title: Imaging characteristics associated with failure of nonoperative management in high-grade pediatric blunt renal trauma.
abstract: BACKGROUND
  Some children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention.
  
  
  METHODS
  A retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain.
  
  
  RESULTS
  One patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect (P = 0.040) (Fig. A) and lacked ureteral opacification (P = 0.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5-2.5), additional operative interventions occurred from day 4-16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission (Fig. B).
  
  
  CONCLUSIONS
  Collecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised.
authors.affiliation: Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA. Electronic address: jau@bcm.edu.
authors.forename: J K
authors.initials: JK
authors.lastname: Au
authors.affiliation: Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, 10th Floor, Suite A10.136, Houston, TX 77030, USA.
authors.forename: X
authors.initials: X
authors.lastname: Tan
authors.affiliation: Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, 10th Floor, Suite A10.136, Houston, TX 77030, USA.
authors.forename: M
authors.initials: M
authors.lastname: Sidani
authors.affiliation: Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
authors.forename: I
authors.initials: I
authors.lastname: Stanasel
authors.affiliation: Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
authors.forename: D R
authors.initials: DR
authors.lastname: Roth
authors.affiliation: Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
authors.forename: C J
authors.initials: CJ
authors.lastname: Koh
authors.affiliation: Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
authors.forename: A
authors.initials: A
authors.lastname: Seth
authors.affiliation: Department of Urology, 200 1st St SW, Rochester, MN 55902, USA.
authors.forename: P C
authors.initials: PC
authors.lastname: Gargollo
authors.affiliation: Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
authors.forename: D
authors.initials: D
authors.lastname: Tu
authors.affiliation: Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
authors.forename: E T
authors.initials: ET
authors.lastname: Gonzales
authors.affiliation: Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, 10th Floor, Suite A10.136, Houston, TX 77030, USA.
authors.forename: T G
authors.initials: TG
authors.lastname: Smith
authors.affiliation: Baylor College of Medicine, Division of Pediatric Urology and Texas Children's Hospital, Clinical Care Center, 6701 Fannin Street, 6th Floor, Houston, TX 77030, USA.
authors.forename: N
authors.initials: N
authors.lastname: Janzen
mesh_terms: D000293:Adolescent; D002648:Child; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007668:Kidney / Q000000981:diagnostic imaging* / Q000293:injuries*; D008297:Male; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging* / Q000628:therapy*
keywords: Imaging; Nonoperative management; Pediatric; Renal trauma