Conservative management trumps early urinary tract drainage in non-penetrating renal trauma
Conservative management appears to be the favoured option in managing non-penetrating renal trauma with urinary extravasation, according to a study presented at EAU 2018.
“Conservative management was associated with good outcomes as 83 percent of the patients didn’t require any drainage of their upper [urinary] tract and the urinary extravasation at repeat [computed tomography (CT) scan] was still present for 36 percent of the patients only,” said Dr Ala Chebbi from the CHU Hôpitaux de Rouen in Rouen, France who presented the findings.
This retrospective study was conducted in 17 centres in France between 2005 and 2015. Of the 1,800 patients who had renal trauma, 268 patients met the inclusion criteria (ie, urinary extravasation at their initial CT scan). Patients who had undergone a nephrectomy, were haemodynamically unstable, or who had penetrating renal trauma were excluded.
Patients were divided into two groups based on whether they had undergone early upper urinary tract drainage of the injured kidney with ureteric stent insertion (within 48 hours of admission; n=69, mean age 32 years, 78 percent male) or conservative management (observation; n=199, mean age 25 years, 79 percent male) following non-penetrating renal trauma.
Based on a repeat CT scan carried out after a mean 6 days, the incidence of persistent urinary extravasation at repeat CT was comparable between patients who had undergone early upper urinary tract drainage and conservative management (28 percent vs 36 percent; p=0.47). [EAU 2018, abstract 127]
This persistent leak led to a delayed upper urinary tract drainage with ureteric stent insertion in 17 percent of patients who initially underwent conservative management, while 3 percent of patients who initially underwent drainage required a repeat drainage (p=0.04).
Patients who underwent early upper urinary tract drainage had a longer length of hospitalization compared with those who underwent conservative management (mean, 21 vs 14 days; p=0.03). Incidence of complications and trauma-related death was comparable between the two groups.
“Management of non-penetrating renal trauma associated with urinary tract rupture [AAST Grade IV-V] is not clearly codified regarding the usefulness of upper tract drainage with stent insertion,” said Chebbi.
“Our results suggest that we should initially observe these patients with non-penetrating renal trauma and urinary extravasation. Initial clinical monitoring and a follow-up CT scan to reassess urinary leak is a good, useful, and less invasive option than a systematic urinary drainage,” he concluded.