Review of 48 consecutive cases of renal injury: Outcome of management by conservative vs operative approach

Objectives : To analyse the outcome of conservative and surgical management of renal injuries in terms of renal salvage and complications. Methods: Medical records of 48 consecutive patients of renal injury occurring in isolation or in association with polytrauma, managed during January 2000 to April 2002 were reviewed. After initial clinical evaluation and re­suscitation, patients were evaluated by abdominal ultra­sound followed by computerized tomography to stage the injury. The patients were classified into group 1 compris­ing of 29 patients having renal injuries of grade 1-III and group 2 consisting of 19 patients of grade IV, V and pen­etrating injuries. Initially, all patients in group 1 and 9 of group 2 were managed conservatively. Follow up evalu­ation included blood pressure monitoring, urinalysis and estimation of serum creatinine at each visit and intrave­nous urography after 6-8 weeks. Outcome in terms of re­nal salvage was evaluated in two subsets of patients in accordance with management adopted for renal injury (conservative vs operative) as well as severity of renal injure and the significance of difference between two pa­tient groups was assessed statistically by Chi-square test. Results : There were 37 males and 11 females in the age group of 11-70 years (mean 28 years). Blunt abdomi­nal trauma accounted for renal injury in 85.4% (41/48) patients. Flank pain (43/48; 89.5%) and haematuria (40/ 48; 85.4%) were the common presenting symptoms. Thirty four (70.8%) patients had associated one or more organ injuries. In group 1, all renal units were salvaged except one, who underwent nephrectomy for massive secondary haemorrhage. In group 2, half of the patients (5/10) man­aged surgically (]for haemodynamic instability, 3 for non­salvageable kidney and ]for secondary haemorrhage after repair of renal laceration) lost their injured kidney. Dur­ing follow-up, 2 patients in group 2 managed conserva­tively lost their kidney. In one patient, the kidney became non-functioning due to renovascular injury and one pa­tient of stab injury managed earlier by angioembolisation underwent nephrectomy for recurrent haematuria due to pseudoaneurysm of intrarenal artery. The renal loss was significantly more in cases with severe renal injury (7/19 vs 1/29, χ2 = 9.22, p < 0.01) and in cases who underwent operative management (5/10 vs 3/38, χ2 = 10.105, p < 0.01). Conclusions : The data in this study suggest that con­servative management of renal injuries yields more favour­able results with high renal salvage rate, low morbidity and minimal complications when compared with immedi­ate renal exploration. However, in this retrospective study, the decision of conservativs vs operative management was influenced by several factors. Therefore, a randomized prospective study including those cases in whom both the options are feasible would be helpful to derive a definite conclusion.