Shefler Alexander, Gremitzky Andrei, Vainrib Michael, Tykochinsky Giora, Shalev Moshe, Richter Santiago, Erlich Nachum, Schiwartz Ivan, Leibovitch Ilan
Department of Urology. Sapir Medical Center, Kfar Saba.
Harefuah. 2007 May;146(5):345-8, 406-7.
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.
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.
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.
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.
穿透性肾损伤传统上采用肾探查术治疗。鉴于严重钝性肾损伤非手术治疗取得成功，在某些特定病例中，穿透性肾损伤的治疗方法已逐渐转变。本研究回顾了穿透性肾损伤保守治疗方法的本地经验。
研究人员回顾性分析了两个医疗中心（位于卡法萨巴的梅尔医疗中心和位于哈代拉的希勒尔·雅法医疗中心）10年间穿透性肾损伤患者的病历。数据包括损伤机制、损伤分级、血流动力学稳定性、血尿情况、合并伤、保守治疗与手术治疗、并发症及预后。
研究组由18例患者组成，平均年龄22.5岁（15 - 40岁）。损伤机制包括刺伤（10例患者）和枪伤（8例患者）。9例患者（50%）因合并伤需要手术干预。10例患者（55.5%）选择了泌尿系统损伤的非手术治疗，其中4例因合并腹部损伤需要手术，但未进行肾或腹膜后探查；8例患者（44.5%）主要接受了肾探查术。I - II级肾损伤采用保守治疗，而所有V级损伤均进行了探查。III级损伤中，3例采用保守治疗，2例进行了肾探查。IV级损伤中有一半（4例患者）采用保守治疗。对保守治疗患者的随访显示，所有病例的肾脏均存活。在主要接受肾探查术的8例患者中，3例进行了肾切除术。这些患者为IV级或V级损伤。其余5例患者进行了肾修补术，其中1例需要延迟肾切除术。总体而言，手术治疗患者中有一半失去了受伤的肾单位。
本研究显示，18例穿透性肾损伤患者中有10例采用保守治疗取得成功。与手术治疗患者中仅一半的肾单位得以保留相比，非手术治疗患者的所有肾单位均得以保留。因此，对于大多数轻度穿透性肾损伤以及许多选定的高级别损伤，非手术治疗是一种合理的选择。这种方法能最大程度地保留受伤肾脏，并使并发症易于处理。
