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THE JOURNAL OF UROLQGY Vol. 154,352355, August 1%
U R O ~ I CAsocIAnoN,
Copyright 0 1995 by MUCAN AL bc. Printed m U.S&


From the Department of Urology, University of California School of Medicine and San Francisco General Hospital,
San Fmncisco, California

Purpose: We sought to evaluate the continuing validity of our criteria for radiographic imaging
of renal injuries, that is penetrating flank or abdominal trauma, blunt trauma with gross
hematuria or microscopic hematuria and shock, deceleration or major associated abdominal
injury and pediatric renal trauma.
Materials and Methods: We reviewed the records of 2,254 patients who presented to our
institution with suspected renal trauma between 1977 and 1992.
Results: Of the 1,588blunt trauma patients with microscopic hematuria and no shock 3 had
sigdicant injury but these cases were discovered during imaging or exploratory laparotomy for
associated injuries. Followup in 515 of 1,004patients (51%) who did not undergo initial imaging
revealed no significant complications.
Conclusions: Adults with blunt renal trauma, microscopic hematuria and no shock or major
associated intra-abdominal injuries can safely be spared radiographic imaging.
KEY WORDS:kidney, wounds and injuries, radiography, hematuria
Decisions about radiographic imaging in cases of suspected (2,024) or penetrating (230) renal injury. After initial evalu-
renal trauma have traditionally been based on the mecha- ation of vital signs, a history was obtained and physical
nism of injury and clinical suspicion. It is well reported that examination was performed. The first voided or catheterized
the majority of renal injuries are grade 1(contusions) result- urine specimen was examined grossly, tested with a urine
ing from blunt trauma and require no staging or active treat- dipstick in the emergency room and then sent for microscopic
ment.1-4 Significant (grades 2 to 5) renal injuries, that is analysis. All associated visceral injuries and skeletal fiac-
those that the urologist would wish to stage completely, tures as well as significant findings on physical examination,
comprise only 10% of all renal injuries and less than 5%of all including flank tenderness, ecchymosis and abdominal ten-
blunt renal injuries. Therefore, controversy exists in identi- derness, were recorded. Patients with a systolic blood pres-
fying patients with a greater likelihood of signilicant renal sure of less than 90 mm. Hg recorded in the emergency room,
injury without unnecessarily subjecting the majority without or at any time by the paramedics during in-field evaluation
a significant injury to the discomfort, possible allergic reac- or transport, were considered to be in shock.
tion, radiation exposure and expense of excretory urography Indications for radiographic assessment included all cases
(IVP). of flank abdominal penetrating trauma, blunt trauma asso-
Addressing this issue, in 1989 Mee et al from our institu- ciated with gross hematuria, blunt trauma with microscopic
tion reported a 10-year experience with 1,146 consecutive hematuria associated with shock, deceleration injury or sus-
patients with suspected renal trauma.4 Within the blunt pected intra-abdominal injuries, and all pediatric renal inju-
injury group (1,007 patients) all 44 significant renal injuries ries with hematuria. When renal injury alone was suspected,
occurred among patients who presented with gross hematu- IVP with nephrotomography was the initial imaging test
ria or microscopic hematuria and shock (defined as systolic performed. Renal injuries were evaluated by computerized
blood pressure less than 90 mm. Hg). None of the 812 pa- tomography (CT) if IVP results were equivocal or if CT was
tients who presented with microscopic hematuria and no initially performed to assess the extent of associated intra-
shock had significant renal injuries. On the basis of these abdominal injuries. Arteriography, which was rarely per-
findings, we recommended that adults who present with formed, was reserved for stable patients with suspected
blunt renal trauma and microscopic hematuria without renovascular injuries and in whom CT findings were incon-
shock need not undergo radiographic evaluation. clusive. Patients who underwent emergency laparotomy for
As part of the ongoing assessment of renal trauma a t our associated injuries without complete renal staging under-
general hospital, we have currently expanded our series dur- went IVP while on the operating room table before renal
ing a 15-year period with an accumulated 2,254 consecutive exploration was done. Patients with blunt trauma and mi-
cases. We present our data to assess objectively the contin- croscopic hematuria or a positive dipstick reading but with-
ued validity of our imaging criteria. out shock did not undergo an imaging study.
Renal injuries were classified as established by the Organ
PATIENTS AND METHODS Injury Scaling Committee of the American Association for
Between 1977 and 1992, 2,254 patients presented to our the Surgery of Trauma (fig. 1):s grade 1 (renal contusions+
emergency mom with hematuria and a history of blunt bruises or subcapsular hematomas associated with an intad
renal capsule, grade 2 (minor lacerations)-superficial corti-
Accepted for publication January 6, 1995. cal parenchymal disruptions that did n o t involve the collect-
* Re uests for re r i n k Department of Urology, U-575, University ing system or the deep renal medulla, grades 3 to 4 (major
of Cali!ornia, San &ancisco, California 94143-0738. lacerations)-parenchymal disruptions extending through
U t o r ’ u Note: This article is the second of 5 published in this
issue for which category 1 CME credits can be earned. Instructions the cortex, deep medulla or collecting system with or without
for obtaining credits are given with the questions on pages 568 and urinary extravasation. grades 4 to 5 ivaecular injuries+
569. occlusions or tears of the rerial :irtPry or vein, or their

FIG. 1. Classification of renal injuries as established by Organ Injury scaling Committee of h e r i a Association for Surgery of

segmental branches and grade 5 (combined vascular and

parenchymal injuries& completely shattered kidneys and
I Adult Blunt Trauma I
avulsions of the renal hilum with devascularizedkidneys. AU Gross Hematuria or
grade 1injuries were treated conservatively. Grades 2 to 5
iqjuries were classified as significant, and warranting com- Microhematuria and Shock
plete radiological evaluation to stage the injury completely (SBP .Z 90mmHg)
and define its full extent. All pertinent information for each
patient (presenting trauma history, physical findings and 422 Palients
examination, microscopic and dipstick urinalysis results, ra-
diographic assessment, treatment, surgical findings and pro-
cedures, hospital record and followup) was recorded and en-
tered into our computer data base.
Of the 2,254 patients who presented to our emergency
room with suspected renal trauma during the 15-yearperiod
2,024 had blunt and 230 had penetrating injury. Of the 'Total of 78 significant injuries (Grades 2-51
former patients 422 presented with gross hematuria or mi-
croscopic hematuria with shock. From t h i s group 78 renal FIG. 2. Diagnosis of renal injury in 422 patients with blunt
injuries were significant (grades 2 to 5). The distribution of trauma who presented with gross hematuria or microscopic hema-
injuries by type is demonstrated in figure 2. turia with shock,and thus underwent radio phic im
were 78 significant renal injuries (18.5%). S%, s y a t o l i ~ ~ ~
Of the 1,588 patients with microscopic hematuria and no sure.
shock 1,004 were treated without imaging, while 584 under-
went imaging at the discretion of the emergency room phy-
sician or because of suspected associated intra-abdominal
injuries. Most of these injuries (581) were renal contusions microscopic hematuria and no shock, these were detected in
(fig. 31, while 3 were significant(1grade 2 and 2 grade 3).The a timely manner during evaluation of the concomitant intra-
Fade 2 injury (a minor renal laceration)and 1of the grade 3 abdominal injuries.
mjuries (a major renal laceration)were each identified on CT Figure 5 shows the distribution of renal injuries among the
obtained for suspected intra-abdominalinjury. Both of these 230 patients with penetrating trauma. All of these patients
renal injuries were treated by observation.The other grade 3 underwent radiographic imaging and 154 (67%) had signifi-
injury (major renal laceration) was found at exploratory lap- cant renal injuries (grades 2 to 5). However, it is significant
motomy performed for associated intra-abdominal injuries that no correlation existed between the degree of hematuria
and open renal repair was done. and the extent of renal injury in these patients.
Figure 4 summarizes the incidence of radiographic evalu- Followup. Of the total series urological followup data were
ation and ultimate diagnosis of all 2,024 blunt injuries. A- available in 1,050 patients (46.6%). Followup was notably
though 3 significant injuries occurred in the patients with better in patients with penetrating injury (63.9% versus

IAdult Blunt Trauma 1

Microhematuria and No Shock
1 Penetrating Trauma
230 Patients

Renal Minor Major Vascular Injury and
Injury Lacerations
(Grade 1 ) (Grade z ) (Grades 3 - 4 ) (Grad5 4 - 5 ) (Grade 5 )

76 35 88 13 18

FIG. 5. Diagnosis of renal injury in 230 patients with penetrating

trauma, all of whom underwent radiographc assessment.There ww
n o correlation between degree of hematuria and extent of r e d

FIG.3. Diagnosis of renal iqjury in 1,588 patients with blunt

trauma who presented with mimecopic hematuria and no shock. major parenchymal lacerations, and vascular injuries. In thie
Renal imaging was performed in 584 patients because of associated
intra-abdominal injuries or at request of emergency mom physician. expanded series, consistent with other reports,la only 81 of
Of these patienta 3 had significant renal injuries. 2,024 patients (4%) with blunt trauma had significant renal
injuries. Among 230 patients with penetrating trauma a
much greater proportion (154or 67%) had significant renal
Adult Blunt Trauma injury. Thus, the majority of renal injuries (90%) are from
blunt trauma and the majority of these (96%)are not signif-
2024 Patients icant. Therefore, the objectives are to identify patients with
the presenting clinical findings that are most suggestive of
signiticant renal injury and, conversely, to identify which of
Micmhematuriaand Mihematuna and Shock
the majority of patients can safely be excluded from radio-
l+Y=J-l (SBPc 90 mmHg)
graphic assessment.
Patients with blunt trauma were divided into those who
presented with gross hematuria or microscopic hematuria
and shock, thus constituting a criteria-positive group (group
Injuries 11, and those with microscopic hematuria or a positive d i p
stick reading without shock (group 2). Group 1 patients un-
derwent radiographic staging at initial presentation, while in
group 2 (1,588patients) approximately two-thirds (1,004)
were treated without radiographic imaging according to the
protocol, and all had renal contusions (grade 1).Concern that
a potentially serious injury might have been missed due to
No Signtkanl Renal Injuries Missed 1"1 lack of imaging is valid. Our 51% followup rate (a reasonable
percentage in this population) addresses the issue. No signif-
FIG.4. Incidence of radiographic evaluation and ultimate diagno- icant complications were found and any clinical abnormality
sis of renal injury in 2,024 patients with blunt in ury Three 81
B . ' and no
icant renal iqjuries in patients with microscopic ematuna
shock were detected in timely manner during evaluation of concom-
was subsequently imaged to confirm the presence or absence
of renal injury. If, indeed, an undetected grade 2 or 3 renal
itant intra-abdominal injuries. SBP, systolic blood pressure. injury had been present in this group, it is unlikely in the
absence of clinical sequelae that initial management would
have been Merent. In addition, since most of our patients
44.6% in the blunt injury group) due to the greater likelihood rely on our institution for primary medical care, any delayed
that the penetrating injury would have been explored or complication would most likely have come to the attention of
the urology department.
repaired. Among the 1,004patients with blunt trauma who
initially presented with microscopic hematuria and no shock, The 584 criteria-negative patients who underwent some
and who underwent no initial imaging, there was no clinical form of imaging did so either because of suspected associated
intra-abdominal injury (typically assessed by abdominal CT
evidence of significant injury during the short term. More
importantly, long-term followup data were available in 515 with contrast medium) or because the overall suspicion for
patients (51%). Among these patients hypertension was risk of renal injury by the emergency room physician w88
noted in 1, infection in 1, gross hematuria in 2,microscopic great enough to warrant imaging. The fact that significant
hematuria in 22,flank pain in 8 and a chronic problem in 1. renal injuries were discovered in this group during the course
When any unusual clinical finding, such as persistent hema- of evaluation for associated intra-abdominal injuries SUP
tuna, flank pain or hypertension, was discovered a renal ports the inclusion of such patients in the recommended
imaging study ( I W or CT) was obtained to assess injury imaging category.
status. There were no significant sequelae in this group, thus Other series in the literature reporting experience with
supporting our assertion that these were all renal contusions. similar imaging indications support similar guidelines.
Hardeman et a1 reported on 506 consecutive patients with
blunt trauma and hematuria.3 All were initially assessed
with I W . Among the 474 patients who presented with mi-
The renal injuries for which the urologist would wish com- croscopic hematuria and no shock only 1 minor renal lacer-
plete radiographic staging to make appropriate management ation was discovered, which was treated nonoperativeb'.
decisions are those of grades 2 to 5, encompassing minor and Cass et al retrospectively reviewed 494 patients with blunt
trauma, microscopic hematuria and no shock, all of The large proportion of significant renal iqjuries in
whom were evaluated hitially with m.' six significant penetrating injury group is consistent with that of other
renal injuries were detected but 5 occurred in patients who reported series. We found again,as in the 1989 report,' that
had associated htra-abdominal iqjuries presumably severe no correlation existed between degree of hematuria and the
enough to warrant radiographic assessment or hospitaliza- extent of renal injury. Thus, patients with penetrating
tion. Thus, 1 significant renal injury in their series would trauma and any hematuria, even the slightest detected
have remained undetected without radiographic imaging. amount, should undergo radiographic evaluation.
1992 Eastham et al retrospectively reviewed 317 adulta with Our imaging criteria are intended to serve not as a strict
blunt injury, microscopic hematuria and no shock, and found protocol but rather as guidelines for emergency room physi-
no significant injuries when all patients were assessed with cians and trauma surgeons. Certainly, in the event that an
Iw.2 emergency Mom physician has a concern based on mecha-
Ifthe results of these series are combined with o w , a t&d nism of injury about a patient who has negative criteria we
of 10 sificant renal injuries was present in 2,873 patients would not quarrel with a decision to proceed with w..
with a history of blunt injury, mimscopic hematuria and no this report, we provide substantial data t.a support a declsion
shock. Only 1of these injuries (0.03%)was not detected by not to perform imaging and we demonstrate the safety in
radiographic or exploratory staging procedures for aesociated applying these criteria to that decision process.
intra-abdominal trauma. These data substantiate the safety
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