1. Renal Arterial Injuries: A Single Center Analysis of Management Strategies and Outcomes Sean P. Elliott, Ephrem O. Olweny and Jack W. McAninch * From the Department of Urologic Surgery, University of Minnesota, Minneapolis, Minnesota, and Department of Urology, University of California-San Francisco and San Francisco General Hospital (EOO, JWM), San Francisco, California Vol. 178, 2451-2455, December 2007 THE JOURNAL OF UROLOGY. DOI:10.1016/j.juro.2007.08.002

2. Purpose

3. Renal injury occurs in up to 1.2% of trauma cases in the United States. Only 2.5% to 4% of these cases involves the renal vasculature Renovascular injuries are associated with multiple non-renal organ injuries and with a high mortality rate of 19% to 44% Management of main and segmental renal artery injury following external trauma is controversial After main renal artery injury the controversy surrounds nephrectomy vs revascularization whereas after segmental renal artery injury the debate involves operative vs nonoperative management

4. Materials and Methods

5. Data on a total of 82 renal artery injuries in 81 patients collected between 1978 and 2006 They were retrospectively reviewed Patient demographics, length of stay, transfusion requirements and injury characteristics (artery subtype, grade, mechanism, and associated parenchymal, venous and nonrenal injuries) were recorded. Management strategies and outcomes for each renal artery injury subtype were compared.

6. TABLE 1. Patient and injury characteristics MAI SRAI Totals No. pts (%) 36 (43) 45 (57) 81 Median age (range) 29 (15–74) 27 (4–68) 28 (4–74) No. males (%) 30 (41) 43 (59) 73 (90) No. females (%) 6 (14) 2 (5) 8 (10) No. trauma (%): Penetrating 20 (49) 21 (51) 41 (51) Blunt 16 (40) 24 (60) 40 (49) No. Parenchymal 21 (45) 26 (55) 47 (58) laceration (%) No. associated injuries (%) 34 (47) 38 (53) 72 (89) No. shock (%) 26 (57) 20 (43) 46 (57) No. hematuria/total 30/33 (91) 30/34 (88) 60/67 (90) No. (%): Gross 18/30 (60) 15/30 (50) 33/60 (55) Microscopic 12/30 (40) 15/30 (50) 27/60 (45) Absent 3/33 (9) 4/34 (12) 7/67 (10) Unknown 3/36 (8) 11/45 (24) 14/81 (17) No. RAIs (%): 36 46 82 Isolated arterial injury 16 (29) 39 (71) 55 (67) Combined arterial 20 (74) 7 (26) 27 (33) venous injury No. injury grade/total No. (%): 4 4/48 (8) 44/48 (92) 48/82 (59) 5 32/34 (94 ) 2/34 (6) 34/82 (41)

8. For main renal artery injury the respective outcomes of nephrectomy vs vascular repair were a mean transfusion of 10,275 vs 6,125 ml (p 0.39) Length of stay 18 days for each, mortality rate 26% vs 13%, renal Failure rate 8% vs 25% Renal insufficiency/impaired selective function by renal scintigraphy 4% vs 13% (each p not significant).

9. TABLE 2. Outcomes of nephrectomy vs vessel repair for MRAI Nephrectomy Vessel Repair p Value No. pts 23 8 Mean SD transfusion requirement (ml) 10,275 12,871 6,125 5,393 0.39 Mean SD LOS (days) 17.9 22 18.3 21 0.97 No. death during hospitalization (%) 6 (26) 1 (12.5) 0.4 No. renal failure (%) 2* (8) 2 (25) 0.29 No. hypertension 1* 0 0.57 No. renal insufficiency (Cr mg/dl 1.5 or greater) or impaired renal function 1 (4) 1 (12.5) 0.47 40% or less by renal scan (%) No. other renal related complications during hospitalization (%)† 1 (4) 0 0.57 No. nonrenal nonfatal complications during hospitalization (%) 4 (17) 0 0.28 No. uneventful hospitalization, lost to followup (%) 6 (26) 2 (25) 1 No. no sequelae, Cr 1.5 mg/dl or less at followup 3 (13) 2 (25) 0.59 The patient who underwent bilateral renovascular surgery had hypertension associated with renal failure. †Eg infection

10. For segmental renal artery injury operative vs nonoperative management was associated with a mean transfusionof 4,994 vs 820 ml (p 0.01) Length of stay 29 vs 11 days (p 0.23) and mortality rate 8% vs 6% (p 1.0). Renal failure and impaired selective renal function on scintigraphy were similar between the groups.

11. TABLE 3. Outcomes of operative vs nonoperative SRAD management Operative Nonoperative p Value No. pts 24 18 Mean SD transfusion requirement (ml) 4,994 6,016 820 903 0.01 Mean SD LOS (days) 29.3 59 11.3 12 0.23 No. death during hospitalization (%) 2 (8) 1 (6) 1 No. renal failure (%) 2* (8) 0 0.5 No. hypertension (%) 1* 1 (6) 1 No. renal insufficiency or impaired renal 2 (8) 3 (16) 0.65 function 40% or less by renal scan (%) No. persistent urinoma requiring intervention (%) 0 1 (6) 0.46 No. renal related complications during hospitalization (%)† 1 (4) 0 1 No. nonrenal nonfatal complications during hospitalization (%) 4 (17) 0 0.12 No. uneventful hospitalization, lost to followup (%) 6 (25) 9 (50) 0.11 No. no sequelae, Cr 1.5 mg/dl or less at followup (%) 7 (29) 3 (16) 0.46 * The patient who underwent bilateral renovascular surgery had hypertension associated with renal failure. † Excluding urinoma.

12. Conclusion

13. Nephrectomy for main renal artery injury has outcomes similar to those of vascular repair and it does not worsen posttreatment renal function in the short term Nonoperative management for segmental renal artery injury results in excellent outcomes.

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