闭合性肾损伤的诊治(142例分析)

目的 探讨闭合性肾损伤的诊断及治疗.方法 回顾分析了7003年1月至2008年2月共收治闭合性肾损伤患者142例.结果 闭合性肾损伤患者治愈136例,其中保守治疗124例,肾修补2例,肾切除8例,选择性肾动脉栓塞治疗2例.死亡6例.结论 CT可准确进行伤情评估,对治疗方案有指导作用.严格掌握保守治疗和手术指征,预防并发症的发生.     

Late massive hematuria as a complication of conservative management of blunt renal trauma in children.

The conservative management of blunt renal trauma in children is well accepted and well documented in the medical literature. The majority of children who sustain blunt renal trauma do well with such an approach. However, the complications of conservative management are also well documented. We present 2 patients with blunt renal trauma who were treated conservatively and suffered massive life threatening hemorrhage several weeks after the initial injury. Angiography was not performed until late and in both cases it identified the cause of bleeding. Percutaneous transcatheter embolization provided immediate definitive treatment in both patients.     

Kidney trauma with underlying renal pathology: is conservative management sufficient?

To evaluate the pre-existing renal lesions (PERL) found incidentally during evaluation for blunt renal trauma, determine their importance, and suggest guidelines for effective management, including conservative treatment, we reviewed 180 patients who were hospitalized with blunt renal trauma between 1992 and 2008. Thirty of the 180 (16.6%) patients had PERL, which had been undiagnosed. The mean follow-up was 5 years (range 1-9 years). There were 24 men and 6 women with a mean age of 30 years (range 14-80 years). The most common cause of blunt renal injuries was falls and sports. Renal stones were present in 14 patients, pelvi-ureteric junction obstruction in 12, ectopic kidney in two, and megaureter and renal cyst in one case each. Ureteral stenting was used in four cases, and early nephrectomy was required in the other four. Fourteen patients underwent surgery for the PERL and not trauma, with a pyeloplasty in eight cases, partial nephrectomy in three cases, percutaneous nephrololithotomy in two cases, and ureteroneocystostomy in one case. In our study, the conservative treatment was possible in 73% of cases. We believe the published data support increasing conservative attempts in the hemodynamically stable patient.     

肾损伤450例的诊断和治疗

目的　提高肾损伤的诊疗水平。方法　对450例肾损伤进行了回顾性分析。结果　闭合性损伤423例,开放性损伤27例, 合并伤227例。B超阳性率68.2%,双倍剂量IVU阳性率47.9%,CT阳性率100%。根据病情分别选择手术与保守治疗,非手 术治愈365例,超选择性肾动脉栓塞4例,手术治愈67例,死亡14例。结论　B超检查快捷安全,应作为肾损伤首选检查方法, 在诊断中主要起到筛选作用。CT扫描为肾损伤程度分类和选择治疗方案提供可靠依据,应作为重度肾损伤和术前常规检查方 法。治疗取决于伤情,保守治疗是重要的治疗方法,严格掌握手术和非手术治疗指征是处理肾损伤的关键。     

Renal pseudoaneurysm after blunt renal trauma in a pediatric patient: management by angiographic embolization

Renal pseudoaneurysm is a rare complication after blunt renal trauma. Only 18 cases have been reported in English-language published reports. We present a case of blunt renal trauma in an 11-year-old boy, complicated by delayed bleeding from a renal artery pseudoaneurysm. The patient was initially treated with conservative measures and was later treated with selective embolization of the pseudoaneurysm. The clinical presentation, management options, and clinical decisions are discussed.     

Conservative... and non conservative... treatment of renal blunt injuries

Whether patients with blunt renal trauma should be managed conservatively without surgery or undergo surgery is often hard to decide. We describe three clinical cases of blunt renal trauma, all involving the left kidney. All three patients had abdominal ultrasound studies and computerized tomographic (CT) scans. In the first case, an accidental fall led to severe injury of the renal hilus causing massive retroperitoneal extravasation. The patient underwent emergency nephrectomy and survived. The second case concerned a patient who was involved in a road accident, suffered injuries mainly affecting the spleen, and underwent splenectomy. A postoperative CT scan showed left renal vein thrombosis functionally excluding the inferior pole of the kidney. The patient received conservative non surgical treatment. A follow-up imaging study showed that although the thrombosis had resolved the renal pole had failed to regain normal function. In the third case, mild apparently unimportant trauma led to a massive hemorrhage responsible for a severe shock state. Despite prompt nephrectomy, renal failure and and pulmonary complications developed and one month after the injuries the patient died. The medical history referred to a "chronic hematoma" secondary to a childhood injury. In this case, the pre-existing hematoma probably led to a permanent communication with the vascular and excretory tree thus resulting in a kind of "silent" fistula that the relatively mild injury unexpectedly disrupted. For the two left nephrectomies we used a midline approach after isolating the renal Treitz vessels; special care was taken to mobilize the left colon. Although blunt renal trauma often responds to non surgical conservative treatment, some patients should undergo prompt surgery. All patients must be scheduled for long-term clinical and imaging follow-up.     

Use of hematoma size on computerized tomography and calculated average bleeding rate as indications for immediate surgical intervention in blunt renal trauma.

One of the most demanding situations for a urologist is to decide which blunt renal trauma patients need immediate surgical exploration. Although computerized tomography can offer a lot of invaluable information, clear guidelines for selection of surgical versus conservative treatment are still lacking. A retrospective study of 15 blunt renal trauma cases showed that the hematoma size measured from computerized tomography using the method of summation planimetry bears a much closer correlation with the clinical outcome of the patient than does the degree of kidney parenchymal defect. Moreover, the average bleeding rate, calculated by dividing the size of the hematoma by the time elapsed from injury to scanning, gives a more accurate prediction for the need for immediate surgical treatment.     

Nierentrauma

Most renal injuries are blunt, involve a young patient population, and are caused by motor vehicle accidents or sport injuries. Renal trauma is classified into five grades with the majority of injuries being minor. CT scan has become the standard investigation method and should be performed in blunt trauma with macroscopic hematuria. Open trauma requires a radiological work-up in all forms of hematuria and in cases of clinical suspicion due to the wound entrance. Treatment management of most injuries has become conservative. Absolute indications for surgical revision are persistent life-threatening bleeding, renal pedicle injuries as well as an expanding, pulsatile retroperitoneal hematoma.Indications become relative in the presence of large devitalized renal tissue with urinary extravasation and other abdominal injuries, particularly of the pancreas and the colon. Surgical revision is more often indicated in open trauma, but surgery should enable renal reconstruction in the majority of cases.     

Conservative approach in major renal trauma

IntroductionGenitourinary trauma amount to an 8-10% of abdominal trauma with the kidney being the most affected organ in 50% of cases, especially the left one. The choice of treatment will depend on the kind of lesion found in the affected renal unit and on the patient’s clinical conditions.ObjectiveThe aims of this study are twofold: to determine the applicability of conservative treatment in major renal trauma and to assess the evaluation and emergence of possible complications.Material and methodsWe have analysed 309 cases of renal trauma dealt with in our department between January 1984 and January 2006, analyzing such variables as the etiology of the trauma, associated lesions in other organs, the therapeutic approach adopted as well as the presence of complications, both in the long and short run.ResultsOut of a total of 309 renal trauma analyzed, a 94,1% (291 cases) were blunt renal trauma. The distribution by grade was: Grade I, 213 cases (69%); Grade II, 39 cases (12,6%); Grade III/ IV, 32 cases (10,3%); Grade V, 25 cases (8%). We have given a conservative approach in the 84,6% of the grade III/ IV cases (24 cases). 4 grade III nephrectomies were carried out in the Emergency Room because of haemodynamic instability, other 4 grade IV nephrectomies were done for the same reason, one of which was a partial nephrectomy, 48-72 hours after the trauma. The treatment for grade V was nephrectomy in 67%.ConclusionsAccording to our experience and in the light of the results obtained, we consider the conservative approach adequate for major renal trauma as long as the patient is haemodynamically stable.     

Selective operative management of major blunt renal trauma

BACKGROUND: We reviewed the management and outcomes of patients at our Level I trauma center suffering major blunt renal trauma diagnosed and staged by CT scan. METHODS: We retrospectively reviewed the cases of 26 patients with blunt trauma at our institution who were initially hemodynamically stable and diagnosed with grade 4 or 5 renal injuries by CT scan. Patients were broken down into two groups based on whether they were managed conservatively or surgically. Patient characteristics and morbidity were analyzed. RESULTS: There were 14 patients managed conservatively and 12 patients managed surgically. There was no statistically significant difference in morbidity between the two groups. The only statistically significant predictor of failure of conservative management was a coexisting solid organ intra-abdominal injury. CONCLUSIONS: Conservative management of major blunt renal trauma is appropriate in hemodynamically stable patients.     

Kidney trauma

Most renal injuries in industrialized countries are caused by blunt trauma to the kidney. The management of renal trauma has always been and will always be controversial. Conservative management and aggressive intervention both have their proponents, but conservative treatment is generally favored nowadays, even in the case of grade IV/(V) trauma. Urinary diversion by nephrostomy tube or ureteral stenting is not mandatory in most cases because the extravasation resolves in up to 90% of cases. Overall, there is a tendency toward a multimodal approach in which the interventional radiologist is more and more often part of the team that takes care of the patient with high-grade injuries. The success rate of angioembolization is 70-80%. Long-term consequences can be hypertension or diminished kidney function.     

Nierentrauma

Most renal injuries in industrialized countries are caused by blunt trauma to the kidney. The management of renal trauma has always been and will always be controversial. Conservative management and aggressive intervention both have their proponents, but conservative treatment is generally favored nowadays, even in the case of grade IV/(V) trauma. Urinary diversion by nephrostomy tube or ureteral stenting is not mandatory in most cases because the extravasation resolves in up to 90% of cases. Overall, there is a tendency toward a multimodal approach in which the interventional radiologist is more and more often part of the team that takes care of the patient with high-grade injuries. The success rate of angioembolization is 70–80%. Long-term consequences can be hypertension or diminished kidney function.     

闭合性阴囊损伤的诊断及手术与保守治疗效果的比较

目的：提高闭合性阴囊损伤的诊断和治疗水平。方法：回顾性分析闭合性阴囊损伤62例患者的临床资料，比较其手术和保守治疗的效果。结果：手术治疗组28例，25例获得随访3－12个月，其中23例0.5-3个月时症状完全消失，仅2例阴囊坠痛持续3个月以上，未见睾丸萎缩；保守治疗组34例获得随访6－60个月，20例0.5-3个月、6例3－6个月、4例6－12个月时症状完全消失，4例症状持续1年以上，其中有5例睾丸萎缩。结论：闭俣性阴囊损伤除小的单纯性阴囊血肿可保守治疗外，对大的、增长较快的血肿均应手术探查，清除血肿，充分引流，修补破裂的睾丸，避免睾丸萎缩及生精障碍。     

Evaluation and treatment of blunt renal trauma

We examined retrospectively the records of 126 patients with blunt renal trauma to determine the criteria for radiological investigations and the imaging study of choice. Of the 3,993 patients admitted to our regional trauma unit during the last 13 years 126 (3.1%) had blunt renal trauma. Mean patient age was 32 years (range 13 to 87 years) and the male-to-female ratio was 3:1. Mean followup was 7 months (median 4 months). Of the patients 72% had a minor renal injury, 17% had a moderate injury and 11% had a major renal injury. Treatment was conservative in 114 patients, while 9 underwent a genitourinary operation. Results were excellent in 87% of the patients and good in 8%, while 5% failed treatment. All patients who had microscopic hematuria without shock had minor injuries. Excretory urograms (IVPs) were normal in 74% and 39% of the patients when performed for minor and moderate renal injuries, respectively. Computerized tomography (CT) was abnormal in all cases when performed, and was more sensitive and specific than an IVP. Therefore, the majority of patients with blunt renal trauma can be treated conservatively with an excellent result. Furthermore, radiological investigations are not needed in those with microscopic hematuria and no shock. When radiological investigations are indicated a CT scan is the imaging study of choice.     

Renal injury: 5-year experience and literature review

INTRODUCTION: Appropriate management of renal trauma is controversial. The purpose of this study is to present our 5-year experience in renal trauma and review the literature. MATERIALS AND METHODS: From 1999 to 2003, 28 patients were identified with renal injuries. 25 (89.3%) of the injuries were caused by blunt trauma, 2 (7.1%) by stab wounds, and 1 (3.6%) by gunshot wound. Methods for diagnosis included ultrasonography (US), computed tomography (CT), diagnostic peritoneal lavage (DPL), combinations of more than one technique or no one of them. The English-language literature about renal trauma was also identified using Medline, and additional cited works not detected in the initial search obtained. RESULTS: 18 patients underwent immediate or during 24 h operation; while 5 nephrectomies were performed. 11 patients with grade I to III injuries were selected for nonoperative management of renal injuries. All complications were noted and studied according to the initial therapeutic management and grade. Follow-up was clinical and radiological. 3 postoperative deaths were observed. CONCLUSION: The goals of treatment of renal injuries include accurate staging and minimal complications. Surgery can be avoided in most cases of blunt renal injury but there is also a trend towards conservative management of penetrating trauma. Nephrectomy is associated with high-grade renal injuries, while minor renal injuries can safely be managed conservatively.     

Two weeks delayed bleeding in blunt liver injury: case report and review of the literature

Most cases of blunt hepatic trauma are treated nowadays non-operatively. This type of conservative treatment has resulted in increased complication rate. Delayed complications occur in cases that didn't require surgical intervention during the first 24 hours. The most common late complication is hemorrhage. We report a case of two weeks delayed hemorrhage after blunt hepatic trauma in an adult. We describe the diagnostic procedures, the surgical treatment and review the relevant literature.     

Significance of hematoma size for evaluating the grade of blunt renal trauma

BACKGROUND: The hematoma size relative to the body size was measured on computed tomography films using a personal computer system in order to define whether that parameter is useful for decision-making in the management of blunt renal trauma. METHODS: From 1982 to 1997, 33 patients with intermediate or severe grade blunt renal trauma were retrospectively divided into three groups: group 1, managed conservatively without transcatheter embolization; group 2, managed by bedrest after selective transcatheter embolization; and group 3, managed operatively. In these three groups, the hematoma area (H) and the ratio of hematoma area to body area on CT (H/B) were measured and the chronological changes of the H/B in groups 1 and 2 were studied. RESULTS: The H and H/B of group 3 were significantly larger than those of group 1. The H/B was more clearly distinguished for each group compared with the H alone. Well-preserved kidney integrity, despite the presence of a large hematoma in group 2, allowed the conservative treatment following transcatheter embolization of the bleeding site. The H/B of all group 1 patients gradually decreased and on the 40th or 50th day after injury they reached a level equivalent to the ratio of contra-lateral normal kidney area to body area. CONCLUSION: The ratio of hematoma area to body area on CT was very useful in evaluating the grade of blunt renal trauma. In conservative treatment for blunt renal trauma changes of the hematoma size is a useful indicator for management.     

Upper urinary tract trauma – current concepts

This paper reviews current concepts and controversies in regard to the classification, clinical findings, imaging techniques, and management of upper urinary tract trauma. The impact of CT, and especially spiral CT, in differentiating significant from nonsignificant renal trauma is reviewed. The controversy in regard to the correct approach to the management of any significant renal trauma (i.e., conservative vs. aggressive therapy) as well as the differences in opinion as to the appropriate treatment between blunt and penetrating trauma are also reviewed.     

Pneumoperitoneum in polytraumatized patients without perforated hollow viscera

Bowel and mesenteric injuries from blunt abdominal trauma are infrequent and difficult to diagnose. A finding of pneumoperitoneum on computed tomography is useful, although not specific. In associated blunt chest trauma gas can reach the peritoneal cavity through congenital or post-traumatic diaphragmatic interruptions. Two cases of pneumoperitoneum following associated blunt chest and abdominal trauma are reported. In both patients laparotomy did not show bowel perforation and conservative treatment could have been provided.     

闭合性阴囊损伤的诊断和治疗

目的：提高闭合性阴囊损伤的诊断和治疗水平。方法：对手术或保守治疗的52例闭合性阴囊损伤患者进行随访和分析，比较其治疗效果。结果：手术治疗组28例，25例获随访3－12个月，其中23例0.5-3个月症状完全消失，仅2例阴囊附痛持续3个月以上，本组未见睾丸萎缩；保守治疗组34例获随访6－60个月，20例在0.5-3个月、6例－6个月、4例－12个月症状完全消失，4例症状持续1年以上，本组随访有5例睾丸萎缩。结论：闭合性阴囊损伤除小的单纯性阴囊血肿可保守治疗外，对大的、增长较快的血肿均应手术探查，清除血肿，充分引流，修补破裂的睾丸，避免发生睾丸萎缩及生精障碍。