Henderson C G, Sedberry-Ross S, Pickard R, Bulas D I, Duffy B J, Tsung D, Eichelberger M R, Belman A B, Rushton H G
Division of Pediatric Urology, Children's National Medical Center, Department of Urology, George Washington University School of Medicine and Health Sciences, DC, USA.
J Urol. 2007 Jul;178(1):246-50; discussion 250. doi: 10.1016/j.juro.2007.03.048. Epub 2007 May 17.
In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution.
We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V).
We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury.
Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.
在过去20年中，我院对重度钝性肾损伤的处理方式已从主要采用手术治疗转变为采用非手术观察等待治疗。为评估我院对儿童重度钝性肾损伤采用非手术观察等待治疗的经验，我们回顾了20年来在我院接受治疗的患者的评估、处理及治疗结果。
我们回顾性研究了1983年至2003年间所有发生肾损伤的患者。查阅病历，了解损伤机制、肾损伤分级、患者治疗情况、手术指征及时间，以及治疗结果。损伤分为低级别（Ⅰ至Ⅲ级）或高级别（Ⅳ至Ⅴ级）。
我们回顾了1983年至2003年间164例连续发生钝性肾损伤儿童的病历。因信息不充分排除38例患者。其余126例儿童中，60%为低级别肾损伤，40%为高级别肾损伤。共有11例患者（8.7%）因肾脏原因需要手术或内镜干预，其中2例因先天性肾脏异常，1例因血凝块残留。8例患者（6.3%）因单纯性肾损伤需要手术干预，其中2例（1.6%）因血流动力学不稳定需要立即手术干预，6例（4.8%）采用延迟腹膜后入路治疗。仅4例患者（3.2%）需要行肾切除术。所有接受手术干预的患者均为高级别肾损伤。
儿童重度钝性肾损伤的初始非手术治疗是有效的，推荐用于血流动力学稳定的儿童。当儿童持续出现有症状的尿外渗时，可能需要延迟腹膜后引流以降低发病率。在进行开放性手术干预之前应考虑采用微创技术。除血流动力学不稳定的儿童外，单纯性肾损伤很少需要早期手术治疗。
