Health Services Research Adult Blunt Renal Trauma: Routine Follow-up Imaging Is Excessive Kieran J. Breen, Paul Sweeney, Patrick J. Nicholson, Eamonn A. Kiely, and M. F. O’Brien OBJECTIVE
METHODS
RESULTS
CONCLUSION
To determine the yield of follow-up imaging in patients sustaining renal trauma at our level-1 trauma center and hence, whether the 2013 European Association of Urology guidelines are clinically applicable. All patients who attended Cork University Hospital with a diagnosis of renal injury from 2000-2012 were identified. Review of all medical records and radiologic imaging was undertaken. Injuries were graded using the American Association for the Surgery of Trauma Organ Injury Scale and were grouped as low-grade injuries (I, II, and III) or high-grade injuries (IV and V). One hundred and two patients (105 renal units) were identified with a median age of 23 years (interquartile range, 18-39 years). The mechanism of injury was blunt force in 98 of 102 cases (96%). Injuries were diagnosed at the time of admission using contrast-enhanced computed tomography (CT) imaging. Low-grade injuries accounted for 78 of 102 cases (77%); all were managed conservatively with a complication rate of 2 of 78 (3%). Twenty-four patients (23%) had high-grade injuries; 2 cases required nephrectomy, 22 of 24 (92%) were managed conservatively with a complication rate of 5 of 24 (21%). All patients with complications were symptomatic, prompting repeat imaging. Overall, 38 of 102 patients (37%) underwent at least 1 follow-up CT: 20 of 78 (25%) of low-grade injuries and 18 of 24 (75%) of high-grade injuries. Concurrent thoracoabdominal injuries mandated the need for repeat CT evaluation in 21 of 38 patients (55%). Thirty-one (30%) patients were reimaged by renal ultrasonography. Selective reimaging of renal injuries based on clinical and laboratory criteria would have detected all complications. The 2013 European Association of Urology guidelines on urologic trauma are clinically appropriate in a major tertiary-trauma unit. UROLOGY -: -e-, 2014. 2014 Elsevier Inc.
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enal injury is the most common genitourinary problem encountered by urologists in trauma situations, accounting for 1%-5% of all trauma injuries.1 In most cases, the mechanism of injury is blunt force, with penetrating injuries reported less frequently outside the United States of America and South Africa.2 A nonoperative approach to both blunt and penetrating renal injuries has yielded higher rates of renal salvage and decreased morbidity compared with primary operative management.3-5 There is mounting evidence in the literature that routine reimaging, in the absence of clinical deterioration or altered laboratory findings, has little impact on decision-making or clinical outcomes and therefore may not be justified.6-8 All reported adult series to date used repeat computed tomography (CT) imaging to follow up renal injuries. However, the pediatric
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Cork University Hospital, Cork, Ireland; and the Department of Radiology, Cork University Hospital, Cork, Ireland Reprint requests: Kieran J. Breen, M.D., Department of Urology, Cork University Hospital, Wilton, Cork, Ireland. E-mail: [email protected] Submitted: December 9, 2013, accepted (with revisions): March 8, 2014
ª 2014 Elsevier Inc. All Rights Reserved
literature has demonstrated that ultrasonography (US) is a safe and effective alternative imaging modality to monitor blunt renal trauma patients.9 The benefits of US in terms of cost and radiation are weighed against its lack of sensitivity and specificity when compared with CT. Our series is the first to examine adult patients that had only US follow-up and those with CT follow-up. The purpose of this study was to determine the yield of repeat follow-up imaging in patients sustaining renal trauma and its impact on patient outcomes. We hypothesized that our current liberal reimaging strategy does not predict complications or alter patient outcomes and is excessive.
MATERIALS AND METHODS Cork University Hospital serves a population of 620,000 and is the only level-1 trauma center in Ireland. After approval from the research and ethics committee, all patients who were admitted with a diagnosis of renal injury from 2000-2012 were identified from the hospital in-patient enquiry database. A retrospective review of all patients’ medical records and radiologic imaging was undertaken. 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2014.03.013
1
Patient data collected included demographics, mechanism of injury, blood pressure, hemoglobin level, and Glasgow Coma Scale value on admission and Injury Severity Score. Operative records, complications, date, and results of follow-up imaging were also reviewed. Injuries were diagnosed at the time of admission using contrast-enhanced CT imaging. Final staff radiologist reports were reviewed, and all kidney injuries were graded according to the American Association for the Surgery of Trauma (AAST)Organ Injury Scale.10 The modality and timing of follow-up renal imaging was at the discretion of the managing urologist but also mandated by concurrent injuries. As a general rule, patients with isolated grade-I renal injuries had no follow-up imaging, patients with isolated renal injuries graded II-III had follow-up US imaging, and patients with renal injuries graded IV-V had follow-up CT imaging. In line with standard practice, we take a nonoperative approach to treating all renal trauma patients unless absolute indications for operative intervention exist, that is, hemodynamic instability, peritonitis, and clinically unevaluable patient. Using the AAST-Organ Injury Scale, renal injuries were grouped as low-grade (I, II, and III) or high-grade (IV and V). Outcomes noted included complications (classified according to the Clavien-Dindo grading system for surgical complications11), mortality, and hospital and intensive care length of stay. We correlated clinical outcomes with repeat imaging results. Descriptive statistics focused on frequencies and proportions for categorical variables. Medians and interquartile ranges (IQRs) were reported for continuous data. The chi square test was used to compare frequencies for categorical data. Reported P values are 2-sided, with P .05 considered to indicate statistical significance.
Table 1. Demographics, clinical presentation, length of stay, and mortality Variables
n (%)
IQR
Number of patients Age (y), median Gender Male Female Mechanism of injury Blunt Penetrating Cause of injury Road traffic accident Fall from height Sports related Assault Farming related Suicide attempt Side of Injury Left Right Bilateral Visible hematuria Yes No Glasgow coma scale, median Injury severity score, median Hemoglobin on admission (g/dL), median Blood pressure on admission (mm Hg), median ICU admissions ICU length of stay (d), median Total length of stay (d), median Mortality
102 23
18-39
91 (89) 11 (11) 98 (96) 4 (4) 45 22 19 7 7 2
(44) (22) (18) (7) (7) (2)
52 (51) 47 (46) 3 (3) 56 (55) 46 (45) 15 16 13.2
14-15 9-36 11.2-13.4
120/70 110/60-135/80 32 (31) 4 5 3 (3)
2-7 3-11
ICU, intensive care unit; IQR, interquartile range.
RESULTS Between 2000 and 2012, a total of 102 patients (91 male and 11 female) were admitted to Cork University Hospital, with a total of 105 renal injuries. Patient demographics and clinical presentations are listed in Table 1. The median age was 23 years (IQR, 18-39 years). The mechanism of injury was blunt force in 98 patients (96%). On admission, the median hemoglobin level was 13.1 g/dL (IQR, 11.1-14.3 g/dL); the median Glasgow Coma Scale value was 15 (IQR, 14-15). Thirty-two patients required admission to intensive care unit (ICU), with median length of ICU stay of 4 days (IQR, 27 days). All ICU admissions had concurrent injuries except 1 isolated grade-V renal injury. The median length of stay was 5 days (IQR, 3-11 days). Table 2 lists complications by injury grade, type of complication, intervention required, and Clavien-Dindo classification. Low-grade injuries accounted for 78 of 102 (77%) cases; all were managed conservatively with a complication rate 3% (2 of 78) Twenty-four patients (23%) were classified as having high-grade injuries (IV or V), with a complication rate of 21% (5 of 24). Two patients (1 grade-I and 1 grade-IV renal injury) were readmitted with pain on day 2 after discharge, both had stable injuries on reimaging, and their pain settled with analgesia. Two patients (1 grade-II and 1 grade-IV 2
renal injury) were noted to be febrile, with an elevated white cell count on day 2 and day 3, respectively. Repeat imaging revealed stable injuries with no evidence of collection or abscess formation, and both were managed successfully with intravenous antibiotics. After this febrile episode, the patient with a grade-IV injury was noted to be hypertensive in the outpatient clinic at 3 months. She was treated with an antihypertensive for 2 years and currently does not require medication. Another patient with a grade-V injury was noted to be hypertensive at day 3 after admission. He was treated with an antihypertensive and remains on medication. Two patients (both grade-IV injuries) developed a urinoma. The first patient was successfully managed conservatively. The second patient was noted to have a large urinoma at presentation and had a percutaneous nephrostomy drain placed. On day 3, a nephrostogram showed no extravasation of contrast, the nephrostomy was clamped and removed on day 5. The median length of time to presentation with a complication was 3 days (range, 0-60 days). Two cases (both grade-IV renal injuries) required operative management. After major road traffic accidents, both patients were hemodynamically unstable on admission and had exploratory laparotomies. Intraoperatively, UROLOGY
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Table 2. Renal injuries classified according to AAST grade, operative management, complications, intervention, and ClavienDindo grading system for surgical complications Renal Injuries
Grade
Low grade
I II III
28 23 27 78
IV
V
Total Operative management High grade
n (%)
Total Operative management
(28) (22) (27) (77) 0
Complications Time to (%) Complication Type Presentation (days) 1 1 0 2 (3)*
Pain Febrile episode
22 (21)
4
2 (2) 24 (23) 2
1 5 (21)*
Urinoma 2 Febrile episode þ Hypertension 1 Pain 1 Hypertension 1
Intervention
Clavien-Dindo Grade
Analgesia IV antibiotics
I II
Nephrostomy 1 Antihypertensive þ IV antibiotics Analgesia Antihypertensive
IIIa II
2 2
0, 4 3 60 2 3
I II
Nephrectomy 2
AAST, American Association for the Surgery of Trauma; IV, intravenous. * Chi square test, P ¼ .002.
both patients were found to have grade-IV or -V splenic and grade-IV left renal injuries. Both patients required splenectomy and left nephrectomy. Both patients died in intensive care of severe brain injuries sustained at the time of accident, at day 1 and day 5, respectively. The third mortality was a 40-year-old man also involved in a high-speed road traffic accident. Hemodynamically stable on admission, CT imaging showed a grade-2 right renal injury and grade-4 liver injury with hemoperitoneum. He became unstable and while being prepped in the operating room, developed cardiac asystole and could not be resuscitated. In total, 38 patients had at least 1 follow-up CT scan (Table 3). As in-patients, 10 of 11 (91%) follow-up CT scans performed in low-grade injuries were mandated by concurrent abdominal or thoracic injuries. In the inpatient high-grade group, 16 of 26 CT scans (61%) were mandated by concurrent injuries. The outpatient group was defined as the remaining patients not reimaged as in-patients. In the outpatient low-grade group, 5 of 8 CT scans (63%) were mandated by concurrent injuries. In the outpatient high-grade group, all 4 repeat CT scans were performed as followup for isolated grade-IV renal injuries. In total, 31 (30%) patients were reimaged by renal US. Reimaging with renal US was preferred over CT imaging, especially for isolated low-grade renal injuries; 27 of 31 US scans were performed for low-grade injuries, with 4 of 31 US scans performed for high-grade injuries. Twentysix patients (25%) had no follow-up imaging scheduled, all diagnosed with low-grade injuries. There were 6 patients who did not attend follow-up outpatient appointments, 3 (3%) of whom were scheduled for repeat imaging. All patients who developed complications were clinically symptomatic or had altered laboratory findings, which prompted repeat imaging that aided a diagnosis. UROLOGY
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Table 3. Repeat imaging as an inpatient and outpatient by modality and rates of concurrent injuries in patients with repeat CT imaging No Concurrent Renal Reimaging Injuries (n) US (n) (n)
Follow-up Imaging
CT (n)
As inpatient Low grade (I-III) High grade (IV-V) Total inpatient
11 15 26
10 6 16
5 0 5
As outpatient Low grade (I-III) High grade (IV-V) Total outpatient
8 4 12
5 0 5
22 4 26
32 0 32
Total inpatient and outpatient (%)
38 (37%)
31 (30%)
32 (31%)
21 (55%)
CT, computed tomography; US, ultrasound.
Results of repeat imaging did not independently predict any complication or prompt urologic intervention (Supplementary Fig. 1).
COMMENT Since the advent of widespread CT imaging, the majority of renal injuries are successfully managed nonoperatively with few absolute indications for surgical intervention.2 Based on CT criteria, renal injuries are graded according to the AAST-Organ Injury Scale, which has been shown to be predictive of the need for operative intervention.10,12,13 Blunt injuries are particularly amenable to conservative management with lower rates of nephrectomy and complications when compared with penetrating injuries.4,7 There is mounting evidence in the literature that in the absence of clinical or laboratory abnormalities, routine reimaging may not be justified.6-8 The updated 3
2013 European Association of Urology (EAU) guidelines on urologic trauma have been amended accordingly and advocate no repeat imaging for renal injuries graded I-IV in the absence of clinical deterioration.14 Following the adoption of conservative management for renal trauma, the purpose of repeat imaging was to identify complications early, before the evolution and clinical deterioration. Complication rates associated with renal trauma vary between 3% and 33% according to the reported clinical series and are grade dependent.15 Current Evidence for Selective Reimaging All current evidence guiding repeat renal imaging strategies comes from retrospective series. Earlier published reports advocated CT reimaging, especially for high-grade injuries, 24-72 hours after injury.16 However, more recent evidence, from larger cohorts, suggests that a selective reimaging approach, even in cases of high-grade injury, does not compromise patient outcomes. A group from the University of Tennessee were among the first to recommend early reimaging (24-48 hours after injury for blunt grade III injuries) based on a liberal reimaging approach, which detected 50% of complications with 33% of those requiring invasive intervention.16 Having subsequently reviewed this policy in a larger cohort (n ¼ 207), they noted a complication rate of 2.4%, most of which were associated with high-grade injuries with reimaging not independently predictive of requirement for invasive intervention. The University of Tennessee group have revised their management strategy, which is under prospective evaluation. Similarly, Bukur et al7 reported a selective reimaging approach to blunt and penetrating injuries with complication rates of 1.8% and 11.8%, respectively. All patients were clinically symptomatic before imaging, with a mean time from injury to complication of 9 days. In a cohort of conservatively managed grade-III and grade-IV renal injuries, Shirazi et al8 concluded that the group’s intensive reimaging strategy (at 36 hrs and 5 days) did not alter clinical decision-making. The authors noted that repeat CT imaging was not predictive of failure of conservative management and that clinical symptoms and laboratory results should guide decisions to perform additional imaging. At our trauma center, all patients presenting with renal injury are managed conservatively unless they have absolute indications for surgical exploration, that is, hemodynamic instability and peritonitis. At the time of this study, the modality and timing of repeat imaging was at the discretion of the admitting urologist but also mandated by concurrent injuries. However, as a general rule, patients with isolated grade-I renal injuries had no follow-up imaging, grade-II and grade-III renal injuries had follow-up US imaging, and patients with high-grade renal injuries had follow-up CT imaging. Complications Seven patients (7%) developed complications in our series, 2 of 78 patients (3%) with low-grade injuries vs 5 of 4
24 patients (21%) with high-grade injuries (P ¼ .002; Table 2). Complications consisted of 2 readmissions of patients with pain, 2 patients who developed fevers, 1 of whom also developed post-injury hypertension, and another patient who developed post-injury hypertension. Two patients developed urinomas; 1 patient was successfully managed conservatively and the other patient, who underwent nephrostomy insertion (classified as IIIa on the Clavien-Dindo system), was the only complication that required procedural intervention. Delayed complications typically occur at least 1-3 weeks after injury. We had a median follow-up of 3 months (IQR, 3-6 months) on 96 of 102 patients (21%) and an overall reimaging rate of 67%. This allowed us detect both early and late complications of renal trauma and report on postinjury hypertension (a complication absent from other series6,7). However, the risk of hypertension is long-term. All patients attending a follow-up outpatient appointment had their blood pressure checked and were advised to have an annual blood pressure measurement with their general practitioner. This study does not capture those patients who developed hypertension outside the median 3 months follow-up. All patients who developed complications were symptomatic or had altered laboratory results (febrile, leukocytosis, flank pain, hypertension), which prompted repeat imaging that aided diagnosis. In no case did results of follow-up imaging independently identify a complication or initiate urologic intervention. Follow-up Imaging: CT vs US In total, 38 patients (37%) had at least 1 follow-up CT scan, 55% of which were mandated by concurrent abdominal or thoracic injuries. A further 31 patients (30%) had a follow-up renal US scan. The benefit of documenting abnormalities after renal trauma, such as atrophic renal scars, has not been shown to correlate with post-injury hypertension or deteriorating renal function and is therefore of limited clinical significance.17 Given the low yield of follow-up imaging, there are significant cost savings to be attained with a more selective imaging approach. Reducing unnecessary radiation exposure is another benefit of a more selective approach, especially when considering the well-documented long-term risks associated with CT imaging and young age profile of renal trauma patients (median age 23 years in our series).18-20 The “as low as reasonably achievable” concept aims to balance the potential future risk of radiation induced malignancy with the additional information gained from ionizing-radiation imaging. It was designed to reduce radiation exposure in the pediatric population but also has obvious relevance to young adults. A group from Toronto have examined the efficacy of using US as the first-line imaging modality in the follow-up of blunt renal trauma in a pediatric population. Their US reimaging strategy detected all clinically relevant complications. Furthermore, CT imaging was reserved for those patients with hemodynamic instability, abnormalities detected on serial UROLOGY
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Figure 1. Blunt renal trauma management algorithm. CT, computed tomography; IV, intravenous.
US, or associated thoracoabdominal injuries. This led to 85% patients not requiring a further CT after initial diagnosis, 12% requiring repeat CT for nonurologic injuries, and 3% undergoing further CT evaluation for renal injuries.9 In our series 27 of 31 follow-up renal US scans were performed for low-grade injuries, with 4 of 31 US performed for high-grade injuries. None of these patients developed a complication. The use of US as a first line reimaging modality in symptomatic patients with lowgrade renal injuries will be incorporated into our new renal trauma reimaging strategy (Fig. 1). Based on the results of our study, we contend that routine reimaging for renal injuries grade I-IV, in the absence of clinical deterioration, is unnecessary. Our findings are in line with the most recent publications regarding reimaging in renal trauma and support the recommendations of the updated 2013 EAU guidelines on urologic trauma.14 Our study is limited by its retrospective design, which by its nature, may involve selection bias. Most of the injuries in the study were grouped as low grade (77%), which have a lower complication rate. This may influence our findings; however, our overall complication rate UROLOGY
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of 7% is consistent with the published literature.7,14 Grade-IV injuries account for 21% of our cases, which is also consistent with other published series; however, our data is lacking in grade-V injuries (n ¼ 2).12,20 Management Algorithm We are implementing and prospectively evaluating a new management strategy (Fig. 1). No routine reimaging will be obtained for renal injuries grade I-III or grade-IV injuries without urinary extravasation in the absence of clinical or laboratory abnormalities. If these patients deteriorate but are hemodynamically stable and have a stable hemoglobin, they will first be assessed by a US scan. If US imaging is inadequate in aiding a diagnosis, the patients will progress to CT imaging. Patients with grade-IV injuries with urinary extravasation will be reimaged by US at 48 hours, and grade-V injuries managed conservatively will be reimaged using a CT scan at 48 hours. The rationale for this approach is as follows: significant urinomas are detectable by a US scan, and based on our study and the literature, are most likely to occur in grade-IV injuries with urinary extravasation or grade-IV injuries.6,9 CT imaging should be reserved for 5
patients in whom delayed or ongoing bleeding is a concern, a rapid precise diagnosis is needed, or when US findings are inconclusive. We will report on this new management approach when sufficient patient numbers are reached.
CONCLUSIONS In the absence of clinical or laboratory abnormalities, the yield of routine follow-up imaging in renal trauma is low. A selective re-imaging approach guided by clinical deterioration would have detected all complications in our series. Based on these findings, we recommend no routine reimaging for renal injuries graded I-III and grade-IV injuries without urinary extravasation. The evolution of grade-IV injuries with urinary extravasation and grade-V injuries should be monitored with early repeat US and CT imaging, respectively, to guide management decisions. Based on retrospective evidence, 2013 EAU guidelines are clinically appropriate in a major tertiary trauma unit. We will prospectively test these conclusions with a new reimaging strategy. References 1. Lynch TH, Martınez-Piñeiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol. 2005;47:1-15. 2. Santucci RA, Wessells H, Bartsch G, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int. 2004;93:937-954. 3. Moudouni SM, Patard JJ, Manunta A, et al. A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments. BJU Int. 2001;87:290-294. 4. Broghammer JA, Fisher MB, Santucci RA. Conservative management of renal trauma: a review. Urology. 2007;70:623-629. 5. Robert M, Drianno N, Muir G, et al. Management of major blunt renal lacerations: surgical or nonoperative approach? Eur Urol. 1996;30:335-339. 6. Malcolm JB, Derweesh IH, Mehrazin R, et al. Nonoperative management of blunt renal trauma: is routine early follow-up imaging necessary? BMC Urol. 2008;8:11. 7. Bukur M, Inaba K, Barmparas G, et al. Routine follow-up imaging of kidney injuries may not be justified. J Trauma. 2011;70:1229-1233. 8. Shirazi M, Sefidbakht S, Jahanabadi Z, et al. Is early reimaging CT scan necessary in patients with grades III and IV renal trauma under conservative treatment? J Trauma. 2010;68:9-12. 9. Eeg KR, Khoury AE, Halachmi S, et al. Single center experience with application of the ALARA concept to serial imaging studies after blunt renal trauma in children—is ultrasound enough? J Urol. 2009;181:1834-1840. 10. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207:646-655. 11. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187-196. 12. Shariat SF, Roehrborn CG, Karakiewicz PI, et al. Evidence-based validation of the predictive value of the American Association for the Surgery of Trauma kidney injury scale. J Trauma. 2007;62: 933-939.
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13. Santucci RA, McAninch JW, Safir M, et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma. 2001;50:195-200. 14. Summerton DJ, Djakovic N, Kitrey ND, et al. European Association of Urology. Guidelines on urological trauma 2013. Available at: http://www.uroweb.org/gls/pdf/1406Urological%20Trauma_LR.pdf. Accessed May 2013. 15. Al-Qudah HS, Santucci RA. Complications of renal trauma. Urol Clin North Am. 2006;33:41-53. 16. Blankenship JC, Gavant ML, Cox CE, et al. Importance of delayed imaging for blunt renal trauma. World J Surg. 2001;25:1561-1564. 17. Dunfee BL, Lucey BC, Soto JA. Development of renal scars on CT after abdominal trauma: does grade of injury matter? Am J Roentgenol. 2008;190:1174-1179. 18. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357:2277-2284. 19. Brenner DJ, Hall EJ. Cancer risks from CT scans: now we have data, what next? Radiology. 2012;265:330-331. 20. Shoobridge JJ, Bultitude MF, Koukounaras J, et al. A 9-year experience of renal injury at an Australian level 1 trauma centre. BJU Int. 2013;112:53-60.
APPENDIX SUPPLEMENTARY DATA
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.urology. 2014.03.013.
EDITORIAL COMMENT What do we know about the need for routine reimaging after renal trauma? In the adult blunt renal trauma population, follow-up computed tomography (CT) scans on asymptomatic patients are not required (their citations 6-8). Less is known about the proper follow up of children with blunt renal trauma. Eeg et al (their citation 9) decreased the number of follow-up CT scans in children with blunt renal trauma to 3%, partly by eliminating imaging in asymptomatic patients and partly by substituting ultrasound. In this adult series, the authors reimaged 69% of their patients: 37% with CT and 30% with ultrasonography. However, these authors found that imaging did not actually help make any new diagnoses in the absence of symptoms such as pain, fever, or elevated white blood count. If imaging had been skipped in asymptomatic patients, they would not be harmed. Those who had no planned imaging, too, did not suffer harm in their series. So, you can skip reimaging in asymptomatic grade I-III blunt renal trauma patients. For grade IV-V injuries, you might also reasonably skip rescanning in those without symptoms (my conclusion, not theirs), or follow the author’s guidelines: (1) follow-up ultrasonography in all grade-IV patients, escalating to a CT if it is not diagnostic, (2) follow-up CT in all grade-V injuries. We continue to learn what we do and don’t have to do in renal trauma. Richard A. Santucci, M.D., F.A.C.S., The Center for Urologic Reconstruction, Detroit Receiving Hospital, Detroit Medical Center; Michigan State College of Medicine, Detroit, MI http://dx.doi.org/10.1016/j.urology.2014.03.018 UROLOGY
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UROLOGY
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METHODS
RESULTS
CONCLUSION
To determine the yield of follow-up imaging in patients sustaining renal trauma at our level-1 trauma center and hence, whether the 2013 European Association of Urology guidelines are clinically applicable. All patients who attended Cork University Hospital with a diagnosis of renal injury from 2000-2012 were identified. Review of all medical records and radiologic imaging was undertaken. Injuries were graded using the American Association for the Surgery of Trauma Organ Injury Scale and were grouped as low-grade injuries (I, II, and III) or high-grade injuries (IV and V). One hundred and two patients (105 renal units) were identified with a median age of 23 years (interquartile range, 18-39 years). The mechanism of injury was blunt force in 98 of 102 cases (96%). Injuries were diagnosed at the time of admission using contrast-enhanced computed tomography (CT) imaging. Low-grade injuries accounted for 78 of 102 cases (77%); all were managed conservatively with a complication rate of 2 of 78 (3%). Twenty-four patients (23%) had high-grade injuries; 2 cases required nephrectomy, 22 of 24 (92%) were managed conservatively with a complication rate of 5 of 24 (21%). All patients with complications were symptomatic, prompting repeat imaging. Overall, 38 of 102 patients (37%) underwent at least 1 follow-up CT: 20 of 78 (25%) of low-grade injuries and 18 of 24 (75%) of high-grade injuries. Concurrent thoracoabdominal injuries mandated the need for repeat CT evaluation in 21 of 38 patients (55%). Thirty-one (30%) patients were reimaged by renal ultrasonography. Selective reimaging of renal injuries based on clinical and laboratory criteria would have detected all complications. The 2013 European Association of Urology guidelines on urologic trauma are clinically appropriate in a major tertiary-trauma unit. UROLOGY -: -e-, 2014. 2014 Elsevier Inc.
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enal injury is the most common genitourinary problem encountered by urologists in trauma situations, accounting for 1%-5% of all trauma injuries.1 In most cases, the mechanism of injury is blunt force, with penetrating injuries reported less frequently outside the United States of America and South Africa.2 A nonoperative approach to both blunt and penetrating renal injuries has yielded higher rates of renal salvage and decreased morbidity compared with primary operative management.3-5 There is mounting evidence in the literature that routine reimaging, in the absence of clinical deterioration or altered laboratory findings, has little impact on decision-making or clinical outcomes and therefore may not be justified.6-8 All reported adult series to date used repeat computed tomography (CT) imaging to follow up renal injuries. However, the pediatric
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Cork University Hospital, Cork, Ireland; and the Department of Radiology, Cork University Hospital, Cork, Ireland Reprint requests: Kieran J. Breen, M.D., Department of Urology, Cork University Hospital, Wilton, Cork, Ireland. E-mail: [email protected] Submitted: December 9, 2013, accepted (with revisions): March 8, 2014
ª 2014 Elsevier Inc. All Rights Reserved
literature has demonstrated that ultrasonography (US) is a safe and effective alternative imaging modality to monitor blunt renal trauma patients.9 The benefits of US in terms of cost and radiation are weighed against its lack of sensitivity and specificity when compared with CT. Our series is the first to examine adult patients that had only US follow-up and those with CT follow-up. The purpose of this study was to determine the yield of repeat follow-up imaging in patients sustaining renal trauma and its impact on patient outcomes. We hypothesized that our current liberal reimaging strategy does not predict complications or alter patient outcomes and is excessive.
MATERIALS AND METHODS Cork University Hospital serves a population of 620,000 and is the only level-1 trauma center in Ireland. After approval from the research and ethics committee, all patients who were admitted with a diagnosis of renal injury from 2000-2012 were identified from the hospital in-patient enquiry database. A retrospective review of all patients’ medical records and radiologic imaging was undertaken. 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2014.03.013
1
Patient data collected included demographics, mechanism of injury, blood pressure, hemoglobin level, and Glasgow Coma Scale value on admission and Injury Severity Score. Operative records, complications, date, and results of follow-up imaging were also reviewed. Injuries were diagnosed at the time of admission using contrast-enhanced CT imaging. Final staff radiologist reports were reviewed, and all kidney injuries were graded according to the American Association for the Surgery of Trauma (AAST)Organ Injury Scale.10 The modality and timing of follow-up renal imaging was at the discretion of the managing urologist but also mandated by concurrent injuries. As a general rule, patients with isolated grade-I renal injuries had no follow-up imaging, patients with isolated renal injuries graded II-III had follow-up US imaging, and patients with renal injuries graded IV-V had follow-up CT imaging. In line with standard practice, we take a nonoperative approach to treating all renal trauma patients unless absolute indications for operative intervention exist, that is, hemodynamic instability, peritonitis, and clinically unevaluable patient. Using the AAST-Organ Injury Scale, renal injuries were grouped as low-grade (I, II, and III) or high-grade (IV and V). Outcomes noted included complications (classified according to the Clavien-Dindo grading system for surgical complications11), mortality, and hospital and intensive care length of stay. We correlated clinical outcomes with repeat imaging results. Descriptive statistics focused on frequencies and proportions for categorical variables. Medians and interquartile ranges (IQRs) were reported for continuous data. The chi square test was used to compare frequencies for categorical data. Reported P values are 2-sided, with P .05 considered to indicate statistical significance.
Table 1. Demographics, clinical presentation, length of stay, and mortality Variables
n (%)
IQR
Number of patients Age (y), median Gender Male Female Mechanism of injury Blunt Penetrating Cause of injury Road traffic accident Fall from height Sports related Assault Farming related Suicide attempt Side of Injury Left Right Bilateral Visible hematuria Yes No Glasgow coma scale, median Injury severity score, median Hemoglobin on admission (g/dL), median Blood pressure on admission (mm Hg), median ICU admissions ICU length of stay (d), median Total length of stay (d), median Mortality
102 23
18-39
91 (89) 11 (11) 98 (96) 4 (4) 45 22 19 7 7 2
(44) (22) (18) (7) (7) (2)
52 (51) 47 (46) 3 (3) 56 (55) 46 (45) 15 16 13.2
14-15 9-36 11.2-13.4
120/70 110/60-135/80 32 (31) 4 5 3 (3)
2-7 3-11
ICU, intensive care unit; IQR, interquartile range.
RESULTS Between 2000 and 2012, a total of 102 patients (91 male and 11 female) were admitted to Cork University Hospital, with a total of 105 renal injuries. Patient demographics and clinical presentations are listed in Table 1. The median age was 23 years (IQR, 18-39 years). The mechanism of injury was blunt force in 98 patients (96%). On admission, the median hemoglobin level was 13.1 g/dL (IQR, 11.1-14.3 g/dL); the median Glasgow Coma Scale value was 15 (IQR, 14-15). Thirty-two patients required admission to intensive care unit (ICU), with median length of ICU stay of 4 days (IQR, 27 days). All ICU admissions had concurrent injuries except 1 isolated grade-V renal injury. The median length of stay was 5 days (IQR, 3-11 days). Table 2 lists complications by injury grade, type of complication, intervention required, and Clavien-Dindo classification. Low-grade injuries accounted for 78 of 102 (77%) cases; all were managed conservatively with a complication rate 3% (2 of 78) Twenty-four patients (23%) were classified as having high-grade injuries (IV or V), with a complication rate of 21% (5 of 24). Two patients (1 grade-I and 1 grade-IV renal injury) were readmitted with pain on day 2 after discharge, both had stable injuries on reimaging, and their pain settled with analgesia. Two patients (1 grade-II and 1 grade-IV 2
renal injury) were noted to be febrile, with an elevated white cell count on day 2 and day 3, respectively. Repeat imaging revealed stable injuries with no evidence of collection or abscess formation, and both were managed successfully with intravenous antibiotics. After this febrile episode, the patient with a grade-IV injury was noted to be hypertensive in the outpatient clinic at 3 months. She was treated with an antihypertensive for 2 years and currently does not require medication. Another patient with a grade-V injury was noted to be hypertensive at day 3 after admission. He was treated with an antihypertensive and remains on medication. Two patients (both grade-IV injuries) developed a urinoma. The first patient was successfully managed conservatively. The second patient was noted to have a large urinoma at presentation and had a percutaneous nephrostomy drain placed. On day 3, a nephrostogram showed no extravasation of contrast, the nephrostomy was clamped and removed on day 5. The median length of time to presentation with a complication was 3 days (range, 0-60 days). Two cases (both grade-IV renal injuries) required operative management. After major road traffic accidents, both patients were hemodynamically unstable on admission and had exploratory laparotomies. Intraoperatively, UROLOGY
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Table 2. Renal injuries classified according to AAST grade, operative management, complications, intervention, and ClavienDindo grading system for surgical complications Renal Injuries
Grade
Low grade
I II III
28 23 27 78
IV
V
Total Operative management High grade
n (%)
Total Operative management
(28) (22) (27) (77) 0
Complications Time to (%) Complication Type Presentation (days) 1 1 0 2 (3)*
Pain Febrile episode
22 (21)
4
2 (2) 24 (23) 2
1 5 (21)*
Urinoma 2 Febrile episode þ Hypertension 1 Pain 1 Hypertension 1
Intervention
Clavien-Dindo Grade
Analgesia IV antibiotics
I II
Nephrostomy 1 Antihypertensive þ IV antibiotics Analgesia Antihypertensive
IIIa II
2 2
0, 4 3 60 2 3
I II
Nephrectomy 2
AAST, American Association for the Surgery of Trauma; IV, intravenous. * Chi square test, P ¼ .002.
both patients were found to have grade-IV or -V splenic and grade-IV left renal injuries. Both patients required splenectomy and left nephrectomy. Both patients died in intensive care of severe brain injuries sustained at the time of accident, at day 1 and day 5, respectively. The third mortality was a 40-year-old man also involved in a high-speed road traffic accident. Hemodynamically stable on admission, CT imaging showed a grade-2 right renal injury and grade-4 liver injury with hemoperitoneum. He became unstable and while being prepped in the operating room, developed cardiac asystole and could not be resuscitated. In total, 38 patients had at least 1 follow-up CT scan (Table 3). As in-patients, 10 of 11 (91%) follow-up CT scans performed in low-grade injuries were mandated by concurrent abdominal or thoracic injuries. In the inpatient high-grade group, 16 of 26 CT scans (61%) were mandated by concurrent injuries. The outpatient group was defined as the remaining patients not reimaged as in-patients. In the outpatient low-grade group, 5 of 8 CT scans (63%) were mandated by concurrent injuries. In the outpatient high-grade group, all 4 repeat CT scans were performed as followup for isolated grade-IV renal injuries. In total, 31 (30%) patients were reimaged by renal US. Reimaging with renal US was preferred over CT imaging, especially for isolated low-grade renal injuries; 27 of 31 US scans were performed for low-grade injuries, with 4 of 31 US scans performed for high-grade injuries. Twentysix patients (25%) had no follow-up imaging scheduled, all diagnosed with low-grade injuries. There were 6 patients who did not attend follow-up outpatient appointments, 3 (3%) of whom were scheduled for repeat imaging. All patients who developed complications were clinically symptomatic or had altered laboratory findings, which prompted repeat imaging that aided a diagnosis. UROLOGY
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Table 3. Repeat imaging as an inpatient and outpatient by modality and rates of concurrent injuries in patients with repeat CT imaging No Concurrent Renal Reimaging Injuries (n) US (n) (n)
Follow-up Imaging
CT (n)
As inpatient Low grade (I-III) High grade (IV-V) Total inpatient
11 15 26
10 6 16
5 0 5
As outpatient Low grade (I-III) High grade (IV-V) Total outpatient
8 4 12
5 0 5
22 4 26
32 0 32
Total inpatient and outpatient (%)
38 (37%)
31 (30%)
32 (31%)
21 (55%)
CT, computed tomography; US, ultrasound.
Results of repeat imaging did not independently predict any complication or prompt urologic intervention (Supplementary Fig. 1).
COMMENT Since the advent of widespread CT imaging, the majority of renal injuries are successfully managed nonoperatively with few absolute indications for surgical intervention.2 Based on CT criteria, renal injuries are graded according to the AAST-Organ Injury Scale, which has been shown to be predictive of the need for operative intervention.10,12,13 Blunt injuries are particularly amenable to conservative management with lower rates of nephrectomy and complications when compared with penetrating injuries.4,7 There is mounting evidence in the literature that in the absence of clinical or laboratory abnormalities, routine reimaging may not be justified.6-8 The updated 3
2013 European Association of Urology (EAU) guidelines on urologic trauma have been amended accordingly and advocate no repeat imaging for renal injuries graded I-IV in the absence of clinical deterioration.14 Following the adoption of conservative management for renal trauma, the purpose of repeat imaging was to identify complications early, before the evolution and clinical deterioration. Complication rates associated with renal trauma vary between 3% and 33% according to the reported clinical series and are grade dependent.15 Current Evidence for Selective Reimaging All current evidence guiding repeat renal imaging strategies comes from retrospective series. Earlier published reports advocated CT reimaging, especially for high-grade injuries, 24-72 hours after injury.16 However, more recent evidence, from larger cohorts, suggests that a selective reimaging approach, even in cases of high-grade injury, does not compromise patient outcomes. A group from the University of Tennessee were among the first to recommend early reimaging (24-48 hours after injury for blunt grade III injuries) based on a liberal reimaging approach, which detected 50% of complications with 33% of those requiring invasive intervention.16 Having subsequently reviewed this policy in a larger cohort (n ¼ 207), they noted a complication rate of 2.4%, most of which were associated with high-grade injuries with reimaging not independently predictive of requirement for invasive intervention. The University of Tennessee group have revised their management strategy, which is under prospective evaluation. Similarly, Bukur et al7 reported a selective reimaging approach to blunt and penetrating injuries with complication rates of 1.8% and 11.8%, respectively. All patients were clinically symptomatic before imaging, with a mean time from injury to complication of 9 days. In a cohort of conservatively managed grade-III and grade-IV renal injuries, Shirazi et al8 concluded that the group’s intensive reimaging strategy (at 36 hrs and 5 days) did not alter clinical decision-making. The authors noted that repeat CT imaging was not predictive of failure of conservative management and that clinical symptoms and laboratory results should guide decisions to perform additional imaging. At our trauma center, all patients presenting with renal injury are managed conservatively unless they have absolute indications for surgical exploration, that is, hemodynamic instability and peritonitis. At the time of this study, the modality and timing of repeat imaging was at the discretion of the admitting urologist but also mandated by concurrent injuries. However, as a general rule, patients with isolated grade-I renal injuries had no follow-up imaging, grade-II and grade-III renal injuries had follow-up US imaging, and patients with high-grade renal injuries had follow-up CT imaging. Complications Seven patients (7%) developed complications in our series, 2 of 78 patients (3%) with low-grade injuries vs 5 of 4
24 patients (21%) with high-grade injuries (P ¼ .002; Table 2). Complications consisted of 2 readmissions of patients with pain, 2 patients who developed fevers, 1 of whom also developed post-injury hypertension, and another patient who developed post-injury hypertension. Two patients developed urinomas; 1 patient was successfully managed conservatively and the other patient, who underwent nephrostomy insertion (classified as IIIa on the Clavien-Dindo system), was the only complication that required procedural intervention. Delayed complications typically occur at least 1-3 weeks after injury. We had a median follow-up of 3 months (IQR, 3-6 months) on 96 of 102 patients (21%) and an overall reimaging rate of 67%. This allowed us detect both early and late complications of renal trauma and report on postinjury hypertension (a complication absent from other series6,7). However, the risk of hypertension is long-term. All patients attending a follow-up outpatient appointment had their blood pressure checked and were advised to have an annual blood pressure measurement with their general practitioner. This study does not capture those patients who developed hypertension outside the median 3 months follow-up. All patients who developed complications were symptomatic or had altered laboratory results (febrile, leukocytosis, flank pain, hypertension), which prompted repeat imaging that aided diagnosis. In no case did results of follow-up imaging independently identify a complication or initiate urologic intervention. Follow-up Imaging: CT vs US In total, 38 patients (37%) had at least 1 follow-up CT scan, 55% of which were mandated by concurrent abdominal or thoracic injuries. A further 31 patients (30%) had a follow-up renal US scan. The benefit of documenting abnormalities after renal trauma, such as atrophic renal scars, has not been shown to correlate with post-injury hypertension or deteriorating renal function and is therefore of limited clinical significance.17 Given the low yield of follow-up imaging, there are significant cost savings to be attained with a more selective imaging approach. Reducing unnecessary radiation exposure is another benefit of a more selective approach, especially when considering the well-documented long-term risks associated with CT imaging and young age profile of renal trauma patients (median age 23 years in our series).18-20 The “as low as reasonably achievable” concept aims to balance the potential future risk of radiation induced malignancy with the additional information gained from ionizing-radiation imaging. It was designed to reduce radiation exposure in the pediatric population but also has obvious relevance to young adults. A group from Toronto have examined the efficacy of using US as the first-line imaging modality in the follow-up of blunt renal trauma in a pediatric population. Their US reimaging strategy detected all clinically relevant complications. Furthermore, CT imaging was reserved for those patients with hemodynamic instability, abnormalities detected on serial UROLOGY
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Figure 1. Blunt renal trauma management algorithm. CT, computed tomography; IV, intravenous.
US, or associated thoracoabdominal injuries. This led to 85% patients not requiring a further CT after initial diagnosis, 12% requiring repeat CT for nonurologic injuries, and 3% undergoing further CT evaluation for renal injuries.9 In our series 27 of 31 follow-up renal US scans were performed for low-grade injuries, with 4 of 31 US performed for high-grade injuries. None of these patients developed a complication. The use of US as a first line reimaging modality in symptomatic patients with lowgrade renal injuries will be incorporated into our new renal trauma reimaging strategy (Fig. 1). Based on the results of our study, we contend that routine reimaging for renal injuries grade I-IV, in the absence of clinical deterioration, is unnecessary. Our findings are in line with the most recent publications regarding reimaging in renal trauma and support the recommendations of the updated 2013 EAU guidelines on urologic trauma.14 Our study is limited by its retrospective design, which by its nature, may involve selection bias. Most of the injuries in the study were grouped as low grade (77%), which have a lower complication rate. This may influence our findings; however, our overall complication rate UROLOGY
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of 7% is consistent with the published literature.7,14 Grade-IV injuries account for 21% of our cases, which is also consistent with other published series; however, our data is lacking in grade-V injuries (n ¼ 2).12,20 Management Algorithm We are implementing and prospectively evaluating a new management strategy (Fig. 1). No routine reimaging will be obtained for renal injuries grade I-III or grade-IV injuries without urinary extravasation in the absence of clinical or laboratory abnormalities. If these patients deteriorate but are hemodynamically stable and have a stable hemoglobin, they will first be assessed by a US scan. If US imaging is inadequate in aiding a diagnosis, the patients will progress to CT imaging. Patients with grade-IV injuries with urinary extravasation will be reimaged by US at 48 hours, and grade-V injuries managed conservatively will be reimaged using a CT scan at 48 hours. The rationale for this approach is as follows: significant urinomas are detectable by a US scan, and based on our study and the literature, are most likely to occur in grade-IV injuries with urinary extravasation or grade-IV injuries.6,9 CT imaging should be reserved for 5
patients in whom delayed or ongoing bleeding is a concern, a rapid precise diagnosis is needed, or when US findings are inconclusive. We will report on this new management approach when sufficient patient numbers are reached.
CONCLUSIONS In the absence of clinical or laboratory abnormalities, the yield of routine follow-up imaging in renal trauma is low. A selective re-imaging approach guided by clinical deterioration would have detected all complications in our series. Based on these findings, we recommend no routine reimaging for renal injuries graded I-III and grade-IV injuries without urinary extravasation. The evolution of grade-IV injuries with urinary extravasation and grade-V injuries should be monitored with early repeat US and CT imaging, respectively, to guide management decisions. Based on retrospective evidence, 2013 EAU guidelines are clinically appropriate in a major tertiary trauma unit. We will prospectively test these conclusions with a new reimaging strategy. References 1. Lynch TH, Martınez-Piñeiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol. 2005;47:1-15. 2. Santucci RA, Wessells H, Bartsch G, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int. 2004;93:937-954. 3. Moudouni SM, Patard JJ, Manunta A, et al. A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments. BJU Int. 2001;87:290-294. 4. Broghammer JA, Fisher MB, Santucci RA. Conservative management of renal trauma: a review. Urology. 2007;70:623-629. 5. Robert M, Drianno N, Muir G, et al. Management of major blunt renal lacerations: surgical or nonoperative approach? Eur Urol. 1996;30:335-339. 6. Malcolm JB, Derweesh IH, Mehrazin R, et al. Nonoperative management of blunt renal trauma: is routine early follow-up imaging necessary? BMC Urol. 2008;8:11. 7. Bukur M, Inaba K, Barmparas G, et al. Routine follow-up imaging of kidney injuries may not be justified. J Trauma. 2011;70:1229-1233. 8. Shirazi M, Sefidbakht S, Jahanabadi Z, et al. Is early reimaging CT scan necessary in patients with grades III and IV renal trauma under conservative treatment? J Trauma. 2010;68:9-12. 9. Eeg KR, Khoury AE, Halachmi S, et al. Single center experience with application of the ALARA concept to serial imaging studies after blunt renal trauma in children—is ultrasound enough? J Urol. 2009;181:1834-1840. 10. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207:646-655. 11. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187-196. 12. Shariat SF, Roehrborn CG, Karakiewicz PI, et al. Evidence-based validation of the predictive value of the American Association for the Surgery of Trauma kidney injury scale. J Trauma. 2007;62: 933-939.
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13. Santucci RA, McAninch JW, Safir M, et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma. 2001;50:195-200. 14. Summerton DJ, Djakovic N, Kitrey ND, et al. European Association of Urology. Guidelines on urological trauma 2013. Available at: http://www.uroweb.org/gls/pdf/1406Urological%20Trauma_LR.pdf. Accessed May 2013. 15. Al-Qudah HS, Santucci RA. Complications of renal trauma. Urol Clin North Am. 2006;33:41-53. 16. Blankenship JC, Gavant ML, Cox CE, et al. Importance of delayed imaging for blunt renal trauma. World J Surg. 2001;25:1561-1564. 17. Dunfee BL, Lucey BC, Soto JA. Development of renal scars on CT after abdominal trauma: does grade of injury matter? Am J Roentgenol. 2008;190:1174-1179. 18. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357:2277-2284. 19. Brenner DJ, Hall EJ. Cancer risks from CT scans: now we have data, what next? Radiology. 2012;265:330-331. 20. Shoobridge JJ, Bultitude MF, Koukounaras J, et al. A 9-year experience of renal injury at an Australian level 1 trauma centre. BJU Int. 2013;112:53-60.
APPENDIX SUPPLEMENTARY DATA
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.urology. 2014.03.013.
EDITORIAL COMMENT What do we know about the need for routine reimaging after renal trauma? In the adult blunt renal trauma population, follow-up computed tomography (CT) scans on asymptomatic patients are not required (their citations 6-8). Less is known about the proper follow up of children with blunt renal trauma. Eeg et al (their citation 9) decreased the number of follow-up CT scans in children with blunt renal trauma to 3%, partly by eliminating imaging in asymptomatic patients and partly by substituting ultrasound. In this adult series, the authors reimaged 69% of their patients: 37% with CT and 30% with ultrasonography. However, these authors found that imaging did not actually help make any new diagnoses in the absence of symptoms such as pain, fever, or elevated white blood count. If imaging had been skipped in asymptomatic patients, they would not be harmed. Those who had no planned imaging, too, did not suffer harm in their series. So, you can skip reimaging in asymptomatic grade I-III blunt renal trauma patients. For grade IV-V injuries, you might also reasonably skip rescanning in those without symptoms (my conclusion, not theirs), or follow the author’s guidelines: (1) follow-up ultrasonography in all grade-IV patients, escalating to a CT if it is not diagnostic, (2) follow-up CT in all grade-V injuries. We continue to learn what we do and don’t have to do in renal trauma. Richard A. Santucci, M.D., F.A.C.S., The Center for Urologic Reconstruction, Detroit Receiving Hospital, Detroit Medical Center; Michigan State College of Medicine, Detroit, MI http://dx.doi.org/10.1016/j.urology.2014.03.018 UROLOGY
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