Effect of an institutional policy of nonoperative treatment of grades I to IV renal injuries

Purpose: Nonoperative treatment of serious renal injuries has been advocated and yet to our knowledge the optimum level of operative treatment has not been established to date. We report a unique data set, in which patients with severe renal injuries were treated with an ultraconservative nonoperative approach during a period when urological consultation was not available at a major urban trauma center. Materials and Methods: We retrospectively reviewed the charts of 51 patients identified with renal trauma in the Detroit Receiving Hospital trauma data base from 1997 to 2001. Results: Injuries were grades I to V in 15, 7, 11, 14 and 4 cases, respectively, and had a tendency toward serious injury. Renorrhaphy was never performed. Nephrectomy was done sparingly, only for grade V renal injuries and only in patients who were exsanguinating from the kidney. Two of the 4 patients with grade V injury died of multiple injuries, including massive head injuries. Only 2 of the patients treated nonoperatively (4%) had complications, including fever and hematuria in 1 each. Conclusions: This data set seems to support an ultraconservative approach of limiting renal surgery to only patients with active exsanguination. The nephrectomy rate for 14 grade IV injuries, including some gunshot wounds to the kidney, was 0%. When comparing this rate with that in the literature, we would expect it to be 1 patient to as high as 10. This approach was safe and resulted in a low complication rate of 4%. Series in which more aggressive therapy for renal injuries is advocated should compare favorably to ultraconservative therapy if aggressive therapy is to continue to be widely advocated.