Conservative Management of Penetrating Renal Injuries

1. Conservative Management of Penetrating Renal Injuries Aaron Smith, DO Efraim Serafetinides, MD Richard A. Santucci, MD

2. Introduction • Penetrating renal trauma had traditionally been treated by renal exploration.1 • Renal exploration is associated with nephrectomy rates ranging from 11-64%. 2 • Nephrectomy can lead to increased morbidity, mortality, renal failure rates. 3-,4 • Currently, non-operative management has gained acceptance for management of renal stab wounds. 5 • Expectant management has an increasing role in the management of abdominal gunshot wounds (GSW). 6,7 • Scott, R., Jr., Carlton, C., et al. Penetrating injuries of the kidney: an analysis of 181 patients. J. Urol., 101: 247, 1969. • Wessells H, Suh D, Parker Jr, et al. Renal injury and operative management in the United States: results of a population-based study. J. Trauma, 2003; 54: 423-430. • McGonigal MD, Lucas CE, Ledgerwood AM. The effects of treatment of renal trauma on renal function. J Trauma. 1987; 27: 471-476. • Narrod JA, Moore EE, Posner M, et al. Nephrectomy following trauma-impact on patient outcome. J Trauma. 1985; 25: 842-844. • Armenakas NA, Duckett CP, McAninch JW. Indications for nonoperative management of renal stab wounds. J Urol. 1999; 161: 768-771. • Hammer CC, Santucci RA. Effect of an institutional policy of nonoperative treatment of grade I-IV renal injuries. J Urol. 2003; 169: 1751-1753 • Wessells H, McAninch JW, Meyer A, et al. Criteria for nonoperative treatment of significant penetrating renal lacerations. J Urol. 1997; 157. 24-27.

3. Purpose • Review our experience in penetrating renal trauma when employing principles of expectant management • Bolster current literature on expectant management of penetrating renal injury • Reduce iatrogenic nephrectomy rates

4. Study Design • IRB approved • Multi-institutional • Detroit Medical Center (DMC) • Athens, Greece • Retrospective analysis • 1990-2004 (Greece) • 2000-2007 (DMC)

5. Patients • Greece • AAST Grade II-III • 85 stab wounds • 41 GSWs • 30 low-velocity gunshot wounds (LVGSW) • 11 high-velocity gunshot wounds (HVGSW) • DMC • AAST Grade III-IV • 2 stab wounds • 11 GSWs (LVGSW)

6. Materials & Methods • 139 charts were reviewed from two trauma databases • Injury type (stab, GSW), AAST Grade, physical and radiographic findings, associated injuries, management and follow-up was noted • Initial evaluation included physical exam, lab tests and radiographic staging • All hemodynamically stable patients were selected for conservative management of their GU injuries

7. Materials & Methods • Patients with hemodynamic instability or injury to renal pelvis/ureter on imaging were taken for renal exploration • Those selected for expectant management were treated with: • Serial physical exams by experienced teams • Hematocrit monitoring • Hemodynamic monitoring • Antibiotics • Bed rest

8. Materials & Methods • The GSW, stab wound subgroups were compared with regard to: • Mean associated injuries/patient • Transfusion requirement • Need for nephrectomy • Delayed complications • Mean Length of Stay (LOS) • Death

9. Results

10. Results

11. Results

12. Results • 83/87 (95.2%) of patients with stab wounds were successfully treated expectantly. Number of lost renal units=0 • 20/41 (48.8%) of LVGSW patients did not require GU-specific surgical intervention (51% operative rate). Number of lost renal units= 5 • 11/11 (100%) of HVGSW patients underwent nephrectomy • 16/52 (30.8%) total GSW patients underwent nephrectomy

13. Conclusions • Expectant management is a reasonable option for the treatment of renal stab wounds • Approximately 50% of patients with LVGSW will require GU-specific surgical intervention • HVGSW mandated more aggressive treatment • A renal salvage rate of 88.5% (123/139) for penetrating trauma was achieved with selected exploration and an organ preserving strategy for grades II-IV renal injury.