Is systematic early drainage relevant to treat urinary tract rupture in non-penetrating renal trauma? results from a multicenter study
Management of non-penetrating renal trauma (NPRT) associated with urinary tract rupture (AAST Grade IV-V) is not clearly codified regarding the usefulness of upper tract drainage with stent insertion. The aim of this study was to compare the outcomes of an early upper urinary tract drainage (ED) to a conservative management (CM) after a NPRT with a urinary extravasation at initial CT-scan assessment.
A multicenter retrospective national study was conducted, including all patients treated for renal trauma in 17 centers from 2005 to 2015. Patients who had a urinary extravasation at the initial CT-scan assessment delayed phase were considered for inclusion. Penetrating traumas, hemodynamically unstable patients and those who were initially treated with nephrectomy were excluded. Patients were divided into 2 groups: ED defined by drainage of upper urinary tract of the injured kidney within the 48 hours following the admission and CM. The persistence of urinary extravasation at repeat CT-scan, the need for delayed drainage, length of stay, early and late complications, and specific death related to the current episode of trauma were analyzed.
Among a total of 1500 kidney trauma over the studied period 268 patients met the inclusion criteria. The median age was 25 years and 158 (79%) patients were male. Clinicians performed an ED with ureteric stent insertion for 69 patients (26%). A persistent urinary extravasation was found in 50 patients (36%) of the CM on the repeat CT in mean delay of 6 days. This persistent leak required a delayed ureteric stent insertion in 23 patients (17%). The mean length of stay was longer after ED 21 days vs. 14 days after CM (p=0,03). There was no difference in complications rate and death related to the trauma between the 2 groups.
Our results suggest that conservative management should be considered for the management of renal trauma associated with urinary extravasation at the initial CT-assessment. CM was associated with good outcomes as 83% of the patients didn't required any drainage of their upper tract and the urinary extravasation at repeat CT was still present for 36% of the patients only. Initial clinical monitoring and repeat CT-scan to re-assess the urine leak might be useful and less invasive than a systematic early drainage.