Professional Documents
Culture Documents
: 10-year experience
Wichien Sirithanaphol, MD
Introduction
Urogenital system injuries are seen in 10% of traumatic patients and mostly in patients with multiple trauma and severe trauma of lower parts of abdomen or pelvis The prevalence of urogenital injuries has been reported between 10 and 30% in adults and less than 3% in children
MC Aninch JW. Genitourinary trauma. World Urol 1999.17: 95-96.
Introduction
Renal injury is the most common injury in urogenital system
The prevalence of Renal Injury in Abdomonal Traumatic Patients has reported 8 10%1 and 13.6 % in Siriraj Hospital2
1 Peterson NE. complications of renal trauma. Urol Clin North Am 1989; 16: 221-36. 2 , : , .. : , 2522: 1-13.
Introduction
Blunt trauma is the cause of more than 90% of Renal Injuries1
Accidents, falling and being hit are the most frequent of blunt injury
Bullet and stab wounds are the most common cause for penetrating injuries2
1 Dreitlein AA, Snner S, Basler J. Genitourinary trauma.Emery med clin North Am 2001 19(3): 599-90. 2 Palmer LS, Rosenbaum RR, Gershbaum MD. Penetrating ureteral trauma at an urban trauma center.
Urology 1999 54(1): 34-36.
Introduction
Grading of renal injuries is performed using the American Association for the Surgery of Trauma organ injury severity scale
Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: spleen, liver, and kidney. 29: 16641666, 1989.
J Trauma
Introduction
Nonoperative management of renal injuries has gained much support in past decades
A trial of Nonoperative management has been advocated for most adult blunt renal injuries1, many renal stab wounds2, and selective renal gunshot wounds3
1 Danuser H, Wille S, Zoscher G, et al: How to treat blunt kidney ruptures: primary open surgery or
conservative treatment with deferred surgery when necessary? Eur Urol 39: 914, 2001.
2 Bernath AS, Schutte H, Fernandez RR, et al: Stab wounds of the kidney: conservative management in
flank penetration. J Urol 129: 468470, 1983 Urol 171: 20, 2004.
Research methodology
Retrospective review : case review
Srinagarind hospital, university hospital in Khon-Kaen Period of study : 1 Jan 1999 - 31 Dec 2008 Retrieve data from ICD10 code
Renal trauma Renal injury
Exclusion criteria Penetrating injury Iatrogenic Renal injury Referred patients with Non-Renal Injury related complication
Group of Study
Non Operative Management (NOM) group (+Interventional Treatment) - Successful NOM - Failed NOM Operative Management group - Renal exploration
Management
The absolute indications for renal exploration
Life-threatening hemorrhage from a renal source
Pulsatile perirenal hematoma (suggestive of a grade V vascular injury) Active extravasation of intravenous contrast
Management
The patients who were considered non-operative treatment
Absolute bed rest until gross hematuria resolves Regular & frequent vital sign measurement Serial abdominal examination Serial Hct checked
Ethical Consideration
This study have proved by The Khon Kaen University Ethics Committee for Human Research No : HE 521112
Results
Characteristic
Blunt injury 69 pt
56 pt (82%) 13 pt (18%)
Male Female
Mean age
Underlying disease
No 55 pt (80%)
Mechanism of injury
Blunt Renal injury 69 pt
Management
Blunt Renal injury 69 pt
35% (15-48%)
30% (20-44%)
5/55 pt
86% 78%
22% 14%
Grading of injury
Blunt Renal injury 69 pt
9%
33% 23%
14%
21%
Operative group 7 pt
Associated injury
Extra-abdominal injury
Head injury
Pt
23
Intra-abdominal injury
Spleen Liver
pt
13 8
Hemo/pneumothorax
Rib fracture
22
18 12 8 6 5
Small bowel
Colon Pancreas
2
1 1
IVC
Management outcome
Management outcome
Non-operative Group (55 Pt)
Failed NOM 4/55 pt (7.3%) Peritonitis : 1 pt - Avulsion of upper pole of kidney Complication : 3 pt - Pseudoaneurysm : 1 pt - Infected urinoma : 1 pt - Delayed bleeding : 1 pt
Management outcome
Operative Group (7 Pt)
Procedure EL c nephrectomy 6 pt EL c ureteropyeloplasty 1 pt
2 2
1
Specific complication
1 1
failed
EL c nephrectomy
EL c left lower pole nephrectomy
1 1
Embolization
failed
EL c nephrectomy
Compartmental syndrome
Discussion
According to the obtained results from this study, Renal Injury develops in a little portion of abdominal traumatic patients
4.07% This is quite less than findings of other studies
However, these injuries may lead to mortality, urogenital dysfunction, neglecting them could cause serious sequelae
Discussion
20 30 years are the most common age group, may be because of traumatic pattern which mostly affect the youth
Regarding gender, Male were enrolled 4.5 times more than female in this study
Blunt trauma is the cause of more than 90% of Renal Injuries
Discussion
NOM Groups
NOM is the treatment of choice in stable patients Most of blunt renal injury can be managed conservatively
Grade 5 is only 1 pt
Failed NOM
3 pt : Death due to serious associated injury 2 pt : due to late sequale (Infected urinoma, Delayed bleeding) 1 pt : due to immediated sequale (Developed peritonitis)
Discussion
Mortality in operative group is higher than NOM group
5% vs. 36% Severe Renal Injury Severe associated injury
Conservative Management have also been applied to penetrating renal injuries, who were hemodynamically stable and without peritoneal signs
In this study can't be manage due to contraindication
Conclusion
Most of blunt renal injury can be managed conservatively Penetrating renal injuries can be managed nonoperatively in selected patients
Multimodality of Treatment
Procedure should be suited for individual
Thank You