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Clinical Indications for Radiographic Evaluation of Blunt Renal Trauma
0022-534 7/86/1362-0370$02.00/0 Vol. 136, August Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1986 by The Williams & Wilkins Co.
CLINICAL INDICATIONS FOR RADIOGRAPHIC EVALUATION OF BLUNT RENAL TRAUMA A. S. CASS,* M. LUXENBERG, P. GLEICH
AND
C. S. SMITH
From the Department of Urology, St. Paul-Ramsey Medical Center, St. Paul and Urology Service, Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT
The evaluation of patients with blunt renal trauma has become controversial. We tested the hypothesis that renal contusion can be diagnosed clinically and that these patients do not require radiographic evaluation. To evaluate the association of microhematuria without shock and with renal contusion, we reviewed the medical records of 831 patients with hematuria following blunt renal trauma. Microscopic hematuria without shock was noted in 160 of 241 patients without and 334 of 590 with associated injuries. Of the former 160 patients 159 had renal contusion and 1 had a renal laceration, while of the latter 334 patients 329 had renal contusion, 3 had renal laceration, 1 had renal rupture and 1 had a pedicle injury. Most patients with microscopic hematuria and no shock after blunt renal trauma had a renal contusion, especially those with no associated injury. All of the patients with renal contusions experienced no complications from nonoperative management. However, avoiding a radiographic evaluation in patients with blunt renal trauma plus microhematuria and no shock would miss a few cases of severe renal injury. arteriography if the IVP showed indeterminate findings or nonvisualization. The type of renal injury was diagnosed by clinical findings, radiographic evaluation, renal exploration or autopsy. Renal injuries were classified as 1) renal contusion-bruise or subcapsular hematoma with an intact renal capsule (793 patients, 95 per cent), 2) renal laceration-parenchymal disruption with rupture of the renal capsule and perirenal hematoma (22 patients, 3 per cent), 3) renal rupture-shattered kidney with multiple deep lacerations (8 patients, 1 per cent) and 4) renal pedicle injury-occlusion or tearing of the renal artery or vein, or their main branches (8 patients, 1 per cent). Followup 3 months after injury included clinical evaluation, blood pressure recording and radiological evaluation with IVP, isotope studies or CT.
Time and money would be saved if a radiographic evaluation could be avoided in patients who were known to have a renal contusion only following blunt renal trauma, since all renal contusions resolve with no complications from nonoperative management. Nicolaisen and associates studied 306 patients with blunt renal trauma and reported that all patients with clinical findings of microhematuria and no shock (systolic blood pressure less than 90 mm. Hg) following blunt trauma had a renal contusion. 1 They recommended that excretory urography (IVP) could be avoided in this group, since these patients experienced no complications from nonoperative management. We studied 831 patients with hematuria following blunt renal trauma to determine if there was any correlation among the degree of hematuria, presence or absence of shock and type of renal injury. MATERIAL AND METHODS
RESULTS
From 1976 to 1983, 84 7 consecutive patients with hematuria following blunt external trauma were admitted to our hospitals. Of these 84 7 patients 16 were excluded from the study because they had associated urinary tract injuries that could cause hematuria. Patients with hematuria, a pelvic fracture and a normal IVP were diagnosed as having a bladder injury, since the hematuria was believed to be from the bladder and not the kidney. Blunt renal trauma was owing to traffic accidents in 651 patients (78 per cent), a fall in 90 (11 per cent), a blow in 55 (7 per cent) and a sports injury in 35 (4 per cent). The age of the 831 patients was less than 20 years in 280 (34 per cent), 20 to 39 years in 435 (52 per cent), 40 to 59 years in 72 (9 per cent) and 60 or more years in 44 (5 per cent). There were 609 male patients (73 per cent). The clinical findings recorded on initial evaluation were the degree of hematuria found on microscopic urinalysis of centrifuged urine, shock (systolic blood pressure less than 100 mg. Hg) and all associated injuries (including intra-abdominal injuries that were found at admission laparotomy). The radiographic evaluation consisted of an initial IVP followed by a repeat IVP, computerized tomography (CT), or
The correlation between the degree of hematuria and type of renal injury is shown in table 1. Most patients with renal contusions had microhematuria and most with severe renal injuries had gross hematuria. However, 7 patients with severe renal injuries had microhematuria. The correlation between the IVP findings and the type of renal injury with the subsequent investigations needed to diagnose the type of renal injury is listed in table 2. A definitive IVP finding was present in 756 of the 813 patients (93 per cent) having an IVP. Incomplete filling or delayed visualization on an IVP was present in 57 patients (7 per cent), and the diagnosis of the type of renal injury was made with a repeat IVP in 7, retrograde pyelogram in 1, renal arteriogram in 14, renal exploration in 17 and clinical diagnosis in 18. Associated injuries were present in 557 of 793 patients (70 per cent) with renal contusion, 18 of 22 (82 per cent) with renal laceration, 7 of 8 (88 per cent) with renal rupture and all 8 (100 per cent) with pedicle injury (table 3). Analysis of the clinical findings and type of renal injury is given in table 4. Group 1 consisted of 337 patients with gross or microscopic hematuria and shock (systolic blood pressure less than 100 mm. Hg). Group 2 consisted of 494 patients with microscopic hematuria and no shock, including 6 with severe renal injuries and 488 with renal contusion. Of the former 6 patients 5 had associated injuries, while 1 did not. All 488
Accepted for publication March 7, 1986. *Requests for reprints: Department of Urology, St. Paul-Ramsey Medical Center, 640 Jackson St., St. Paul, Minnesota 55101.
370
371
RADIOGRAPHIC EVALUATION OF BLUNT RENAL TRAUMA TABLE
L Correlation between degree of hematuria and type of renal
TABLE 3.
injury
Correlation of associated injuries with type of renal injury and clinical findings
Type of Renal Injury Contusion Urinalysis (red blood cells per high power field): <8 8-30 30-50 Full field/ gross Totals
TABLE
Laceration
15 236 312 230 793
Rupture
Type of Renal Injury Pedicle Injury
17
0 1 7
0 0 1 7
22
8
8
0 1 4
0
Totals
15 237 318 261 831
2. Correlation between !VP findings and subsequent
classification of blunt renal injuries Type of Renal Injury Pedicle Injury
Totals
0 3 0
8
0 5 3 0
4
732 9* 15t 45:j:
11
1
0
0
12§
14 793
3
0
1
22
8
8
1811 831
IVP Finding Contusion Normal Nonfunction Extravasation Incomplete filling Delayed visualization Not done Totals
732 1 ?2 33
Laceration
0 0 10
Rupture
Pedicle Injury
Totals
Contusion
Laceration
No. pts. with associated injury No. pts. with laparotomy
557
18
7
8
590
194
13
7
6
220
Ruptured diaphragm Ruptured spleen Ruptured liver Ruptured bowel Abdominal vessel injury Retroperitoneal hematoma Fractured ribs Fractured skull Fractured spine Fractured pelvis Fractured extremities Totals
11 121 69 22 7
0 7
1 5
2 0
0 6 1 1 0
1 0
12 139 76 26 7
37
8
3
4
52
165 105 91 81 232 941
6 3 4 0 3
2 2 2 1 2
3 1 3 2 3
37
20
25
176 111 100 84 240 1,023
TABLE 4.
Rupture
4
2
Clinical findings and type of blunt renal injury Type of Renal Injury
Contusion
* Confirmed by renal exploration in 9 patients. t Confirmed by renal exploration in 12 patients, CT in 2 and renal arteriogram in 1. :j: Confirmed by repeat !VP in 7 patients, renal arteriogram in 11, renal exploration in 13 and clinical diagnosis in 14. § Confirmed by retrograde pyelogram in 1 patient, renal arteriogram in 3, renal exploration in 4 and clinical diagnosis in 4. II Confirmed by CT in 1 patient, renal arteriogram in 1, renal exploration in 1, clinical diagnosis in 9 and autopsy in 6.
patients with renal contusion, microhematuria and no shock were managed nonoperatively with no complications. One patient had a pre-existing congenital hydronephrosis owing to ureteropelvic junction obstruction and a delayed nephrectomy was performed. DISCUSSION
Nicolaisen and associates evaluated 306 patients with blunt renal injuries prospectively and reported that all of the patients with the clinical findings of microhematuria and no shock at hospitalization had a renal contusion. 1 They recommended that an IVP could be avoided in this group, since these patients experienced no complications from nonoperative management. A retrospective evaluation of our 831 patients with hematuria following blunt renal trauma showed that microhematuria and no shock were present at hospitalization in 494 patients: 6 (1 per cent) had severe renal injuries (laceration in 4, rupture in 1 and pedicle injury in 1) and 488 (99 per cent) had renal contusion. Five of 334 patients (1.5 per cent) with associated injuries had severe renal injuries, compared to only 1 of 160 (0.6 per cent) with no associated injuries. All of our patients with renal contusion had no complications with nonoperative management.
Laceration
Rupture
Pedicle Injury
Totals
Patients with no w;sociated injury Group 1 Group 2 Totals
77 159 236
3 1
4
1 0
I
0 0
0
81 160 241
Patients with w;sociated injuries Group 1 Group 2 Totals
228 329 557
15 3
6 1
Is
7 1
7
8
256 334 590
The aim of urologists managing renal trauma is to determine at hospitalization the exact site and extent of renal injury, and which renal injury will resolve with nonoperative management. Nicolaisen and associates furthered this aim by correlating clinical findings with the type of renal injury, and advocating the avoidance of radiographic evaluation in patients with microscopic hematuria and no shock. 1 In their study all such patients had renal contusions that resolved with no complication on nonoperative management. Our data show that while most patients with microhematuria and no shock after blunt renal trauma had a renal contusion and experienced no complications with nonoperative management, a small number with this clinical presentation had severe renal injuries that would have been missed without radiographic evaluation. REFERENCE
1. Nicolaisen, G. S., McAninch, J. W., Marshall, G. A., Bluth, R. F.,
Jr. and Carroll, P. R.: Renal trauma: re-evaluation of the indications for radiographic assessment. J. Urol., 133: 183, 1985.
THE JOURNAL OF UROLOGY
Copyright © 1986 by The Williams & Wilkins Co.
CLINICAL INDICATIONS FOR RADIOGRAPHIC EVALUATION OF BLUNT RENAL TRAUMA A. S. CASS,* M. LUXENBERG, P. GLEICH
AND
C. S. SMITH
From the Department of Urology, St. Paul-Ramsey Medical Center, St. Paul and Urology Service, Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT
The evaluation of patients with blunt renal trauma has become controversial. We tested the hypothesis that renal contusion can be diagnosed clinically and that these patients do not require radiographic evaluation. To evaluate the association of microhematuria without shock and with renal contusion, we reviewed the medical records of 831 patients with hematuria following blunt renal trauma. Microscopic hematuria without shock was noted in 160 of 241 patients without and 334 of 590 with associated injuries. Of the former 160 patients 159 had renal contusion and 1 had a renal laceration, while of the latter 334 patients 329 had renal contusion, 3 had renal laceration, 1 had renal rupture and 1 had a pedicle injury. Most patients with microscopic hematuria and no shock after blunt renal trauma had a renal contusion, especially those with no associated injury. All of the patients with renal contusions experienced no complications from nonoperative management. However, avoiding a radiographic evaluation in patients with blunt renal trauma plus microhematuria and no shock would miss a few cases of severe renal injury. arteriography if the IVP showed indeterminate findings or nonvisualization. The type of renal injury was diagnosed by clinical findings, radiographic evaluation, renal exploration or autopsy. Renal injuries were classified as 1) renal contusion-bruise or subcapsular hematoma with an intact renal capsule (793 patients, 95 per cent), 2) renal laceration-parenchymal disruption with rupture of the renal capsule and perirenal hematoma (22 patients, 3 per cent), 3) renal rupture-shattered kidney with multiple deep lacerations (8 patients, 1 per cent) and 4) renal pedicle injury-occlusion or tearing of the renal artery or vein, or their main branches (8 patients, 1 per cent). Followup 3 months after injury included clinical evaluation, blood pressure recording and radiological evaluation with IVP, isotope studies or CT.
Time and money would be saved if a radiographic evaluation could be avoided in patients who were known to have a renal contusion only following blunt renal trauma, since all renal contusions resolve with no complications from nonoperative management. Nicolaisen and associates studied 306 patients with blunt renal trauma and reported that all patients with clinical findings of microhematuria and no shock (systolic blood pressure less than 90 mm. Hg) following blunt trauma had a renal contusion. 1 They recommended that excretory urography (IVP) could be avoided in this group, since these patients experienced no complications from nonoperative management. We studied 831 patients with hematuria following blunt renal trauma to determine if there was any correlation among the degree of hematuria, presence or absence of shock and type of renal injury. MATERIAL AND METHODS
RESULTS
From 1976 to 1983, 84 7 consecutive patients with hematuria following blunt external trauma were admitted to our hospitals. Of these 84 7 patients 16 were excluded from the study because they had associated urinary tract injuries that could cause hematuria. Patients with hematuria, a pelvic fracture and a normal IVP were diagnosed as having a bladder injury, since the hematuria was believed to be from the bladder and not the kidney. Blunt renal trauma was owing to traffic accidents in 651 patients (78 per cent), a fall in 90 (11 per cent), a blow in 55 (7 per cent) and a sports injury in 35 (4 per cent). The age of the 831 patients was less than 20 years in 280 (34 per cent), 20 to 39 years in 435 (52 per cent), 40 to 59 years in 72 (9 per cent) and 60 or more years in 44 (5 per cent). There were 609 male patients (73 per cent). The clinical findings recorded on initial evaluation were the degree of hematuria found on microscopic urinalysis of centrifuged urine, shock (systolic blood pressure less than 100 mg. Hg) and all associated injuries (including intra-abdominal injuries that were found at admission laparotomy). The radiographic evaluation consisted of an initial IVP followed by a repeat IVP, computerized tomography (CT), or
The correlation between the degree of hematuria and type of renal injury is shown in table 1. Most patients with renal contusions had microhematuria and most with severe renal injuries had gross hematuria. However, 7 patients with severe renal injuries had microhematuria. The correlation between the IVP findings and the type of renal injury with the subsequent investigations needed to diagnose the type of renal injury is listed in table 2. A definitive IVP finding was present in 756 of the 813 patients (93 per cent) having an IVP. Incomplete filling or delayed visualization on an IVP was present in 57 patients (7 per cent), and the diagnosis of the type of renal injury was made with a repeat IVP in 7, retrograde pyelogram in 1, renal arteriogram in 14, renal exploration in 17 and clinical diagnosis in 18. Associated injuries were present in 557 of 793 patients (70 per cent) with renal contusion, 18 of 22 (82 per cent) with renal laceration, 7 of 8 (88 per cent) with renal rupture and all 8 (100 per cent) with pedicle injury (table 3). Analysis of the clinical findings and type of renal injury is given in table 4. Group 1 consisted of 337 patients with gross or microscopic hematuria and shock (systolic blood pressure less than 100 mm. Hg). Group 2 consisted of 494 patients with microscopic hematuria and no shock, including 6 with severe renal injuries and 488 with renal contusion. Of the former 6 patients 5 had associated injuries, while 1 did not. All 488
Accepted for publication March 7, 1986. *Requests for reprints: Department of Urology, St. Paul-Ramsey Medical Center, 640 Jackson St., St. Paul, Minnesota 55101.
370
371
RADIOGRAPHIC EVALUATION OF BLUNT RENAL TRAUMA TABLE
L Correlation between degree of hematuria and type of renal
TABLE 3.
injury
Correlation of associated injuries with type of renal injury and clinical findings
Type of Renal Injury Contusion Urinalysis (red blood cells per high power field): <8 8-30 30-50 Full field/ gross Totals
TABLE
Laceration
15 236 312 230 793
Rupture
Type of Renal Injury Pedicle Injury
17
0 1 7
0 0 1 7
22
8
8
0 1 4
0
Totals
15 237 318 261 831
2. Correlation between !VP findings and subsequent
classification of blunt renal injuries Type of Renal Injury Pedicle Injury
Totals
0 3 0
8
0 5 3 0
4
732 9* 15t 45:j:
11
1
0
0
12§
14 793
3
0
1
22
8
8
1811 831
IVP Finding Contusion Normal Nonfunction Extravasation Incomplete filling Delayed visualization Not done Totals
732 1 ?2 33
Laceration
0 0 10
Rupture
Pedicle Injury
Totals
Contusion
Laceration
No. pts. with associated injury No. pts. with laparotomy
557
18
7
8
590
194
13
7
6
220
Ruptured diaphragm Ruptured spleen Ruptured liver Ruptured bowel Abdominal vessel injury Retroperitoneal hematoma Fractured ribs Fractured skull Fractured spine Fractured pelvis Fractured extremities Totals
11 121 69 22 7
0 7
1 5
2 0
0 6 1 1 0
1 0
12 139 76 26 7
37
8
3
4
52
165 105 91 81 232 941
6 3 4 0 3
2 2 2 1 2
3 1 3 2 3
37
20
25
176 111 100 84 240 1,023
TABLE 4.
Rupture
4
2
Clinical findings and type of blunt renal injury Type of Renal Injury
Contusion
* Confirmed by renal exploration in 9 patients. t Confirmed by renal exploration in 12 patients, CT in 2 and renal arteriogram in 1. :j: Confirmed by repeat !VP in 7 patients, renal arteriogram in 11, renal exploration in 13 and clinical diagnosis in 14. § Confirmed by retrograde pyelogram in 1 patient, renal arteriogram in 3, renal exploration in 4 and clinical diagnosis in 4. II Confirmed by CT in 1 patient, renal arteriogram in 1, renal exploration in 1, clinical diagnosis in 9 and autopsy in 6.
patients with renal contusion, microhematuria and no shock were managed nonoperatively with no complications. One patient had a pre-existing congenital hydronephrosis owing to ureteropelvic junction obstruction and a delayed nephrectomy was performed. DISCUSSION
Nicolaisen and associates evaluated 306 patients with blunt renal injuries prospectively and reported that all of the patients with the clinical findings of microhematuria and no shock at hospitalization had a renal contusion. 1 They recommended that an IVP could be avoided in this group, since these patients experienced no complications from nonoperative management. A retrospective evaluation of our 831 patients with hematuria following blunt renal trauma showed that microhematuria and no shock were present at hospitalization in 494 patients: 6 (1 per cent) had severe renal injuries (laceration in 4, rupture in 1 and pedicle injury in 1) and 488 (99 per cent) had renal contusion. Five of 334 patients (1.5 per cent) with associated injuries had severe renal injuries, compared to only 1 of 160 (0.6 per cent) with no associated injuries. All of our patients with renal contusion had no complications with nonoperative management.
Laceration
Rupture
Pedicle Injury
Totals
Patients with no w;sociated injury Group 1 Group 2 Totals
77 159 236
3 1
4
1 0
I
0 0
0
81 160 241
Patients with w;sociated injuries Group 1 Group 2 Totals
228 329 557
15 3
6 1
Is
7 1
7
8
256 334 590
The aim of urologists managing renal trauma is to determine at hospitalization the exact site and extent of renal injury, and which renal injury will resolve with nonoperative management. Nicolaisen and associates furthered this aim by correlating clinical findings with the type of renal injury, and advocating the avoidance of radiographic evaluation in patients with microscopic hematuria and no shock. 1 In their study all such patients had renal contusions that resolved with no complication on nonoperative management. Our data show that while most patients with microhematuria and no shock after blunt renal trauma had a renal contusion and experienced no complications with nonoperative management, a small number with this clinical presentation had severe renal injuries that would have been missed without radiographic evaluation. REFERENCE
1. Nicolaisen, G. S., McAninch, J. W., Marshall, G. A., Bluth, R. F.,
Jr. and Carroll, P. R.: Renal trauma: re-evaluation of the indications for radiographic assessment. J. Urol., 133: 183, 1985.