How to treat blunt kidney ruptures: primary open surgery or conservative treatment with deferred surgery when necessary?

OBJECTIVE: We analyzed two consecutive series of 69 and 34 patients, respectively, with kidney ruptures covering two time periods with different treatment strategies to assess whether outcome is better after initial surgical or initial conservative treatment.
METHODS: One hundred and three patients with blunt kidney ruptures grade 2-4 (American Association for the Surgery of Trauma) excluding patients with pedicle injuries of the main renal vessels were evaluated. In the first time period, 1973-1988 (group A) the primary routine treatment of blunt kidney rupture at our institution was surgical. In the second time period 1989- 1995 (group B) the treatment was primarily conservative. Surgery was deferred and performed only if necessary. Rates of surgery, time of surgery, surgical procedures (open or minimal invasive) and loss of renal parenchyma by surgery or trauma were analyzed for the two time periods. Blood loss was estimated for all patients. Postoperative hypertension was evaluated for all patients excluding those who were treated by nephrectomy.
RESULTS: In group A 42 of the 69 patients had 42 surgical interventions (61%) and in group B 11 of the 34 patients had 12 interventions (35%). Thirty-nine of the 69 group A patients (57%) had immediate surgery and 3 (4%) had deferred surgery. In group B 1 of the 34 patients (3%) had immediate surgery and 11 (32%) had deferred surgery. All interventions in group A were open. In group B 5 of the 12 interventions were minimally invasive (percutaneous or internal drainage with a JJ-stent). Partial or total nephrectomies were performed in 33 of the 42 surgically treated group A patients (79%) and in 5 of the 12 group B patients (42%). Blood loss in patients with isolated grade 4 kidney rupture seems to be less when treated conservatively or with deferred surgery than with immediate open surgery. The hypertension rate in patients after blunt kidney rupture is 10%; in a similar control population without renal trauma it is 12%.
CONCLUSION: Patients with primary conservative treatment of blunt kidney rupture seem to need less surgery, especially less open surgery and loose less blood and renal parenchyma than patients treated by initial surgery. Posttraumatic hypertension is not higher than in a similar control population, independent of the treatment.