Selective management of isolated and nonisolated grade IV renal injuries.

PURPOSE: We reviewed all grade IV renal injuries to report outcomes, and determined if operative and selective nonoperative management can lead to high salvage rates. We also determined if management and outcome differ significantly between cases of isolated grade IV renal injuries and those with associated multiorgan injuries.
MATERIALS AND METHODS: We retrospectively reviewed the records of 153 grade IV renal injuries from a 25-year period. We divided these into isolated grade IV renal injuries (43) and those with associated nonrenal injuries (110), and analyzed both groups on the basis of type of renal injury, operative vs nonoperative management, operative nephrectomy rate and renal salvage rate. Salvage was defined as 25% or greater overall renal function (50% or greater function of the injured kidney).
RESULTS: Of the 153 patients 103 were treated operatively and 50 nonoperatively with an overall salvage rate of 84%. Penetrating trauma accounted for 87 injuries and blunt trauma 66, while 52% (79 of 153) involved a renal vascular injury. The grade IV renal injuries with concurrent associated injuries requiring operative exploration were repaired at exploration with a 15% nephrectomy rate and an 83% salvage rate. Of the 43 patients with isolated injuries 18 (42%) underwent operative exploration with an average transfusion requirement of 8.5 units packed red blood cells. Two patients (11%) required nephrectomy, 1 kidney was nonfunctional postoperatively and 2 minor complications were identified. The remaining 25 (58%) isolated grade IV renal injuries were managed nonoperatively, with only 12 patients requiring transfusion (average 2.6 units) and a renal salvage rate of 88%. None of the 50 nonoperative cases (isolated or nonisolated renal injuries) required delayed nephrectomy. Six cases demonstrated nonfunctioning kidneys and 4 incurred minor complications.
CONCLUSIONS: Management of grade IV renal injuries is complex and demanding if renal salvage is to be achieved. Selective operative vs nonoperative management is based on the presence of associated nonrenal injuries, the hemodynamic stability of the patient, the degree of renal staging and the skill of the surgeon. Isolated grade IV renal injuries represent a unique situation to treat the patient based solely on the extent of the renal injury, thus nonoperative management is used more frequently. Persistent bleeding represents the main indication for renal exploration and reconstruction. In all cases of severe renal injury nonoperative management should only occur after complete renal staging in hemodynamically stable patients.