The role of nonoperative management of penetrating renal trauma

Introduction: Penetrating renal trauma has been treated traditionally by renal exploration. In view of the successful outcome of nonoperative treatment of major blunt renal trauma, there has been a gradual shift in the approach to penetrating renal injuries, in selected cases. This study reviews the local experience with the conservative approach to penetrating renal injuries. Patients and methods: The researchers retrospectively reviewed the medical records of patients with penetrating renal injuries during a period of 10 years at two medical centers (Meir in Kfar Saba and Hillel Yaffe in Hadera). The data included mechanisms of injury, grading of the injury, homodynamic stability presence of hematuria, associated injuries, management - conservative versus operative, complications and outcome. Results: The study group consisted of 18 patients, with mean age of 22.5 years (15-40 years). The mechanisms of injury were stab wounds (10 patients) and gunshot injuries (8 patients). Nine patients (50%) required surgical intervention for associated injuries. Nonoperative treatment of the urological injury was selected in 10 patients (55.5%), 4 of them required surgery for associated abdominal injuries but did not undergo renal or retroperitoneal exploration, 8 patients (44.5%), were managed primarily by renal exploration. Grade I-II renal injuries were treated conservatively while all grade V injuries were explored. Of grade III injuries, 3 were treated conservatively and renal exploration was performed in 2. Half of grade IV injuries (4 patients) were treated conservatively. Follow-up of conservatively treated patients, demonstrated a viable kidney in all cases. Nephrectomy was performed in 3/8 patients who were treated primarily by renal exploration. These patients had grade IV or V injuries. Renorrhaphy was performed in the remaining 5 patients of whom one required delayed nephrectomy. Overall, the injured renal unit was lost in half of the operated patients. Conclusions: The present study presents a successful conservative approach to penetrating renal injuries in 10 out of 18 cases. All renal units in the nonoperated patients were preserved in comparison to only half in the surgically treated patients. Hence, nonoperative treatment is a reasonable option for the majority of minor penetrating renal injuries as well as in many selected high-grade injuries. This approach provides maximal preservation of the injured kidney with manageable complications.