Does a collecting system injury with grade iv renal blunt trauma always need urinary intervention?

PURPOSE: This study aimed to identify the characteristics associated with the need for urinary intervention for a blunt renal injury with collection system involvement using a computed tomography (CT) protocol for trauma. MATERIALS AND METHODS: Abdominal CT images of patients with blunt renal injuries from 2016 to 2020 were reviewed. Patients with low-grade renal trauma, non-collecting system involvement, American Association for the Surgery of Trauma grade V shattered kidney, and emergent nephrectomy were excluded. The largest perinephric mass thickness was measured in the axial view using CT, and a cutoff value was obtained using a receiver-operating characteristic curve analysis. Risk factors for further urinary intervention were analyzed. RESULTS: Among the 70 patients included in this study, those with perinephric mass thicknesses < 25 mm (n = 36) had a significantly lower rate of urinary intervention than those with perinephric mass thicknesses ≥ 25 mm (0 vs. 5; p = 0.023). There was no significant difference in the follow-up durations of the groups (19 days vs. 38 days; p = 0.198). More than 90% of the perinephric mass in the < 25 mm group resolved within a median follow-up duration of 38 days, whereas nearly half of the ≥ 25 mm group had a residual perinephric mass during a median follow-up duration of 19 days. CONCLUSION: The initial CT protocol for trauma was useful for predicting the need for further urinary interventions for collecting system injuries. A perinephric mass thickness < 25 mm is predictive of a low likelihood of requiring urinary intervention.

A retrospective study of pediatric renal trauma: A single-center experience in Japan.

OBJECTIVES: To report pediatric renal trauma experiences at the National Center for Child Health and Development in Japan according to the Japanese Association for the Surgery of Trauma (JAST) classification 2008. METHODS: Medical records were retrospectively reviewed for 45 children younger than 18 years old diagnosed with renal trauma from February 2004 to December 2021, regarding details of external causes, treatments, complications, and injury scales according to the JAST classification 2008. The cases who cannot be classified into the JAST classification 2008 will be categorized into our original type 0. RESULTS: There were 24 males and 21 females with a mean age of 8.5 years. Left kidneys were the predominantly affected side. Blunt injury was involved in every case (mainly falls and traffic accidents). Concomitant organ injuries were found in 13 cases. The injury scales were type Ia (13.3%), II (11.1%), IIIa (13.3%), IIIb (24.4%). Type 0 accounted for 37.8%, which were type 0c (congenital anomalies of the kidney and urinary tract without hematoma and/or laceration of kidney parenchyma) at 11.1% and type 0h (only hematuria and normal radiologic finding) at 26.7%. Treatments were blood transfusion, ureteral stenting, nephrostomy, and no nephrectomy. Complications were pseudoaneurysm, hypertension, and infection. CONCLUSIONS: Nearly 38% of cases cannot be classified into the JAST classification 2008, comprising at least two irrelevant types (type 0c and type 0h ). Accordingly, a pediatric renal injury scale should be established to achieve the precise diagnosis and treatments. However, further studies are still needed.

Cushioning the blow: role of perirenal fat in renal trauma injury severity.

OBJECTIVES: To explore the association between perirenal fat thickness (PFT) and renal trauma grade. We hypothesise this association is related to a shock-absorbing effect of adiposity around the kidney. PATIENTS AND METHODS: We identified all patients with renal trauma who arrived at the emergency department of a single trauma centre between 2014 and 2020. Radiology images were reviewed to measure the PFT around the uninjured kidney due to disrupted PFT around the traumatised kidney. Patients with no available images or penetrating trauma mechanism were excluded. Logistic regression was used to assess the relation between PFT and high-grade renal trauma (HGRT; defined as American Association for the Surgery of Trauma Renal Grade IV-V), adjusting for age, sex, and Injury Severity Scale (ISS). RESULTS: A total of 150 patients with renal trauma were included. The median (interquartile range) age was 38.5 (26-52) years and 106 (70.7%) were males. The PFT ranged between 2.1 and 50.1 mm, and 31 (20.7%) had HGRT. Interestingly, PFT only mildly correlated with body mass index (BMI; Pearson correlation coefficient 0.42, P < 0.001). Those with HGRT had significantly lower PFT compared to those without HGRT (median 9.5 vs 11.9 mm, P = 0.047). In the multivariable analysis adjusting for age, sex, and ISS, increasing PFT was associated with decreased odds (odds ratio 0.91, 95% confidence interval 0.84-0.98; P = 0.015) of HGRT. CONCLUSION: Increasing PFT is associated with lower risk of HGRT following blunt injury. These results support a protective cushion role of adiposity in renal trauma. Notably, PFT was not strongly correlated with BMI, underscoring limitations of BMI in measuring adiposity.

High-frequency shock wave lithotripsy: stone comminution and evaluation of renal parenchyma injury in a porcine ex-vivo model.

BACKGROUND: The electrohydraulic high-frequency shock wave (Storz Medical, Taegerwilen, Switzerland) is a new way to create small fragments with frequencies up to 100 Hertz (Hz). This study evaluated the efficacy and safety of this method in a stone and porcine model. MATERIALS AND METHODS: BEGO stones were put in a condom in a specifically designed fixture treated with different modulations to see stone comminution. Standardized ex vivo porcine model with perfused kidneys with 26 upper and lower poles of 15 kidneys was treated with the following modulations: voltage 16-24 kV, capacitor 12 nF and frequency up to 100 Hz. 2000-20,000 shock waves were applied to each pole. The kidneys were perfused with barium sulfate solution (BaSO4) and x-ray was performed to quantify the lesions using pixel volumetry. RESULTS: There was no correlation between the number of shock waves and the powdering degree or the applied Energy and the grade of pulverization in the stone model. Regarding the perfused kidney model, the number of shock waves, applied voltage and frequency had no direct correlation with the occurrence of parenchymal lesions The detected lesions of the renal parenchyma were minimal, technical parameters had no significant impact and the lesions did not differ from the results of former experiments using 1-1.5 Hz in the same model. CONCLUSIONS: High-frequency shock wave lithotripsy can produce small stone fragments to pass in a very short time. The injury to the renal parenchyma is comparable to the results of the conventional SWL using 1-1.5 Hz.

Factors affecting and effects of hemodynamic stability of pediatric patients with grades 3-5 renal trauma: a prospective non-randomized comparative study.

BACKGROUND: Researches on the effect of hemodynamic stabilization on the implantation of conservative management for pediatric high-grade renal traumas are lacking. We aimed to assess the effect of maintaining the initial hemodynamic stability of pediatric patients with grades 3-5 renal trauma on the implementation of the conservative treatment and identify its defining factors. METHODS: A prospective study was performed on pediatric patients with grade 3-5 renal traumas who presented to our hospital during July 2020-June 2022. Hemodynamically stable patients were compared with the unstable patients for clinical characteristics, hemodynamic stabilization, and rates of success of conservative treatment. RESULTS: Forty-three patients were studied, including 26 boys and 17 girls. Of them, 28 (65.1%) patients presented with hemodynamic stability and 15 (34.9%) patients were unstable. Overall, 32 (74.4%) patients achieved and/or maintained hemodynamic stability for conservative management. There was a significant difference in blood pressure level at presentation (p < 0.001). The improvement of the hemodynamic parameters was significant per group and, in comparison (p < 0.001). The size of hematoma was significantly smaller in patients with hemodynamic stability (p = 0.023). Despite the longer (p = 0.033) hospital stay with conservative management, the rates of blood transfusion (p = 0.597) and hospital stay (p = 0.785) were not significantly different between both groups. The rates of nephrectomy and mortality were 14% and 0%, respectively. Blood pressure was independently associated with the achievement of maintained hemodynamic stability for conservative management (p = 0.022). CONCLUSIONS: Hemodynamic stabilization seems to be effective and safe for implementing successful conservative management for pediatric patients with high-grade renal traumas. Blood pressure was the only independent factor of maintaining hemodynamic stability.

Who Is at Risk of Death after Renal Trauma? An Analysis of Thirty-Day Mortality after 1,799 Cases of Renal Trauma.

INTRODUCTION: The aim of the study was to report the 30-day mortality (30DM) after renal trauma and identify the risk factors associated with death. METHODS: The TRAUMAFUF project was a retrospective multi-institutional study including all patients with renal trauma admitted to 17 French hospitals between 2005 and 2015. The included population focused on patients of all age groups who underwent renal trauma during the study period. The primary outcome was death within 30 days following trauma. The multivariate logistic regression model with a stepwise backward elimination was used to identify predictive factors of 30DM. RESULTS: Data on 1,799 renal trauma were recorded over the 10-year period. There were 59 deaths within 30 days of renal trauma, conferring a 30DM rate of 3.27%. Renal trauma was directly involved in 5 deaths (8.5% of all deaths, 0.3% of all renal trauma). Multivariate stepwise logistic regression analysis revealed that age >40 years (odds ratio [OR] 2.18; 95% confidence interval [CI]: 1.20-3.99; p = 0.01), hemodynamic instability (OR 4.67; 95% CI: 2.49-9; p < 0.001), anemia (OR 3.89; 95% CI: 1.94-8.37; p < 0.001), bilateral renal trauma (OR 6.77; 95% CI: 2.83-15.61; p < 0.001), arterial contrast extravasation (OR 2.09; 95% CI: 1.09-3.96; p = 0.02), and concomitant visceral and bone injuries (OR 6.57; 95% CI: 2.41-23.14; p < 0.001) were independent predictors of 30DM. CONCLUSION: Our large multi-institutional study supports that the 30DM of 3.27% after renal trauma is due to the high degree of associated injuries and was rarely a consequence of renal trauma alone. Age >40 years, hemodynamic instability, anemia, bilateral renal trauma, arterial contrast extravasation, and concomitant visceral and bone lesions were predictors of death. These results can help clinicians to identify high-risk patients.

Analysis and approach to renal trauma: A five-year experience at a level I trauma centre in north India.

PURPOSE: Renal trauma constitutes 0.5% - 5% of all trauma patients, and 10% - 20% of abdominal trauma. It is the most commonly injured organ in the genitourinary tract. Road traffic crash (RTC) is the most common cause. In recent years due to the advances in radiological imaging and endovascular techniques, there has been an increase in the nonoperative management of renal trauma. We investigated a large trauma cohort at a level I trauma centre to evaluate patients' demographics with renal trauma, their management, and the outcomes. METHODS: This was a retrospective analysis of the prospectively collected data of renal trauma patients managed from January 2016 to December 2020. Patients who visited the level I trauma centre in north India with renal trauma were included in this study. Patients who were dead on arrival in the emergency department were excluded. Demographics, mechanism of injury, presence of hemorrhagic shock, associated injuries, complications, length of hospital stay (LOS), discharge, and mortality were recorded. The data were entered in Microsoft Excel 365 and analysed using SPSS version 21. RESULTS: This study collected data from 303 renal trauma patients. Males constituted 86.5% of the patients. Most patients were young, aged from 20 - 40 years. Blunt renal trauma was the predominant mode of injury (n = 270, 89.1%). RTCs (n = 190, 62.7%) and falls from height (n = 65, 21.4%) were the 2 most common mechanisms of injury. Focused assessment with sonography in trauma was positive in 68.4% of patients. Grade III (grading by the American Association for the Surgery of Trauma) renal trauma (30.4%) was the most common grade in our study. The liver (n = 104, 34.3%) and splenic trauma (n = 96, 31.7%) were the most commonly associated injuries. Of the 303 patients, 260 (85.8%) were managed nonoperatively. The mean (SD) of the patients' LOS was 12.5 (6.5) days. There were 25 (8.3%) mortalities during the study period and all of them had associated other injuries. The comparison of LOS of isolated renal trauma group and renal trauma with associated injuries group was not statistically significant (p = 0.322). All the patients who died during the study period had renal trauma with associated other organ injuries. None of the patients with isolated renal trauma died during the study. The outcome comparison between both groups was not statistically significant (p = 0.110). CONCLUSION: Renal trauma predominantly occurs in young males, especially due to RTCs followed by fall from height. Focused assessment with sonography in trauma is not reliable in detecting renal injuries, other diagnostic tools such as contrast enhanced computed tomography torso should be considered in diagnosing and grading these injuries. Renal trauma usually does not occur in isolation. Majority are associated with other abdominal and extra abdominal injuries. Most of the times these injuries can be managed nonoperatively, which can achieve a low mortality. The patients who required surgery had high mortality as compared to patients who managed nonoperatively. These patients who required surgery had either severe renal or extra renal trauma and were in hemorrhagic shock. Renal trauma from this large cohort may contribute to improving the quality of care for patients with renal trauma by obtaining knowledge about the patient's characteristics, management, and outcomes.

The effect of transarterial embolization versus nephrectomy on acute kidney injury in blunt renal trauma patients.

PURPOSE: The impact of transarterial embolization (TAE) and nephrectomy on acute kidney injury (AKI) in blunt renal trauma patients remains unclear, and we used the National Trauma Data Bank (NTDB) to investigate this issue. METHODS: Adult patients from the NTDB between 2007 and 2015 who survived traumatic events with blunt injuries were eligible for inclusion. The exclusion criteria were those without outcome information, who required dialysis, or with chronic renal failure prior to the traumatic injury. Patients sustaining hepatic, splenic, or pelvic fractures or who had bilateral nephrectomy were also excluded. The patients were divided into three treatment groups, including conservative treatment, TAE, and nephrectomy. Two statistical models, logistic regression (LR) and inverse probability treatment weighting (IPTW), were used to clarify the AKI predictors. RESULTS: The study included 10,096 patients. There were 9697 (96.0%), 202 (2.0%) and 197 (2.0%) patients in the conservative, TAE and nephrectomy groups, respectively. Nephrectomy was a statistically significant predictor of AKI in blunt renal trauma patients in the standard LR (odds ratio [OR], 4.58; 95% confidence interval [CI] 1.92-10.38; p < 0.001) and IPTW (OR, 5.16; 95% CI 1.07-24.85; p = 0.023) models. In addition, TAE was not a risk factor for AKI in blunt renal trauma patients (p > 0.05 in all models). CONCLUSION: AKI is less likely affect patients with blunt renal trauma with TAE than those with nephrectomy. Nephrectomy is a risk factor for AKI in blunt renal trauma patients. TAE should be considered first when blunt renal trauma patients need a hemostatic procedure.

[Late complications after blunt renal trauma: A French multicenter study]. / Complications tardives après traumatisme fermé du rein : résultats de l'étude observationnelle nationale multicentrique TraumAFUF.

INTRODUCTION: Among genitourinary traumas, blunt trauma to the kidney are the most frequent: their initial management has been well studied but their development at a distance is poorly documented. The objective of this study was to assess the late complications of blunt renal trauma, and to investigate their predictive factors for occurrence. MATERIALS AND METHODS: A retrospective observational study of the TraumAFUF project was conducted, including, between 2005 and 2018, all blunt renal trauma treated in 18 French hospitals and followed for more than 3 months. The characteristics of the initial trauma, as well as any complications occurring after three months, were identified. The patients were divided into two groups: onset of a late complication (LC) or uncomplicated (UC). The groups were compared in univariate and multivariate analyses to identify the risk factors for the occurrence of these complications. RESULTS: Among the 454 patients included, 50 presented with LC (11%), as symptomatic morphologically altered kidney (2.9%), secondarily impaired biological renal function (2.9%), or secondary arterial hypertension (2.4%). The risk factors identified were, during initial medical care, a high-grade renal trauma≥IV (OR=2.4, P=0.025), active bleeding (OR=2.6, P=0.007), the need for transfusion (OR=2.3, P=0.001), or interventional (R=1.7, P=0.09) or endoscopic treatment (OR=2.0, P=0.035). CONCLUSION: In this study, late complications occurred in 11% of cases after blunt renal trauma. The risk factors identified make it possible to draw up a patient profile who would benefit from prolonged follow-up to detect these complications.

[Magnetic resonance imaging in diagnosis of complications of kidney and ureteral injury in different periods of traumatic disease]. / Magnitno-rezonansnaya tomografiya v diagnostike oslozhnenii povrezhdenii pochek i mochetochnikov v razlichnye periody travmaticheskoi bolezni.

OBJECTIVE: To assess the possibility of magnetic resonance imaging in diagnosis of complications of kidney and ureteral injury in different periods of traumatic disease. MATERIAL AND METHODS: There were 139 patients with kidney and ureteral injuries between 2015 and 2019. We clarified the MR-signs of renal complications in different periods of traumatic disease. RESULTS: We analyzed the effectiveness of MRI in identification of renal complications compared to ultrasound, excretory urography, computed tomography, intraoperative and follow-up data. High diagnostic accuracy of MRI for early and late manifestations of traumatic disease was demonstrated.

Observation vs. early drainage for grade IV blunt renal trauma: a multicenter study.

INTRODUCTION: The aim of this study was to compare observation and early drainage by ureteral stenting in patients with blunt renal trauma and urinary extravasation. MATERIALS AND METHODS: A retrospective national multicenter study was performed including all patients admitted for renal trauma at 17 hospitals between 2005 and 2015. Patients presenting with a urinary extravasation on initial imaging were considered for inclusion. Patients were divided in two groups according to the initial approach: observation vs. early drainage by ureteral stent (within 48 h after admission). The primary endpoint was the persistence of urinary extravasation on follow-up imaging. RESULTS: Out of 1799 patients with renal trauma, 238 were included in the analysis (57 in the early drainage and 181 in the observation group). In the early drainage group, 29 patients had persistent urinary extravasation vs. 77 in the observation group (50.9% vs. 42.5%; p value = 0.27). The rates of secondary upper urinary tract drainage did not differ significantly between the early drainage group (26.4%) and the observation group (16%) (p = 0.14). There were no statistically significant differences between the two groups in terms of secondary nephrectomy (0% vs. 2.8%; p = 0.34), and death from trauma (0% vs. 1.8%; p = 0.99). In multivariate analysis, early drainage remained not statistically associated with persistence of urinary extravasation on follow-up imaging (OR = 1.35; p = 0.36) CONCLUSION: In this multicenter cohort, observation was not different from early drainage in terms of persistent urinary extravasation after grade IV blunt renal trauma. Further randomized controlled prospective trials are needed to confirm these findings.

Early discharge in selected patients with low-grade renal trauma.

INTRODUCTION: The aim of this study was to assess whether early discharge could be non-inferior to inpatient management in selected patients with low-grade renal trauma (AAST grades 1-3). MATERIALS AND METHODS: A retrospective national multicenter study was conducted including all patients who presented with renal trauma at 17 hospitals between 2005 and 2015. Exclusion criteria were iatrogenic and AAST grades 4 and 5 trauma, non-conservative initial management, Hb < 10 g/dl or transfusion within the first 24 h, and patients with concomitant injuries. Patients were divided into two groups according to the length of hospital stay: ≤ 48 h (early discharge), and > 48 h (inpatient). The primary outcome was "Intervention" defined as any interventional procedure needed within the first 30 days. A Stabilized Inverse Probability of Treatment Weighting (SIPTW) propensity score based binary response model was used to estimate risk difference. RESULTS: Out of 1764 patients with renal trauma, 311 were included in the analysis (44 in the early discharge and 267 in the inpatient group). In the early discharge group, only one patient required an intervention within the first 30 days vs. 10 in the inpatient group (3.7% vs. 5.2%; p = 0.99). Adjusted analysis using SIPTW propensity score showed a risk difference of - 2.8% [- 9.3% to + 3.7%] of "interventions" between the two groups meeting the non-inferiority criteria. CONCLUSION: In a highly selected cohort, early discharge management of low-grade renal trauma was not associated with an increased risk of early "intervention" compared to inpatient management. Further prospective randomized controlled trials are needed to confirm these findings.

Challenges in the diagnosis of severe renal trauma in child: A case report and literature review.

INTRODUCTION: To report the management and outcome of one case of pediatric patient sustaining high-grade blunt renal trauma. We present and discuss the clinical characteristics and radiologic features of the patient. PATIENTS AND METHODS: A 10 years old child was admitted for serious blunt renal trauma formed a huge urinoma in the right renal after injury gradually in 2018. We treated the patient with synchronous percutaneous nephrostomy drainage and retrograde ureteral catheterization. A retrospective review was performed of this case, including the clinical features, imaging studies and short-term follow-up. A literature review was also performed to highlight the principals of diagnosis and treatment of severe blunt renal trauma in children. RESULTS: After drainage, the symptoms of abdominal distension gradually disappeared, and the physical examination shows that the abdomen gradually reduced to normal. The huge urinoma was cured by synchronous drainge. No complications occurred in short-term follow-up. COMMENTS: The choice of surgical treatment is based on the degree and location of renal trauma. Grade IV injuries are a heterogeneous group and management should be tailored to the patient, especially among pediatric patients. Persistent urinary extravasation and/or symptomatic urinoma is a common complication of high-grade renal trauma, which will be amenable to ureteral stent placement or percutaneous drainage. For huge urinoma, synchronous percutaneous nephrostomy drainage and retrograde ureteral catheterization can relieve symptoms quickly.

Does routine repeat imaging change management in high-grade renal trauma? Results from three level 1 trauma centers.

PURPOSE: Guidelines call for routine reimaging of Grade 4-5 renal injuries at 48-72 h. The aim of the current study is to evaluate the clinical utility of computed tomography (CT) reimaging in high-grade renal injuries. MATERIALS AND METHODS: We assembled data on 216 trauma patients with high-grade renal trauma at three level 1 trauma centers over a 19-year span between 1999 and 2017 in retrospectively collected trauma database. Demographic, radiographic, and clinical characteristics of patients were retrospectively reviewed. RESULTS: In total, 151 cases were Grade 4 renal injuries, and 65 were Grade 5 renal injuries. 53.6% (81) Grade 4 and 15.4% (10) Grade 5 renal injuries were initially managed conservatively. Of the 6 asymptomatic cases where repeat imaging resulted in intervention, 100% had collecting system injuries at initial imaging. Collecting system injuries were only present in 42.9% of cases where routine repeat imaging did not trigger surgical intervention. Collecting system injury at the time of initial imaging was a statistically significant predictor of routine repeat imaging triggering surgical intervention (p = 0.022). Trauma grade and the presence of vascular injury were not significant predictors of intervention after repeat imaging in asymptomatic patients. CONCLUSION: In asymptomatic patients with high-grade renal trauma, the number needed to image is approximately one in eight (12.5%) to identify need for surgical intervention. There is potentially room to improve criteria for routine renal imaging in high-grade renal trauma based on the more predictive imaging finding of collecting system injury.

Management of paediatric high-grade blunt renal trauma: a 10-year single-centre UK experience.

OBJECTIVE: To report the management and outcome of paediatric patients sustaining high-grade blunt renal trauma. PATIENTS AND METHODS: Medical records were examined for all American Association for the Surgery of Trauma (AAST) grade III-V blunt renal trauma cases admitted to a paediatric trauma centre from 2005 to 2015. Data collected and analysed included: demographics, imaging modalities, management, length of hospital stay (LOS), complications, and follow-up outcomes. RESULTS: In all, 18 children (12 boys, six girls) with mean (range) age 11 (4-15) years were included. According to the AAST grading criteria, 39% (seven of 18) of the patients had grade III, 50% (nine of 18) grade IV, and 11% (two of 18) grade V injuries; 44% (eight of 18) had concomitant injuries. Most of the patients were managed conservatively (89%, 16 of 18), although two of the 16 subsequently needed JJ-stent insertion during inpatient stay for symptomatic urinoma(s). In all, 11% (two of 18) of the patients required interventional radiology service(s), involving selective embolisation for life-threatening renal tract haemorrhage. Blood transfusion for renal injury exclusively was required in 11% (two of 18) of the patients. In all, 89% (16 of 18) of the patients had at least one follow-up imaging study before hospital discharge; most (13 of 16) had ultrasonography and three required computed tomography. The median (range) LOS was 11 (4-31) days. In all, 17% (three of 18) of the patients required hospital re-admission within 30 days for complications and all required interventional procedures: JJ stent for urinoma (one), embolisation of renal arterio-venous fistula (one), and embolisation for a post-traumatic pseudoaneurysm (one). Overall, the median (range) follow-up was 6 (2-60) months. In all, 78% (14 of 18) of the patients had dimercaptosuccinic acid studies, with 11 showing reductions in renal function (range 3-44%). CONCLUSIONS: This study supports a care pathway strategy advocating conservative management of high-grade renal injuries in children. However, patients may experience a relative decline in renal function with higher grade injuries indicating the need for monitoring and follow-up.

Inter-rater reliability in the radiological classification of renal injuries.

INTRODUCTION: Although many radiologists invoke the surgical classification of renal injury proposed by the American Association for Surgery in Trauma (AAST), there has been only limited work on the role of the AAST system as an imaging stratification. The aim was to determine the inter-rater reliability (IRR) amongst radiologists and urologists using the AAST system. METHODS: A 1-year retrospective study of consecutive patients with computed tomography (CT) evidence of renal trauma managed at a Level 1 trauma center. Three radiologists and three urologists independently stratified the presentation CT findings according to the AAST renal trauma classification. Agreement between independent raters and mutually exclusive groups was determined utilizing weighted kappa coefficients. RESULTS: One hundred and one patients were included. Individual inter-observer agreements ranged from 54/101 (53.4%) to 62/101 (61.4%), with corresponding weighted kappa values from 0.61 to 0.69, constituting substantial agreement. Urologists achieved intra-disciplinary agreement in 49 cases (48.5%) and radiologists in 36 cases (35.6%). Six-reader agreement was achieved in 24 cases (23.7%). The AAST grade I injuries had the highest level of agreement, overall. CONCLUSION: The finding of substantial IRR amongst radiologists and urologists utilizing the AAST system supports continued use of the broad parameters of the AAST system, with some modification in specific categories with lower agreement.

Renal Embolization: Current Recommendations and Rationale for Clinical Practice.

PURPOSE OF REVIEW: Renal embolization (RE) is a minimally invasive endovascular procedure performed primarily by interventional radiology that can be used to treat a variety of urologic conditions including malignant renal tumors, angiomyolipomas, renal trauma, and complications following biopsy. The following review examines renal embolization indications, technique, and potential complications. RECENT FINDINGS: Renal embolization is a versatile therapeutic and adjunctive tool for many acute and chronic urologic conditions. RE has become a first-line therapy for renal trauma in lower grade injuries and increasing in prevalence for higher grade injuries. Additionally, the safety and efficacy of chemoembolization for primary treatment of renal cell carcinoma is under evaluation. A multidisciplinary approach between urology and interventional radiology should be pursued for all patients undergoing renal embolization regardless of indication. Preprocedural planning and careful monitoring of complications should be performed to optimize clinical outcomes.

Management of the patients with blunt renal trauma: 20 years of clinical experience.

OBJECTIVE: Introduction: Blunt renal trauma (BRT) is a dangerous medical condition. The aim: Analysis of effectiveness of conservative and expectant treatment tactics under ultrasound and CT monitoring in patients with blunt renal trauma (BRT). PATIENTS AND METHODS: Materials and methods: The results of treatment of 81 patients with BRT during 20 years (1998-2017) were analyzed. Amount of men was 58 (71.6%), women - 23 (28.4%). Grade I trauma was seen in 37.0% of cases, grade II - in 25.9%, grade III - in 11.1%, grade IV - in 16.1% and grade V - in 9.9% of observations. RESULTS: Review: Conservative tactics was effective in 67.9% of observations. In 11.1% of cases treatment was accompanied with percutaneous drainage of liquid perirenal hematoma and urohematomas (in 2 cases with formation of perirenal abscess). Indications for surgical treatment (in 21.0% of observations) were progressing perirenal hematoma, unstable hemodynamics, inefficiency of hemorrhage stop with conservative treatment. In 9 cases, the kidney was sutured. Eight patients with multiple ruptures of the kidney, damage of the kidney vessels, massive bleeding underwent nephrectomy. CONCLUSION: Conclusions: Achievements in visualization and therapeutic technologies can avoid and, at severe trauma, reduce the surgical treatment rates in BRT. In the presence of urohematomas with the formation of perinephral abscess and development of sepsis, the method of choice is percutaneous drainage. Indications for surgical treatment are multiple parenchymal lacerations with damage of the segmental vessels and vessels of the renal hilum when the hemorrhage stop is ineffective by conservative or noninvasive methods.

Management of Pediatric Grade IV Renal Trauma.

PURPOSE OF REVIEW: Review the current literature regarding the management of grade IV renal injuries in children. RECENT FINDINGS: Children are at increased risk for renal trauma compared to adults due to differences in anatomy. Newer grading systems have been proposed and are reviewed. Observation of most grade IV renal injuries is safe. Operative intervention is necessary for the unstable patient to control life-threatening bleeding with either angioembolization or open exploration. Symptomatic urinomas may require percutaneous drainage and/or endoscopic stent placement. Ureteropelvic junction (UPJ) disruption, seen more often in children, requires immediate surgical repair. Grade IV renal injuries in children are increasingly managed in a conservative manner.

Utility of MDCT findings in predicting patient management outcomes in renal trauma.

PURPOSE: The purpose of this study is to assess the utility of computed tomography (CT) in predicting clinical outcomes in renal trauma. MATERIALS/METHODS: This retrospective study was IRB approved and HIPAA compliant; informed consent was waived. One-hundred-sixty-two, trauma-related renal injuries (157 adults) from January 01, 2006 to December 31, 2013 were included in this retrospective study. CT findings of vascular and collecting system (CS) injuries were recorded, and American Association for the Surgery of Trauma (AAST) renal injury grades were assigned. Fisher's exact test evaluated correlations between AAST grade and active hemorrhage, AAST grade and surgical/endovascular therapy, active hemorrhage and surgical/endovascular therapy, and size of perinephric hematomas and CS injuries. The unpaired t test correlated to the size of perinephric hematomas in CS injuries diagnosed on initial versus repeat imaging. RESULTS: AAST grades were as follows: 120 grades I-III and 42 grade IV/V. Active hemorrhage was diagnosed in 25 (15%) patients and CS injury in 22 (14%) patients. Seven (8%) patients received surgical/endovascular therapy. There were statistically significant correlations between AAST grade and active hemorrhage (p = 0.003), active hemorrhage and surgical/endovascular therapy (p < 0.0001), and large perinephric hematomas (>2 cm) and CS injuries (p < 0.0001). There was no significant correlation between AAST grade and surgical/endovascular therapy (p = 0.08). Of the CS injuries (50%), 11/22 had no evidence of CS injury on initial imaging, being detected on follow-up CT. These "masked cases" demonstrated significant differences in perinephric hematoma size when compared to CS injuries diagnosed on initial imaging (p = 0.01). CONCLUSION: Active hemorrhage in renal trauma is a significant predictor of surgical/endovascular therapy, in contradistinction to the AAST grade. In collecting system injuries, a large fraction was not detectable on initial CT, supporting the need for repeat imaging in cases with large perinephric hematomas.