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Kidney and Uro-Trauma: WSES-AAST Guidelines Federico Coccolini1*, Ernest E

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Kidney and Uro-Trauma: WSES-AAST Guidelines Federico Coccolini1*, Ernest E Coccolini et al. World Journal of Emergency Surgery (2019) 14:54 https://doi.org/10.1186/s13017-019-0274-x REVIEW Open Access Kidney and uro-trauma: WSES-AAST guidelines Federico Coccolini1*, Ernest E. Moore2, Yoram Kluger3, Walter Biffl4, Ari Leppaniemi5, Yosuke Matsumura6, Fernando Kim7, Andrew B. Peitzman8, Gustavo P. Fraga9, Massimo Sartelli10, Luca Ansaloni11, Goran Augustin12, Andrew Kirkpatrick13, Fikri Abu-Zidan14, Imitiaz Wani15, Dieter Weber16, Emmanouil Pikoulis17, Martha Larrea18, Catherine Arvieux19, Vassil Manchev20, Viktor Reva21, Raul Coimbra22, Vladimir Khokha23, Alain Chichom Mefire24, Carlos Ordonez25, Massimo Chiarugi1, Fernando Machado26, Boris Sakakushev27, Junichi Matsumoto28, Ron Maier29, Isidoro di Carlo30, Fausto Catena31 and WSES-AAST Expert Panel Abstract Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines. Keywords: Kidney, Urogenital, Urethra, Ureter, Bladder, Trauma, Adult, Pediatric, Classification, Guidelines, Embolization, Surgery, Operative, Non-operative, Conservative, Stenting, Urological, Endovascular trauma management, Flow chart Background injuries caused by penetrating mechanisms; in fact, in In both, adult and children cohorts, urogenital trauma gunshot and stab wounds, OM is applied in 75% and has a cumulative incidence of 10-20%, and the kidney is 50% of cases, respectively [1]. As for the other abdomi- involved in 65–90% of the time [1–3]. Males are in- nopelvic lesion management, decisions should be based volved 3 times more than females (both in adults and on physiology, anatomy, and associated injuries [6–9]. children) [2, 4]. As in other abdominal injuries, the use Another important consideration relates to the different of non-operative management (NOM) has significantly management approach to kidney and urological trauma increased in last decades, particularly due to the intro- urologists and trauma surgeons [10]. Urologic guidelines duction of hybrid rooms and endovascular trauma and tend in general to focus more on organ preservation, bleeding management (EVTM) associated with modern whereas trauma surgeons tend to consider the urological mini-invasive procedures [5, 6]. Moreover, In stabilization of physiology more importantly than organ pediatric patients, NOM should be the first option as preservation [10]. Despite this different point of view, an soon as it is viable and safe. However, operative manage- integrated approach and active collaboration between ment (OM) remains the gold standard in unstable pa- the two specialties forms the basis to achieve optimal tients, after failure of NOM (fNOM), and in many management and the best outcomes [10]. This is par- ticularly true for urogenital and urinary tract injuries in which the multidisciplinary approach is the cornerstone * Correspondence: [email protected] to improve short- and long-term outcomes. 1General, Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia, 56124 Pisa, Italy Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Coccolini et al. World Journal of Emergency Surgery (2019) 14:54 Page 2 of 25 Notes on the use of the guidelines kidney, injuries, trauma, urogenital, adult, pediatric, The guidelines are evidence-based, with the grade of rec- hemodynamic instability/stability, angioembolization, ommendation based on the evidence. The guidelines management, nonoperative, conservative, operative, sur- present the diagnostic and therapeutic methods for opti- gery, diagnosis, follow-up, combined with AND/OR. No mal management of urogenital trauma. The practice search restrictions were imposed. The dates were se- guidelines promulgated in this work do not represent a lected to allow comprehensive published abstracts of standard of practice. They are suggested plans of care, clinical trials, consensus conference, comparative studies, based on the best available evidence and the consensus congresses, guidelines, government publication, multi- of experts, but they do not exclude other approaches as center studies, systematic reviews, meta-analysis, large being within the standard of practice. For example, they case series, original articles, and randomized controlled should not be used to compel adherence to a given trials. Case reports and small case series were excluded. method of medical management, which method should Narrative review articles were also analyzed to determine be finally determined after taking account of the condi- if other cited studies should be included. The literature tions at the relevant medical institution (staff levels, ex- selection is reported in the flow chart (Fig. 1). perience, equipment, etc.) and the characteristics of the The level of evidence (LE) was evaluated using the individual patient. However, responsibility for the results GRADE system [11] (Table 1). of treatment rests with those who are directly engaged A group of experts in the field coordinated by a central co- therein, and not with the consensus group. ordinator was contacted to express their evidence-based opinion on several issues about the pediatric (< 16 years old) Methods and adult urogenital trauma [12, 13]. Urogenital trauma was A computerized search was done by the bibliographer in assessed by the anatomy of the injury (kidney, urogenital different databanks (MEDLINE, Scopus, EMBASE) and tract, bladder), type of injury (blunt and penetrating injury), citations were included for the period between January management (conservative and operative management), and 1990 and August 2018 using the primary search strategy: type of patient (adults, pediatrics). Through the Delphi Fig. 1 PRISMA flow chart Coccolini et al. World Journal of Emergency Surgery Table 1 GRADE system to evaluate the level of evidence and recommendation Grade of recommendation Clarity of risk/benefit Quality of supporting evidence Implications 1A Strong recommendation, high- Benefits clearly outweigh risk and burdens, RCTs without important limitations or Strong recommendation, applies to quality evidence or vice versa overwhelming evidence from observational studies most patients in most circumstances without reservation 1B (2019)14:54 Strong recommendation, Benefits clearly outweigh risk and burdens, RCTs with important limitations (inconsistent results, Strong recommendation, applies to most moderate-quality evidence or vice versa methodological flaws, indirect analyses or imprecise patients in most circumstances without conclusions) or exceptionally strong evidence from reservation observational studies 1C Strong recommendation, low- Benefits clearly outweigh risk and burdens, Observational studies or case series Strong recommendation but subject to quality or very low-quality or vice versa change when higher quality evidence evidence becomes available 2A Weak recommendation, high- Benefits closely balanced with risks and burden RCTs without important limitations or overwhelming Weak recommendation, best action may quality evidence evidence from observational studies differ depending on the patient, treatment circumstances, or social values 2B Weak recommendation, Benefits closely balanced with risks and burden RCTs with important limitations (inconsistent results, Weak recommendation, best action may moderate-quality evidence methodological flaws, indirect or imprecise) or exceptionally differ depending on the patient, treatment strong evidence from observational studies circumstances, or social values 2C Weak recommendation, Low- Uncertainty in the estimates of benefits, risks, and Observational studies or case series Very weak recommendation; alternative quality or very low-quality burden; benefits, risk, and burden may be closely treatments may be equally reasonable evidence balanced and merit consideration Page 3 of 25 Coccolini et al. World Journal of Emergency Surgery (2019) 14:54 Page 4 of 25 process, different issues were discussed in subsequent – Minor (WSES class I) rounds. The central coordinator assembled the different an- – Moderate (WSES class II) swers derived from each round. Each version was then re- – Severe (WSES class III and IV) vised and improved. The definitive version was discussed during the WSES World Congress (in
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