THE JO\'RNAL OF UROLOC:,
VoL 114. October
Copyright © 1975 hy The Williams & Wilk ins Co.
Printed in US A.
RENAL TRAUMA IN THE MULTIPLE IN,JURED PATIENT ALEXA'iDEH S CASS
From the D epartmen t of Urologv. St . Pau l-Ram sev Hospital and the Uniuersit_v of Min nesota M edical School. St. Paul. Minnesota
ABSTRACT
Immediate radiological evaluation of renal mJuries by a large dose or infusion excretory urogram resulted in a definitive diagnosis in 87 per cent of the cases. Further radiological evaluation or explorat ion was required to make a definitive diagnosis in the remaining 13 per cent. Blunt external trauma was responsible for 94 per cent of the renal injuries. Less morbidity and a sharp reduction in delayed renal operation followed the introduction of immediate surgical management with the m ore severe types of renal injury. Clamping of the renal vessels prior to openin g Gerota's fascia prevents reactivation of hemorrhage and allows for a deliberate operation with conservation of undamaged renal tissue. Associated injuries were present in 73 per cent of t he patients, including intra-abdominal injuries in 42 per cent. The over-all nephrectomy rate of 5 per cent in this study compares favorably to the nephrectomy rate in studies reporting the expectant manage ment of renal injuries. S ince conservat ive management of re na l injuries has been associated with signifi ca nt morbidit y a nd a defini te mortality rate in the multiple injured patient the method of managing renal injuries was re-evaluated. The results of immediate radiological evaluation of re na l injuries and immediate surgical m anagement of the more severe degrees of 1t1Jury are recorded. MATERIAL ANO MANAGEMENT
Between 1959 and mid 1974. 471 renal 1t1Juries were noted in 466 patients (3 patients h ad bilatera l renal injuries a nd 2 patients had 2 different injuries in the sam e kidney) . An infusion or la rge dose excretory urogram (TVP) was performed when macroscopic or microscopic hem at uria was present. If extra vasat ion of dye within or out s ide the kidney was demonstrated t he kidney was explored with repair of the defect and evacuation with drainage of the urine and hematoma in the tissues. If distortion of calices or non-function was shown on t he IVP selective renal a rt eriogra phy was performed. The presence of a definite large devasculari zed segment or a vascula r inj ury on a rt eriography was a n indicat ion fo r explorat ion of the kidne~· with repair of the defect or partia l nephrectomy. During laparot omy for visceral injury the presence of a perirena l or retroperitoneal hemato ma was the indicat ion for a la rge dose or infusion IVP to be performed whil e the laparotom:-.' was in progress. This procedure was poss ibl e with the use of a specia lly modified operating room table wit h its radiographic t a ble top, whic h a llowed for a Accepted for publication April 4. 1975.
diagnostic qua lity IVP during t he o perative procedure . 1 If an abnormality was shown the kidney was explored a ft er the rena l vessels were clamped nea r the aorta . The presence of pain in the side of the abd omen or back without hemat uria a nd tenderness with muscular guarding or a mass in the abdom en or flank were indications fo r an IVP . F ractures of t he t ra ns verse process of t he Ium bar vert ebrae, revealed on a pla in radiogra m of the abdomen, are often assoc iat ed with rena l injury . RESULTS
Age and sex. More than three-q uarters of the patients were young, with 192 (41 per cent) less t ha n 20 years old. 181 (:39 per cent ) bet ween 20 a nd 39 yea rs old. 60 (1 :l per cent) between 40 a nd :°'>9 years old a nd :l:1 (7 per cent) more than 60 years old . Oft he 466 pat ient s. :i:n were m a le subjects (72 per cen t). Tvpe of injury . Blunt t ra uma was the la rgest cause. with traffi c accidents caus ing 349 cases (75 per cent), fa lls causing 40 (9 per cent) . blows causing 25 (5 per cent) a nd sport injuries causing 2:1 (5 per cent ). Penetrat ing wounds of t he kidney comprised 21 gu nshot wounds (4.5 per cent) and 8 knife wounds (1.5 per cent) . The renal wounds were classified into 4 groups: I ) cont us ion. 2) laceration, :s) rupture a nd 4) renal pedicl e in.iur~·. 2 Cont us ions include bruises or m inor tea rs of the renal tiss ue wit h a n intact renal capsul e. Lacerat ions were parenchymal disruptions with damage to the renal capsule with or wit hout ca liceal disrupt ion . Rupt ure or shattering consist eel of fragmen t at ion of the kidney. Renal
495
t
496
CASS
pedicle mJury included tea ring or occlusion of the renal vei n or of the renal a rtery , its main branches or polar arteries. In t h is series of 471 renal injuries, 380 (80. 5 per cent) were classified as contusions. 6:1 (13 .5 per cent) as lacerations , 9 (2 per cent) as rupt ures and 19 (4 per cent) as pedic le inju ries . Radio/of?ica/ evaluation. A normal IVP was found in 324 of the 360 pat ients with renal contusion undergoing an IVP. A no rmal-appearing kidney was found on furt h er radiological eval uatio n or renal exploration in 18 patients and t he remaining 18 were managed conservatively without further eva luation (table 1). Nine of the 10 patients with a normal IVP and a rena l laceration had penetrating wounds (6 gunshot and 3 knife) , while the remain ing patient had a cortical lacera tion found at autopsy even though the arteriogram was normal. A renal laceration was diagnosed in 22 kidneys showing t he indeterminate IVP finding of incomplete fi lling or delayed visualization by subsequent radiological evaluation in 11 and renal exploration in 11. Renal exploration revealed the diagnos is in 2 cases of ruptured kidneys and 2 cases of pedicle injuries wit h indeterminate IVP findings and a perirenal hematoma found at laparotomy. Indeterminate IVP findings were fo und in ,56 of the 431 IVPs (13 per cent). Associated injuries. Associated injuries were p resent in 342 of t he 466 patients (7 3 per cent) (table 2). Some patients had more than 1 injury. T he severity of these associated injuries is shown in the mortality rates for t he various groups of renal injury. All 43 deaths occurred with associated injuries , none with renal inj ury alone. Immed iate laparotomy was requ ired for the associated intraabdominal injury in 57 per cent of the 342 patients with associated injuries and 42 per cen t of the 466 patients with renal injuries . Treatment. With renal contusions , 6 patients had immediate exploration of the kidney and 1 patient had de layed nephrectomy for a massive
congenital hydronephrosis. The remammg 373 renal contusions were treated expectantly (table 3). Immed iate surgical management of t he more severe degrees of renal injury (laceration, rupture, pedicle injury) was carried out in 57 cases . Nine patients died in the early postoperative period of associated injuries and 48 survived. Of the survivors only 1 required a delayed renal operation. Conservative management was carried out in the earlier years of the study in 34 of the more severe degrees of renal injury. Ten d ied of associated injuries. Of t he 24 surv ivors a delayed renal operat ion was requ ired in 10 and loss of the functioning kidney from pedicle injury occurred in 4. DISC USS ION
All renal contusions were managed successfully with expectant treatment and no complications or TABLE
2. Associated injuries with renal injuries (no
deaths with renal injury alone) Classification of Rena l Injury Associated Inju ry
(19)
Number of patients with associated injurie:.,,, Fractured ribs Lacerat ed diaphragm Lacerated spleen Lacerated liver Lacerated bowel F ractured sku ll Fractu red spine Fractured pelvis F racture d extremities
Other (vena cava, pancreas, ao rta. head injury ) Deaths Mortality rate
TABLE
Findin1;s on !VP with th e various ty pes of renal injuries and subsequent management with indeterminate finding~
Normal Non-function Extravasat ion Incomplete filling§ Delayed visu alization ll Not done1]
Lacer ation
324 4t ?2:j: 24
10* 9 10 19
6
3
20
12
Rupture
5
Pedicle Injury
10
1
2
2
6
'Arteriogram 1, exploration 9. 3, exploration I. :j: Arteriogram 1, retrograde pyelogram 1. Arteriogram 10, retrograde pyelogram 4, exploration 12. conservative management 20 . II Arteriogram 2, retrograde pyelogram 1. exploration 4. death 1. conservative management 2. 11 Renal injury found at autopsy or exploration.
t Art eriogram
*
47
9
19
342
92 4 84 46 24 48 31 21 109 45
19 5 21 21 11 8 3 5 11 8
5 1 6 4 2 1
6 3 7 10 11 2 4 4 5 5
122 13 118 81 48 59 38 31 127 58
24 6%
2
10
8 16% 11 % 42%
43 9%
Classification of Renal Injury Mana1;ement
Classification of Renal Inju ry Contusion
267
3. Treatment of rena l injuries
TABLE 1.
!VP Findings
PedCon- Lacer- Rup- icle tusion at ion ture In- Totals (380) (63) (9) jury
I mmediate surgical and subsequent surgery: N ephrectomy Partial nephrectomy Suture Exploration / drainage Nephrostomy Conservative and subsequent surgery: Non-surgical Delayed nephrectomy De layed partial nephrectomy Delayed suture Delayed exploration Total s
PedCon- Lacer- Rup- icle Totusion ation ture In- tals jury
6
373
8 13 13* 3 1
6 1
6 2
5
I 380
'One required de layed nephrectomy. t Congenital hy dronephrosis. :j: Required dela;•ed nephrectomy .
l:j: 63
20 15 17
10 1
18
It
6 1 4 1
9
19
397 4 5 1 1 471
497
RENAL TRAUMA IN M ULTIPLE INJURED PATIENT
delayed renal operation occurred in this group. The controversy between expectant and surgical management applies only to the more severe types of renal injury (laceration , rupture, pedicle injury). The 3 main issues in this controversy are: 1) the results with surgical treatment are not superior to expectant treatment, 2) the nephrectomy rate is higher with surgical treatment and 3) the renal salvage rate with pedicle injuries is insignificant with surgical treatment. Expectant management for all t ypes of renal injury was carried out in the earlier years of t he study. There were 24 patients wit h the more severe types of renal injury who survived their associa ted injuries, 10 requiring delayed renal operations and 4 losing the functioning kidney from pedicle injury. The incidence of significant sequelae and/or delayed renal operation in studies of t he expect ant treatment wit h the more severe degrees of renal injury (excluding pre-existing renal a nomalies ) has been recorded in followup to be 31 3 and 45 per cent• in pediatric cases and 15, 2 17. 5 18, • 22, 7 25, 8 30, • 31 ' 0 and 32 per cent 11 in over-all cases . Immediate surgical management for the more severe types of renal injury was carried out in the later years of the study. Forty-eight patients survived t he postopera tive period wit h shorter hospit alization and reduced mor b idity a nd only 1 patient required a delayed renal o peration . The second stated disadvantage of early surgical management is the react ivation of hemorrhage after opening Gerota's fascia from release of the perirenal tamponade and result ing high nephrectomy rate. The cla mping of the renal vessels prior t o openin g Gerota's fasc ia prevents this hemorrhage a nd a llows for a deliberate operation with conservation of unda maged renal t issue. Studies reporting the use of preliminary vascular control document the reduced nephrectomy rate. ' 2 · 1 3 A nephrectomy rate of 5 per cent with immediate surgical management was found with a ll cases in this study . This rate compa res favorab ly to t he nephrectomy rate in studies of rena l injuries ma n aged expectantly (exclud ing pre-existing re nal anomalies) 21, 11 13, • 12, " · 15 9, 1 • 8.9, 7 8.5, 1 1 8, • 6, 2 4 5 and 3.5 per cent. 8 • 9 The nephrectomy ra te with expectant treatment was higher when there was a significant percentage of associated injuries, especially int ra-abdominal visceral injuries. Wit h immediat e surgical m a nagem ent of pedicle injuries 4 primary repairs of t he rupt ured vessels were performed while 6 kidneys were removed . T his repair rate of 40 per cent is significant compared to the 100 per cent renal loss rate with
t he expectant Guerriero a nd prima ry repa ir agement of 41 patients. ' "
management of pedicle injuries . associates reported a 56 per cent rate with immediate surgical manrenal artery or vein injuries in 33 REFERENCES
1. Cass, A. S ., Irela nd , G . W., Bressler, E. , Bjornson , R., DeM e ules. ,J. a nd Perry, J., Jr. : Modi fi ca tion of a n opera ting-room tahle for immed iate ra diographic evalua tion of t h e urina ry tract in the acute, severe trauma patien t. ,J. Urol.. 105: 569, 1971. 2. Sargent, ,I. C . a nd Marquardt , C.R. : Renal injuries . J. Urol. , 63: I , 19,50. 3 . R eid, I. S.: Re nal t rauma in children : a t e n-yea r review. Aust. N. Zea l. J. Surg., 42: 260, 197:i. 4. M ertz. J. H. 0. , Wish ard. W. N .. Jr .. Nourse. M. H. a nd M e rtz . H . 0.: Injury of the kid ney in c hild re n. J.A.M.A., 183: 730, 1963. 5. Vermillion , C'. D., Mc La ughlin. A. P ., III and Pfist e r. R. C .: M a nagement of hlu nt rena l tra uma . J. Urol.. 106: 478, 1971. 6. Nation , E. F. and Massey , B. D .: Renal trauma: expe rience with 2F,8 cases. J. Urol. . 89: 775, 196:l. 7. Forsythe. W . E. a nd Persky, L. : Comparison of ureteral a nd re nal injuries . Ame r. J. S urg. , 97: 558, 1959. 8 . S lade, N .: Ma nagement of closed re na l inj u ries. Brit . ,I. Uro l. , 43 : 6:l9. 1971. 9. G le nn , J. F. a nd Harvard. R. M.: T he inj ured kidn ey. ,J.A.M.A. . 173: 1189, 1960 . 10. H a le, S . D .: Re nal injuries. Read a t a nnua l meeting of Northeastern Section, Ame rican Urological Associa tion. Toronto, Canada. Septemher 16- 19. 197:l. 11. Mo rrow. J. W . and M endez. R. : Rena l trauma . J . Urol. , 104: 649, 1970 . 12. Scott, R., J r. , Car lton , C . E ., Jr. a nd Goldman, M .: Pen et rating injuries of th e kidne~·: an a na lysis o f 181 pa tients . ,J. Urol.. 101: 247. 1969. 1:1. Cass. A. S . a nd Irela nd . G. W. : Compa rison of the conservative a nd surgical manage ment of th e more seve re d egrees of rena l trauma in mult iple injured pati ents . J. Urol. . 109: 8, 197:J. 14 . Pers ky . L. a nd Forsythe, W . E.: Renal t rau ma in chil d hood . ,J. A. M.A. , 182: 709. 196:2 . 15 . Lucey, D. T. , S mit h , M. J. V. an d Koontz. W . W., Jr. : M odern t rends in t h e management of urologic traum a . J . U rol.. 107: 641 , 1972. 16. Wa t e rhouse. K . and G ross, M. : Trau m a to the genit ourina rv tract: a 5-yea r expe rie nce with 251 cases. ,J. Urol. . 101 : 24 1. 1969. 17. Mo rse, T. S .. S m ith. J.P ., Howa rd, W . H. R. a nd Rowe. M . I. : Kidney in juries in c hildren . ,I. Urol.. 98: 5:39. 1967 . 18. G uerriero, W . G .. Carlton , C . E .. Jr ., Scott. R. , J r. a n d Hea ll . A. C.: Renal ped icle inj uries. J . Trau ma , II: 5:l. 197 1.
t
VoL 114. October
Copyright © 1975 hy The Williams & Wilk ins Co.
Printed in US A.
RENAL TRAUMA IN THE MULTIPLE IN,JURED PATIENT ALEXA'iDEH S CASS
From the D epartmen t of Urologv. St . Pau l-Ram sev Hospital and the Uniuersit_v of Min nesota M edical School. St. Paul. Minnesota
ABSTRACT
Immediate radiological evaluation of renal mJuries by a large dose or infusion excretory urogram resulted in a definitive diagnosis in 87 per cent of the cases. Further radiological evaluation or explorat ion was required to make a definitive diagnosis in the remaining 13 per cent. Blunt external trauma was responsible for 94 per cent of the renal injuries. Less morbidity and a sharp reduction in delayed renal operation followed the introduction of immediate surgical management with the m ore severe types of renal injury. Clamping of the renal vessels prior to openin g Gerota's fascia prevents reactivation of hemorrhage and allows for a deliberate operation with conservation of undamaged renal tissue. Associated injuries were present in 73 per cent of t he patients, including intra-abdominal injuries in 42 per cent. The over-all nephrectomy rate of 5 per cent in this study compares favorably to the nephrectomy rate in studies reporting the expectant manage ment of renal injuries. S ince conservat ive management of re na l injuries has been associated with signifi ca nt morbidit y a nd a defini te mortality rate in the multiple injured patient the method of managing renal injuries was re-evaluated. The results of immediate radiological evaluation of re na l injuries and immediate surgical m anagement of the more severe degrees of 1t1Jury are recorded. MATERIAL ANO MANAGEMENT
Between 1959 and mid 1974. 471 renal 1t1Juries were noted in 466 patients (3 patients h ad bilatera l renal injuries a nd 2 patients had 2 different injuries in the sam e kidney) . An infusion or la rge dose excretory urogram (TVP) was performed when macroscopic or microscopic hem at uria was present. If extra vasat ion of dye within or out s ide the kidney was demonstrated t he kidney was explored with repair of the defect and evacuation with drainage of the urine and hematoma in the tissues. If distortion of calices or non-function was shown on t he IVP selective renal a rt eriogra phy was performed. The presence of a definite large devasculari zed segment or a vascula r inj ury on a rt eriography was a n indicat ion fo r explorat ion of the kidne~· with repair of the defect or partia l nephrectomy. During laparot omy for visceral injury the presence of a perirena l or retroperitoneal hemato ma was the indicat ion for a la rge dose or infusion IVP to be performed whil e the laparotom:-.' was in progress. This procedure was poss ibl e with the use of a specia lly modified operating room table wit h its radiographic t a ble top, whic h a llowed for a Accepted for publication April 4. 1975.
diagnostic qua lity IVP during t he o perative procedure . 1 If an abnormality was shown the kidney was explored a ft er the rena l vessels were clamped nea r the aorta . The presence of pain in the side of the abd omen or back without hemat uria a nd tenderness with muscular guarding or a mass in the abdom en or flank were indications fo r an IVP . F ractures of t he t ra ns verse process of t he Ium bar vert ebrae, revealed on a pla in radiogra m of the abdomen, are often assoc iat ed with rena l injury . RESULTS
Age and sex. More than three-q uarters of the patients were young, with 192 (41 per cent) less t ha n 20 years old. 181 (:39 per cent ) bet ween 20 a nd 39 yea rs old. 60 (1 :l per cent) between 40 a nd :°'>9 years old a nd :l:1 (7 per cent) more than 60 years old . Oft he 466 pat ient s. :i:n were m a le subjects (72 per cen t). Tvpe of injury . Blunt t ra uma was the la rgest cause. with traffi c accidents caus ing 349 cases (75 per cent), fa lls causing 40 (9 per cent) . blows causing 25 (5 per cent) a nd sport injuries causing 2:1 (5 per cent ). Penetrat ing wounds of t he kidney comprised 21 gu nshot wounds (4.5 per cent) and 8 knife wounds (1.5 per cent) . The renal wounds were classified into 4 groups: I ) cont us ion. 2) laceration, :s) rupture a nd 4) renal pedicl e in.iur~·. 2 Cont us ions include bruises or m inor tea rs of the renal tiss ue wit h a n intact renal capsul e. Lacerat ions were parenchymal disruptions with damage to the renal capsule with or wit hout ca liceal disrupt ion . Rupt ure or shattering consist eel of fragmen t at ion of the kidney. Renal
495
t
496
CASS
pedicle mJury included tea ring or occlusion of the renal vei n or of the renal a rtery , its main branches or polar arteries. In t h is series of 471 renal injuries, 380 (80. 5 per cent) were classified as contusions. 6:1 (13 .5 per cent) as lacerations , 9 (2 per cent) as rupt ures and 19 (4 per cent) as pedic le inju ries . Radio/of?ica/ evaluation. A normal IVP was found in 324 of the 360 pat ients with renal contusion undergoing an IVP. A no rmal-appearing kidney was found on furt h er radiological eval uatio n or renal exploration in 18 patients and t he remaining 18 were managed conservatively without further eva luation (table 1). Nine of the 10 patients with a normal IVP and a rena l laceration had penetrating wounds (6 gunshot and 3 knife) , while the remain ing patient had a cortical lacera tion found at autopsy even though the arteriogram was normal. A renal laceration was diagnosed in 22 kidneys showing t he indeterminate IVP finding of incomplete fi lling or delayed visualization by subsequent radiological evaluation in 11 and renal exploration in 11. Renal exploration revealed the diagnos is in 2 cases of ruptured kidneys and 2 cases of pedicle injuries wit h indeterminate IVP findings and a perirenal hematoma found at laparotomy. Indeterminate IVP findings were fo und in ,56 of the 431 IVPs (13 per cent). Associated injuries. Associated injuries were p resent in 342 of t he 466 patients (7 3 per cent) (table 2). Some patients had more than 1 injury. T he severity of these associated injuries is shown in the mortality rates for t he various groups of renal injury. All 43 deaths occurred with associated injuries , none with renal inj ury alone. Immed iate laparotomy was requ ired for the associated intraabdominal injury in 57 per cent of the 342 patients with associated injuries and 42 per cen t of the 466 patients with renal injuries . Treatment. With renal contusions , 6 patients had immediate exploration of the kidney and 1 patient had de layed nephrectomy for a massive
congenital hydronephrosis. The remammg 373 renal contusions were treated expectantly (table 3). Immed iate surgical management of t he more severe degrees of renal injury (laceration, rupture, pedicle injury) was carried out in 57 cases . Nine patients died in the early postoperative period of associated injuries and 48 survived. Of the survivors only 1 required a delayed renal operation. Conservative management was carried out in the earlier years of the study in 34 of the more severe degrees of renal injury. Ten d ied of associated injuries. Of t he 24 surv ivors a delayed renal operat ion was requ ired in 10 and loss of the functioning kidney from pedicle injury occurred in 4. DISC USS ION
All renal contusions were managed successfully with expectant treatment and no complications or TABLE
2. Associated injuries with renal injuries (no
deaths with renal injury alone) Classification of Rena l Injury Associated Inju ry
(19)
Number of patients with associated injurie:.,,, Fractured ribs Lacerat ed diaphragm Lacerated spleen Lacerated liver Lacerated bowel F ractured sku ll Fractu red spine Fractured pelvis F racture d extremities
Other (vena cava, pancreas, ao rta. head injury ) Deaths Mortality rate
TABLE
Findin1;s on !VP with th e various ty pes of renal injuries and subsequent management with indeterminate finding~
Normal Non-function Extravasat ion Incomplete filling§ Delayed visu alization ll Not done1]
Lacer ation
324 4t ?2:j: 24
10* 9 10 19
6
3
20
12
Rupture
5
Pedicle Injury
10
1
2
2
6
'Arteriogram 1, exploration 9. 3, exploration I. :j: Arteriogram 1, retrograde pyelogram 1. Arteriogram 10, retrograde pyelogram 4, exploration 12. conservative management 20 . II Arteriogram 2, retrograde pyelogram 1. exploration 4. death 1. conservative management 2. 11 Renal injury found at autopsy or exploration.
t Art eriogram
*
47
9
19
342
92 4 84 46 24 48 31 21 109 45
19 5 21 21 11 8 3 5 11 8
5 1 6 4 2 1
6 3 7 10 11 2 4 4 5 5
122 13 118 81 48 59 38 31 127 58
24 6%
2
10
8 16% 11 % 42%
43 9%
Classification of Renal Injury Mana1;ement
Classification of Renal Inju ry Contusion
267
3. Treatment of rena l injuries
TABLE 1.
!VP Findings
PedCon- Lacer- Rup- icle tusion at ion ture In- Totals (380) (63) (9) jury
I mmediate surgical and subsequent surgery: N ephrectomy Partial nephrectomy Suture Exploration / drainage Nephrostomy Conservative and subsequent surgery: Non-surgical Delayed nephrectomy De layed partial nephrectomy Delayed suture Delayed exploration Total s
PedCon- Lacer- Rup- icle Totusion ation ture In- tals jury
6
373
8 13 13* 3 1
6 1
6 2
5
I 380
'One required de layed nephrectomy. t Congenital hy dronephrosis. :j: Required dela;•ed nephrectomy .
l:j: 63
20 15 17
10 1
18
It
6 1 4 1
9
19
397 4 5 1 1 471
497
RENAL TRAUMA IN M ULTIPLE INJURED PATIENT
delayed renal operation occurred in this group. The controversy between expectant and surgical management applies only to the more severe types of renal injury (laceration , rupture, pedicle injury). The 3 main issues in this controversy are: 1) the results with surgical treatment are not superior to expectant treatment, 2) the nephrectomy rate is higher with surgical treatment and 3) the renal salvage rate with pedicle injuries is insignificant with surgical treatment. Expectant management for all t ypes of renal injury was carried out in the earlier years of t he study. There were 24 patients wit h the more severe types of renal injury who survived their associa ted injuries, 10 requiring delayed renal operations and 4 losing the functioning kidney from pedicle injury. The incidence of significant sequelae and/or delayed renal operation in studies of t he expect ant treatment wit h the more severe degrees of renal injury (excluding pre-existing renal a nomalies ) has been recorded in followup to be 31 3 and 45 per cent• in pediatric cases and 15, 2 17. 5 18, • 22, 7 25, 8 30, • 31 ' 0 and 32 per cent 11 in over-all cases . Immediate surgical management for the more severe types of renal injury was carried out in the later years of the study. Forty-eight patients survived t he postopera tive period wit h shorter hospit alization and reduced mor b idity a nd only 1 patient required a delayed renal o peration . The second stated disadvantage of early surgical management is the react ivation of hemorrhage after opening Gerota's fascia from release of the perirenal tamponade and result ing high nephrectomy rate. The cla mping of the renal vessels prior t o openin g Gerota's fasc ia prevents this hemorrhage a nd a llows for a deliberate operation with conservation of unda maged renal t issue. Studies reporting the use of preliminary vascular control document the reduced nephrectomy rate. ' 2 · 1 3 A nephrectomy rate of 5 per cent with immediate surgical management was found with a ll cases in this study . This rate compa res favorab ly to t he nephrectomy rate in studies of rena l injuries ma n aged expectantly (exclud ing pre-existing re nal anomalies) 21, 11 13, • 12, " · 15 9, 1 • 8.9, 7 8.5, 1 1 8, • 6, 2 4 5 and 3.5 per cent. 8 • 9 The nephrectomy ra te with expectant treatment was higher when there was a significant percentage of associated injuries, especially int ra-abdominal visceral injuries. Wit h immediat e surgical m a nagem ent of pedicle injuries 4 primary repairs of t he rupt ured vessels were performed while 6 kidneys were removed . T his repair rate of 40 per cent is significant compared to the 100 per cent renal loss rate with
t he expectant Guerriero a nd prima ry repa ir agement of 41 patients. ' "
management of pedicle injuries . associates reported a 56 per cent rate with immediate surgical manrenal artery or vein injuries in 33 REFERENCES
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