Outcome of angioembolisation for blunt renal trauma in haemodynamically unstable patients: 10 year analysis of Queensland Public hospitals )

IntroductionIncidence of renal risk factors such as diabetes, hypertension and obesity are increasing globally. Accordingly there has been a shift towards renal preservation surgery, not only in the tumour setting, but also in the context of renal trauma. Role of angioembolisation as means of renal preservation in trauma has not been thoroughly studied. Therefore this study examines renal angioembolisation as a means of renal preservation in the trauma context.

ConclusionsSelective renal angioembolisation is an effective management method of haemodynamic instability in select patients with blunt renal trauma. It potentially allows renal preservation with acceptable long-term outcomes. This data is comparable to US national trauma data and is the first Australian study to analyse this approach.

Results

Angioembolisation was performed in 112 patients during the study period (RBWH 58, PAH 50, GCH 4). There were 46 tumours, 21 AVMs, 15 blunt traumas, 13 biopsies, 4 post PCNL, 4 penetrating trauma, 4 retroperitoneal haemorrhage, 2 post nephrostomy, 2 with endovascular repair to AAA and 1 post radio frequency ablation.

Concurrently during this period, 668 renal trauma patients were managed (RBWH 224, PAH 365, GCH 79), 33 of whom underwent emergency nephrectomy.

In total 15 patients met the inclusion criteria. The medical records of one patient was unavailable and therefore this patient was excluded from the study. Thus the final study population included 14 patients (7 RBWH; 7 PAH) comprising 13 males & 1 female (age range 16 to 47 years).

Trauma mechanisms included 8 road accidents, 3 falls, 2 crush injuries and 1 sporting injury. There were 7 left kidney injuries and 7 right kidney injuries. All injuries were unilateral. American Association for the Surgery of Trauma Grading classification was grade III in 3 patients, grade IV in 8 patients and grade V in 3 patients.

The median length of stay was 17 days. The median blood transfusion was 6 (0 to 20) units. Selective angioembolisation was performed by interventional radiologists with the urologist on site during the procedure. Angioembolisation coils were used in all patients except one who had plug embolisation. Post procedure renal function in all patients returned to normal values. None of the patients developed hypertension in the follow up period.

Immediate complications occurred in 2 patients, comprising one nephrectomy for ongoing bleeding, and 1 ureteric stent with additional percutaneous drainage for a urinoma. Long-term complications included two patients with devascularised atrophic kidneys & 1 patient with a ureteric stricture requiring nephrectomy after failed auto transplantation. Median follow up 4 (2 – 41) months. There was no mortality.

In total 12 of 14 renal units were initially spared. Ultimately function was preserved in 10 of the 14 units (71%) in the long term without sequelae. Had these units undergone initial surgical exploration, it is likely that most, if not all, of these renal units would have been removed at presentation. CT – left renal traumaAngioembolisation with coilsFig 1a

Fig 1bFig 1c Fig 1d

MethodsRetrospective study conducted at Queensland public hospitals equipped with angiography and interventional capabilities from June 2002 to June 2012. Database search of interventional radiology and medical records for patients undergoing renal angiography & angioembolisation and operating theatre database for trauma nephrectomies was undertaken.The inclusion criterion was haemodynamic instability in blunt renaltrauma patients treated with angioembolisation. The exclusion criteria were angioembolisation in the context of penetrating trauma, post percutaneous nephrolithotomy (PCNL) haemorrhage, renal tumours, renal arterio-venous malformations (AVMs), miscellaneous causes, and also paediatric patients (< 16 years).

AcknowledgementsMedical records – RBWH, PAH, GCH

HREC committee – RBWH for their guidance and support

Dr Nigel Dunglison - Director of Urology, RBWH

AimThe aim was to evaluate the efficacy of selective angioembolisation in the management of haemodynamically unstable blunt renal trauma patients as a means of renal preservation.

This multi-institutional study (Royal Brisbane and Women’s hospital – RBWH, Princess Alexandra hospital – PAH, Gold Coast hospital – GCH) received ethics approval from Queensland Health.

ReferencesUS national trauma data bank 9002 patients over 5 years165 (2%) angiography : 77 (0.8%) angioembolisation10 nephrectomy : 87 % preserved

J Urol 185 (4):1316-20

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Devang Desai 1, Kevin Lah 1, Cameron Scott 1, Simon Wood 2, Justin Baulch 2, Ben Pearch2, Ahmad Ali 3, Andrew Oar 4, Troy Gianduzzo 1

1Royal Brisbane and Women’s Hospital, 2Princess Alexandra Hospital, 3Ipswich Hospital, 4Gold Coast Hospital, Australia

No. 076

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