Delayed Surgery to Preserve Kidney with Grade IV Injury

BACKGROUND: Since the introduction of the ALARA (“as low as reasonably achievable”) concept, the management of severe renal trauma has shifted. Our hospital promotes delayed surgical intervention for grade IV closed renal injury, to preserve renal function. In this study, we retrospectively reviewed the management and outcomes of patients with grade IV closed renal injury in our hospital. OBJECTIVE: To evaluate the management and outcome of grade IV closed renal injury. METHODS: We retrospectively reviewed the medical records of 45 patients with grade IV closed renal injury; namely, 36 men and 9 women with an average age of 35.6 years. All patients were diagnosed with grade IV closed renal injury in accordance with the guidelines of the American Association for the Surgery of Trauma. All hemodynamically-stable patients with renal trauma were treated conservatively for approximately 13 days and then underwent surgery only to clear the perirenal hematoma and not to repair or resect the affected kidney. Abstracted data included patient demographics, mechanism of injury, admission hemodynamics, CT findings, and mortality. The primary outcome was the success rate of nonsurgical treatment, and the secondary outcome was the complication of nonsurgical treatment. RESULTS: All patients responded and were discharged, and no patients died. We followed 35 (77.8%) patients for at least 1 year. One patient with partially devitalized renal parenchyma underwent surgery to remove the affected kidney. Eleven patients (31.4%) suffered complications, namely, three (8.6%) cases of hypertension, four (11.4%) cases of hematuria, two cases (5.7%) of urinary tract infection, and two (5.7%) cases of urinoma. CONCLUSIONS: Delayed exploratory surgery only to remove the hematoma should be considered in hemodynamically-stable patients with grade IV closed renal injury. This approach can avoid high nephrectomy rates associated with emergency surgery and reduce the complications that result from conservative treatment without surgery.