CONTEMPORARY MANAGEMENT OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

ABSTRACT:Background:The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted towards a non-operative 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 [AAST] 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 patients (39%). 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 AAST grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy.Conclusions: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:Level III, Prognostic/epidemiologic study Background: The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted towards a non-operative 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 [AAST] 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 patients (39%). 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 AAST grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy. Conclusions: 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: Level III, Prognostic/epidemiologic study Corresponding Author: Sorena Keihani, MD, Division of Urology, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132, Phone: 801-213-2700, Fax: 801-213-2700. Sorena.keihani@hsc.utah.edu Conflicts of Interest: None Disclosure: This study was not directly supported by any industrial or federal funds. The investigation was in part supported by the University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-05 (formerly 8UL1TR000105 and UL1RR025764). Presentations: This paper 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, USA. © 2018 Lippincott Williams & Wilkins, Inc.

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