Tuesday, December 16, 2014

Historical Contribution: 1951, Hodges, Gilbert & Scott, Renal Trauma


1951
Hodges CV, Donald RG, Scott WW. Renal Trauma: A Study of 71 Cases. J Urol. 1951;56;5:627-37.


In 1951, axial imaging was not available for the diagnosis and staging of renal trauma. Given shortcomings in diagnostics, the invasiveness of existing diagnostics (i.e. retrograde pyelogram), and the, in general, favorable outcomes associated with renal trauma, the consensus of most general surgeons and urologists was to manage renal trauma conservatively. Expert opinion at the time stated:

"the majority of patients with renal trauma may be treated conservatively with the expectation that the injured kidney will recover sufficient function to be a useful and serviceable organ."
"extensive urologic investigation, including cystoscopy and retrograde pyelography, immediately after renal injury is usually unnecessary and often undesirable"
"in the majority of cases, medical treatment will be followed by functional results which are satisfactory, although various types of anatomic abnormalities may persist."
"most kidney injuries should be left alone. If the renal· pelvis is reasonably intact, the patient will soon recover. If the contour of the pelvis is blasted beyond recognition, nephrectomy is necessary."
The authors of this manuscript poke a number of holes in the argument for conservative treatment:
  1. The favorable outcomes of patients managed "conservatively" is biased by the inherent self-selection of severe renal trauma – those patients with the most severe injuries succumb to those injuries, those left for "conservative" management have an inherently improved chance at survival.
  2. Late complications (abscess, hydronephrosis, pyonephrosis, etc.) can cause complete loss of renal function.
  3. Unassociated renal diseases (hydronephrosis, malignancy of cortex or renal pelvis, cysts or polycystic kidney disease) are unrecognized in the setting of trauma and may have implications for future management.
  4. Patients undergoing "conservative" management can undergo protracted convalescence for weeks or years.
The authors therefore created a diagnostic and therapeutic algorithm based stratification of 71 renal injuries seen at the Johns Hopkins Hospital (1930-1948). They classified injuries as (1) minor, (2) major and (3) critical injuries.

Minor Injuries

Definition: Parenchymal damage without rupture of the capsule of extension of the defect into the collecting system.
Prevalence: 66.2%
Presentation: Do not present in shock, may have hematuria that resolves within 48-72 hours. Pain, when present, also improves within 72 hours.
Most importantly, excretory and retrograde pyelogram demonstrates integrity of the collecting system (– "the greatest single criterion for placing injuries in the minor group").
Management: Urography.
Average Hospitalization: 8 days

Major Injuries

Definition: Parenchymal damage with rupture of the capsule or calyces.
Prevalence: 32.4%
Presentation: Often presents as mass around the kidney and hematuria. Shock may or may not be present (and may be delayed for hours or days). Hematuria and symptoms persist for several days.
Extravasation on excretory or retrograde pyelogram indicates a "major" injury.
Management:

  • Immediate Surgery: 39% for repair or nephrectomy
  • Delayed Surgery: 48% (21 days to 35 years after trauma) for incapacitating sequelae of injury.
  • Conservative Management: 13%; of which 85.7% developed renal disease of "severe proportions" requiring future nephrectomy.

Average Hospitalization: 19.1 days (if operated on), 20 days (if conservative management)

Critical Injuries

Definition: Extension into or disruption of the renal vessels.
Prevalence: 1.4%
Presentation: Exquisite pain, early and profound shock; urography is not necessary nor does it yield valuable information if the vasculature is disrupted.
Management: Immediate surgery.
Average Hospitalization: 11 days

 

While our grading of renal trauma has developed into a more complex system, many of the principles outlined in this 1951 manuscript hold true today.

AAST (American Association for the Surgery of Trauma): 
http://www.aast.org/library/traumatools/injuryscoringscales.aspx


Also of interest are images of lower and upper pole heminephrectomy to preserve kidney function on the injured side (below).




To read the entire manuscript: follow the link above, visit the Centennial Website or click here.


HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

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