Study: Surgery less common for blunt renal trauma

A new study suggests that surgical care for renal trauma cases is evolving in two different directions: Endovascular procedures have become more common for blunt trauma, supplanting nephrectomy and laceration repair. But surgeons still prefer surgical exploration and laceration repair for penetrating trauma injuries, although endovascular procedures are on the rise somewhat.

Dr. Terlecki"Less blunt trauma is being managed surgically overall, with a strong drop in nephrectomy, but the rate of renal repair among patients who are taken to the OR hasn't really changed. We were surprised that these rates hadn't changed, and we were surprised to see the rise in endovascular management of penetrating trauma,” said study co-author Ryan P. Terlecki, MD, associate professor of urology at Wake Forest Baptist Health, Winston-Salem, NC.

At issue: How are surgeons treating renal trauma cases like those caused by gunshots and accidents?

For the study, which was presented at the AUA annual meeting in Boston, the authors performed a retrospective cross-sectional analysis of blunt and penetrating renal trauma cases via the National Trauma Data Bank. They looked at 4,296 cases (2,635 of blunt trauma and 1,661 of penetrating trauma) from 2002-2012 that were treated with intervention.

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According to Dr. Terlecki, the study authors had expected to see less surgery for blunt injuries, but not necessarily for penetrating injuries.

"If patients are stable and have blunt trauma kidney injuries, we often observe them with serial physical examinations and monitoring of their blood counts and occasionally put them on modified bed rest," he said. "Embolization is an option to consider if these more conservative options fail, but so is surgery. It is clear to see which one is less invasive. The risk of surgery is that opening of that collection of blood behind the fascia can make the operation very challenging, such that some providers may find it simpler and faster to remove the entire kidney. But in some cases, devastating injuries or the patient's overall condition may necessitate this approach."

The authors predicted that for cases still going to the operating room, "the injuries are likely to be more severe and more likely to lead to nephrectomy so that the rates of repair would fall among all cases going to the OR," Dr. Terlecki said. "We felt this hypothesis was further strengthened by the concept that less surgery overall for blunt kidney trauma would mean less experience among providers in managing these types of operations, and therefore less confidence in repair, which is often a more challenging operation than removing the kidney."

However, he said, "Our analysis did not show a drop in the rate of repair among cases going to the operating room." About 80% of cases that do involve surgical intervention in blunt trauma cases are laceration repair, and this proportion remains stable.

Next: Endovascular cases grow to 53.3%

Endovascular cases grow to 53.3%

Among blunt renal cases, endovascular procedures grew from 1.4% in 2002 to 53.3% in 2012 (p<.01), while nephrectomy fell from 8.2% to 2.1% (p=.068) over that time period. Laceration repair fell from 32.9% to 10.2% (p<.01).

What about penetrating injuries? In these injuries, "the fascia-the internal 'pressure dressing'-has been disrupted, and there is often the possibility of injury to other structures (e.g., bowel)," Dr. Terlecki said. "The traditional dogma is that these patients undergo surgical exploration. However, there may be instances of isolated injuries in stable patients, and our imaging technology is quite sophisticated at this point. Thus, we also wanted to see if the trend in increased use of interventional radiology (i.e., embolization) was also crossing over into the realm of penetrating injuries. Surprisingly, it has."

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For penetrating cases, the percentage of endovascular procedures grew from 0 in 2002 to 11.3% in 2012 (p<.01), while nephrectomy fell from 19.3% to 4.4% (p<.01). Laceration repair stayed steady at 75.4% and 70.9% for 2002 and 2012 (p=.91).

Dr. Terlecki cautions that the study does not provide guidance to physicians about patient management and selection.

"However, the trend of increased use at least suggests the possibility that endovascular management may be considered increasingly useful and effective for cases of penetrating renal trauma," he said. "This information is relevant to urologists, trauma/general surgeons, emergency medicine providers, and interventional radiologists.”

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