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Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study

Keihani, Sorena, MD; Xu, Yizhe, MS; Presson, Angela, P., PhD; Hotaling, James, M., MD; Nirula, Raminder, MD; Piotrowski, Joshua, MD, PhD; Dodgion, Christopher, M., MD; Black, Cullen, M.; Mukherjee, Kaushik, MD; Morris, Bradley, J.; Majercik, Sarah, MD; Smith, Brian, P., MD; Schwartz, Ian, MD; Elliott, Sean, P., MD; DeSoucy, Erik, S., DO; Zakaluzny, Scott, MD; Thomsen, Peter, B.; Erickson, Bradley, A., MD; Baradaran, Nima, MD; Breyer, Benjamin, N., MD; Miller, Brandi, DO; Santucci, Richard, A., MD; Carrick, Matthew, M., MD; Hewitt, Timothy; Burks, Frank, N., MD; Kocik, Jurek, F., MD; Askari, Reza, MD; Myers, Jeremy, B., MDfor the Genito-Urinary Trauma Study Group

Journal of Trauma and Acute Care Surgery: March 2018 - Volume 84 - Issue 3 - p 418–425
doi: 10.1097/TA.0000000000001796
AAST 2017 Podium Paper
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BACKGROUND The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for high-grade renal trauma (HGRT). We aimed to describe the contemporary management of HGRT in the United States and also evaluate clinical factors associated with nephrectomy after HGRT.

METHODS From 2014 to 2017, data on HGRT (American Association for the Surgery of Trauma grades III-V) were collected from 14 participating Level-1 trauma centers. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Management was classified into three groups—expectant, conservative/minimally invasive, and open operative. Descriptive statistics were used to report management of renal trauma. Univariate and multivariate logistic mixed effect models with clustering by facility were used to look at associations between proposed risk factors and nephrectomy.

RESULTS A total of 431 adult HGRT were recorded; 79% were male, and mechanism of injury was blunt in 71%. Injuries were graded as III, IV, and V in 236 (55%), 142 (33%), and 53 (12%), respectively. Laparotomy was performed in 169 (39%) patients. Overall, 300 (70%) patients were managed expectantly and 47 (11%) underwent conservative/minimally invasive management. Eighty-four (19%) underwent renal-related open operative management with 55 (67%) of them undergoing nephrectomy. Nephrectomy rates were 15% and 62% for grades IV and V, respectively. Penetrating injuries had significantly higher American Association for the Surgery of Trauma grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy.

CONCLUSION Expectant and conservative management is currently utilized in 80% of HGRT; however, the rate of nephrectomy remains high. Clinical factors, such as surrogates of hemodynamic instability and metabolic acidosis, are associated with nephrectomy for HGRT; however, higher renal injury grade and penetrating trauma remain the strongest associations.

LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; Therapeutic study, level IV.

From the Division of Urology, Department of Surgery (S.K., J.M.H., J.B.M.), Division of Epidemiology, Department of Internal Medicine (Y.X., A.P.P.), Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; Department of Urology (J.P.), Department of Surgery (C.M.D.), University of Wisconsin, Milwaukee, Wisconsin; Division of Acute Care Surgery (C.M.B., K.M.), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma and Surgical Critical Care (B.J.M., S.M.), Intermountain Medical Center, Murray, Utah; Division of Trauma and Surgical Critical Care (B.P.S.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Urology (I.S., S.P.E.), Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota; Department of Surgery (E.S.D.), Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery (S.Z.), University of California Davis Medical Center, Sacramento, California; Department of Urology (P.B.T., B.A.E.), University of Iowa, Iowa City, Iowa; Department of Urology (N.B., B.N.B.), University of California-San Francisco, San Francisco, California; Department of Urology (B.M., R.A.S.), Detroit Medical Center, Detroit, Miami; Medical City Plano (M.M.C.), Plano, Texas; Department of Urology (T.H., F.N.B.), Oakland University William Beaumont School of Medicine, Royal Oak, Michigan; Department of Surgery (J.F.K.), East Texas Medical Center, Tyler, Texas; and Division of Trauma, Department of Surgery (R.A.), Brigham and Women's Hospital, Boston, Massachusetts.

Submitted: August 31, 2017, Revised: December 13, 2017, Accepted: December 22, 2017, Published online: January 2, 2018.

Address for reprints: Sorena Keihani, MD, Division of Urology, Department of Surgery, University of Utah School of Medicine, 30, North 1900, Salt Lake City, UT 84132; email: Sorena.keihani@hsc.utah.edu.

This article is presented as a podium presentation at the 76th Annual Meeting of the American Association for the Surgery of Trauma (AAST) and Clinical Congress of Acute Care Surgery, September 13–16, 2017, Baltimore, MD.

© 2018 Lippincott Williams & Wilkins, Inc.