Introduction - Imperial College London



Traumatic Renal injury in a UK Major Trauma Centre – Current Management strategies and the role of early re-imaging.M. ALDIWANI1, F. GEORGIADES1, I. OMAR1,2, H. ANGEL-SCOTT1, T THARAKAN1, J. VALE1,2, E. MAYER1,21 Department of Urology, St Mary’s Hospital, Imperial College NHS Trust, London2 Department of Surgery & Cancer, Imperial College LondonKey Words: Renal Injury, Kidney Trauma, Major Trauma Centre, Embolisation, Re-imaging.Corresponding author: Mohammed Aldiwani, ORCID 0000-0002-1298-6503Email: Mohammed.aldiwani@.ukAddress: Department of Urology, St Marys Hospital, Praed Street, London W2 1NY Telephone (+44) 7976 141 338Declarations of interest: noneTraumatic Renal injury in a UK Major Trauma Centre – Current Management strategies and the role of early re-imaging.IntroductionRenal injury is the most common site of urinary tract trauma. The introduction of the Major Trauma Centre (MTC) network has led to the centralisation of UK trauma and subsequently exposed single centres to higher concentrations of renal injury. Renal trauma accounts for 1-5% of all trauma with 80-95% of cases resulting from blunt injuryADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s003450050109","ISSN":"0724-4983","author":[{"dropping-particle":"V.","family":"Meng","given":"Maxwell","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brandes","given":"Steven B.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McAninch","given":"Jack W.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"World Journal of Urology","id":"ITEM-1","issue":"2","issued":{"date-parts":[["1999","5","5"]]},"page":"71-77","publisher":"Springer-Verlag","title":"Renal trauma: indications and techniques for surgical exploration","type":"article-journal","volume":"17"},"uris":[""]}],"mendeley":{"formattedCitation":"(1)","plainTextFormattedCitation":"(1)","previouslyFormattedCitation":"¹"},"properties":{"noteIndex":0},"schema":""}(1). Blunt renal injuries are typically caused by road traffic accidents, falls and assault. They are frequently seen as part of a polytrauma with other non-urological injuries. A higher proportion of penetrating injuries is seen in the urban setting and these injuries are typically more severe due to direct tissue puted Tomography (CT) is the gold standard imaging modality to assess haemodynamically stable patients with suspected trauma. For suspected renal injury, the preferred imaging protocol is a multi-phase CT with pre-contrast, arterial phase, nephrogenic and delayed phase imaging. The produced images give an accurate description of; the presence of renal injury, the grade of the injury and the involvement of proximal organs. The most widely used grading system for renal injury assessment is the American Association for the Surgery of Trauma (AAST) grading scaleADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"0022-5282","PMID":"2593197","abstract":"The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) was appointed by President Trunkey at the 1987 Annual Meeting. The principal charge was to devise injury severity scores for individual organs to facilitate clinical research. The resultant classification scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. A number of similar scales have been developed in the past, but none has been uniformly adopted. In fact, this concept was introduced at the A.A.S.T. in 1979 as the Abdominal Trauma Index (A.T.I.) and has proved useful in several areas of clinical research. The enclosed O.I.S.'s for spleen, liver, and kidney represent an amalgamation of previous scales applied for these organs, and a consensus of the O.I.S. Committee as well as the A.A.S.T. Board of Managers. The O.I.S. differs from the Abbreviated Injury Score (A.I.S.), which is also based on an anatomic scale but designed to reflect the impact of a specific organ injury on ultimate patient outcome. The individual A.I.S.'s are, of course, the basic elements used to calculate the Injury Severity Score (I.S.S.) as well as T.R.I.S.S. methodology. To ensure that the O.I.S. interdiffuses with the A.I.S. and I.C.D.-9 codes, these are listed alongside the respective O.I.S. Both the currently used A.I.S. 85 and proposed A.I.S. 90 are provided because of the obligatory transition period. Indeed, A.I.S. 90 contains the identical descriptive text as the current O.I.S.'s. The Abdominal Trauma Index and other similar indices using organ injury scoring can be easily modified by replacing older scores with the O.I.S.'s.(ABSTRACT TRUNCATED AT 250 WORDS)","author":[{"dropping-particle":"","family":"Moore","given":"E E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shackford","given":"S R","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pachter","given":"H L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McAninch","given":"J W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Browner","given":"B D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Champion","given":"H R","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Flint","given":"L M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gennarelli","given":"T A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Malangoni","given":"M A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ramenofsky","given":"M L","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Journal of trauma","id":"ITEM-1","issue":"12","issued":{"date-parts":[["1989","12"]]},"page":"1664-6","title":"Organ injury scaling: spleen, liver, and kidney.","type":"article-journal","volume":"29"},"uris":[""]}],"mendeley":{"formattedCitation":"(2)","plainTextFormattedCitation":"(2)","previouslyFormattedCitation":"²"},"properties":{"noteIndex":0},"schema":""}(2) (Table 1). In UK practice, patients typically undergo a whole-body multi-phase CT scan and additional phases may be required due to unsafe nature of a trauma patient remaining in a CT scanner for the delayed phase scan. The modern approach to the management of renal injuries favours conservative, non-operative interventions as this has been demonstrated to improve renal salvage rates and reduce incidence of complicationsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"0003-4401","PMID":"9480627","abstract":"The choice of treatment (surgical or conservative) for major renal trauma still remains controversial. The objective of this study was to compare the results of patients with major renal trauma (grade III and IV) primarily treated by surgical intervention (1980-1992) with those in patients mainly treated conservatively (1992-1995). Between 1980 and 1995, 83 patients with major renal trauma were hospitalized at our institution. Our results show a higher nephrectomy rate of 44% in the case of primary surgical intervention compared to conservative management (27%). The outcome of twenty-two patients treated conservatively was analyzed prospectively with repeated radiological imaging, blood pressure profiles, and renal function assessment by means of MAG 3 renal scintigraphy. No patient developed renovascular hypertension and the relative function of the traumatized kidney was greater than 40% in 95% of patients. In conclusion, our results confirm a lower nephrectomy rate in the case of conservative management without any increase of the immediate or long-term morbidity. Major renal trauma (grade III, IV) can therefore be effectively treated by conservative management and primary surgical repair is only indicated in patients with hemodynamic instability, persistent hematuria and associated visceral injuries.","author":[{"dropping-particle":"","family":"Schmidlin","given":"F R","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rohner","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hadaya","given":"K","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Iselin","given":"C E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vermeulen","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Khan","given":"H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Farshad","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Niederer","given":"P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Graber","given":"P","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Annales d'urologie","id":"ITEM-1","issue":"5","issued":{"date-parts":[["1997"]]},"page":"246-52","title":"[The conservative treatment of major kidney injuries].","type":"article-journal","volume":"31"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.euf.2017.04.011","abstract":"X X X (2 0 17) X X X – X X X a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m / e u f o c u s Abstract Context: The management of high-grade (Grade IV–V) renal injuries remains contro-versial. There has been an increase in the use of (NOM) but limited data exists comparing outcomes with open surgical exploration. Objective: To conduct a systematic review to determine if NOM is the best first-line option for high-grade renal trauma in terms of safety and effectiveness. Evidence acquisition: Medline, Embase, and Cochrane Library were searched for all relevant publications, without time or language limitations. The primary harm outcome was overall mortality and the primary benefit outcome was renal preservation rate. Secondary outcomes included length of hospital stay and complication rate. Single-arm studies were included as there were few comparative studies. Only studies with more than 50 patients were included. Data were narratively synthesised in light of methodo-logical and clinical heterogeneity. The risk of bias of each included study was assessed. Evidence synthesis: Seven nonrandomised comparative and four single-arm studies were selected for data extraction. Seven hundred and eighty-seven patients were included from the comparative studies with 535 patients in the NOM group and 252 in the open surgical exploration group. A further 825 patients were included from single-arm studies. Results from comparative studies: overall mortality: NOM (0–3%), open surgical exploration (0–29%); renal preservation rate: NOM (84–100%), open surgical exploration (0–82%); complication rate: NOM (5–32%), open surgical explora-tion (10–76%). Overall mortality and renal preservation rate were significantly better in the NOM group whereas there was no statistical difference with regard to complication rate. Length of hospital stay was found be significantly reduced in the NOM group. Patients in the open surgical exploration group were more likely to have Grade V injuries, have a lower systolic blood pressure, and higher injury severity score on admission. Conclusions: No randomised controlled trials were identified and significant heteroge-neity existed with regard to outcome reporting. However, NOM appeared to be safe and effective in a stable patient with a higher renal preservation rate, a shorter length of stay, and a comparable complication rate to open surgical explorati…","author":[{"dropping-particle":"","family":"Sujenthiran","given":"Arunan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Elshout","given":"Pieter Jan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Veskimae","given":"Erik","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Maclennan","given":"Steven","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yuan","given":"Yuhong","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Serafetinidis","given":"Efraim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharma","given":"Davendra M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kitrey","given":"Noam D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Djakovic","given":"Nenad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lumen","given":"Nicolaas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kuehhas","given":"Franklin E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Summerton","given":"Duncan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Eur Urol Focus","id":"ITEM-2","issued":{"date-parts":[["2017"]]},"title":"Is Nonoperative Management the Best First-line Option for High-grade Renal trauma? A Systematic Review","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"(3,4)","plainTextFormattedCitation":"(3,4)","previouslyFormattedCitation":"^3,4"},"properties":{"noteIndex":0},"schema":""}(3,4). With advancements in interventional radiology techniques there has been increasing number of trauma patients undergoing embolization for bleeding with fewer reported complications in the literatureADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/bju.12003","ISSN":"14644096","PMID":"23418742","abstract":"OBJECTIVE To detail the 9-year experience of renal trauma at a modern Level 1 trauma centre and report on patterns of injury, management and complications. PATIENTS AND METHODS We analysed 338 patients with renal injuries who presented to our institution over a 9-year period. Data on demographics, clinical presentation, management and complications were recorded. RESULTS Males comprised 74.9% of patients with renal injuries and the highest incidence was amongst those aged 20-24 years. Blunt injuries comprised 96.2% (n = 325) of all the renal injuries, with road trauma being the predominant mechanism accounting for 72.5% of injuries. The distribution of injury grade was; 21.6% grade 1 (n = 73), 24.3% grade 2 (n = 82), 24.9% grade 3 (n = 84), 16.6% grade 4 (n = 56), and 12.7% grade 5 (n = 43). Conservative management was successful in all grade 1 and 2 renal injuries, and 94.9%, 90.7% and 35.1% of grade 3, 4 and 5 injuries respectively. All but one of the 13 patients with penetrating injuries were successfully managed conservatively. CONCLUSIONS Road trauma is the greatest cause of renal injury. Most haemodynamically stable patients are successfully managed conservatively.","author":[{"dropping-particle":"","family":"Shoobridge","given":"Jennifer J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bultitude","given":"Matthew F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Koukounaras","given":"Jim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martin","given":"Katherine E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Royce","given":"Peter L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Corcoran","given":"Niall M.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BJU International","id":"ITEM-1","issued":{"date-parts":[["2013","11"]]},"page":"53-60","title":"A 9-year experience of renal injury at an Australian level 1 trauma centre","type":"article-journal","volume":"112"},"uris":[""]}],"mendeley":{"formattedCitation":"(5)","plainTextFormattedCitation":"(5)","previouslyFormattedCitation":"⁵"},"properties":{"noteIndex":0},"schema":""}(5). As such, Angiography and embolization is now considered first line treatment for stable patients with active bleeding. Grade IV injuries with persistent urine extravasation can be managed with retrograde endoscopic ureteral stent. These more conservative approaches have rendered renal exploration and emergency nephrectomy increasingly uncommon events.In haemodynamically unstable trauma cases, imaging is usually omitted in favour of emergency laparotomy. High grade renal injuries (Grades III-V) are often accompanied with other major injuries which can be simultaneously managed during exploratory laparotomy.There is no clear consensus on the role of routine re-imaging in the first few days post-renal injury. The aim of repeat imaging is to minimise the risk of missed complications such as persistent urine leak, expanding haematoma, and vascular malformation such as pseudoaneurysm or arterio-venous malformation (AVM). Current European association of Urology (EAU) guidelines recommend repeat imaging in response to clinical changes such as; fever, worsening flank pain or falling haematocrit. Although no strong recommendations are made, omission of repeat imaging in grade I-IV injuries is suggested if patients remain clinically wellADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Kitrey","given":"N D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Djakovic","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kuehhas","given":"F E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lumen","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Serafetinidis","given":"E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharma","given":"D M","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Presented at the EAU Annual Congress Copenhagen","id":"ITEM-1","issue":"ISBN 978-94-92671-01-1.","issued":{"date-parts":[["2018"]]},"title":"EAU Guidelines on Urological Trauma","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"(6)","plainTextFormattedCitation":"(6)","previouslyFormattedCitation":"⁶"},"properties":{"noteIndex":0},"schema":""}(6). This study aims to analyse the contemporary management of renal injuries in a UK MTC and to evaluate the utility and value of follow up imaging.Materials and MethodsAll major trauma patients attending our MTC are entered into the prospectively maintained “Trauma Audit and Research Network (TARN)” database. The TARN database is maintained by dedicated TARN staff for all forms of major trauma and data is added to a national system. Prospectively collected data includes age, sex, mechanism, list of injuries, injury severity scoreADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"0022-5282","PMID":"4814394","author":[{"dropping-particle":"","family":"Baker","given":"S P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"O'Neill","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haddon","given":"W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Long","given":"W B","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Journal of trauma","id":"ITEM-1","issue":"3","issued":{"date-parts":[["1974","3"]]},"page":"187-96","title":"The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care.","type":"article-journal","volume":"14"},"uris":[""]}],"mendeley":{"formattedCitation":"(7)","plainTextFormattedCitation":"(7)","previouslyFormattedCitation":"⁷"},"properties":{"noteIndex":0},"schema":""}(7) (ISS), operations and the TARN probability of survival score (PS14) which takes into account ISS as well as patient factors and co-morbiditiesADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"","accessed":{"date-parts":[["2018","4","14"]]},"id":"ITEM-1","issued":{"date-parts":[["0"]]},"title":"The TARN Probability of Survival Model","type":"webpage"},"uris":[""]}],"mendeley":{"formattedCitation":"(8)","plainTextFormattedCitation":"(8)","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}(8).The database was reviewed to identify all patients presenting with urinary tract injury between January 2014 and December 2017 (36 months). In cases of renal injury, further retrospective analysis of the medical records and the imaging modalities were performed. Extracted variables included: the initial mode of imaging, renal injury grade according to AAST, details of any early or late renal intervention, indication and results of any early or late re-imaging, and the incidence/frequency of complications. Completion CT imaging with excretory phase urogram was not considered as follow-up re-imaging.Unpaired t test was used to compare injury severity score (ISS) between patient groups. P<0.05 was considered statistically significant.ResultsA total of 11,047 trauma cases were recorded during the study period (36 months). From this cohort, 112 patients were identified as having sustained any urinary tract injury (1%), including 90 patients with renal injuries who were included in the final analysis. Male patients outnumbered female patients by a ratio of 7.2:1 (79 Males, 11 Females). The average age was 35.5 (SD 17.4, Range 1.5-94) and the average ISS 28.5 (SD 15.8, Range 4-66). 22 patients had associated bony pelvic fracture (all high-energy blunt injury). The majority of renal trauma resulted from blunt mechanisms (74%). Overall injury severity were: 18 (20%) grade I, 19 (21%) grade II, 27 (30%) grade III, 22 (24%) grade IV and 4 (4%) grade V. The distribution of injury by grade and mechanism are illustrated in Figure 1.The vast majority of cases (84%) were managed conservatively. Early intervention (<24 hours) was recorded in 14 cases (16%). The majority of these cases were managed by interventional radiology (IR) techniques with angiography and embolization (8 patients – 9%) and attempted endovascular IR stent for devascularised kidney (1 patient - unsuccessful). Embolization was successful in all cases including two grade V injuries which did not require further invasive intervention. Collecting system injury was present in 21 out of 22 grade IV injuries. One patient had a ureteric stent insertion within the first 24 hours for a grade IV injury. Figure 2 illustrates the management of patients by grade. Surgery was performed on four patients, all of which underwent open renal exploration. These patients were haemodynamically unstable during their initial assessment and had immediate laparotomy by the duty trauma surgeon without preoperative CT. The characteristics of these patients are summarised in Table 2. Renorrhaphy was successful in renal salvage for two patients with penetrating injuries and the remaining two required nephrectomy. Laparotomy for other injuries without renal exploration was performed in 19 cases. In three of these cases, renal injury was managed with IR techniques (one embolisation pre-laparotomy, one attempted endovascular stenting post laparotomy for thrombosed renal artery, one embolisation of pseudoaneurysm).Early inpatient re-imaging was performed in 59 patients (66%). Average time from initial to repeat CT scan was 3.4 days (range 0-25, SD 3.74). The majority of these were planned re-evaluation scans (49 patients; 83%) and the remaining scans (10 patients; 17%) were due to clinical indications such as fever, pain or suspicion of active bleeding. In the planned group, there were six additional relevant renal findings (12%). These included three cases of urine extravasation, one ureteric obstruction from foreign body and two pseudo-aneurysm formations. Retrograde endoscopic ureteric stent placement was performed for two cases with a further two cases of urine leak resolving uneventfully with continued conservative management. The two cases of pseudoaneurysms were managed successfully with selective embolization (both grade III injuries). In the clinical indications imaging group (n=10), there were three additional findings. Two of these findings were not related to the renal injury and one patient was noted to have a contralateral grade II injury which was managed conservatively. Clinical management of renal injury did not change in any of these cases.Overall, 12 patients (13%) did not survive at 30-days. The ISS was significantly higher in this group compared to those who survived 41.2 vs 26.5 (p<0.01) and PS14 score much lower 45.6 vs 92.1% (p<0.01). Of the 12 mortalities, 10 had contained stable renal injuries which did not contribute to their death. Two patients had grade V injuries resulting in emergency nephrectomy but also accompanied with other major injuries.DiscussionThis descriptive study demonstrates the increased concentration of renal trauma cases as a result of trauma service centralisation. Using the same inclusion criterion, a previous analysis at our institution between 2009 and 2013 yielded 36 cases of renal injury over 56 months (0.64 cases per month)ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1308/003588414X14055925061117","ISSN":"0035-8843","abstract":"IntroductionThe aim of this study was to analyse the treatment and management of renal injury patients presenting to our major trauma unit to determine the likelihood of patients needing immediate nephrectomy. MethodsThe Trauma Audit and Research Network (TARN) database was used to review trauma cases presenting to our department between February 2009 and September 2013. Demographic data, mechanism and severity of injury, grade of renal trauma, management and 30-day outcome were determined from TARN data, electronic patient records and imaging. ResultsThere were a total of 1,856 trauma cases, of which 36 patients (1.9%) had a renal injury. In this group, the median age was 28 years (range: 16–92 years), with 28 patients (78%) having blunt renal trauma and 8 (22%) penetrating renal trauma. The most common cause for blunt renal trauma was road traffic accidents. Renal trauma cases were stratified into American Association for the Surgery of Trauma (AAST) grades (grade I: 19%, grade II: 22%, grade III: 28%, ...","author":[{"dropping-particle":"","family":"McPhee","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Arumainayagam","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Clark","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Burfitt","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"DasGupta","given":"R","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Annals of The Royal College of Surgeons of England","id":"ITEM-1","issue":"3","issued":{"date-parts":[["2015","4","12"]]},"page":"194-197","publisher":" Royal College of Surgeons ","title":"Renal injury management in an urban trauma centre and implications for urological training","type":"article-journal","volume":"97"},"uris":[""]}],"mendeley":{"formattedCitation":"(9)","plainTextFormattedCitation":"(9)","previouslyFormattedCitation":"⁹"},"properties":{"noteIndex":0},"schema":""}(9). The previous analysis was performed at the early stage of implementation of the London trauma network. In comparison, our experience of 90 cases in 36 months (2.5 cases/month) demonstrates the maturation of the network and subsequent growth of trauma exposure at our unit.This study highlights several key points with regards to the non-operative and operative management of renal trauma and also the role of re-imaging.4.1 Non-operative management This study reinforces the growing consensus that most renal trauma can be managed safely with non- operative interventions ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.euf.2017.04.011","abstract":"X X X (2 0 17) X X X – X X X a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m / e u f o c u s Abstract Context: The management of high-grade (Grade IV–V) renal injuries remains contro-versial. There has been an increase in the use of (NOM) but limited data exists comparing outcomes with open surgical exploration. Objective: To conduct a systematic review to determine if NOM is the best first-line option for high-grade renal trauma in terms of safety and effectiveness. Evidence acquisition: Medline, Embase, and Cochrane Library were searched for all relevant publications, without time or language limitations. The primary harm outcome was overall mortality and the primary benefit outcome was renal preservation rate. Secondary outcomes included length of hospital stay and complication rate. Single-arm studies were included as there were few comparative studies. Only studies with more than 50 patients were included. Data were narratively synthesised in light of methodo-logical and clinical heterogeneity. The risk of bias of each included study was assessed. Evidence synthesis: Seven nonrandomised comparative and four single-arm studies were selected for data extraction. Seven hundred and eighty-seven patients were included from the comparative studies with 535 patients in the NOM group and 252 in the open surgical exploration group. A further 825 patients were included from single-arm studies. Results from comparative studies: overall mortality: NOM (0–3%), open surgical exploration (0–29%); renal preservation rate: NOM (84–100%), open surgical exploration (0–82%); complication rate: NOM (5–32%), open surgical explora-tion (10–76%). Overall mortality and renal preservation rate were significantly better in the NOM group whereas there was no statistical difference with regard to complication rate. Length of hospital stay was found be significantly reduced in the NOM group. Patients in the open surgical exploration group were more likely to have Grade V injuries, have a lower systolic blood pressure, and higher injury severity score on admission. Conclusions: No randomised controlled trials were identified and significant heteroge-neity existed with regard to outcome reporting. However, NOM appeared to be safe and effective in a stable patient with a higher renal preservation rate, a shorter length of stay, and a comparable complication rate to open surgical explorati…","author":[{"dropping-particle":"","family":"Sujenthiran","given":"Arunan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Elshout","given":"Pieter Jan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Veskimae","given":"Erik","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Maclennan","given":"Steven","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yuan","given":"Yuhong","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Serafetinidis","given":"Efraim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharma","given":"Davendra M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kitrey","given":"Noam D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Djakovic","given":"Nenad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lumen","given":"Nicolaas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kuehhas","given":"Franklin E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Summerton","given":"Duncan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Eur Urol Focus","id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"Is Nonoperative Management the Best First-line Option for High-grade Renal trauma? A Systematic Review","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"(4)","plainTextFormattedCitation":"(4)","previouslyFormattedCitation":"⁴"},"properties":{"noteIndex":0},"schema":""}(4). We have demonstrated that conservative management, without any intervention, is safe and feasible for stable patients with grade I-IV injury. Patients with active bleeding have been safely and successfully managed with angiography and embolization. The scope of cases manageable with embolization has expanded and even patients with some haemodynamic instability from isolated renal injuries can be safely managed in a well-supported and designed interventional radiology facility. This highlights the integral role of 24-hour interventional radiology services in major trauma centresADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/bju.14165","ISSN":"14644096","author":[{"dropping-particle":"","family":"Hadjipavlou","given":"Marios","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Grouse","given":"Edmund","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gray","given":"Robert","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sri","given":"Denosshan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Huang","given":"Dean","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brown","given":"Christian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharma","given":"Davendra","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BJU International","id":"ITEM-1","issued":{"date-parts":[["2018","3","13"]]},"publisher":"Wiley/Blackwell (10.1111)","title":"Managing penetrating renal trauma: experience from two major trauma centres in the UK","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"(10)","plainTextFormattedCitation":"(10)","previouslyFormattedCitation":"¹⁰"},"properties":{"noteIndex":0},"schema":""}(10). The historical belief that high-grade injuries always require open operative intervention has not been supported in this study. Two parenchymal grade V injuries were treated with single successful embolization with no further bleeding on repeat CT scans. Although the residual function of these kidneys was significantly impaired, no further complications such as fistula, sepsis or re-bleeding was detected. One further case underwent attempted endovascular stenting of a totally de-vascularised kidney but was unsuccessful. This was a case of traumatic thrombosis of the main renal artery (without active bleeding) and conservative management continued without the need for nephrectomy.Similarly, in cases of collecting system injury, ureteric stenting is not always requiredADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"0022-5347","PMID":"10840417","abstract":"PURPOSE We determined the feasibility of a nonoperative approach to blunt grade 5 renal injury. MATERIALS AND METHODS We retrospectively reviewed the records of all patients with grade 5 renal injury who presented to our level 1 trauma center from 1993 to 1998. Those treated nonoperatively and surgically were assigned to groups 1 and 2, respectively. Each group was compared with respect to the initial emergency department evaluation, computerized tomography findings, associated injuries, duration of hospital stay and intensive care unit stay, transfusion requirements, complications and followup imaging. RESULTS Of 218 renal injuries evaluated 13 were grade 5. In group 1, 6 patients were treated nonoperatively and in group 2, 7 underwent exploration. Each group had similar average hospitalization (12.0 and 12.8 days, respectively). Patients in group 1 had fewer intensive care unit days (4.3 versus 9.0), significantly lower transfusion requirements (2.7 versus 25.2 units, p = 0.0124) and fewer complications during the hospital course. Followup computerized tomography of nonoperatively managed cases revealed functioning renal parenchyma with resolution of retroperitoneal hematoma. CONCLUSIONS Conservative management of blunt grade 5 renal injury is feasible in patients who are hemodynamically stable at presentation.","author":[{"dropping-particle":"","family":"Altman","given":"A L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haas","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dinchman","given":"K H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spirnak","given":"J P","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Journal of urology","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2000","7"]]},"page":"27-30; discussion 30-1","title":"Selective nonoperative management of blunt grade 5 renal injury.","type":"article-journal","volume":"164"},"uris":[""]}],"mendeley":{"formattedCitation":"(11)","plainTextFormattedCitation":"(11)","previouslyFormattedCitation":"¹¹"},"properties":{"noteIndex":0},"schema":""}(11). Of the 22 grade IV injuries in our series, 21 patients had collecting system injuries and 1 had a vascular grade IV injury. The majority of patients (86%) were successfully managed conservatively, with only 3 patients having retrograde ureteric stenting and 0 having percutaneous nephrostomy. No complications such as infected urinoma were seen. This supports the recommendation of a period of conservative management with follow up excretory phase CT. Ureteric stent insertion can be reserved for those with significant persisting urinary extravasation, urinoma or sepsis. Retrograde ureteric stenting has been our preferred option, as opposed to percutaneous nephrostomy and antegrade stenting. This is to minimise risk of further vascular injury to an already significantly injured kidney. Percutaneous nephrostomy would also invariably traverse a perinephric haematoma with a theoretical risk of introducing infection. An indwelling urethral catheter is also inserted to avoid reflux through the stent.4.2 Operative Management4.2.1 Laparotomy for associated injuryHigh grade renal trauma is frequently associated with other intra-abdominal injuries which may necessitate laparotomy. EAU guidelines recommend to proceed with renal exploration in the presence of laparotomy for associated injuriesADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.eururo.2014.12.034","abstract":"a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m Article info Abstract Context: The most recent European Association of Urology (EAU) guidelines on urologi-cal trauma were published in 2014. Objective: To present a summary of the 2014 version of the EAU guidelines on upper urinary tract injuries with the emphasis upon diagnosis and treatment. Evidence acquisition: The EAU trauma guidelines panel reviewed literature by a Med-line search on upper urinary tract injuries; publication dates up to December 2013 were accepted. The focus was on newer publications and reviews, although older key references could be included. Evidence synthesis: A full version of the guidelines is available in print and online. Blunt trauma is the main cause of renal injuries. The preferred diagnostic modality of renal trauma is computed tomography (CT) scan. Conservative management is the best approach in stable patients. Angiography and selective embolisation are the first-line treatments. Surgical exploration is primarily for the control of haemorrhage (which may necessitate nephrectomy) and renal salvage. Urinary extravasation is managed with endourologic or percutaneous techniques. Complications may require additional imaging or interventions. Follow-up is focused on renal function and blood pressure. Penetrating trauma is the main cause of noniatrogenic ureteral injuries. The diagnosis is often made by CT scanning or at laparotomy, and the mainstay of treatment is open repair. The type of repair depends upon the severity and location of the injury. Conclusions: Renal injuries are best managed conservatively or with minimally invasive techniques. Preservation of renal units is feasible in most cases. This review, performed by the EAU trauma guidelines panel, summarises the current management of upper urinary tract injuries. Patient summary: Patients with trauma benefit from being accurately diagnosed and treated appropriately, according to the nature and severity of their injury. #","author":[{"dropping-particle":"","family":"Serafetinides","given":"Efraim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kitrey","given":"Noam D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Djakovic","given":"Nenad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kuehhas","given":"Franklin E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lumen","given":"Nicolaas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharma","given":"Davendra M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Summerton","given":"Duncan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issue":"9","issued":{"date-parts":[["2015"]]},"page":"3-0","title":"Review of the Current Management of Upper Urinary Tract Injuries by the EAU Trauma Guidelines Panel","type":"article-journal","volume":"7"},"uris":[""]}],"mendeley":{"formattedCitation":"(12)","plainTextFormattedCitation":"(12)","previouslyFormattedCitation":"¹²"},"properties":{"noteIndex":0},"schema":""}(12). However, this study has demonstrated that this is not always required. Patients undergoing laparotomy for associated injuries may frequently have renal injuries suitable for conservative management. In our series, 19 patients had laparotomy for associated injuries, but due to the lack of expanding/pulsatile haematoma, retroperitoneal exploration was not performed. In 3 of these cases, angiography and embolization was utilised for the renal injury and further renal intervention was not required.These modern approaches represent a new attitude in managing renal trauma. When emergency laparotomy is indicated for trauma, the aim is to control bleeding, prevent contamination/infection and stabilise the patient. Therefore, renal exploration should be avoided as disturbing the retroperitoneum may lead to loss of tamponade and increased bleeding thereby increasing operating time and higher probability of nephrectomyADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1159/000474192","ISSN":"0302-2838","abstract":"Objective: To evaluate changes in the management of major blunt renal trauma\nsince the introduction of computerized tomographic diagnosis and followup.\nMaterial and Methods: Twenty-three consecutive patients with deep blunt\nrenal lacerations without major pedicle injury or shattered kidney were treated\nfrom 1986 to 1995. In group 1 (1986-1989, 12 patients), initial management\nwas conservative, but with open surgery in cases of hemodynamic instability\nor persistent urinary extravasation. In group 2 (1990-1995, 11 patients), a\nplain conservative approach was followed and open surgery was reserved for\nmajor complications only. Results: In group 1, 6 patients required early renal\nexploration (4 nephrectomies, 2 renorrhaphies). A persistent urinary fistula\nled to late nephrectomy in 1 of the renorrhaphy patients. Retroperitoneal\nhematoma and urinary extravasation spontaneously resolved in 6 cases.\nLength of hospital stay was significantly lower (p = 0.02) for nonoperated\npatients. None suffered from hypertension at long-term follow-up (5-8 years,\nmean 7.2). In groups 2, all 11 patients were treated conservatively, with endoscopic\nureteric stenting in 4 cases. Urinary extravasation always resolved, but\n9 patients had residual perirenal hematoma at the time of discharge. Length of\nhospital stay was significantly higher (p = 0.0005) with ureteric stenting. Nine\nmonths after trauma, 1 patient suffered from recurrent pyelonephritis. Radiographic\nfollow-up (1-30 months, mean 10.2) revealed minor sequelae in all\nevaluated patients. Conclusion: In most patients with major blunt renal lacerations,\na conservative approach is safe. Most extravasation spontaneously\nresolves and minimally invasive techniques will deal with nearly all complications.\nIn our experience, open surgery usually results in nephrectomy.","author":[{"dropping-particle":"","family":"Robert","given":"Maxime","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Drianno","given":"Nicolas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Muir","given":"Gordon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Delbos","given":"Olivier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guiter","given":"Jacques","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"European Urology","id":"ITEM-1","issue":"3","issued":{"date-parts":[["1996"]]},"page":"335-339","publisher":"Karger Publishers","title":"Management of Major Blunt Renal Lacerations: Surgical or Nonoperative Approach?","type":"article-journal","volume":"30"},"uris":[""]}],"mendeley":{"formattedCitation":"(13)","plainTextFormattedCitation":"(13)","previouslyFormattedCitation":"¹³"},"properties":{"noteIndex":0},"schema":""}(13). 4.2.2 Renal ExplorationThe overall rate of renal exploration in our series was low at 4.4% (4 cases). The need for open renal exploration was indicated to manage ongoing haemodynamic instability. Only two nephrectomies were performed in our series and both patients were critically unstable on arrival, requiring cardiopulmonary resuscitation (CPR) in the operating theatre. Both patients did not survive. This demonstrates that emergency nephrectomy as a lifesaving procedure has become a very rare event in the era of vascular embolization. Conversely, unstable patients with penetrating injuries secondary to stabbing are more amenable to open renal repair with renorrhaphyADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"0094-0143","PMID":"10086060","abstract":"In general, the authors surgically reconstruct kidneys with major parenchymal lacerations or vascular injuries, particularly when intra-abdominal injuries are present. Regardless of the mechanism of injury, roughly 90% of explored kidneys can be successfully reconstructed. Adherence to the principles of early proximal vascular control, debridement of devitalized tissue, hemostasis, closure of the collecting system, and coverage of the defect maximizes the salvage of renal function while minimizing potential complications. As to ureteral injuries, a high index of suspicion is crucial, especially because urinalysis and imaging studies can be unreliable. The majority of ureteral injuries can be successfully reconstructed by primary repair, ureteroureterostomy, or ureteral reimplantations, with or without a psoas bladder hitch.","author":[{"dropping-particle":"","family":"Brandes","given":"S B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McAninch","given":"J W","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Urologic clinics of North America","id":"ITEM-1","issue":"1","issued":{"date-parts":[["1999","2"]]},"page":"183-99, x","title":"Reconstructive surgery for trauma of the upper urinary tract.","type":"article-journal","volume":"26"},"uris":[""]}],"mendeley":{"formattedCitation":"(14)","plainTextFormattedCitation":"(14)","previouslyFormattedCitation":"¹⁴"},"properties":{"noteIndex":0},"schema":""}(14). The decision for renal salvage is judged intra-operatively based on the viability of the kidney and haemodynamic stability of the patient. This decision can be assisted by the use of an intra-operative “one-shot” intravenous urogram (IVU) to confirm the presence of a contralateral kidney. In our series, both cases of renal repair were caused by stabbing. The overall low rates of operative intervention for renal trauma has implications on the role of Urologists in renal trauma. The modern trained UK Urologist is unlikely to experience many emergency intra-operative scenarios both in training and as a newly appointed consultant. MTC’s in the UK are continuing to develop, and the skillset of the “UK trauma surgeon” can be variableADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/jramc-2014-000350","abstract":"Introduction Trauma care delivery in England has been transformed by the development of trauma net-works, and the designation of trauma centres. A special-ist trauma service is a key component of such centres. The aim of this survey was to determine to which extent, and how, the new major trauma centres (MTCs) have been able to implement such services. Methods Electronic questionnaire survey of MTCs in England. Results All 22 MTCs submitted responses. Thirteen centres have a dedicated major trauma service or trauma surgery service, and a further four are currently develop-ing such a service. In 7 of these 17 centres, the service is or will be provided by orthopaedic surgeons, in 2 by emergency medicine departments, in another 2 by general or vascular surgeons, and in 6 by a multidiscip-linary group of consultants. Discussion A large proportion of MTCs still do not have a dedicated major trauma service. Furthermore, the models which are emerging differ from other countries. The relative lack of involvement of surgeons in MTC trauma service provision is particularly noteworthy, and a potential concern. The impact of these different models of service delivery is not known, and warrants further study.","author":[{"dropping-particle":"","family":"Jansen","given":"Jan O","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Morrison","given":"J J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tai","given":"N R M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Midwinter","given":"M J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jo","given":"Jansen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jj","given":"Morrison","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nrm","given":"Tai","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"J R Army Med Corps","id":"ITEM-1","issued":{"date-parts":[["2015"]]},"page":"341-344","title":"A survey of major trauma centre staffing in England","type":"article-journal","volume":"161"},"uris":[""]}],"mendeley":{"formattedCitation":"(15)","plainTextFormattedCitation":"(15)","previouslyFormattedCitation":"¹⁵"},"properties":{"noteIndex":0},"schema":""}(15). Whilst a well-trained general or vascular surgeon on a trauma rota may be competent managing intra-operative renal injury scenarios, the Urologist may still be called upon. It is therefore important for Urologists working within MTCs to have a good understanding and experience of the modern management of renal trauma.4.3 Need for Early Re-imagingThe aim of early re-imaging for renal trauma is to monitor for early complications such as ongoing bleeding, persistent urinary extravasation and vascular malformationsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s00268-001-0150-0","ISSN":"0364-2313","author":[{"dropping-particle":"","family":"Blankenship","given":"John C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gavant","given":"Morris L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cox","given":"Clair E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chauhan","given":"Ravi D.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gingrich","given":"Jeffrey R.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"World Journal of Surgery","id":"ITEM-1","issue":"12","issued":{"date-parts":[["2001","12","22"]]},"page":"1561-1564","publisher":"Springer-Verlag","title":"Importance of Delayed Imaging for Blunt Renal Trauma","type":"article-journal","volume":"25"},"uris":[""]}],"mendeley":{"formattedCitation":"(16)","plainTextFormattedCitation":"(16)","previouslyFormattedCitation":"¹⁶"},"properties":{"noteIndex":0},"schema":""}(16). This has increasing importance with the growing number of patients being managed non-operatively. The timing and role of routine re-imaging is unclear. Up until 2012, EAU guidelines carried a grade B recommendation for repeat imaging between 2-4 days after injury. AUA and SIU guidelines both recommend follow up imaging at 48 hours (AUA) or 36-72 hours (SIU) for grade 4 or 5 injuriesADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/bju.13040","ISSN":"14644096","PMID":"25600513","abstract":"OBJECTIVE To review the guidelines released in the last decade by several organisations for the optimal evaluation and management of genitourinary injuries (renal, ureteric, bladder, urethral and genital). METHODS This is a review of the genitourinary trauma guidelines from the European Association of Urology (EAU) and the American Urological Association (AUA), and renal trauma guidelines from the Société Internationale d'Urologie (SIU). RESULTS Most recommendations are guided by the American Association for the Surgery of Trauma (AAST) organ injury severity system. Grade A evidence is rare in genitourinary trauma, and most recommendations are based on Grade B or C evidence. The findings of the most recent urological trauma guidelines are summarised. All guidelines recommend conservative management for low-grade injuries. The major difference is for haemodynamically stable patients who have high-grade renal trauma; the SIU guidelines recommend exploratory laparotomy, the EAU guidelines recommend renal exploration only if the injury is vascular, and the AUA guidelines recommend initial conservative management. CONCLUSION There is generally consensus among the three guidelines. Recommendations are based on observational or retrospective studies, as well as clinical principles and expert opinions. Multi-institutional collaborative research can improve the quality of evidence and direct more effective evaluation and management of urological trauma.","author":[{"dropping-particle":"","family":"Bryk","given":"Darren J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zhao","given":"Lee C.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BJU International","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2016","2"]]},"page":"226-234","title":"Guideline of guidelines: a review of urological trauma guidelines","type":"article-journal","volume":"117"},"uris":[""]}],"mendeley":{"formattedCitation":"(17)","plainTextFormattedCitation":"(17)","previouslyFormattedCitation":"¹⁷"},"properties":{"noteIndex":0},"schema":""}(17). Several studies have argued that routine re-imaging is not necessary in stable patientsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1186/1471-2490-8-11","ISSN":"1471-2490","abstract":"There is no consensus on the role of routine follow-up imaging during nonoperative management of blunt renal trauma. We reviewed our experience with nonoperative management of blunt renal injuries in order to evaluate the utility of routine early follow-up imaging. We reviewed all cases of blunt renal injury admitted for nonoperative management at our institution between 1/2002 and 1/2006. Data were compiled from chart review, and clinical outcomes were correlated with CT imaging results. 207 patients were identified (210 renal units). American Association for the Surgery of Trauma (AAST) grades I, II, III, IV, and V were assigned to 35 (16%), 66 (31%), 81 (39%), 26 (13%), and 2 (1%) renal units, respectively. 177 (84%) renal units underwent routine follow-up imaging 24–48 hours after admission. In three cases of grade IV renal injury, a ureteral stent was placed after serial imaging demonstrated persistent extravasation. In no other cases did follow-up imaging independently alter clinical management. There were no urologic complications among cases for which follow-up imaging was not obtained. Routine follow-up imaging is unnecessary for blunt renal injuries of grades I-III. Grade IV renovascular injuries can be followed clinically without routine early follow-up imaging, but urine extravasation necessitates serial imaging to guide management decisions. The volume of grade V renal injuries in this study is not sufficient to support or contest the need for routine follow-up imaging.","author":[{"dropping-particle":"","family":"Malcolm","given":"John B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Derweesh","given":"Ithaar H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mehrazin","given":"Reza","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"DiBlasio","given":"Christopher J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vance","given":"David D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Joshi","given":"Salil","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wake","given":"Robert W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gold","given":"Robert","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMC Urology","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2008","12","3"]]},"page":"11","publisher":"BioMed Central","title":"Nonoperative management of blunt renal trauma: Is routine early follow-up imaging necessary?","type":"article-journal","volume":"8"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.juro.2010.08.085","ISSN":"00225347","abstract":"<h3>Purpose</h3><p>Management for blunt high grade renal injury is controversial with most disagreement concerning indications for exploration. At our institution all patients are considered candidates for conservative treatment regardless of injury grade or computerized tomography appearance with clinical status the sole determinant for intervention. We define clinical factors predicting the need for emergency intervention as well the development of complications.</p><h3>Materials and Methods</h3><p>We analyzed the records of 117 patients with high grade renal injury (III to V) secondary to blunt trauma who presented to our institution in an 8-year period. Patients were categorized by the need for emergency intervention and, in those treated conservatively, by complications. We generated logistic regression models to identify significant clinical predictors of each outcome.</p><h3>Results</h3><p>Grade III to V injury occurred in 48 (41.1%), 42 (35.9%) and 27 patients (23%), respectively. Of the 117 patients 20 (17.1%) required emergency intervention. On multivariate analysis only grade V injury (RR 4.4, 95% CI 1.9–10.5, p=0.001) and the need for platelet transfusion (RR 8.9, 95% CI 2.1–32.1, p <0.001) significantly predicted the need for intervention. A total of 90 patients (82.9%) who did not require emergency intervention underwent a trial of conservative treatment, of whom 9 (9.3%) experienced complications requiring procedural intervention. On multivariate analysis only patient age (RR 1.06, 95% CI 1.02–1.1, p=0.004) and hypotension (RR 12, 95% CI 1.9–76.7, p=0.009) were significant predictors.</p><h3>Conclusions</h3><p>High grade injury can be successfully managed conservatively. However, grade V injury and the need for platelet transfusion predict the need for emergency intervention while older patient age and hypotension predict complications.</p>","author":[{"dropping-particle":"","family":"McGuire","given":"James","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bultitude","given":"Matthew F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davis","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Koukounaras","given":"Jim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Royce","given":"Peter L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Corcoran","given":"Niall M.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Journal of Urology","id":"ITEM-2","issue":"1","issued":{"date-parts":[["2011","1","1"]]},"page":"187-191","publisher":"Elsevier","title":"Predictors of Outcome for Blunt High Grade Renal Injury Treated With Conservative Intent","type":"article-journal","volume":"185"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1097/TA.0b013e3181e5bb8e","abstract":"Background: The purpose of this investigation was to determine the yield of repeat follow-up imaging in patients sustaining renal trauma.\r\n\r\nMethods: The Los Angeles County + University of Southern California Medical Center trauma registry was reviewed to identify all patients with a diagnosis of kidney injury from 2005 to 2008. All final attending radiologist interpretations and the dates of the initial and follow-up computerized tomography (CT) scans were also reviewed. Grades I, II, and III were grouped as low-grade injuries and grades IV and V as high-grade injuries.\r\n\r\nResults: During the 4-year study period, 120 (1.2% of all trauma admissions) patients had a total of 121 kidney injuries: 85.8% were male, and the mean age ± SD was 31.1 years ± 14.5 years. Overall, 22.6% of blunt and 35.6% of penetrating kidney injuries were high grade (IV-V; p = 0.148). These high-grade injuries were managed operatively in 35.7% and 76.2% of blunt and penetrating injuries, respectively, (p = 0.022). Overall, 31.7% underwent at least one follow-up CT; 24.2% of patients with blunt and 39.7% of patients with penetrating kidney injury, respectively. None of the patients with a low-grade injury managed nonoperatively developed a complication, independent of the injury mechanism. High-grade blunt and penetrating kidney injuries managed nonoperatively were associated with 11.1% and 20.0% complication rate identified on follow-up CT, respectively. For patients who underwent surgical interventions for penetrating kidney injuries, the diagnosis of the complication was made at 9.8 days ± 7.0 days (range, 1–24 days), with 83.3% of them diagnosed within 8 days postoperatively. The most frequent complication identified was an abscess in the renal fossa (50.0% of all complications). Other complications included urinoma, ureteral stricture, and pseudoaneurysm. All patients who developed complications were symptomatic, prompting the imaging that led to the diagnosis. All patients who developed a complication after a penetrating injury required intervention for the management of the complication.\r\n\r\nConclusion: Selective reimaging of renal injuries based on clinical and laboratory criteria seems to be safe regardless of injury mechanism or management. High-grade penetrating injuries undergoing operative intervention should carry the highest degree of vigilance and lowest threshold for repeat imaging.","author":[{"dropping-particle":"","family":"Bukur","given":"Marko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Inaba","given":"Kenji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Barmparas","given":"Galinos","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Paquet","given":"Christian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Best","given":"Charles","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lam","given":"Lydia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Plurad","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Demetriades","given":"Demetrios","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Journal of Trauma: Injury, Infection, and Critical Care","id":"ITEM-3","issue":"5","issued":{"date-parts":[["2011","5"]]},"page":"1229-1233","title":"Routine Follow-Up Imaging of Kidney Injuries May Not Be Justified","type":"article-journal","volume":"70"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.1016/j.juro.2017.02.2928","author":[{"dropping-particle":"","family":"BETARI","given":"Reem","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"FIARD","given":"Gaelle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"RUGGIERO","given":"Marine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"DOMINIQUE","given":"Ines","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"FRETON","given":"Lucas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"OLIVIER","given":"Jonathan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"LANGOUET","given":"Quentin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"MILLET","given":"Clémentine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"BERGERAT","given":"Sébastien","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"PANAYATOPOULOS","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"MATILLON","given":"Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"CHEBBI","given":"Ala","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"CAES","given":"Thomas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"PATARD","given":"Pierre-Marie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"SZABLA","given":"Nicolas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"BRICHART","given":"Nicolas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"SABOURIN","given":"Laura","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"GULERYUZ","given":"Kerem","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"DARIANE","given":"Charles","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"LEBACLE","given":"Cédric","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"RIZK","given":"Jér?me","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"MADEC","given":"Fran?ois-Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"NOUHAUD","given":"Fran?ois-Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"PRADERE","given":"Benjamin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"ROD","given":"Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"HUTIN","given":"Marine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"PEYRONNET","given":"Benoit","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Journal of Urology","id":"ITEM-4","issue":"4","issued":{"date-parts":[["2017","4","1"]]},"page":"e1255-e1256","publisher":"Elsevier","title":"ROLE OF REPEAT IMAGING IN RENAL TRAUMA MANAGEMENT : RESULTS OF A FRENCH MULTICENTRIC STUDY (TRAUMAFUF)","type":"article-journal","volume":"197"},"uris":[""]}],"mendeley":{"formattedCitation":"(18–21)","plainTextFormattedCitation":"(18–21)","previouslyFormattedCitation":"^18–21"},"properties":{"noteIndex":0},"schema":""}(18–21). Updated EAU 2018 guidance now recommends repeat imaging in response to clinical symptomsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.eururo.2014.12.034","abstract":"a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m Article info Abstract Context: The most recent European Association of Urology (EAU) guidelines on urologi-cal trauma were published in 2014. Objective: To present a summary of the 2014 version of the EAU guidelines on upper urinary tract injuries with the emphasis upon diagnosis and treatment. Evidence acquisition: The EAU trauma guidelines panel reviewed literature by a Med-line search on upper urinary tract injuries; publication dates up to December 2013 were accepted. The focus was on newer publications and reviews, although older key references could be included. Evidence synthesis: A full version of the guidelines is available in print and online. Blunt trauma is the main cause of renal injuries. The preferred diagnostic modality of renal trauma is computed tomography (CT) scan. Conservative management is the best approach in stable patients. Angiography and selective embolisation are the first-line treatments. Surgical exploration is primarily for the control of haemorrhage (which may necessitate nephrectomy) and renal salvage. Urinary extravasation is managed with endourologic or percutaneous techniques. Complications may require additional imaging or interventions. Follow-up is focused on renal function and blood pressure. Penetrating trauma is the main cause of noniatrogenic ureteral injuries. The diagnosis is often made by CT scanning or at laparotomy, and the mainstay of treatment is open repair. The type of repair depends upon the severity and location of the injury. Conclusions: Renal injuries are best managed conservatively or with minimally invasive techniques. Preservation of renal units is feasible in most cases. This review, performed by the EAU trauma guidelines panel, summarises the current management of upper urinary tract injuries. Patient summary: Patients with trauma benefit from being accurately diagnosed and treated appropriately, according to the nature and severity of their injury. #","author":[{"dropping-particle":"","family":"Serafetinides","given":"Efraim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kitrey","given":"Noam D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Djakovic","given":"Nenad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kuehhas","given":"Franklin E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lumen","given":"Nicolaas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharma","given":"Davendra M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Summerton","given":"Duncan J","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issue":"9","issued":{"date-parts":[["2015"]]},"page":"3-0","title":"Review of the Current Management of Upper Urinary Tract Injuries by the EAU Trauma Guidelines Panel","type":"article-journal","volume":"7"},"uris":[""]}],"mendeley":{"formattedCitation":"(12)","plainTextFormattedCitation":"(12)","previouslyFormattedCitation":"¹²"},"properties":{"noteIndex":0},"schema":""}(12). In our institution, we have endorsed routine repeat imaging in the first 48 hours. The majority of these were planned re-imaging (83%), compared to clinical indications. In the planned asymptomatic group, 6/49 patients (12.2%) were found to have additional findings that necessitated a change in management in 3/49 patients (6.1%). All patients with additional findings had grade 3 injury or above. Interestingly, this implies that strict adherence to EAU guidelines may have resulted in missed complications presenting later with infected urinoma or major bleeding. In the case of pseudoaneurysms in our series, both developed from penetrating grade 3 injuries. Our positive finding rates are similar to a recently presented large multi-centre studyADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.juro.2017.02.2928","author":[{"dropping-particle":"","family":"BETARI","given":"Reem","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"FIARD","given":"Gaelle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"RUGGIERO","given":"Marine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"DOMINIQUE","given":"Ines","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"FRETON","given":"Lucas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"OLIVIER","given":"Jonathan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"LANGOUET","given":"Quentin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"MILLET","given":"Clémentine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"BERGERAT","given":"Sébastien","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"PANAYATOPOULOS","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"MATILLON","given":"Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"CHEBBI","given":"Ala","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"CAES","given":"Thomas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"PATARD","given":"Pierre-Marie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"SZABLA","given":"Nicolas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"BRICHART","given":"Nicolas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"SABOURIN","given":"Laura","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"GULERYUZ","given":"Kerem","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"DARIANE","given":"Charles","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"LEBACLE","given":"Cédric","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"RIZK","given":"Jér?me","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"MADEC","given":"Fran?ois-Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"NOUHAUD","given":"Fran?ois-Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"PRADERE","given":"Benjamin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"ROD","given":"Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"HUTIN","given":"Marine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"PEYRONNET","given":"Benoit","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Journal of Urology","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2017","4","1"]]},"page":"e1255-e1256","publisher":"Elsevier","title":"ROLE OF REPEAT IMAGING IN RENAL TRAUMA MANAGEMENT : RESULTS OF A FRENCH MULTICENTRIC STUDY (TRAUMAFUF)","type":"article-journal","volume":"197"},"uris":[""]}],"mendeley":{"formattedCitation":"(21)","plainTextFormattedCitation":"(21)","previouslyFormattedCitation":"²¹"},"properties":{"noteIndex":0},"schema":""}(21). Whilst it could be argued a 6% rate of re-intervention is low, we believe there may be a role for re-imaging in grade 3 or above injuries given the yield of additional findings and change in management demonstrated in our series. It may be suggested that penetrating injuries are at greater risk of developing vascular complications and therefore re-imaging would be more pertinent. The small numbers of patients in our subgroup analysis makes it difficult to define indications according to mechanism. A larger study with subgroup analysis would be necessary to clarify this.Conversely, the clinical indication re-imaging group (n=10) did not yield any significant renal additional findings which altered patient management. Whilst these numbers are too small to draw significant conclusions, they demonstrate that depending on clinical features alone is unreliable for detecting evolving renal trauma pathology. Owing to this ambiguity and the significant findings in our asymptomatic group, we recommend routine reimaging in all grade III or above renal trauma patients. In keeping with other published studies, repeat imaging for low grade injuries (Grade I-II) did not demonstrate any complications in our series, therefore, routine re-imaging in this group is not required unless there are specific concerns. 4.3.1 Optimal timing of reimaging The optimal timing for re-imaging is not clear. In our two cases of pseudo-aneurysm malformation, one case was diagnosed on CT scan at 2 days, however the second case did not demonstrate the abnormality on the initial repeat scan on day 2. A third CT scan was performed on day 7 for other reasons and demonstrated the pseudoaneurysm. Both of these cases resulted from penetrating injury. Whilst it is difficult to ascertain the optimal timing of repeat imaging, a small delay in repeat imaging in stable patients may maximise the potential to detect vascular abnormalities, whilst allowing a reasonable period of conservative management of extravasating injuries. 4.4 LimitationsThere are of course limitations to this study. Whilst the TARN data reliably captures all significant injuries due to prospective data collection, it is likely that low grade injuries are under-represented in our analysis. TARN does not capture patients who are discharged within 72hours of admission unless there is HDU/ITU requirement or the patient did not survive. This is a single centre retrospective study with relatively small numbers, particularly when stratifying patients into subgroups. Larger multi-centre studies will give adequate power for subgroup analysis. In addition, due the nature of the major trauma network, many patients undergo follow up at their local hospitals meaning that long term follow up data for long term complications is lacking. This is particularly important for monitoring hypertension in high grade injuries managed conservatively.4.5 ConclusionsIn conclusion, the centralisation of trauma services has led to a focussed experience in dealing with high volume of high-grade renal injuries in major trauma centres. The modern management of renal trauma has evolved, with most cases managed conservatively. High grade injuries with active bleeding can be successfully managed by angiography and embolization, even when associated injuries necessitate exploratory laparotomy. Retroperitoneal exploration is not mandatory unless there is expanding/pulsatile haematoma or ongoing haemodynamic instability. The role of routine re-imaging of renal injury remains controversial. Whilst it is agreed that low grade injuries do not require re-imaging, high grade injuries (III- V) are at risk of developing complications. Re-imaging in the setting of clinical symptoms alone could result in missed complications, however, the optimal timing of imaging is unclear and larger data analyses are required. Based on our experience, repeat imaging should be considered 3-5 days post-injury in all grade 3 injuries and above unless there are clinical concerns mandating it to be performed earlier.AcknowledgementsWe would like to acknowledge Dr Nicola Batrick and the Imperial Major Trauma Centre. We also wish to thank Joanne Graves, Major Trauma Audit Lead for providing the TARN data. This work was supported by the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre.ReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. Meng M V., Brandes SB, McAninch JW. Renal trauma: indications and techniques for surgical exploration. 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