1. Conservative Management of Penetrating Renal Injuries Aaron Smith, DO Efraim Serafetinides, MD Richard A. Santucci, MD

2. Introduction Penetrating renal trauma had traditionally been treated by renal exploration. 1 Renal exploration is associated with nephrectomy rates ranging from 11- 64%. 2 Nephrectomy can lead to increased morbidity, mortality, renal failure rates. 3-,4 Currently, non-operative management has gained acceptance for management of renal stab wounds. 5 Expectant management has an increasing role in the management of abdominal gunshot wounds (GSW). 6,7 1.Scott, R., Jr., Carlton, C., et al. Penetrating injuries of the kidney: an analysis of 181 patients. J. Urol., 101: 247, 1969. 2.Wessells H, Suh D, Parker Jr, et al. Renal injury and operative management in the United States: results of a population-based study. J. Trauma, 2003; 54: 423-430. 3.McGonigal MD, Lucas CE, Ledgerwood AM. The effects of treatment of renal trauma on renal function. J Trauma. 1987; 27: 471- 476. 4.Narrod JA, Moore EE, Posner M, et al. Nephrectomy following trauma-impact on patient outcome. J Trauma. 1985; 25: 842-844. 5.Armenakas NA, Duckett CP, McAninch JW. Indications for nonoperative management of renal stab wounds. J Urol. 1999; 161: 768-771. 6.Hammer CC, Santucci RA. Effect of an institutional policy of nonoperative treatment of grade I-IV renal injuries. J Urol. 2003; 169: 1751-1753 7.Wessells H, McAninch JW, Meyer A, et al. Criteria for nonoperative treatment of significant penetrating renal lacerations. J Urol. 1997; 157. 24-27.

3. Purpose Review our experience in penetrating renal trauma when employing principles of expectant management Bolster current literature on expectant management of penetrating renal injury Reduce iatrogenic nephrectomy rates

4. Study Design IRB approved Multi-institutional – Detroit Medical Center (DMC) – Athens, Greece Retrospective analysis 1990-2004 (Greece) 2000-2007 (DMC)

5. Patients Greece – AAST Grade II-III – 85 stab wounds – 41 GSWs 30 low-velocity gunshot wounds (LVGSW) 11 high-velocity gunshot wounds (HVGSW) DMC – AAST Grade III-IV – 2 stab wounds – 11 GSWs (LVGSW)

6. Materials & Methods 139 charts were reviewed from two trauma databases Injury type (stab, GSW), AAST Grade, physical and radiographic findings, associated injuries, management and follow-up was noted Initial evaluation included physical exam, lab tests and radiographic staging All hemodynamically stable patients were selected for conservative management of their GU injuries

7. Materials & Methods Patients with hemodynamic instability or injury to renal pelvis/ureter on imaging were taken for renal exploration Those selected for expectant management were treated with: – Serial physical exams by experienced teams – Hematocrit monitoring – Hemodynamic monitoring – Antibiotics – Bed rest

8. Materials & Methods The GSW, stab wound subgroups were compared with regard to: – Mean associated injuries/patient – Transfusion requirement – Need for nephrectomy – Delayed complications – Mean Length of Stay (LOS) – Death

9. Results OutcomeStatusStab (N=87)GSW (N=52)P-value TransfusionYes14 (16%)40 (77%) <.0001 No73 (84%)12 (23%) NephrectomyYes0 (0%)16 (31%)<.0001 No87 (100%)36 (69%) Delayed Complication Yes9 (10%)4 (8%)0.767 No78 (90%)48 (92%)

10. Results OutcomeStab (N=87)GSW (N=52) Mean associated injuries/patient 0.532.1 Mean days of hospitalization 6.817.6 Death01

11. Results Surgical Intervention Stab (N=87) LVGSW (N=41) HVGSW (N=11) Drainage/ stent 1 (1.1%)3 (7.3%)0 (0%) Renorrhaphy2 (2.3%)8 (19.5%)0 (0%) Partial Nephrectomy 1 (1.1%)5 (12.2%)0 (0%) Nephrectomy0 (0%)5 (12.2%)11 (100%)

12. Results 83/87 (95.2%) of patients with stab wounds were successfully treated expectantly. Number of lost renal units=0 20/41 (48.8%) of LVGSW patients did not require GU- specific surgical intervention (51% operative rate). Number of lost renal units= 5 11/11 (100%) of HVGSW patients underwent nephrectomy 16/52 (30.8%) total GSW patients underwent nephrectomy

13. Conclusions Expectant management is a reasonable option for the treatment of renal stab wounds Approximately 50% of patients with LVGSW will require GU-specific surgical intervention HVGSW mandated more aggressive treatment A renal salvage rate of 88.5% (123/139) for penetrating trauma was achieved with selected exploration and an organ preserving strategy for grades II-IV renal injury.