Loftus Christopher J, Hagedorn Judith C, Johnsen Niels V
From the Department of Urology (C.J.L., J.C.H.), University of Washington Medical Center, Seattle, Washington; and Department of Urology (N.V.J.), Vanderbilt University Medical Center, Nashville, Tennessee.
J Trauma Acute Care Surg. 2021 Jan 1;90(1):143-147. doi: 10.1097/TA.0000000000002966.
Most high-grade renal injuries with urinary extravasation (UE) may be managed conservatively without intervention. For such patients, the American Urological Association Urotrauma guidelines recommend repeat imaging within 48 to 72 hours of injury. We sought to examine whether routine, proactive follow-up renal imaging was associated with need for urologic intervention or risk of complications.
Patients treated to an urban level 1 trauma center for a five-state region, between 2005 and 2017 were identified by International Classification of Diseases, Ninth Revision and Tenth Revision, codes from a prospectively collected institutional trauma registry. Individual patient charts and imaging were reviewed to identify all patients with American Association for the Surgery of Trauma grade IV renal injuries. Those with UE were included, and patients with penetrating trauma, immediate urologic surgery, or in-hospital mortality were excluded.
Of 342 patients with grade IV injuries, 108 (32%) met the inclusion criteria. Urologic intervention was performed in 23% (25 of 108 patients) including endoscopic procedure (24 of 108 patients) and nephrectomy (1 of 108 patients). Repeat imaging was performed within 48 to 72 hours after initial imaging in 65% (70 to 108 patients). Patients who underwent routine reimaging had a higher rate of undergoing subsequent urologic procedure (31.4% vs. 7.1%, p = 0.008). For patients with reimaging who underwent a procedure, 18% (4 of 22 patients) were symptomatic, while all nonroutinely reimaged patients who underwent a procedure were symptomatic (3 of 3 patients). Patients who received routine repeat imaging had a higher mean number of abdominal computed tomography scans during their admission (2.5 vs. 1.7, p < 0.001), while the complication rate was similar between groups.
Patients with grade IV renal lacerations with UE from blunt trauma who received routine repeat imaging were more likely to undergo an operation in the absence of symptoms and received more radiation during their hospital stay. Forgoing repeat imaging was not associated with an increase in urological complications. These data suggest that, in the absence of signs/symptoms, repeat imaging may be avoidable.
Therapeutic/care management, level IV.
大多数伴有尿外渗（UE）的重度肾损伤可采取保守治疗而无需干预。对于此类患者，美国泌尿外科学会尿创伤指南建议在损伤后48至72小时内进行重复影像学检查。我们试图研究常规的、积极的随访肾脏影像学检查是否与需要泌尿外科干预或并发症风险相关。
通过前瞻性收集的机构创伤登记处的国际疾病分类第九版和第十版编码，确定2005年至2017年期间在一个五州地区的城市一级创伤中心接受治疗的患者。查阅个体患者病历和影像学资料，以确定所有美国创伤外科学会IV级肾损伤患者。纳入伴有UE的患者，排除穿透性创伤、立即进行泌尿外科手术或住院死亡的患者。
在342例IV级损伤患者中，108例（32%）符合纳入标准。23%（108例患者中的25例）进行了泌尿外科干预，包括内镜手术（108例患者中的24例）和肾切除术（108例患者中的1例）。65%（108例患者中的70例）在初次影像学检查后48至72小时内进行了重复影像学检查。接受常规再次影像学检查的患者接受后续泌尿外科手术的比例更高（31.4%对7.1%，p = 0.008）。对于接受手术的再次影像学检查患者，18%（22例患者中的4例）有症状，而所有接受手术的非常规再次影像学检查患者均有症状（3例患者中的3例）。接受常规重复影像学检查的患者住院期间腹部计算机断层扫描的平均次数更多（2.5次对1.7次，p < 0.001），而两组间并发症发生率相似。
钝性创伤导致的伴有UE 的IV级肾裂伤患者接受常规重复影像学检查，更有可能在无症状的情况下接受手术，且住院期间接受更多辐射。放弃重复影像学检查与泌尿外科并发症增加无关。这些数据表明，在没有体征/症状的情况下，重复影像学检查可能是不必要的。
治疗/护理管理IV级。
