, and there is no evidence to suggest that any particular management course is associated with reduced length of stay.5,12,21,37,38 Rogers et al.38 reported an increased length of stay in patients undergoing conserva- tive therapy compared with operative therapy of 23 days versus 11 days, respectively. Reese et al.37 reported no statistically significant difference between early and late intervention groups but found that patients who had successful conserva- tive management required the shortest stay. Buckley and McAninch12 reported longer stay for operatively managed patients compared with nonoperatively managed patients. In- cluded studies do report that presence of nonrenal injury sub- stantially affects lengthof stay.5,21 In studies thatcomparedgrade of renal injury, they determined it had no significant effect on length of stay.5,33 DISCUSSION As management of high-grade renal injury trends to- ward conservative protocols, it is increasingly important to devise a pathway that optimizes recovery and minimizes length of stay and unnecessary intervention. There are currently no randomized control trials that assess the utility of ICU admission, urinary catheter drainage, antibiotics, bed rest, or routine imaging. Based on the findings of this review, there is minimal evidence to support routine ICU care for high-grade renal trauma patients. Patients should be maintained in the ICU based on daily assessment of monitoring needs. Although no studies directly compare outcomes for patients cared for in the ICU versus the floor, the five studies that reported routine ICU 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. Studies that 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 do not recommend routine placement.12 Antibiotic therapy may have a role after minimally invasive intervention but should otherwise be reserved for use when signs or symptoms of in- fection emerge. Failure of compliance with bed rest may be related to recurrence of gross hematuria,23 but studies that did not use this measure did not demonstrate inferior therapeutic success.22 In addition, there is minimal evidence to support the use of routine imaging, especially in patients with Grade IV injury, as part of a conservative protocol. Ultrasound is an adequate tool for the assessment of signs and symptoms of injury pro- gression.19 CT should be considered if ultrasound is equivocal or 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 be used for all patients, and immediate surgical intervention for both Grade IV and V injury should be based exclusively on hemodynamic stability, as studies demonstrate that immediate surgical intervention is associated with higher nephrectomy rates.7 Although several studies identified findings including medial extravasation of contrast, nonopacification of ureter, and interpolar contrast extravasation as associated with higher rates 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 are necessary to identify optimal timing of surgical intervention when indicated. Minimally invasive therapy including percutaneous drain- age, stenting, and angioembolization are often successful at preventing 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 size criteria, we recommend intervention for urinoma greater than 4 cm.37 Several studies reported failure of isolated percuta- neous drainage alone, with subsequent success with ureteral stenting.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 J Trauma Acute Care Surg Volume 80, Number 3LeeVan et al. 526 * 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
- 9. recommendation of stenting as the initial choice of urinoma management. Therapeutic intervention should not be delayed for greater than 2 weeks because urinoma is likely to resolve after this time point. Angioembolization is a very useful tool and, where available, should be used for renal artery pseudoaneurysm and hemorrhage amenable to intervention. Although resolution of gross hematuria was commonly used in conservative protocols as a criterion for discharge, there are limited data to support this claim. As a result, we recommend discharge on the basis of symptomatic control and assessment 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. Overall functional 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 development of hypertension, it is a relatively uncommon sequelae of renal trauma.16,20,25Y27,30,31,34,36,40 LIMITATIONS The review was limited by the retrospective nature of the studies included and the relatively small sample size be- cause of the infrequency with which pediatric renal trauma occurs. Further limitations include the lack of uniformity in reporting timing of intervention, definition of failure of con- servative therapy, and reasoning behind operative intervention. CONCLUSION This review synthesizes the past 15 years of literature regarding blunt pediatric renal trauma. The primary limitation to the analysis is the small size and the retrospective nature of the available literature. Based on the analysis of the avail- able literature, we recommend implementation of conservative management protocols to treat high-grade blunt pediatric renal trauma. It is not recommended that protocols routinely re- quire bed rest, serial imaging, and ICU admission, although prospective comparative data are lacking to support specific management strategies. Early operative intervention should be implemented for hemodynamic instability. Intervention due to CT findings alone is not recommended. Minimally invasive interventions including angioembolization, stenting, and per- cutaneous drainage should be used when indicated and do not 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 studies including prospective, randomized studies and cost-benefit analyses 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., and F.C. conducted the literature search. E.L.V., F.C., and R.V.B. contributed to the data collection. E.L.V. performed the data analysis and wrote the manuscript. R.V.B., J.Z., and J.S.U. participated in the critical revision. DISCLOSURE The authors declare no conflicts of interest. REFERENCES 1. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990Y2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385(9963):117Y171. 2. Centers for Disease Control and Prevention. Ten Leading Causes of Death and Injury. Injury Prevention & Control: Data & Statistics. 2015. 3. Agran PF, Anderson C, Winn D, Trent R, Walton-Haynes L, Thayer S. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics. 2003;111(6 Pt 1):e683Ye692. 4. AgranPF,WinnD,AndersonC,TrentR,Walton-HaynesL.Ratesofpediatric and adolescent injuries by year of age. Pediatrics. 2001;108(3):E45. 5. Broghammer JA, Langenburg SE, Smith SJ, Santucci RA. Pediatric blunt renal trauma: its conservative management and patterns of associated in- juries. Urology. 2006;67(4):823Y827. 6. Wessel L, Scholz S, Jester I, Arnold R, Lorenz C, Hosie S, Wirth H, Waag K. Management of kidney injuries in children with blunt abdominal trauma. J Pediatr Surg. 2000;35(9):1326Y1330. 7. Jacobs MA, Hotaling JM, Mueller BA, Koyle M, Rivara F, Voelzke BB. Conservative management vs early surgery for high grade pediatric renal traumaVdo nephrectomy rates differ? J Uro. 2012;187(5):1817Y1822. 8. Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Shackford SR, Champion HR, McAninch JW. Organ injury scaling. Surg Clin North Am. 1995;75(2):293Y303. 9. Bartley JM, Santucci RA. Computed tomography findings in patients with pediatric blunt renal trauma in whom expectant (nonoperative) manage- ment failed. Urology. 2012;80(6):1338Y1343. 10. Bonatti M, Lombardo F, Vezzali G, Zamboni F, Ferro F, Pernter P, Pycha A, Bonatti G. MDCT of blunt renal trauma: imaging findings and therapeutic implications. Insights Imaging. 2015;6(2):261Y272. 11. Broghammer JA, Fisher MB, Santucci RA. Conservative management of renal trauma: a review. Urology. 2007;70(4):623Y629. 12. Buckley JC, McAninch JW. Pediatric renal injuries: management guide- lines from a 25-year experience. J Urol. 2004;172(2):687Y690. 13. Shoobridge JJ, Corcoran NM, Martin KA, Koukounaras J, Royce PL, Bultitude MF. Contemporary management of renal trauma. Rev Urol. 2011;13(2):65Y72. 14. Umbreit E, Routh J, Husmann D. Nonoperative management of non- vascular grade IV blunt renal trauma in children: meta-analysis and sys- tematic review. Urology. 2009;74(3):579Y582. 15. Higgens J, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Wiley; 2008. Available at http://www.cochrane-handbook.org. 16. Barsness K, Bensard D, Partrick D, Hendrickson R, Koyle M, Calkins C, Karrer F. Renovascular injury: an argument for renal preservation. J Trauma. 2004;57(2):310Y315. 17. Ceylan H, Gunsar C, Etensel B, Sencan A, Karaca I, Mir E. Blunt renal injuries in Turkish children: a review of 205 cases. Pediatr Surg Int. 2003; 19(11):710Y714. 18. Eassa W, El-Ghar MA, Jednak R, El-Sherbiny M. Nonoperative man- agement of grade 5 renal injury in children: does it have a place? Eur Urol. 2010;57(1):154Y163. 19. Eeg KR, Khoury AE, Halachmi S, Braga LH, Farhat WA, Ba¨gli DJ, Pippi Salle JL, Lorenzo AJ. Single center experience with application of the ALARA concept to serial imaging studies after blunt renal trauma in childrenVis ultrasound enough? J Urol. 2009;181(4):1834Y1840. 20. El-Sherbiny M, Aboul-Ghar M, Hafez A, Hammad A, Bazeed M. Late renal functional and morphological evaluation after non-operative treatment of high-grade renal injuries in children. BJU Int. 2004;93(7):1053Y1056. 21. Fitzgerald CL, Tran P, Burnell J, Broghammer JA, Santucci R. Instituting a conservative management protocol for pediatric blunt renal trauma: evalu- ation of a prospectively maintained patient registry. J Urol. 2011;185(3): 1058Y1064. 22. Graziano KD, Juang D, Notrica D, Grandsoult VL, Acosta J, Sharp SW, Murphy JP, St Peter SD. Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children. J Pediatr Surg. 2014;49(1):198Y200. 23. He B, Lin T, Wei G, He D, Li X. Management of blunt renal trauma: an experience in 84 children. Int Urol Nephrol. 2011;43(4):937Y942. 24. Henderson CG, Sedberry-Ross S, Pickard R, Bulas DI, Duffy BJ, Tsung D, Eichelberger MR, Belman AB, Rushton HG. Management of high grade J Trauma Acute Care Surg Volume 80, Number 3 LeeVan et al. * 2016 Wolters Kluwer Health, Inc. All rights reserved. 527 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
- 10. renal trauma: 20-year experience at a pediatric level I trauma center. J Urol. 2007;178(1):246Y250. 25. Impellizzeri P, Borruto FA, Scalfari G, Arena F, Antonuccio P, Santacaterina E, Montalto AS, Romeo C. Natural history of non-operative treatment for renal injuries in children. Minerva Pediatr. 2012;64(3):319Y323. 26. Keller MS, Eric Coln C, Garza JJ, Sartorelli KH, Christine Green M, Weber TR. Functional outcome of nonoperatively managed renal injuries in children. J Trauma. 2004;57(1):108Y110. 27. Keller MS, Green MC. Comparison of short- and long-term functional outcome of nonoperatively managed renal injuries in children. J Pediatr Surg. 2009;44(1):144Y147. 28. Kiankhooy A, Sartorelli K, Vane D, Bhave A. Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. J Trauma. 2010;68(3):526Y531. 29. Manikandan R, Dorairajan LN, Kumar S. Successful timely minimally invasive management of grade 4 renal injury in children: a report of two cases. Int Urol Nephrol. 2009;42(3):553Y556. 30. Margenthaler JA, Weber T, Keller MS. Blunt renal trauma in children: experience with conservative management at a pediatric trauma center. J Trauma. 2002;52(5):928Y932. 31. Mohamed AZ, Morsi HA, Ziada AM, Habib EM, Aref AM, Kotb EA, Eissa MA, Daw M. Management of major blunt pediatric renal trauma: single-center experience. J Pediatr Urol. 2010;6(3):301Y305. 32. Moog R, Becmeur F, Dutson E, Chevalier-Kauffmann I, Sauvage P, Brunot B. Functional evaluation by quantitative dimercaptosuccinic acid scin- tigraphy after kidney trauma in children. J Urol. 2003;169(2):641Y644. 33. Nance ML, Lutz N, Carr MC, Canning DA, Stafford PW. Blunt renal injuries in children can be managed nonoperatively: outcome in a con- secutive series of patients. J Trauma. 2004;57(3):474Y478. 34. Nerli R, Metgud T, Patil S, Guntaka A, Umashankar P, Hiremath M, Suresh S. Severe renal injuries in children following blunt abdominal trauma: selective management and outcome. Pediatr Surg Int. 2011;27(11): 1213Y1216. 35. Ozturk H, Dokucu AI, Onen A, Otc¸u S, Gedik S, Azal OF. Non-operative management of isolated solid organ injuries due to blunt abdominal trauma in children: a fifteen-year experience. Eur J Pediatr Surg. 2004; 14(1):29Y34. 36. Philpott J, Nance M, Carr M, Canning D, Stafford P. Ureteral stenting in the management of urinoma after severe blunt renal trauma in children. J Pediatr Surg. 2003;38(7):1096Y1098. 37. Reese JN, Fox JA, Cannon GM Jr, Ost Mc. Timing and predictors for urinary drainage in children with expectantly managed grade IV renal trauma. J Urol. 2014;192(2):512Y517. 38. Rogers CG, Knight V, MacUra KJ, Ziegfeld S, Paidas CN, Mathews RI. High-grade renal injuries in childrenVis conservative management pos- sible? Urology. 2004;64(3):574Y579. 39. Russell RS, Gomelsky A, McMahon DR, Andrews D, Nasrallah PF. Management of grade IV renal injury in children. J Urol. 2001;166(3): 1049Y1050. 40. Tsui A, Lazarus J, Sebastian van As AB. Non-operative management of renal trauma in very young children: experiences from a dedicated South African paediatric trauma unit. Injury. 2012;43(9):1476Y1481. 41. Wan J, Corvino TF, Greenfield SP, DiScala C. The incidence of recreational genitourinary and abdominal injuries in the western New York pediatric population. J Urol. 2003;170(4 Pt 2):1525Y1527. 42. Gerstenbluth RE, Spirnak JP, Elder JS. Sports participation and high grade renal injuries in children. J Urol. 2002;168(6):2575Y2578. J Trauma Acute Care Surg Volume 80, Number 3LeeVan et al. 528 * 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.