JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 7, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0006
Retroperitoneal Laparoscopic Nephrectomy for Acute Blunt Grade 4 Renal Injuries Wenying Wang, MD,1,2 Li Wang, PhD,2 Jianfeng Xu, MD, PhD,2 Tamara S. Adams, MS,2 and Ye Tian, MD1
Abstract
Objective: To first describe laparoscopic nephrectomy (LN) for patients with acute blunt Grade 4 renal injuries using a retroperitoneal approach. Patients and Methods: Three patients (2 males and 1 female) with acute blunt renal trauma underwent retroperitoneal LN successfully. The revised American Association for Surgery of Trauma grading system was used to grade renal injuries. All three patients with Grade 4 renal injuries required blood transfusions preoperatively and angiographic embolization because of hemodynamic instability. Given the severity of the renal injuries, failure of angiographic embolization, and persistent blood loss, surgical intervention was used. We performed retroperitoneal LN using four trocars within 24 hours after trauma for the patients. Results: Pure retroperitoneal LN was successfully performed in all 3 patients without requiring hand-assisted or open surgery. The renal hematoma dimension for the patients was 7.5, 8.4, and 9.2 cm, respectively. Operative time was 80, 110, and 130 minutes, respectively. Estimated blood loss was 100, 140, and 300 mL, respectively. The incision size was 4.2, 4.2, and 4.5 cm, respectively. The average hospital stay was 6 days. Pathology showed renal injuries without incidental renal tumors. Conclusions: Despite the technical challenges, LN for patients with acute blunt Grade 4 renal injuries using a retroperitoneal approach is safe and feasible in carefully selected patients if conservative measures and angiographic embolization fail. However, it is important to note that one should keep a low threshold for open conversion or the hand-assisted approach whenever necessary.
Introduction
R
enal trauma is one of the most common solid organ injuries; it occurs in up to 3%–10% of all abdominal trauma injuries, and up to 80%–90% renal injuries are due to acute blunt trauma.1 The management of blunt renal trauma includes nonoperative and operative procedures. Conservative management has a high success rate for Grade 1–3 renal injuries, but the best approach for managing high-grade (Grades 4 and 5) renal injuries is still controversial.2 Open surgery is the gold standard treatment for patients with acute renal trauma necessitating nephrectomy. Laparoscopic nephrectomy (LN) has been widely used since its first description in 1991 by Clayman et al.3 The indications for LN have expanded over the last two decades and have been consistently extended to include more difficult procedures. To date, LN has been successfully performed for a variety of benign and malignant conditions that were traditionally considered relatively contraindicated. LN for spontaneous nontraumatic retroperitoneal
1 2
hemorrhage secondary to renal neoplasm4,5 and late LN for previously documented renal trauma using the transperitoneal approach6 have been reported. The presence of acute renal trauma is usually considered as a relative contraindication for LN because of risk of secondary hemorrhage. But, with continued advancements in laparoscopic surgery, it is possible to perform LN for acute blunt renal injuries. Accurate recognition of injuries and staging of the severity of a patient’s status allow appropriate patient selection for laparoscopic management and should minimize subsequent complications for patients. To the best of our knowledge, we are the first to report findings on the application of LN in patients with acute blunt high-grade renal injuries using the retroperitoneal approach. Patients and Methods
Three patients (2 males and 1 female) diagnosed with acute blunt renal trauma (2 patients with left and 1 patient
Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing, China. Center for Cancer Genomics, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
451
452
WANG ET AL.
with right) received retroperitoneal LN at our institute between May 2005 and January 2012. The mean age was 37 years (range, 21–65 years). The 3 patients were referred to the emergency room of our hospital: 1 was admitted 9 hours after a low-speed fall, 1 presented with lumbar pain and severe gross hematuria after a second extracorporeal shockwave lithotripsy procedure, and 1 was transferred to our hospital 10 hours after a motor vehicle accident. Blood pressure measurements ranged from 85/60 mm Hg to 90/70 mm Hg, and heart rate measurements ranged from 116 beats/minute to 130 beats/minute upon admission. Laboratory results showed the range for hemoglobin levels was 77–102 g/L. All patients had severe gross hematuria upon catheter insertion. Physical examinations revealed that none of the patients had peritonitis. Abdominal and pelvic ultrasonography showed retroperitoneal hematoma around the kidney, and no fluid was observed in the abdominal or pelvic cavity. Computed tomography (CT) with intravenous contrast showed that the parenchymal laceration extended into the collecting system for all 3 patients. CT images in 2 patients (1 left and 1 right) are shown in Figure 1. No other abdominal organ injuries were suspicious according to abdominal or pelvic CT imaging. Traditionally, the American Association for Surgery of Trauma (AAST) grading system was used to reflect and define injury severity (including renal trauma grades) and to predict which injuries are suitable for operative management. A revised grading system, suggested by Buckley and McAninch,7 defined Grade 4 injuries to include parenchymal lacerations extending through the renal cortex into the collecting system with or without urinary extravasation, renal pelvis laceration, and/or ureteral pelvic disruption, segmental artery, and vein injury. In addition, the revised system defines Grade 5 injuries to include only severe hilar injuries. In our study, we defined renal injury grades based on the revised grading system. Based on the updated classifications, all 3 patients were found to have Grade 4 renal injuries. All the patients required preoperative blood transfusions (2 U, 4 U, and 6 U of packed red cells, respectively) because of hemodynamic instability while being examined in the emergency room. Selective segmental renal artery embolization was performed based on the location of renal injury because no major bleeding vessels or significant signs were found during angiography in these 3 patients, but all the pa-
FIG. 1.
tients still experienced continued severe gross hematuria, decreased hemoglobin level, and hemodynamic instability after receiving angiographic embolization. Ultrasonography revealed enlarged hematomas in 2 patients. Given the severity of the renal injuries, failure of angiographic embolization, continued blood loss, and normal contralateral renal function, we decided to proceed with nephrectomy and elected to attempt LN. The hand-assisted approach or open conversion was an alternative to LN, in the event the artery could not be controlled quickly or the patient became unstable intraoperatively. All patients received LN within 24 hours after trauma. General anesthesia was given to the patients by tracheal intubation. Patients were placed in an extended flank position and received retroperitoneal LN using the four-trocar system, including two 10-mm ports and two 5-mm ports. Finger dissection was performed to separate fatty tissue and to create the initial retroperitoneal space. The pneumoretroperitoneum was established, and a pressure of 12–15 mm Hg was maintained. The hematoma was observed and contained by Gerota’s fascia, which was incised close and parallel to the psoas muscle. The psoas muscle and the ureter were landmarks for dissection of the renal hilum; we tried to expose the renal artery with the least amount of pressure on the hematoma. Although there was some venous blood oozing from the hematoma to the surgical field, it had only a slight effect on the procedures. The whole kidney, together with Gerota’s fascia and perirenal fat, was mobilized en bloc. Thereafter, the ureter was identified and ligated with two Hem-o-lok (Weck; Teleflex Medical, Research Triangle Park, NC) clips. The specimen was entrapped using an ENDO CATCH bag (Ethicon Endo-Surgery, Cincinnati, OH) and delivered by enlarging the lowest trocar incision to 4–5 cm long. The operative time was calculated from first skin incision to application of final dressing. During LN for patients with perirenal hematoma, it is difficult to determine actual blood loss volume; analysis of changes in blood cell count are influenced by many factors, including preoperative and intraoperative fluid resuscitation and blood transfusion. Therefore, we calculated intraoperative blood loss based on the amount of blood collected using two suction device bottles (one for the renal hematoma, the other for the surgical field) and swab weight (if used).
Computed tomography images show Grade 4 injuries in the (A) right kidney and (B) left kidney.
LN FOR ACUTE GRADE 4 RENAL INJURIES
453
Results
Discussion
All operations were completed laparoscopically, without hand-assisted or open conversion. We did not encounter any intraoperative or postoperative complications, including secondary hemorrhage, major vascular injury, postoperative bleeding, pleural injury, pneumonia, or wound infection. All 3 patients required blood transfusions preoperatively. No patient required intraoperative or postoperative blood transfusions. Perihilar adhesion was not observed in any of the patients. The average renal hematoma dimension was 8.4 cm (range, 7.5–9.2 cm). The mean operative time was 107 minutes (range, 80–130 minutes). The mean estimated blood loss was 180 mL (range, 100–300 mL). The average incision size was 4.3 cm (range, 4.2–4.5 cm). In 1 case, a small rupture of the hematoma occurred prior to ligation of the renal artery. A large amount of blood clot extended outside the hematoma; no fresh secondary hemorrhage occurred. Therefore, we suctioned the clot and quickly located and ligated the renal artery. In addition, it was difficult to locate the renal vein after ligating the renal artery for renal vein variation, so we mobilized and dissected the renal vein after mobilizing the whole kidney (Fig. 2). Pathology showed renal injuries without incidental tumors. Postoperative recovery was uneventful. The average hospital stay was 6 days (range, 5–7 days). Patients were discharged without complications and remained well at follow-up visits. Data of clinical characteristics, perioperative variables, and outcomes for patients with Grade 4 renal injuries are given in Table 1.
The kidney is the most frequently injured parenchymal organ in the urologic system, and renal injuries are usually caused by blunt trauma; falls and motor vehicle accidents are the most common causes of renal trauma.1,2 The Organ Injury Severity Scale was developed by the AAST based on the appearance of renal injury at the time of surgery and correlates with CT findings. This classification system has shown that higher grades have a significant correlation with increasing rates of morbidity, mortality, the need for surgery, and nephrectomy. The revised classification scale provides a more rigorous definition of renal injuries and facilitates the discussion on management of renal injuries.7 The management of blunt renal trauma has evolved considerably, and there is a common trend toward nonoperative management in hemodynamically stable patients, but there is controversy regarding the management of hemodynamically stable patients with high-grade renal injuries. There are some risks associated with nonoperative treatment, including delayed renal bleeding, delayed nephrectomy, urine leakage, urinoma, persistent fever, venous thromboembolism after prolonged immobilization, renal insufficiency, arteriovenous fistula, aneurysm, and even death.8,9 Patients with renal injuries rated Grade 4 or higher have increased morbidity and mortality rates for conservative treatment. The incidence of functional renal loss and death occurred in 16% and 7% of patients with Grade 4 renal injuries, respectively.8,9 About 29% of Grade 4 and 60% of Grade 5 renal injuries required surgical intervention.8,9
FIG. 2. Intraoperative images. (A) Hematoma (arrow) contained in Gerota’s fascia. (B) Blood clot (arrow) extending outside the hematoma. (C) The renal artery (arrow) was ligated and dissected. (D) The renal vein (arrow) was ligated and dissected.
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WANG ET AL.
Table 1. Clinical Characteristics, Perioperative Variables, and Outcomes of the Patients Variable Sex/age (years) Year of surgery Laterality Mechanism of renal injury Cause of renal injury AAST grade of renal injury Hematoma dimension (cm) Hemoglobin on admission (g/L) Blood transfusion (packed red blood cells) Preoperative hemoglobin (g/dL) Preoperative angiographic embolization Preoperative serum creatinine (lmol/L) Operative time (minutes) Intraoperative estimated blood loss (mL) Postoperative hemoglobin (g/L) Postoperative serum creatinine (lmol/L) Serum creatinine (lmol/L) 6 months after surgery Size of incision (cm) Hospital stay (days)
Patient 1
Patient 2
Patient 3
M/65 F/21 M/25 2005 2010 2012 Left Right Left Blunt Blunt Blunt SWL Low-speed MVA fall 4 4 4 7.5 8.4 9.2 102 77 94 2U
6U
4U
95
86
88
Yes
Yes
Yes
89
75
55
130 140
110 100
80 300
94
80
82
105
72
69
107
75
60
4.2 6
4.2 5
4.5 7
AAST, American Association for Surgery of Trauma; MVA, motor vehicle accident; SWL, extracorporeal shockwave lithotripsy.
About 10% of Grade 4 injuries required nephrectomy.2 Highrisk factors requiring intervention for patients with Grade 4 injuries include a perirenal hematoma rim distance of >3.5 cm, expanding renal mass, renal pelvis injury, intravascular contrast extravasation, and AAST Grade 4 hilar injury.8,9 Appropriate imaging investigations are critical for accurate preoperative diagnosis and evaluation for trauma grade. Sufficient knowledge of grading for renal trauma will allow for prompt intervention, less morbidity, and less mortality. The CT scan is currently the most valuable tool for diagnosis and grade evaluation of renal trauma and should be performed preoperatively to avoid delayed recognition of other injuries to abdominal organs. CT scans also aid in determining which patients require urgent intervention. The majority of significant renal trauma patients present with concurrent multiorgan injuries; therefore, it is critical to identify and stage injuries to additional organs. In order to avoid delayed diagnosis and identification of collecting system injuries, it is better to perform CT scans with intravenous contrast and obtain excretory images. In the present study, Grade 4 renal injuries were revealed using a CT scan for all patients. Management options for Grade 4 renal injuries include conservative treatment, minimally invasive intervention, and operation.1,2,9,10 Conservative treatment includes bed rest
and monitoring the patient’s hemodynamic status. Minimally invasive interventions such as angiographic embolization are needed if conservative treatments fail. Angiographic embolization has a high success rate for lower grades of renal injuries. Complications may include renal infarction, delayed nephrectomy, hypertension, and abscess, and the failure rate of angiographic embolization has been described as high as 27.2% in some reports.10 Operation interventions include renorrhaphy, partial nephrectomy, and nephrectomy. The nephrectomy rate among patients who have received open surgery for Grade 4 blunt renal injuries within the first 24 hours was 81%.2 In our study, the 3 patients experienced continued blood loss even though angiographic embolization had been performed. Therefore, we decided to proceed with nephrectomy and elected to attempt LN. Based on our experience, although preoperative angiographic embolization may not be successful in controlling blood loss, it may reduce the risk of intraoperative secondary blood loss. There are no known reports of LN use with acute renal trauma. Laparoscopic management in renal trauma should be based on history and mechanism of renal injury, examination findings including hematuria, vital signs, other abdominal organ injuries, and imaging results. Based on our experience, for cases with penetrating renal injuries, the hematoma usually extended outside of Gerota’s fascia to the retroperitoneal and pelvic space. LN is not an option in this situation as there is no retroperitoneal space available for controlling the renal artery. In addition, it is difficult to operate on cases with hematomas larger than 10–12 cm as there is less retroperitoneal space available for controlling the artery, and the hematoma is more likely to rupture intraoperatively, which may result in severe secondary hemorrhages. Considering the feasibility and safety of the operation, retroperitoneal LN is an option for patients with blunt renal trauma necessitating nephrectomy, when conservative measures and angiographic embolization fail, and in cases where the hematoma is not greater than 10–12 cm. Furthermore, severe hilar injuries, penetrating renal injuries, and other abdominal organ injuries should be absent. Both retro- and transperitoneal approaches can be used for LN. The transperitoneal approach may offer a larger working space and identifiable anatomic landmarks compared with the retroperitoneal approach, but using this approach makes it more difficult to manipulate the renal artery.11 Based on our experience with LN, the retroperitoneal approach is better for patients with acute renal trauma; it offers quick and easy access to the renal hilum and facilitates separation and early control of the renal artery.11 All of our patients benefited from early management of the renal artery, which helped to decrease the risk of secondary hemorrhages and to ensure that they underwent successful surgery for their condition. In addition, the retroperitoneal approach saves operative time as it does not require the surgeon to mobilize the colon or duodenum. From a technical standpoint, the renal artery can be controlled with less contact with the hematoma using the retroperitoneal approach; therefore, this approach is strongly recommended for the patients with renal trauma only. The utmost important step for performing LN in these patients is to control the renal artery successfully. For patients with blunt renal trauma, the perirenal fascia is usually complete, and the hematoma is usually contained in Gerota’s fascia, which allows the space for controlling the artery
LN FOR ACUTE GRADE 4 RENAL INJURIES
during the operation. It is important to note that vascular variations exist for some patients, especially in cases where duplicate or multiple renal arteries are present. Lacking the proper knowledge and dissection of renal arteries prior to the removal of perirenal hematomas would be disastrous. This situation increases the likelihood that severe secondary hemorrhages will occur. Renal vein variations have little effect on surgical blood loss volume. In one of our cases, it was difficult to locate the renal vein after ligating the renal artery for renal vein variation. Proper technical modifications helped us to complete the surgery; we mobilized and dissected the renal vein after mobilizing the whole kidney, and this process did not increase blood loss volume. LN has been shown to have several benefits over open nephrectomy, including quicker recovery, shorter hospital stay, reduced blood loss, smaller incision, etc.11 We also regard LN as a less invasive procedure for patients with renal injuries; the blood loss in this study was similar to that in the literature, which is less than that in open surgery.11 In addition, a smaller incision was required to remove the specimen for LN; a 4–5-cm-long incision was enough. Based on our experience with performing open nephrectomies, it would be difficult to perform LN 7 days or more after trauma. Posttraumatic persistent urine leak, perinephric inflammation, and fibrosis often lead to severe retroperitoneal and perihilar adhesions and tissue plane loss, which also make this type of operation more difficult. The rates of blood transfusion and open conversion increase with the presence of inflammatory conditions.12 LN was performed by Siddins et al.6 in patients 13 weeks after initial trauma using a transperitoneal approach, and it was difficult to mobilize the kidney and to identify the renal pedicle because of extensive fibrosis. Hernandez et al.5 had the same experience: they performed LN in patients 3–6 months following spontaneous retroperitoneal hemorrhage from renal tumors, and fibrosis made dissection difficult. Subcapsular LN has been reported in the presence of dense perinephric adhesions, secondary to recurrent pyelonephritis13 and parenchymal infections.14 Associated incidental benign and malignant tumors are also important considerations in patients with renal trauma. Spontaneous hemorrhages were observed with renal angiomyolipoma and renal cell carcinoma; preoperative diagnosis is difficult for associated benign or malignant tumors owing to the presence of hematomas. In this present study, no tumors were found during final histopathology for any of the patients. Hand-assisted or early open conversion should be strongly considered in cases involving severe secondary hemorrhages, complex vascular variations, Grade 4 hilar injuries, or Grade 5 renal injuries. Ivey et al.15 reported the overall open conversion rate for LN was 7.9%. It is nearly impossible to perform LN in patients with Grade 5 renal injuries using the transperitoneal or retroperitoneal approach. Despite technical challenges, conversions to hand-assisted or open surgery were not required in our groups. Our study had some limitations. First, some but not all patients had excretory images, but we think it was not influential when defining the grade of renal injuries. Second, we only performed LN in patients with blunt Grade 4 renal lacerations or injuries; we did not include patients with Grade 4 hilar injuries or Grade 5 renal injuries. Third, because of the limited number of cases, we did not compare our results with open nephrectomy in terms of intraoperative variables and
455
postoperative outcomes. Finally, abdominal organ injuries should be excluded preoperatively via plain film, ultrasonography, CT imaging, and other imaging techniques. Based on our experience, proper patient selection, technical modification, good timing of surgery, and skilled laparoscopists with extensive experience increase the likelihood that LN will be successfully performed in patients with highgrade renal injuries. Our study revealed that retroperitoneal LN was a safe and feasible treatment for Grade 4 renal injuries in a select group of patients; this procedure has an advantage of being a less invasive procedure. It is important to note that we were only able to confirm the feasibility of this technique and do not advocate it as a routine approach at present. More studies are needed to validate the efficacy of this technique. We believe our study will promote discussions on whether acute blunt renal injuries without other injuries could be an indication for LN in selected patients. Conclusions
We assessed and discussed in detail the safety and feasibility of pure LN through the retroperitoneal approach in patients with acute blunt Grade 4 renal injuries when conservative measures and angiographic embolization fail. Although LN may present several technical challenges, it is safe and feasible for a select group of patients. However, surgeons should bear in mind that early hand-assisted or open conversion should be done whenever necessary. Disclosure Statement
No competing financial interests exist. References
1. Buckley JC, McAninch JW. Selective management of isolated and nonisolated grade IV renal injuries. J Urol 2006;176:2498–2502. 2. McClung CD, Hotaling JM, Wang J, et al. Contemporary trends in the immediate surgical management of renal trauma using a national database. J Trauma Acute Care Surg 2013;75:602–606. 3. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: Initial case report. J Urol 1991;146:278–282. 4. Pen˜a JA, Serrano M, Cosentino M, et al. Laparoscopic management of spontaneous retroperitoneal hemorrhage. Urol Int 2011;87:114–116. 5. Hernandez F, Ong AM, Rha KH, et al. Laparoscopic renal surgery after spontaneous retroperitoneal hemorrhage. J Urol 2003;170:749–751. 6. Siddins M, Rao MM, Kanchanabat B, et al. Late laparoscopic nephrectomy following renal trauma. ANZ J Surg 2001;71:618–621. 7. Buckley JC, McAninch JW. Revision of current American Association for the Surgery of Trauma renal injury grading system. J Trauma 2011;70:35–37. 8. Figler BD, Malaeb BS, Voelzke B, et al. External validation of a substratification of the American Association for the Surgery of Trauma renal injury scale for grade 4 injuries. J Am Coll Surg 2013;217:924–928. 9. Hardee MJ, Lowrance W, Brant WO, et al. High grade renal injuries: Application of Parkland Hospital predictors of intervention for renal hemorrhage. J Urol 2013;189: 1771–1776.
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10. Menaker J, Joseph B, Stein DM, et al. Angiointervention: High rates of failure following blunt renal injuries. World J Surg 2011;35:520–527. 11. Nambirajan T, Jeschke S, Al-Zahrani H, et al. Prospective, randomized controlled study: Transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy. Urology 2004;64:919–924. 12. Manohar T, Desai M, Desai M. Laparoscopic nephrectomy for benign and inflammatory conditions. J Endourol 2007;21:1323–1328. 13. Moore RG, Chen RN, Hedican SP. Laparoscopic subcapsular nephrectomy. J Endourol 1998;12:263–264. 14. Xu Z, Xin M, Hong-Zhao L, et al. Retroperitoneoscopic subcapsular nephrectomy for infective nonfunctioning kidney with dense perinephric adhesions. BJU Int 2004;94:1329–1331.
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15. Ivey BS, Lucas SM, Meyer CA, et al. Conversions in laparoscopic renal surgery: Causes and outcomes. J Endourol 2011;25:1167–1173.
Address correspondence to: Ye Tian, MD Department of Urology Beijing Friendship Hospital Capital Medical University 95 YongAn Road Xicheng District, Beijing, 100050 China E-mail: [email protected]
Retroperitoneal Laparoscopic Nephrectomy for Acute Blunt Grade 4 Renal Injuries Wenying Wang, MD,1,2 Li Wang, PhD,2 Jianfeng Xu, MD, PhD,2 Tamara S. Adams, MS,2 and Ye Tian, MD1
Abstract
Objective: To first describe laparoscopic nephrectomy (LN) for patients with acute blunt Grade 4 renal injuries using a retroperitoneal approach. Patients and Methods: Three patients (2 males and 1 female) with acute blunt renal trauma underwent retroperitoneal LN successfully. The revised American Association for Surgery of Trauma grading system was used to grade renal injuries. All three patients with Grade 4 renal injuries required blood transfusions preoperatively and angiographic embolization because of hemodynamic instability. Given the severity of the renal injuries, failure of angiographic embolization, and persistent blood loss, surgical intervention was used. We performed retroperitoneal LN using four trocars within 24 hours after trauma for the patients. Results: Pure retroperitoneal LN was successfully performed in all 3 patients without requiring hand-assisted or open surgery. The renal hematoma dimension for the patients was 7.5, 8.4, and 9.2 cm, respectively. Operative time was 80, 110, and 130 minutes, respectively. Estimated blood loss was 100, 140, and 300 mL, respectively. The incision size was 4.2, 4.2, and 4.5 cm, respectively. The average hospital stay was 6 days. Pathology showed renal injuries without incidental renal tumors. Conclusions: Despite the technical challenges, LN for patients with acute blunt Grade 4 renal injuries using a retroperitoneal approach is safe and feasible in carefully selected patients if conservative measures and angiographic embolization fail. However, it is important to note that one should keep a low threshold for open conversion or the hand-assisted approach whenever necessary.
Introduction
R
enal trauma is one of the most common solid organ injuries; it occurs in up to 3%–10% of all abdominal trauma injuries, and up to 80%–90% renal injuries are due to acute blunt trauma.1 The management of blunt renal trauma includes nonoperative and operative procedures. Conservative management has a high success rate for Grade 1–3 renal injuries, but the best approach for managing high-grade (Grades 4 and 5) renal injuries is still controversial.2 Open surgery is the gold standard treatment for patients with acute renal trauma necessitating nephrectomy. Laparoscopic nephrectomy (LN) has been widely used since its first description in 1991 by Clayman et al.3 The indications for LN have expanded over the last two decades and have been consistently extended to include more difficult procedures. To date, LN has been successfully performed for a variety of benign and malignant conditions that were traditionally considered relatively contraindicated. LN for spontaneous nontraumatic retroperitoneal
1 2
hemorrhage secondary to renal neoplasm4,5 and late LN for previously documented renal trauma using the transperitoneal approach6 have been reported. The presence of acute renal trauma is usually considered as a relative contraindication for LN because of risk of secondary hemorrhage. But, with continued advancements in laparoscopic surgery, it is possible to perform LN for acute blunt renal injuries. Accurate recognition of injuries and staging of the severity of a patient’s status allow appropriate patient selection for laparoscopic management and should minimize subsequent complications for patients. To the best of our knowledge, we are the first to report findings on the application of LN in patients with acute blunt high-grade renal injuries using the retroperitoneal approach. Patients and Methods
Three patients (2 males and 1 female) diagnosed with acute blunt renal trauma (2 patients with left and 1 patient
Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing, China. Center for Cancer Genomics, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
451
452
WANG ET AL.
with right) received retroperitoneal LN at our institute between May 2005 and January 2012. The mean age was 37 years (range, 21–65 years). The 3 patients were referred to the emergency room of our hospital: 1 was admitted 9 hours after a low-speed fall, 1 presented with lumbar pain and severe gross hematuria after a second extracorporeal shockwave lithotripsy procedure, and 1 was transferred to our hospital 10 hours after a motor vehicle accident. Blood pressure measurements ranged from 85/60 mm Hg to 90/70 mm Hg, and heart rate measurements ranged from 116 beats/minute to 130 beats/minute upon admission. Laboratory results showed the range for hemoglobin levels was 77–102 g/L. All patients had severe gross hematuria upon catheter insertion. Physical examinations revealed that none of the patients had peritonitis. Abdominal and pelvic ultrasonography showed retroperitoneal hematoma around the kidney, and no fluid was observed in the abdominal or pelvic cavity. Computed tomography (CT) with intravenous contrast showed that the parenchymal laceration extended into the collecting system for all 3 patients. CT images in 2 patients (1 left and 1 right) are shown in Figure 1. No other abdominal organ injuries were suspicious according to abdominal or pelvic CT imaging. Traditionally, the American Association for Surgery of Trauma (AAST) grading system was used to reflect and define injury severity (including renal trauma grades) and to predict which injuries are suitable for operative management. A revised grading system, suggested by Buckley and McAninch,7 defined Grade 4 injuries to include parenchymal lacerations extending through the renal cortex into the collecting system with or without urinary extravasation, renal pelvis laceration, and/or ureteral pelvic disruption, segmental artery, and vein injury. In addition, the revised system defines Grade 5 injuries to include only severe hilar injuries. In our study, we defined renal injury grades based on the revised grading system. Based on the updated classifications, all 3 patients were found to have Grade 4 renal injuries. All the patients required preoperative blood transfusions (2 U, 4 U, and 6 U of packed red cells, respectively) because of hemodynamic instability while being examined in the emergency room. Selective segmental renal artery embolization was performed based on the location of renal injury because no major bleeding vessels or significant signs were found during angiography in these 3 patients, but all the pa-
FIG. 1.
tients still experienced continued severe gross hematuria, decreased hemoglobin level, and hemodynamic instability after receiving angiographic embolization. Ultrasonography revealed enlarged hematomas in 2 patients. Given the severity of the renal injuries, failure of angiographic embolization, continued blood loss, and normal contralateral renal function, we decided to proceed with nephrectomy and elected to attempt LN. The hand-assisted approach or open conversion was an alternative to LN, in the event the artery could not be controlled quickly or the patient became unstable intraoperatively. All patients received LN within 24 hours after trauma. General anesthesia was given to the patients by tracheal intubation. Patients were placed in an extended flank position and received retroperitoneal LN using the four-trocar system, including two 10-mm ports and two 5-mm ports. Finger dissection was performed to separate fatty tissue and to create the initial retroperitoneal space. The pneumoretroperitoneum was established, and a pressure of 12–15 mm Hg was maintained. The hematoma was observed and contained by Gerota’s fascia, which was incised close and parallel to the psoas muscle. The psoas muscle and the ureter were landmarks for dissection of the renal hilum; we tried to expose the renal artery with the least amount of pressure on the hematoma. Although there was some venous blood oozing from the hematoma to the surgical field, it had only a slight effect on the procedures. The whole kidney, together with Gerota’s fascia and perirenal fat, was mobilized en bloc. Thereafter, the ureter was identified and ligated with two Hem-o-lok (Weck; Teleflex Medical, Research Triangle Park, NC) clips. The specimen was entrapped using an ENDO CATCH bag (Ethicon Endo-Surgery, Cincinnati, OH) and delivered by enlarging the lowest trocar incision to 4–5 cm long. The operative time was calculated from first skin incision to application of final dressing. During LN for patients with perirenal hematoma, it is difficult to determine actual blood loss volume; analysis of changes in blood cell count are influenced by many factors, including preoperative and intraoperative fluid resuscitation and blood transfusion. Therefore, we calculated intraoperative blood loss based on the amount of blood collected using two suction device bottles (one for the renal hematoma, the other for the surgical field) and swab weight (if used).
Computed tomography images show Grade 4 injuries in the (A) right kidney and (B) left kidney.
LN FOR ACUTE GRADE 4 RENAL INJURIES
453
Results
Discussion
All operations were completed laparoscopically, without hand-assisted or open conversion. We did not encounter any intraoperative or postoperative complications, including secondary hemorrhage, major vascular injury, postoperative bleeding, pleural injury, pneumonia, or wound infection. All 3 patients required blood transfusions preoperatively. No patient required intraoperative or postoperative blood transfusions. Perihilar adhesion was not observed in any of the patients. The average renal hematoma dimension was 8.4 cm (range, 7.5–9.2 cm). The mean operative time was 107 minutes (range, 80–130 minutes). The mean estimated blood loss was 180 mL (range, 100–300 mL). The average incision size was 4.3 cm (range, 4.2–4.5 cm). In 1 case, a small rupture of the hematoma occurred prior to ligation of the renal artery. A large amount of blood clot extended outside the hematoma; no fresh secondary hemorrhage occurred. Therefore, we suctioned the clot and quickly located and ligated the renal artery. In addition, it was difficult to locate the renal vein after ligating the renal artery for renal vein variation, so we mobilized and dissected the renal vein after mobilizing the whole kidney (Fig. 2). Pathology showed renal injuries without incidental tumors. Postoperative recovery was uneventful. The average hospital stay was 6 days (range, 5–7 days). Patients were discharged without complications and remained well at follow-up visits. Data of clinical characteristics, perioperative variables, and outcomes for patients with Grade 4 renal injuries are given in Table 1.
The kidney is the most frequently injured parenchymal organ in the urologic system, and renal injuries are usually caused by blunt trauma; falls and motor vehicle accidents are the most common causes of renal trauma.1,2 The Organ Injury Severity Scale was developed by the AAST based on the appearance of renal injury at the time of surgery and correlates with CT findings. This classification system has shown that higher grades have a significant correlation with increasing rates of morbidity, mortality, the need for surgery, and nephrectomy. The revised classification scale provides a more rigorous definition of renal injuries and facilitates the discussion on management of renal injuries.7 The management of blunt renal trauma has evolved considerably, and there is a common trend toward nonoperative management in hemodynamically stable patients, but there is controversy regarding the management of hemodynamically stable patients with high-grade renal injuries. There are some risks associated with nonoperative treatment, including delayed renal bleeding, delayed nephrectomy, urine leakage, urinoma, persistent fever, venous thromboembolism after prolonged immobilization, renal insufficiency, arteriovenous fistula, aneurysm, and even death.8,9 Patients with renal injuries rated Grade 4 or higher have increased morbidity and mortality rates for conservative treatment. The incidence of functional renal loss and death occurred in 16% and 7% of patients with Grade 4 renal injuries, respectively.8,9 About 29% of Grade 4 and 60% of Grade 5 renal injuries required surgical intervention.8,9
FIG. 2. Intraoperative images. (A) Hematoma (arrow) contained in Gerota’s fascia. (B) Blood clot (arrow) extending outside the hematoma. (C) The renal artery (arrow) was ligated and dissected. (D) The renal vein (arrow) was ligated and dissected.
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Table 1. Clinical Characteristics, Perioperative Variables, and Outcomes of the Patients Variable Sex/age (years) Year of surgery Laterality Mechanism of renal injury Cause of renal injury AAST grade of renal injury Hematoma dimension (cm) Hemoglobin on admission (g/L) Blood transfusion (packed red blood cells) Preoperative hemoglobin (g/dL) Preoperative angiographic embolization Preoperative serum creatinine (lmol/L) Operative time (minutes) Intraoperative estimated blood loss (mL) Postoperative hemoglobin (g/L) Postoperative serum creatinine (lmol/L) Serum creatinine (lmol/L) 6 months after surgery Size of incision (cm) Hospital stay (days)
Patient 1
Patient 2
Patient 3
M/65 F/21 M/25 2005 2010 2012 Left Right Left Blunt Blunt Blunt SWL Low-speed MVA fall 4 4 4 7.5 8.4 9.2 102 77 94 2U
6U
4U
95
86
88
Yes
Yes
Yes
89
75
55
130 140
110 100
80 300
94
80
82
105
72
69
107
75
60
4.2 6
4.2 5
4.5 7
AAST, American Association for Surgery of Trauma; MVA, motor vehicle accident; SWL, extracorporeal shockwave lithotripsy.
About 10% of Grade 4 injuries required nephrectomy.2 Highrisk factors requiring intervention for patients with Grade 4 injuries include a perirenal hematoma rim distance of >3.5 cm, expanding renal mass, renal pelvis injury, intravascular contrast extravasation, and AAST Grade 4 hilar injury.8,9 Appropriate imaging investigations are critical for accurate preoperative diagnosis and evaluation for trauma grade. Sufficient knowledge of grading for renal trauma will allow for prompt intervention, less morbidity, and less mortality. The CT scan is currently the most valuable tool for diagnosis and grade evaluation of renal trauma and should be performed preoperatively to avoid delayed recognition of other injuries to abdominal organs. CT scans also aid in determining which patients require urgent intervention. The majority of significant renal trauma patients present with concurrent multiorgan injuries; therefore, it is critical to identify and stage injuries to additional organs. In order to avoid delayed diagnosis and identification of collecting system injuries, it is better to perform CT scans with intravenous contrast and obtain excretory images. In the present study, Grade 4 renal injuries were revealed using a CT scan for all patients. Management options for Grade 4 renal injuries include conservative treatment, minimally invasive intervention, and operation.1,2,9,10 Conservative treatment includes bed rest
and monitoring the patient’s hemodynamic status. Minimally invasive interventions such as angiographic embolization are needed if conservative treatments fail. Angiographic embolization has a high success rate for lower grades of renal injuries. Complications may include renal infarction, delayed nephrectomy, hypertension, and abscess, and the failure rate of angiographic embolization has been described as high as 27.2% in some reports.10 Operation interventions include renorrhaphy, partial nephrectomy, and nephrectomy. The nephrectomy rate among patients who have received open surgery for Grade 4 blunt renal injuries within the first 24 hours was 81%.2 In our study, the 3 patients experienced continued blood loss even though angiographic embolization had been performed. Therefore, we decided to proceed with nephrectomy and elected to attempt LN. Based on our experience, although preoperative angiographic embolization may not be successful in controlling blood loss, it may reduce the risk of intraoperative secondary blood loss. There are no known reports of LN use with acute renal trauma. Laparoscopic management in renal trauma should be based on history and mechanism of renal injury, examination findings including hematuria, vital signs, other abdominal organ injuries, and imaging results. Based on our experience, for cases with penetrating renal injuries, the hematoma usually extended outside of Gerota’s fascia to the retroperitoneal and pelvic space. LN is not an option in this situation as there is no retroperitoneal space available for controlling the renal artery. In addition, it is difficult to operate on cases with hematomas larger than 10–12 cm as there is less retroperitoneal space available for controlling the artery, and the hematoma is more likely to rupture intraoperatively, which may result in severe secondary hemorrhages. Considering the feasibility and safety of the operation, retroperitoneal LN is an option for patients with blunt renal trauma necessitating nephrectomy, when conservative measures and angiographic embolization fail, and in cases where the hematoma is not greater than 10–12 cm. Furthermore, severe hilar injuries, penetrating renal injuries, and other abdominal organ injuries should be absent. Both retro- and transperitoneal approaches can be used for LN. The transperitoneal approach may offer a larger working space and identifiable anatomic landmarks compared with the retroperitoneal approach, but using this approach makes it more difficult to manipulate the renal artery.11 Based on our experience with LN, the retroperitoneal approach is better for patients with acute renal trauma; it offers quick and easy access to the renal hilum and facilitates separation and early control of the renal artery.11 All of our patients benefited from early management of the renal artery, which helped to decrease the risk of secondary hemorrhages and to ensure that they underwent successful surgery for their condition. In addition, the retroperitoneal approach saves operative time as it does not require the surgeon to mobilize the colon or duodenum. From a technical standpoint, the renal artery can be controlled with less contact with the hematoma using the retroperitoneal approach; therefore, this approach is strongly recommended for the patients with renal trauma only. The utmost important step for performing LN in these patients is to control the renal artery successfully. For patients with blunt renal trauma, the perirenal fascia is usually complete, and the hematoma is usually contained in Gerota’s fascia, which allows the space for controlling the artery
LN FOR ACUTE GRADE 4 RENAL INJURIES
during the operation. It is important to note that vascular variations exist for some patients, especially in cases where duplicate or multiple renal arteries are present. Lacking the proper knowledge and dissection of renal arteries prior to the removal of perirenal hematomas would be disastrous. This situation increases the likelihood that severe secondary hemorrhages will occur. Renal vein variations have little effect on surgical blood loss volume. In one of our cases, it was difficult to locate the renal vein after ligating the renal artery for renal vein variation. Proper technical modifications helped us to complete the surgery; we mobilized and dissected the renal vein after mobilizing the whole kidney, and this process did not increase blood loss volume. LN has been shown to have several benefits over open nephrectomy, including quicker recovery, shorter hospital stay, reduced blood loss, smaller incision, etc.11 We also regard LN as a less invasive procedure for patients with renal injuries; the blood loss in this study was similar to that in the literature, which is less than that in open surgery.11 In addition, a smaller incision was required to remove the specimen for LN; a 4–5-cm-long incision was enough. Based on our experience with performing open nephrectomies, it would be difficult to perform LN 7 days or more after trauma. Posttraumatic persistent urine leak, perinephric inflammation, and fibrosis often lead to severe retroperitoneal and perihilar adhesions and tissue plane loss, which also make this type of operation more difficult. The rates of blood transfusion and open conversion increase with the presence of inflammatory conditions.12 LN was performed by Siddins et al.6 in patients 13 weeks after initial trauma using a transperitoneal approach, and it was difficult to mobilize the kidney and to identify the renal pedicle because of extensive fibrosis. Hernandez et al.5 had the same experience: they performed LN in patients 3–6 months following spontaneous retroperitoneal hemorrhage from renal tumors, and fibrosis made dissection difficult. Subcapsular LN has been reported in the presence of dense perinephric adhesions, secondary to recurrent pyelonephritis13 and parenchymal infections.14 Associated incidental benign and malignant tumors are also important considerations in patients with renal trauma. Spontaneous hemorrhages were observed with renal angiomyolipoma and renal cell carcinoma; preoperative diagnosis is difficult for associated benign or malignant tumors owing to the presence of hematomas. In this present study, no tumors were found during final histopathology for any of the patients. Hand-assisted or early open conversion should be strongly considered in cases involving severe secondary hemorrhages, complex vascular variations, Grade 4 hilar injuries, or Grade 5 renal injuries. Ivey et al.15 reported the overall open conversion rate for LN was 7.9%. It is nearly impossible to perform LN in patients with Grade 5 renal injuries using the transperitoneal or retroperitoneal approach. Despite technical challenges, conversions to hand-assisted or open surgery were not required in our groups. Our study had some limitations. First, some but not all patients had excretory images, but we think it was not influential when defining the grade of renal injuries. Second, we only performed LN in patients with blunt Grade 4 renal lacerations or injuries; we did not include patients with Grade 4 hilar injuries or Grade 5 renal injuries. Third, because of the limited number of cases, we did not compare our results with open nephrectomy in terms of intraoperative variables and
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postoperative outcomes. Finally, abdominal organ injuries should be excluded preoperatively via plain film, ultrasonography, CT imaging, and other imaging techniques. Based on our experience, proper patient selection, technical modification, good timing of surgery, and skilled laparoscopists with extensive experience increase the likelihood that LN will be successfully performed in patients with highgrade renal injuries. Our study revealed that retroperitoneal LN was a safe and feasible treatment for Grade 4 renal injuries in a select group of patients; this procedure has an advantage of being a less invasive procedure. It is important to note that we were only able to confirm the feasibility of this technique and do not advocate it as a routine approach at present. More studies are needed to validate the efficacy of this technique. We believe our study will promote discussions on whether acute blunt renal injuries without other injuries could be an indication for LN in selected patients. Conclusions
We assessed and discussed in detail the safety and feasibility of pure LN through the retroperitoneal approach in patients with acute blunt Grade 4 renal injuries when conservative measures and angiographic embolization fail. Although LN may present several technical challenges, it is safe and feasible for a select group of patients. However, surgeons should bear in mind that early hand-assisted or open conversion should be done whenever necessary. Disclosure Statement
No competing financial interests exist. References
1. Buckley JC, McAninch JW. Selective management of isolated and nonisolated grade IV renal injuries. J Urol 2006;176:2498–2502. 2. McClung CD, Hotaling JM, Wang J, et al. Contemporary trends in the immediate surgical management of renal trauma using a national database. J Trauma Acute Care Surg 2013;75:602–606. 3. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: Initial case report. J Urol 1991;146:278–282. 4. Pen˜a JA, Serrano M, Cosentino M, et al. Laparoscopic management of spontaneous retroperitoneal hemorrhage. Urol Int 2011;87:114–116. 5. Hernandez F, Ong AM, Rha KH, et al. Laparoscopic renal surgery after spontaneous retroperitoneal hemorrhage. J Urol 2003;170:749–751. 6. Siddins M, Rao MM, Kanchanabat B, et al. Late laparoscopic nephrectomy following renal trauma. ANZ J Surg 2001;71:618–621. 7. Buckley JC, McAninch JW. Revision of current American Association for the Surgery of Trauma renal injury grading system. J Trauma 2011;70:35–37. 8. Figler BD, Malaeb BS, Voelzke B, et al. External validation of a substratification of the American Association for the Surgery of Trauma renal injury scale for grade 4 injuries. J Am Coll Surg 2013;217:924–928. 9. Hardee MJ, Lowrance W, Brant WO, et al. High grade renal injuries: Application of Parkland Hospital predictors of intervention for renal hemorrhage. J Urol 2013;189: 1771–1776.
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10. Menaker J, Joseph B, Stein DM, et al. Angiointervention: High rates of failure following blunt renal injuries. World J Surg 2011;35:520–527. 11. Nambirajan T, Jeschke S, Al-Zahrani H, et al. Prospective, randomized controlled study: Transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy. Urology 2004;64:919–924. 12. Manohar T, Desai M, Desai M. Laparoscopic nephrectomy for benign and inflammatory conditions. J Endourol 2007;21:1323–1328. 13. Moore RG, Chen RN, Hedican SP. Laparoscopic subcapsular nephrectomy. J Endourol 1998;12:263–264. 14. Xu Z, Xin M, Hong-Zhao L, et al. Retroperitoneoscopic subcapsular nephrectomy for infective nonfunctioning kidney with dense perinephric adhesions. BJU Int 2004;94:1329–1331.
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15. Ivey BS, Lucas SM, Meyer CA, et al. Conversions in laparoscopic renal surgery: Causes and outcomes. J Endourol 2011;25:1167–1173.
Address correspondence to: Ye Tian, MD Department of Urology Beijing Friendship Hospital Capital Medical University 95 YongAn Road Xicheng District, Beijing, 100050 China E-mail: [email protected]
