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Pattern and Management of Renal Injuries at Pakistan Institute of Medical Sciences Abdul Rahim Khan1, Naheed Fatima2 and Khursheed Anwar1

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Pattern and Management of Renal Injuries at Pakistan Institute of Medical Sciences Abdul Rahim Khan1, Naheed Fatima2 and Khursheed Anwar1 ORIGINAL ARTICLE Pattern and Management of Renal Injuries at Pakistan Institute of Medical Sciences Abdul Rahim Khan1, Naheed Fatima2 and Khursheed Anwar1 ABSTRACT Objective: To determine the types and grade of various renal injuries and methods adopted for their management at the Department of Urology, Pakistan Institute of Medical Sciences, Islamabad. Study Design: An observational study. Place and Duration of Study: Department of Urology, Pakistan Institute of Medical Sciences, Islamabad, from January 2005 to December 2007. Methodology: The study included 50 patients with both blunt and penetrating renal trauma of either gender and aged above 13 years. Injuries, grade management and outcome was recorded. The data was entered in structured proforma and analyzed for descriptive statistics using SPSS version 10. Results: Frequency was higher in males (82%). The mode of renal injury was blunt in 78% and penetrating in 22% cases. Blunt injuries were mostly due to road traffic accident (94.9%) and penetrating injuries due to firearm (63.6%). Hematuria was present in 86% and absent in 14% cases. Minor renal injury was seen in 74% and major injury in 26% cases. Seventy- two percent cases were managed conservatively. All grade-V (14%) and one grade-1V injury (2%) patients underwent nephrectomy. Renorrhaphy was done in 6% cases. Urinary extravasation was seen in one case (2%). One patient developed renocolic fistula. No mortality was observed in non-operative group; however, 4% patients expired in operative group due to associated injuries. Conclusion: Blunt trauma accounts for majority of the cases of renal injury and non-operative treatment is the suitable method of management for most cases of blunt as well as selected cases of penetrating renal trauma, who are stable hemodynamically and without peritonitis. Key words: Renal trauma. Conservative management. Renorrhaphy. Nephrectomy. Grade. INTRODUCTION major renal trauma with strong advocates of conservative 5 Renal trauma occurs in 8-10% of all blunt and as well as aggressive surgical management. Due to penetrating abdominal injuries.1 Eighty to ninety percent successful outcome of non-operative management of blunt renal trauma, there has been a gradual shift in the of cases involve blunt rather than penetrating injury.2 Serious renal injuries are frequently associated with approach to penetrating renal injuries in selected cases. Most patients with major renal trauma can be followed injuries to other organs. Multiorgan involvement occurs expectantly, with delayed intervention only as needed in 80% of patients with penetrating trauma and in 75% due to improvements in imaging modalities.6 of those with blunt trauma.3 Seventy-five to eighty percent of renal injuries are classified as minor injuries Urinalysis provides rapidly available information in (Grade I-III). Renal injuries are graded using the patients who may have a renal laceration; however, it classification of the organ injury survey committee from should be viewed in the clinical context.7 Sonography the American Association of Surgery in Trauma may be used in patients with blunt abdominal trauma (AAST).4 and possible renal injury. In patients with multivisceral trauma requiring emergency surgery, imaging is usually There is general consensus on the conservative limited to excretory urography prior to surgery. In stable management of minor renal injuries; however, there patients, CT scan allows accurate diagnosis and staging remains a divergence of opinion on management of of major renal injuries.8 Indications for surgery in renal trauma are avulsion of Department of Urology1/Anaesthesia2, Pakistan Institute of the renal pelvis, injuries to the vascular pedicle and life- Medical Sciences, Islamabad. threatening hemodynamic instability. However, extensive Correspondence: Dr. Abdul Rahim Khan, House No. 36/8, extravasations, devitalized segments and co-existing Street No. 6, Rajput Colony, Jehangir Road, Chaklala, bowel or pancreatic injuries are still considered relative Rawalpindi. indications for renal exploration.9 Vascular injury can E-mail: [email protected] also be effectively treated with angiographic procedures Received September 01, 2008; accepted October 27, 2009. like super selective renal embolization.10 194 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (3): 194-197 Renal injuries The purpose of this study was to analyze the pattern of RESULTS various renal injuries i.e. blunt or penetrating, grade of The study included 50 patients, 41 (82%) males and injuries according to AAST and methods adopted for 9 (18%) females. Mean age was 26 years with age their management, whether conservative or operative in range from 16 to 54 years. Thirty-nine (78%) patients both types of trauma. presented with blunt and 11 (22%) with penetrating trauma. Blunt trauma was due to road traffic accident in METHODOLOGY 37 (94.9%) cases and to fall in 2 (5.1%) cases. This observational study was conducted at the Penetrating injury was due to firearm in 7 (63.6%) and to Department of Urology, Pakistan Institute of Medical stab injury in 4 (36.4%) cases. Emergency surgery was Sciences, Islamabad, from January 2005 to December done in all cases of penetrating trauma due to firearm 2007. A total of 50 patients of either gender and aged and in only one case of stab injury. Three cases were above 13 years, presenting with both blunt and initially managed conservatively who had stab injury penetrating renal trauma due to road traffic injuries, from back. firearm injury and fall were included in this study. Those presenting with other causes of renal injury, like Thirty three (84.6%) cases of blunt renal trauma were iatrogenic injury were excluded from the study. All managed conservatively. Six (15.4%) cases were patients underwent primary followed by secondary explored initially due to hemodynamic instability and survey in accordance with A.T.L.S. guidelines. Hemo- acute abdomen due to associated injuries. dynamically unstable patients at presentation were Associated injuries in both types of trauma included resuscitated and stabilized before imaging. The renal spleen in 7 (14%), liver in 3 (6%), mesentery 6 (12%), 4 injuries were graded according to AAST. colon 4 (8%), small intestine 5 (10%), vertebral column Grade-I was assigned to subcapsular, non-expanding 1 (2%), ribs 5 (10%) and head injury in 4 (8%) cases. hematoma, with no parenchymal laceration. Grade-II Hematuria was gross in 31 (62%), microscopic in 12 was given to non-expanding perirenal hematoma (24%) and absent in 7 (14%) cases. confined to renal retroperitoneum; and to laceration of < 1.0 cm depth of renal cortex without urinary Ten (20%) cases of grade-I, 15 (30%) cases of grade-II, extravasation. Grade-III was given to laceration > 1.0 cm 12 (24%) cases of grade-III, 6 (12%) cases of grade-IV parenchymal depth of renal cortex without collecting and 7 (14%) cases of grade-V were diagnosed. Of the 7 system rupture or urinary extravasation. Grade-IV was patients with grade-V injury, 4 had shattered kidney and assigned to parenchymal laceration extending through 3 were with pedicle avulsion (Table I). renal cortex, medulla and collecting system main renal All grade-V (14%) and 1 (2%) grade-IV underwent artery or vein injury with contained haemorrhage. nephrectomy. Renorrhaphy was done in 3 (6%) cases. Grade-V was the completely shattered kidney and or No early complications were seen in non-operative avulsion of renal hilum leading to devascularized kidney. Table I: Management of associated injuries. All cases of blunt renal trauma were initially managed Variable Number Percentage conservatively except those with shock not responding Age (years) Mean 26 to resuscitation, persistent gross hematuria, associated Age range 16-54 abdominal visceral injury and those with grade-V Sex Male 41 82% injuries. In case of penetrating injury due to firearm, stab Female 9 18% Type of trauma Blunt Road 37 94.9% injury from front and grade-V injury, operative treatment accidents was contemplated after resuscitation. Stab injuries from Falls 2 5.1% back were initially managed conservatively. Penetrating Firearm 7 63.6% Stab injury 4 36.4% Patient's age, gender, injury mechanism, degree of Degree of hematuria Gross 31 62% hematuria, method of management, operative findings Microscopic 12 24% (grade of injury and associated injuries) and early Absent 7 14% complications were recorded. Conservative management Grade of injury 1 10 20% consisted of hemodynamic monitoring, parenteral fluid 11 15 30% 111 12 24% therapy with crystalloid, colloid or blood transfusion, IV 6 12% hematocrit determination, prophylactic antibiotics and V 7 14% bed rest until gross hematuria settled. All patients Associated organ Liver 3 6% planned for operative management were explored injuries Spleen 7 14% through midline incision. Complications were assessed Mesentery 6 12% Colon 4 8% during hospital stay and follow-up in OPD. Non- Small intestine 5 10% probability sampling was done. The data was entered in Vertebral column 1 2% structured proforma and analyzed using SPSS Ribs 5 10% (Statistical Package for Social Sciences) version 10. Head injury 4 8% Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (3): 194-197 195 Abdul Rahim Khan, Naheed Fatima and Khursheed Anwar group except urinary extravasation in one case (2%), suspected major renal trauma or multivisceral injuries. which settled after stenting. Two out of 3 cases due to With massive haemorrhage requiring immediate stab injury managed conservatively were free of laparotomy, CT scan is contraindicated. Salimi et al. complications, however, one case developed renocolic found higher specificity (93.5%) and accuracy (91.6%) fistula. Wound infection was seen in 2 (4%) cases in of CT scan in renal trauma.15 operative group. No death was seen in non-operative Seven cases of renal trauma due to gunshot and one group; however, 2 (4%) patients died in operative group due to stab injury were explored. Three cases of stab due to associated injuries (Table II).
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