Selective Management Of Isolated And Non-Isolated Grade IV Renal Injuries

Few would argue that the majority of grade I to III renal injuries can be managed conservatively while most would agree that controversy exists regarding the management of high grade (IV/V) renal injuries. Some argue for primarily nonoperative management and others cite the necessity of operative exploration and repair. A recent review by Jill Buckley and Jack McAninch from San Francisco examined the selective management of 153 grade IV renal injuries. The report is published in the December 2006 issue of the Journal of Urology.

Data was collected prospectively on 153 cases of grade IV renal trauma during the last 25 years at San Francisco General Hospital. The group of 153 was subdivided into isolated (43 cases) and nonisolated (110 cases) renal injuries to determine operative vs. nonoperative management based solely on grade IV renal injury. There were 87 penetrating injuries and 66 blunt injuries, while 52% (79 of 153) involved a renal vascular injury. Operative management was selected in two-thirds of cases (103). Of the 103 operative cases, 85 (83%) had significant associated nonrenal injuries that required operative exploration, prompting timely renal exploration and attempted reconstruction. The overall renal salvage rate was 84% (128 of 153). The operative nephrectomy rate was 15% (15 of 103), with 13 nephrectomies occurring in a damage control situation. Of the reconstructed kidneys, 5 demonstrated less than 25% of overall renal function and were not considered to be salvaged. Of these kidneys, 4 involved vascular repairs (2 arterial, 1 venous, 1 both). When examining the isolated renal injury group of 43 patients (28% of the group), the majority of the operative cases had a penetrating injury and exploration was performed in 18 of 43 cases (42%) with an 11% nephrectomy rate. This is in contrast to a 77% operative rate for nonisolated grade IV renal injuries. The remaining 25 of 43 (58%) isolated grade IV renal injuries were managed nonoperatively with a renal salvage rate of 88%. The transfusion requirement was higher for operative cases (8.5 units vs. 2.6 units). The hospital stay was similar. None of the 50 nonoperative cases required a nephrectomy. The management of grade IV renal injuries is complex and demanding if renal salvage is to be achieved. Selective operative vs. nonoperative management is based on the presence of associated nonrenal injuries, the hemodynamic stability of the patient, the adequacy of renal staging, and the skill of the surgeon.(Source: Journal of Urology : San Francisco General Hospital : February 2007.)