Redmond Elaine J, Kiddoo Darcie A, Metcalfe Peter D
Division of Urology, University of Alberta, Edmonton, Alberta, Canada. Electronic address: https://twitter.com/elainejredmond.
Division of Urology, University of Alberta, Edmonton, Alberta, Canada.
J Pediatr Urol. 2020 Oct;16(5):656.e1-656.e5. doi: 10.1016/j.jpurol.2020.06.033. Epub 2020 Jul 6.
Current guidelines advocating the conservative management of renal injuries in children are primarily extrapolated from adult series due to a dearth of evidence in the pediatric population.
The aim of this study was to review our experience in the management of pediatric high-grade renal trauma and to clarify the role of conservative management in this cohort of patients.
The Alberta Trauma Registry (ATR) is a comprehensive web-based registry which functions to prospectively collect data on all trauma patients in the province who sustain a severe injury (i.e. Injury Severity Score (ISS) ≥12). The ATR was used to identify all pediatric patients who attended hospitals within the Edmonton region with high grade renal injuries (grade III-V) between January 2006 and December 2018. Hospital records and imaging were reviewed to identify patient demographics, mechanism of injury, AAST grade, haemodynamic stability, associated injuries, management, length of hospital stay (LOS), complications, and follow-up outcomes.
A total of 53 children (38 boys, 15 girls) were identified with a mean age of 13 years (1-16). The mechanism of injury was blunt trauma in 92.5% (49/53) of cases (Supplementary Table). AAST grade distribution was 37.8% Grade III (20/53), 49% Grade IV (26/53) and 13.2% Grade V (7/53). All Grade III injuries were successfully managed conservatively. Overall 11 patients with Grade IV/V injuries required urological intervention (ureteral stenting (5 patients), angioembolization (4 patients), bladder washout with clot evacuation (1 patient), emergency nephrectomy (3 patients)). The overall renal salvage rate was 92.4% (49/53).
Our series confirms the safety of expectant management in high grade pediatric renal trauma. All grade III injuries in our study were managed conservatively without the need for intervention. This suggests that these injuries may be managed safely outside of designated trauma centres. One third of children with grade IV/V injuries required intervention. Therefore we recommend that patients with these injuries are transferred to specialized units with the capacity to provide such procedures if required.
This study supports the conservative management of pediatric renal trauma in the setting of high-grade injury. Expectant management was associated with acceptable rates of intervention and excellent renal salvage rates.
由于儿科人群缺乏证据，目前主张对儿童肾损伤进行保守治疗的指南主要是从成人系列研究中推断出来的。
本研究的目的是回顾我们在小儿重度肾外伤治疗方面的经验，并阐明保守治疗在这组患者中的作用。
艾伯塔创伤登记处（ATR）是一个基于网络的综合登记处，其功能是前瞻性收集该省所有遭受重伤（即损伤严重度评分（ISS）≥12）的创伤患者的数据。ATR用于识别2006年1月至2018年12月期间在埃德蒙顿地区医院就诊的所有患有重度肾损伤（III - V级）的儿科患者。查阅医院记录和影像学资料，以确定患者的人口统计学特征、损伤机制、美国创伤外科学会（AAST）分级、血流动力学稳定性、相关损伤、治疗方法、住院时间（LOS）、并发症及随访结果。
共识别出53名儿童（38名男孩，15名女孩），平均年龄13岁（1 - 16岁）。92.5%（49/53）的病例损伤机制为钝性创伤（补充表）。AAST分级分布为：III级37.8%（20/53），IV级49%（26/53），V级13.2%（7/53）。所有III级损伤均成功进行了保守治疗。总体而言，11例IV/V级损伤患者需要泌尿外科干预（输尿管支架置入术（5例）、血管栓塞术（4例）、膀胱冲洗并清除血凝块（1例）、急诊肾切除术（3例））。总体肾脏挽救率为92.4%（49/53）。
我们的系列研究证实了小儿重度肾外伤期待治疗的安全性。我们研究中的所有III级损伤均采用保守治疗，无需干预。这表明这些损伤在指定创伤中心以外也可安全治疗。三分之一的IV/V级损伤儿童需要干预。因此，我们建议，如果需要，将这些损伤的患者转移到有能力提供此类治疗的专科单位。
本研究支持在重度损伤情况下对小儿肾外伤进行保守治疗。期待治疗与可接受的干预率和优异的肾脏挽救率相关。
