Edwards Angelena, Passoni Niccolo M, Chen Catherine J, Schlomer Bruce J, Jacobs Micah
University of Texas Southwestern Department of Urology, USA.
University of Texas Southwestern Department of Urology, USA.
J Pediatr Urol. 2020 Oct;16(5):559.e1-559.e6. doi: 10.1016/j.jpurol.2020.05.155. Epub 2020 May 31.
With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking.
This study uses the National Trauma Data Bank (NTDB), to evaluate renal outcomes after use of renal artery angiography. We hypothesized that patients undergoing renal artery angiography for renal trauma are unlikely to require additional surgical interventions.
All children ≤18 years old treated for traumatic renal injuries from 2012 to 2015 were identified by the Abbreviated Injury Scaled Score (AISS) codes in the NTDB. AISS codes were converted to American Association for Surgery of Trauma (AAST) grades. ICD-9 codes were used to identify patients that had renal artery angiography, and additional renal interventions such as nephrectomy, partial nephrectomy, percutaneous nephrostomy tube or ureteral stent placement.
536,379 pediatric trauma cases were in the NTDB from 2012 to 2015, with 4506 renal injury cases identified. A total of 88 patients had renal artery angiography (ICD-9 88.45). Only 10% (n = 9) of patients who received renal artery angiography underwent an additional urological intervention. Of those nine, two patients were excluded due to renal angiography taking place after nephrectomy was performed. The remaining seven patients had high grade laceration (AAST grade 4-5). Overall, two patients underwent post angiography nephrectomies, two patients had partial nephrectomies, one percutaneous nephrostomy tube was placed (prior to partial nephrectomy), one aspiration of a kidney (prior to ureteral stent placement), and three had ureteral stent placements.
The limitations of this study include: the NTDB is a national dataset that is not population based, inclusion is limited to the first hospitalization, inaccuracies exist in encounter coding, and the database is lacking laterality of the renal injury. Based on nonspecific nature of ICD-9 coding for angioembolization, we are unable to discern the number of cases that subsequently had angioembolization after or at the time of angiography.
Renal artery angiography in children remains a rare procedure, 88/4,506, in children with renal trauma. In pediatric trauma cases that undergo renal artery angiography additional procedures are more common with higher grade injuries. Further studies are needed to create pediatric specific trauma management algorithms.
由于儿科肾创伤管理文献有限，儿童的治疗途径一直是从成人人群推断而来。向非手术管理的转变导致了更高的肾脏保留率；然而，儿科创伤人群中血管内介入治疗的特征尚缺乏。
本研究使用国家创伤数据库（NTDB）来评估肾动脉血管造影术后的肾脏结局。我们假设因肾创伤接受肾动脉血管造影的患者不太可能需要额外的手术干预。
通过NTDB中的简明损伤严重程度评分（AISS）代码识别2012年至2015年期间因创伤性肾损伤接受治疗的所有18岁及以下儿童。AISS代码被转换为美国创伤外科协会（AAST）分级。使用国际疾病分类第九版（ICD - 9）代码来识别接受肾动脉血管造影的患者，以及其他肾脏干预措施，如肾切除术、部分肾切除术、经皮肾造瘘管置入或输尿管支架置入。
2012年至2015年NTDB中有536379例儿科创伤病例，其中识别出4506例肾损伤病例。共有88例患者接受了肾动脉血管造影（ICD - 9 88.45）。接受肾动脉血管造影的患者中只有10%（n = 9）接受了额外的泌尿外科干预。在这9例患者中，有2例因肾动脉血管造影在肾切除术后进行而被排除。其余7例患者为高级别裂伤（AAST 4 - 5级）。总体而言，2例患者在血管造影后进行了肾切除术，2例患者进行了部分肾切除术，1例放置了经皮肾造瘘管（在部分肾切除术之前），1例对肾脏进行了抽吸（在输尿管支架置入之前），3例进行了输尿管支架置入。
本研究的局限性包括：NTDB是一个全国性数据集，并非基于人群，纳入仅限于首次住院治疗，在病例编码中存在不准确之处，并且数据库缺乏肾损伤的侧别信息。基于ICD - 9血管栓塞编码的非特异性性质，我们无法辨别血管造影后或血管造影时随后进行血管栓塞的病例数量。
儿童肾动脉血管造影仍然是一种罕见的操作，在肾创伤儿童中为88/4506。在接受肾动脉血管造影的儿科创伤病例中，更高级别损伤的额外手术更为常见。需要进一步研究以创建针对儿科的创伤管理算法。
