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JU INSIGHT: Role for Conservative Management in Grade V Renal Trauma
By: Nizar Hakam, MBBS, University of California San Francisco; Nathan M. Shaw, MD, University of California San Francisco; Jason Lui, BA, University of California San Francisco; Behzad Abbasi, MD, University of California San Francisco; Jeremy B. Myers, MD, University of Utah, Salt Lake City; Benjamin N. Breyer, MD, MAS, University of California San Francisco | Posted on: 17 Mar 2023
Hakam N, Shaw NM, Lui J, Abbasi B, Myers JB, Breyer BN. Role for conservative management in grade V renal trauma. J Urol. 2023;209(3):565-572.
Study Need and Importance
Nonoperative management of renal trauma is widely adopted especially in cases of low-grade injury. Few data exist on the American Association for the Surgery of Trauma grade V kidney injuries; thus, we examined a population of these patients in the National Trauma Databank between 2017 and 2019.
What We Found
We assessed 1,474 patients with grade V renal trauma who survived to discharge, of whom 557 (37.8%) were managed conservatively, defined as the absence of surgical or procedural intervention other than ureteral stent or percutaneous drain placement (see Table). In the multivariable analysis, penetrating trauma mechanism (OR 0.13, 95% CI 0.09-0.19, P < .001) and receiving transfusion (OR 0.22, 95% CI 0.17-0.29, P < .001) were associated with decreased odds of conservative management. In the total 1,919 patients with grade V injuries, rate of conservative management was similar (38.1%). After excluding 110 patients who died in the emergency department, there were 1,809 patients, of whom 625 (34.6%) were managed conservatively.
Table. Clinical Characteristics of Patients With Grade V Renal Trauma Who Survived to Discharge, Stratified by Management Approach
| Conservative management N=557 | Operative management N=917 | P value | |
|---|---|---|---|
| Age, mean (SD), ya | 28.9 (18.7) | 30.7 (14.5) | .047 |
| Sex, male, No. (%)b | 388 (69.7) | 740 (80.7) | < .001 |
| Penetrating injury, No. (%) | 51 (9.2) | 482 (52.6) | < .001 |
| Injury Severity Scale, median (IQR)c | 34 (26-38) | 34 (26-41) | .47 |
| Pulse, mean (SD) | 98.3 (25) | 103.2 (26.9) | .0005 |
| Hypotension, No. (%)d | 179 (32.1) | 252 (27.5) | .057 |
| Glasgow Coma Scale, median (IQR) | 15 (15-15) | 15 (14-15) | .0006 |
| Transfusion, No. (%) | 152 (27.3) | 594 (64.8) | < .001 |
| Trauma center level, No. (%) | < .001 | ||
| I | 252 (45.2) | 536 (58.5) | |
| II | 117 (21) | 142 (15.5) | |
| III | 28 (5) | 11 (1.2) | |
| Missing | 160 (28.7) | 228 (24.9) | |
| Associated injuries, No. (%) | 350 (62.8) | 789 (86) | < .001 |
| Liver | 182 (32.7) | 416 (45.4) | < .001 |
| Spleen | 191 (34.3) | 349 (38.1) | .145 |
| Pancreas | 28 (5) | 188 (20.5) | < .001 |
| Intestine | 38 (6.8) | 376 (41) | < .001 |
| Peritoneum | 10 (1.8) | 80 (8.7) | < .001 |
| Adrenal | 69 (30.5) | 89 (25.1) | .155 |
| Abdominal aorta | 6 (1.1) | 29 (3.2) | .011 |
| Abbreviations: IQR, interquartile range; SD, standard deviation. a All normally distributed continuous variables are expressed as a mean (SD) and were compared using t-test. b All categorical variables are expressed as a frequency (%) and were compared using χ2 test. c All skewed continuous variables are expressed as a median (IQR) and were compared using Mann-Whitney test. d Hypotension was defined as systolic blood pressure <90 mm Hg. |
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Limitations
The main limitation to this study is the lack of radiological data; thus, renal trauma grade misclassification may be present. We were not able to compare specific injury patterns between patients managed conservatively and operatively. Lack of treatment intent hindered efficacy assessment of treatment approaches.
Interpretation for Patient Care
A significant portion of patients with grade V renal trauma are amenable to conservative management. These data suggest that hemodynamic stability is an important deciding factor driving management. Clinical trials are needed to establish efficacy of such management in patients with stable clinical status and can avoid immediate surgical intervention.
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