Shekar P Ashwin, Ansari M S, Yadav Priyank, Srivastava Aneesh
Division of Pediatric Urology, Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
J Pediatr Urol. 2020 Oct;16(5):657.e1-657.e9. doi: 10.1016/j.jpurol.2020.07.017. Epub 2020 Jul 23.
Non-operative management of higher-grade renal injuries has gradually become accepted in pediatric circles following multiple studies over the past decade which showed good renal salvage rates. However, some children do fail this conservative approach and need interventions which are mostly minimally invasive. There is still paucity of studies on the functional outcomes in this unique subgroup of patients. In this study, we review our management and functional outcome of children with grade IV renal injury due to blunt trauma of abdomen managed with minimally invasive interventions (MII) in a tertiary referral center.
The present study seeks to summarize contemporary management of pediatric grade IV renal injury due to blunt trauma at our tertiary care center and to assess the functional outcomes in the subgroup who needed MII.
A retrospective review was performed on children≤18 years with abdominal blunt trauma managed at our tertiary care facility over the past 10 years (January 2008-January 2018) to identify those with grade IV renal injuries. Data collected included demographic data like age, sex, mechanism of injury, incidence of hematuria, incidence of pre-existing urologic conditions, associated non-renal injuries, transfusion requirements, imaging findings, type of interventions, length of hospital stay, complications and outcomes on follow up.
Review of our institutional database identified 10 children with grade IV renal injury. Mean age was 11.7 ± 3.6 years (range, 6-18) and majority (6/10) were male. Motor vehicle collision and fall from heights were the commonest mechanisms of injury. While one patient responded to non-operative management, one girl needed emergency renal exploration and later nephrectomy. Eight needed minimally invasive interventions following initial non-operative management. One patient needed nephrectomy due to delayed hemorrhage while three patients needed delayed open reconstruction. The salvage rate in the group which needed interventions was 87.5% (7 of 8) however, the functional outcome was good only in 50% (4 of 8) of patients. The outcomes were better in those who were managed with MII earlier (3/4) compared to those who underwent delayed intervention (1/4). The median hospital stay was 11.5 days (range 7-34 days).
Pediatric patients with non-exsanguinating grade IV renal injuries due to blunt trauma who fail non-operative management and need minimal invasive interventions have good renal salvage rates however, the functional outcomes are poorer. Judicious and early use of these minimally invasive interventions, instead of persisting with non-operative management can possibly improve these functional outcomes.
在过去十年的多项研究表明较高等级肾损伤的非手术治疗具有良好的肾脏挽救率后，这种治疗方法在儿科领域逐渐被接受。然而，一些儿童在这种保守治疗方法下治疗失败，需要进行大多为微创的干预措施。对于这一独特患者亚组的功能结局，研究仍然较少。在本研究中，我们回顾了在一家三级转诊中心采用微创干预措施（MII）治疗腹部钝性创伤所致IV级肾损伤儿童的治疗情况及功能结局。
本研究旨在总结我们三级医疗中心对儿科钝性创伤所致IV级肾损伤的当代治疗方法，并评估需要微创干预措施的亚组患者的功能结局。
对过去10年（2008年1月至2018年1月）在我们三级医疗设施接受治疗的18岁及以下腹部钝性创伤儿童进行回顾性研究，以确定那些患有IV级肾损伤的儿童。收集的数据包括年龄、性别、损伤机制、血尿发生率、既往泌尿系统疾病发生率、相关非肾损伤、输血需求、影像学检查结果、干预类型、住院时间、并发症及随访结局等人口统计学数据。
回顾我们的机构数据库，确定了10例IV级肾损伤儿童。平均年龄为11.7±3.6岁（范围6 - 18岁），大多数（6/10）为男性。机动车碰撞和高处坠落是最常见的损伤机制。1例患者对非手术治疗有反应，1名女孩需要紧急肾脏探查，后来进行了肾切除术。8例在初始非手术治疗后需要微创干预措施。1例患者因延迟出血需要肾切除术，3例患者需要延迟开放重建。需要干预措施的组的挽救率为87.5%（8例中的7例），然而，仅50%（8例中的4例）患者的功能结局良好。早期采用微创干预措施治疗的患者（3/4）的结局优于接受延迟干预的患者（1/4）。中位住院时间为11.5天（范围7 - 34天）。
因钝性创伤导致非出血性IV级肾损伤且非手术治疗失败并需要微创干预措施的儿科患者具有良好的肾脏挽救率，然而，功能结局较差。明智且早期使用这些微创干预措施，而非坚持非手术治疗，可能会改善这些功能结局。
