Au J K, Tan X, Sidani M, Stanasel I, Roth D R, Koh C J, Seth A, Gargollo P C, Tu D, Gonzales E T, Smith T G, Janzen N
Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, 10th Floor, Suite A10.136, Houston, TX 77030, USA.
J Pediatr Urol. 2016 Oct;12(5):294.e1-294.e6. doi: 10.1016/j.jpurol.2016.02.021. Epub 2016 Apr 22.
Some children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention.
A retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain.
One patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect (P = 0.040) (Fig. A) and lacked ureteral opacification (P = 0.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5-2.5), additional operative interventions occurred from day 4-16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission (Fig. B).
Collecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised.
一些遭受严重钝性肾损伤的儿童可能需要手术干预。在本研究中，我们假设存在计算机断层扫描（CT）特征，可识别出这些儿童中哪些最有可能需要手术干预。
对一家一级创伤中心1990年至2015年期间所有小儿钝性肾创伤患者进行回顾性研究。纳入标准为：美国创伤外科学会（AAST）IV级或V级肾损伤的儿童，年龄≤18岁，且有延迟扫描的CT图像。根据Buckley和McAninch在2011年提出的修订AAST分级系统对CT进行重新分级。肾损伤的影像学特征与任何手术干预的主要结局相关：输尿管支架置入、血管造影、肾切除术/肾修补术以及经皮肾造瘘术/引流术。
1例患者为V级损伤，26例患者为IV级损伤。9例患者（33.3%）接受了手术干预。手术干预队列中的患者更有可能出现集合系统充盈缺损（P = 0.040）（图A）且输尿管不显影（P = 0.010）。CT特征，包括实质去血管化百分比、内侧对比剂外渗、血管内对比剂外渗、肾周血肿距离和撕裂伤位置，差异无统计学意义。在21例有集合系统损伤的患者中，8例（38.1%）需要输尿管支架置入。1例患者需要进行肾修补术。虽然首次手术干预的中位时间为住院第1天（范围0.5 - 2.5天），但额外的手术干预发生在第4 - 16天。因此，在损伤后的第一个月对这些患者进行密切随访是谨慎的做法。2例复杂肾损伤患者有副肾动脉，导致上、下极肾段血供良好，采取非手术治疗且未再次入院（图B）。
集合系统缺损和输尿管不显影与非手术治疗失败显著相关。需要进行多中心试验来证实这些发现以及无显著意义的CT表现是否与手术干预相关。在肾损伤后的一个月内，这些患者应留意症状的任何变化，并对前往急诊室就诊保持较低的怀疑指数。对于医生而言，建议对这些高危患者进行密切随访并给予适当的咨询。
