This systematic review examines current practices in managing pediatric blunt renal trauma conservatively. 32 studies met the criteria of including cases of high-grade renal injuries in children. The literature supports applying conservative management protocols including observation, percutaneous drainage, stenting, and angioembolization to high-grade pediatric renal trauma, with short and long-term outcomes generally being favorable.

1. Management of pediatric blunt renal trauma: A systematic review
Elyse LeeVan, MD, Osnat Zmora, MD, Francesca Cazzulino, Rita V. Burke, PhD, MPH, Jessica Zagory, MD,
and Jeffrey Scott Upperman, MD, Los Angeles, California
BACKGROUND: Blunt trauma remains a significant cause of morbidity and mortality in the pediatric population. The use of conservative
management for blunt renal trauma is widely accepted in adult trauma literature and is now increasingly accepted for use in the
pediatric patient population. This study aimed to review current practices in pediatric blunt renal trauma management and to
highlight current practices in conservative protocols, success rates of conservative management strategies, as well as short- and
long-term outcomes of blunt renal trauma management.
METHODS: This is a systematic review of PubMed, Ovid, and the Cochrane Library. The following search was performed in each of
the three databases: (Renal or Kidney) AND (Pediatric or Children) AND Trauma AND Management. Publications were
limited to publish date after January 1, 2000. Inclusion criteria were (1) original research articles regarding management
of pediatric blunt renal trauma, (2) involvement of cases of high-grade renal (Grades IVand V) trauma, and (3) more than one
patient presented per study. Literature reviews and meta-analyses were excluded.
RESULTS: Titles and abstracts (n = 308) were screened to identify scientific articles reporting original research findings. A total of
32 articles met the selection criteria and were included in the review.
CONCLUSION: The literature supports application of conservative management protocols to high-grade blunt pediatric renal trauma. Criteria
for early operative intervention are not well understood. At this time, emergent operative intervention only for hemody-
namic instability is recommended. Minimally invasive interventions including angioembolization, stenting, and percutaneous
drainage should be used when indicated. Short- and long-term outcomes are favorable when using conservative manage-
ment approaches to Grade IV and V renal injuries. Further studies including prospective studies and randomized control
trials are necessary. Cost analyses of current treatment protocols are also necessary to guide efficient management strategies.
(J Trauma Acute Care Surg. 2016;80: 519Y528. Copyright * 2016 Wolters Kluwer Health, Inc. All rights reserved.)
LEVEL OF EVIDENCE: Systematic review, level III.
KEY WORDS: Renal; kidney; pediatric; blunt; trauma.
Blunt trauma remains a significant cause of morbidity and
mortality in the pediatric population.1Y4
Compared with the
adult kidney, the pediatric kidney is more susceptible to
trauma-induced injury due to anatomic factors.5,6
According to
the National Trauma Data Bank, greater than 18,000 pediatric
renal units experienced injury from 2002 to 2007.7
Renal in-
juries are graded based on computed tomography (CT) imaging
as classified by the American Association for the Surgery of
Trauma Organ Injury Scale and are ranked as Grade I (least
severe) to V (most severe) (Table 1).8
The use of conservative management for blunt renal
trauma is widely accepted in adult urologic trauma literature
and is now increasingly accepted for use in the pediatric pa-
tient population.5,9Y13
This strategy aims to preserve renal
units by using careful monitoring and minimally invasive tech-
niques such as percutaneous drainage, endourologic stenting,
and angioembolization. Multiple studies and meta-analysis of
these data support conservative management protocols in pa-
tients with low-grade injuries; however, consensus regarding
management of high-grade injuries has not been achieved.14
Furthermore, many questions remain regarding what an opti-
mal protocol for conservative management should include, what
the threshold for implementation of operative management
should be, and what is the ultimate impact of conservative
management on the patient and health care system. Even the
definition of ‘‘conservative management’’ varies throughout the
literature, with minimally invasive procedures being variably
defined as conservative or operative/interventional manage-
ment. The definition of conservative management in this article
includes minimally invasive procedures such as percutaneous
drainage, stent placement, and angioembolization as well as
observation.
Operative intervention will refer to laparotomy and more
extensive renal exploration or resection. As more studies on
patients with high-grade renal trauma emerge, it is important to
understand differences between Grade IV and Grade V injury
thatmayimpacttreatmentregimens.Inthissystematicreview,we
highlight current practices in conservative protocols, success
rates ofconservative managementstrategies, aswell as short- and
long-term outcomes of blunt renal trauma management.
PATIENTS AND METHODS
A search of all original research studies was conducted
using PubMed, Ovid, and the Cochrane Library. The following
SYSTEMATIC REVIEW
J Trauma Acute Care Surg
Volume 80, Number 3 519
Submitted: September 8, 2015, Revised: November 10, 2015, Accepted: November
24, 2015, Published online: December 26, 2015.
From the Department of General Surgery (E.L.V.), Huntington Hospital, Pasadena;
Division of Pediatric Surgery (F.C., R.V.B., J.Z., J.S.U.), Children’s Hospital Los
Angeles; and Keck School of Medicine (R.V.B., J.S.U.), University of Southern
California, Los Angeles, California; and Tel Aviv Sourasky Medical Center
(O.Z.), Tel Aviv, Israel.
Address for reprints: Jeffrey S. Upperman, MD, Division of Pediatric Surgery,
Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, CA
90027; email: jupperman@chla.usc.edu.
DOI: 10.1097/TA.0000000000000950
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

2. search was performed in PubMed: (Renal or Kidney) AND
(Pediatric or Children) AND Trauma AND Management.
Publications were limited to publish date after January 1, 2000.
Patient population was limited to patients age 0 to 18 years.
Language was limited to English. Search was limited to full
text. Species was limited to humans. The search was repeated
in Ovid and Cochrane library. Abstracts were reviewed, and
those that met the selection criteria specified later were imported
into Endnote, a bibliographic management program. If the full
abstract was unavailable or it remained ambiguous whether
the article complied with the selection criteria, the full article
was obtained and reviewed for inclusion.15
Inclusion criteria
were (1) original research articles regarding management of
pediatric blunt renal trauma, (2) involvement of cases of high-
grade renal (Grades IV and V) trauma, and (3) more than one
patient presented per study. Literature reviews and meta-
analyses were excluded as well as all articles not written in
English or written before the year 2000.
Studies that reported blunt abdominal trauma manage-
ment overall were only included if renal data were presented
independently. Articles were included if the treatments ren-
dered were broken down by grade of injury or grouped into
high- or low-grade injury.
Treatment protocols, intervention type, outcome mea-
sures including percent success of conservative protocols, and
renal salvage rates were recorded. Bias was assessed using the
Cochrane risk of bias assessment tool (Fig. 1).
RESULTS
Three hundred eight titles and abstracts were screened
to identify scientific articles reporting original research find-
ings. A total of 32 articles met the selection criteria and were
included in the review (Table 2).5Y7,9,12,16Y42
Protocol for Conservative Therapy
Although conservative management is discussed as a
cohesive entity, the protocol for conservative management is
inconsistent throughout the literature. The articles reviewed
in this study used diverse nonoperative measures in the sup-
port of acutely injured patients. All studies advocated for
some combination offrequent vital sign evaluation, hemoglobin/
hematocrit measurement, serial abdominal examination, and
intravenous fluid resuscitation.5,6,9,18Y22,25,26,29,30,33,34,36,38Y40
Among the articles that clearly delineated their conservative pro-
tocol, bed rest remained a common measure.5,6,9,12,18Y21,23,25,30,38
Although most studies did not report the duration of bed rest,
typically, bed rest was maintained until resolution of gross
hematuria.5,9,12,20,21,23,30
The study of Graziano et al.22
challenged the need for
bed rest and instead applied an ‘‘abbreviated’’ protocol in-
volving early mobilization; no urinary catheter, antibiotics, or
TABLE 1. American Association for the Surgery of Trauma
Organ Injury Scale for Renal Injury
Grade Type Injury Description
I Contusion Microscopic or gross hematuria, urologic
studies normal
Hematoma Subcapsular, nonexpanding without
parenchymal laceration
II Hematoma Nonexpanding perirenal hematoma confined
to renal retroperitoneum
Laceration G1-cm parenchymal depth of renal cortex
without urinary extravasation
III Laceration 91-cm parenchymal depth of renal cortex without
collecting system rupture or urinary extravasation
IV Laceration Parenchymal laceration extending through renal
cortex, medulla, and collecting system
Vascular Main renal artery or vein injury with contained
hemorrhage
V Laceration Completely shattered kidney
Vascular Avulsion of renal hilum, which devascularizes
the kidney
Figure 1. Cochrane risk of bias assessment toolVarticle bias.
J Trauma Acute Care Surg
Volume 80, Number 3LeeVan et al.
520 * 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

3. TABLE2.CharacteristicsofStudiesIncludedintheReview
AuthorJournalYear
No.
Subjects
AgeRange(Mean)
[Median]LocationStudyTypeHospitalStay,d
Transfusion
(No.Patients)
Barsnessetal.16
JournalofTrauma200447NotrecordedSinglecenter,Denver,
UnitedStates
RetrospectivereviewNotrecordedNotrecorded
Bartleyetal.9
Urology2012611Y16(8)Singlecenter,Detroit,
UnitedStates
RetrospectivereviewBygrade:I=7.7,II=7.9,
III=5.9,IV=8.6,V=9
10
Broghammeretal.5
Urology2006631Y16IVandV:(8.3)Singlecenter,Detroit,
UnitedStates
Retrospectivereview7.711
Buckleyetal.12
JournalofUrology2004374G18Singlecenter,SanFrancisco,
UnitedStates
RetrospectivereviewNonoperative=14.1,
operative=11.5
Notrecorded
Ceylanetal.17
PediatricSurgery
International
20032051Y14(7.4)Singlecenter,Izmir,TurkeyRetrospectivereviewNotrecordedNotrecorded
Eassaetal.18
EuropeanUrology2009183Y14(8.4)Multicenter,Egypt
andMontreal,Canada
Retrospectivereview11.515
Eegetal.19
JournalofUrology200973(10.5)Singlecenter,Toronto,
Canada
RetrospectivereviewNotrecordedNotrecorded
El-Sherbinyetal.20
BritishJournalof
UrologyInternational
2004131Y15(8.4)Singlecenter,
Mansoura,Egypt
Retrospectivecasecontrol97
Fitzgeraldetal.21
JournalofUrology2011810Y19(9.7)Singlecenter,Detroit,
UnitedStates
ProspectivecohortBygrade:I=5,II=6,
III=12,IV=7,V=10
Notrecorded
Gerstenbluthetal.42
JournalofUrology2002685Y15(10.1)Multicenter,Cleveland,
andCleveland,UnitedStates
RetrospectivereviewNotrecordedNotrecorded
Grazianoetal.22
JournalofPediatric
Surgery
2014703Y17(11.8)Singlecenter,KansasCity,
UnitedStates
Prospectivestudy2.96
Heetal.23
InternationalUrology
andNephrology
2011831Y16(7.2)Singlecenter,Chonquing,
China
RetrospectivereviewBygrade:lowgrade=14.8,
highgrade=18.2
15
Hendersonetal.24
JournalofUrology20061260Y17(9)Singlecenter,Districtof
Columbia,UnitedStates
RetrospectivereviewNotrecordedNotrecorded
Impellizzerietal.25
MinervaPediatrica2012153Y15(6.3)Singlecenter,Messina,ItalyRetrospectivereview10.5(3Y11)3
Jacobsetal.7
JournalofUrology20124191Y18NationalTraumaDataBankRetrospectivecohortNotrecordedNotrecorded
Kelleretal.26
JournalofTrauma2004172Y16(10.4)Multicenter,Burlingtonand
St.Louis,UnitedStates
RetrospectivereviewNotrecorded7
Kelleretal.27
JournalofPediatric
Surgery
2009163Y16(10)Singlecenter,StLouis,
UnitedStates
RetrospectivereviewNotrecorded4
Kiankhooyetal.28
JournalofTrauma2010266Y16(12.3)Singlecenter,Burlington,
UnitedStates
RetrospectivereviewRenalspecificinformation,
notrecorded
0
Manikandanetal.29
InternationalUrology
andNephrology
2009212(12)Singlecenter,
Pondicherry,India
CaseseriesNotrecorded1
Margenthaleretal.30
JournalofTrauma2002550Y17(9.1)Singlecenter,St.Louis,
UnitedStates
RetrospectivereviewNotrecorded11
Mohamedetal.31
JournalofPediatric
Urology
2009360Y14(6.2Singlecenter,Cairo,EgyptRetrospectivereview12.5(5Y35)Notrecorded
Moogetal.32
JournalofUrology2003200Y16(9.7)Singlecenter,
Strasbourg,France
RetrospectivereviewwithcontrolNotrecordedNotrecorded
Nanceetal.33
JournalofTrauma2004950Y18(10)Singlecenter,Philadelphia,
UnitedStates
Retrospectivereview623
(Continuedonnextpage)
J Trauma Acute Care Surg
Volume 80, Number 3 LeeVan et al.
* 2016 Wolters Kluwer Health, Inc. All rights reserved. 521
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

4. routine imaging; and discharge when patient tolerated a diet
regardless of hematuria. Although authors reported a reduction
in length of stay from a mean of 6.6 days to 2.9 days after the
protocol was applied, it is notable that this study addressed a
population with greater than 50% low-grade injuries with fewer
than four patients (5%) with Grade V injury. In addition, five
patients (7%) required readmission, although follow-up ultra-
sound results were normal.
Admission to and duration of observation in the inten-
sive care unit (ICU) varied considerably. ICU admission
was recommended for all blunt renal traumas by several
authors.12,30,31,33,35
Duration of ICU stay was recommended
as 24 hours to 1 week.12,31,33,35
Of note, Buckley and
McAninch12
as well as Mohamed et al.,31
who recommended
48 hours and 1 week, respectively, had high length of stays
compared with other study populations. Nance et al.33
had
shorter average length of stay but a study population that was
highly skewed to low-grade injury.
Empiric antibiotic therapy was used in six studies.6,18,20,
31,34,39
Neither the rate of urinary tract infection nor the rate
of infected hematoma was reported in the majority of studies;
thus, the necessity and efficacy of this intervention are not
known, and further study is required to clarify this issue. The use
of urinary catheter for bladder decompression was recommended
by two studies30,38
and specifically not used in one study.22
Guidelines for serial imaging remain a controversial topic
in conservative management protocols. Several studies recom-
mend routine serial imaging protocols.12,18,19,25,30,39
Four stud-
iesrecommendrepeatimagingwithinthefirst24-hour to72-hour
window.12,18,19,25
Eassa et al.18
recommended daily bedside
ultrasounds throughout the hospitalization in his population of
Grade V injury patients. The study by Eeg et al.19
specifically
aimed to apply the ‘‘as low as reasonably achievable’’ concept
to renal trauma imaging. After initial CT, the study team
used ultrasound for the evaluation of clinical changes and only
used repeat CT if ultrasound was inconclusive. Only two pa-
tients required repeat CT for urologic reasons including one
angioembolization and one patient with expanding urinoma.
There were no complications caused by delayed diagnosis. Im-
aging of all patients before discharge to confirm resolution of
extravasation was performed in one study.30
No intervention as
a result of this imaging was described.
Indications for Operative Intervention
The criteria for operative management of blunt renal
trauma in children have not been fully delineated. This con-
tributes to the discrepancy in the success rates seen for con-
servative management throughout the literature.
One area of agreement throughout the literature is that
hemodynamic instability, despite adequate resuscitation, is an
absolute indication for operative intervention or angiography.
Several authors provided specific criteria for blood loss as an
indication for surgery.12,21,34,35,37
Recommendations vary
from a 3-U decrement in hematocrit12
to requirement of 2 U
of blood21,37
to transfusion of greater than 50% of blood
volume.34,35
Ten studies list hemodynamic instability as the
sole indication for operative intervention when considering
treatment of isolated blunt renal trauma.5,9,16,19,20,23,25,30,34,35
TABLE2.(Continued)
AuthorJournalYear
No.
Subjects
AgeRange(Mean)
[Median]LocationStudyTypeHospitalStay,d
Transfusion
(No.Patients)
Nerlietal.34
PediatricSurgery
International
201143NotrecordedSinglecenter,Belgaum,IndiaRetrospectivereviewConservativelymanaged
patientsG2wk
Notrecorded
Ozturketal.35
EuropeanJournalof
PediatricSurgery
2003451Y15[7]Singlecenter,
Diyarbakır,Turkey
RetrospectivereviewRenalspecificinformation,
notrecorded
Renalspecific
information,
notrecorded
Philpottetal.36
JournalofPediatric
Surgery
2003213Y16(14.5)Singlecenter,Philadelphia,
UnitedStates
Caseseries9.50
Reeseetal.37
JournalofUrology2014264Y16(11.2)Singlecenter,Pittsburgh,
UnitedStates
RetrospectivereviewEarlyintervention=7.4,
nonoperative=5.4,
failedconservative
management=7.9
2
Rogersetal.38
Urology2004202Y14(8.9)Singlecenter,Baltimore,
UnitedStates
RetrospectivereviewBygrade:IV=11,
V=16
5
Russelletal.39
JournalofUrology2001154Y16(11.5)[11]Singlecenter,Akron,
UnitedStates
Retrospectivereview11.16
Tsuietal.40
Injury2011151Y11(6.5)Singlecenter,CapeTown,
SouthAfrica
Retrospectivereview16.5Notrecorded
Wanetal.41
JournalofUrology2003168Y17(13.4)[14]Singlecenter,Buffalo,
UnitedStates
RetrospectivereviewNotrecorded3
Wesseletal.6
JournalofPediatricSurgery2000671Y14Singlecenter,Mannheim,GermanyRetrospectivereviewNotrecordedNotrecorded
J Trauma Acute Care Surg
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5. Renal salvage rates with these operative criteria ranged from
0% to 100% for both Grade IV and V injury.
Nine studies identified characteristic CT findings as an
absolute or relative indication for operative intervention.12,18,
21,24,28,37Y40
Injury to the renal artery was a cause for operative
intervention in three studies.12,22,33
In two additional studies,
operative management was reserved for more severe vascular
injury, specifically, unstable vascular Grade V injury21,33
and
vascular pedicle injury.28
Nonvisualized renal units or evidence
of nonviable tissue was identified in three studies as an indi-
cation to bypass a trial of conservative management.12,38,39
Despite implementing broader criteria for operative interven-
tion, within the nine studies that list CT findings as a cause
to intervene surgically, renal salvage rates remained high at
86.7% to 100% and 30% to 100% in Grade IV and V injuries,
respectively.12,18,21,24,28,37Y40
Urinoma and/or extravasation of urine represent a spe-
cific area of controversy in the management of blunt renal
trauma. Overall, most patients with urinoma and/or extrava-
sation of urine were managed effectively with conservative
measures. Several authors specifically advocated a trial of
nonoperative management in this population.18,30,38
Despite
this, there is evidence that expanding urinoma or active
extravasation of urine has a role as an absolute or relative in-
dication for surgery.12,18,24,26,30,31
Extravasation of urine was
identified as the cause of failure of conservative management
for individuals in eight studies.5,17,18,24,30,34,37,38
Although some patients with urinoma or extravasation
of urine went on to require surgery, total nephrectomy was
rarely required after a trial of conservative management. Fol-
lowing a trial of conservative management, at least one patient
in each of eight studies (total of 12 patients) went on to receive
renorrhaphy or partial nephrectomy,5,17,18,24,30,34,38,39
while
only one patient in each of three studies ultimately required
nephrectomy.5,30,37
Four patients who underwent surgical intervention were
found to have ureteropelvic disruption.5,18,30
Patients with ure-
teropelvic junction injury may be a group that warrants specific
management strategies. Eassa et al.18
described four patients
(22%) with suspected ureteropelvic junction avulsion based on
nonopacifyingipsilateral ureters.Tworequiredearly intervention
and received nephrectomies, whereas the remaining two under-
went initial conservative management with percutaneous drain-
age and successful delayed surgical repair.
Patients with complete renal fracture with retained blood
supply to each segment and concomitant perinephric extrava-
sation was suggested by Rogers et al.38
as a subpopulation of
patients who are more likely to fail conservative therapy and
may benefit from early surgical intervention, but this was based
on two individuals with this finding. Reese et al.37
corroborated
that this CT finding was a good predictor of a need for inter-
vention but recommended endourologic management.
Medial extravasation of contrast was identified by two
studies as a predictor of conservative management failure.9,18
Of four individuals (22%) found to have medial extravasation
of contrast in the study of Eassa et al., one required immediate
nephrectomy and three required delayed nephrectomies. Of
the two patients requiring delayed surgical intervention in the
population of Bartley and Santucci, both demonstrated medial
contrast extravasation on CT. Given these findings, it seems
that medial extravasation of contrast may portend extensive
renal injury, which is not amenable to conservative therapy.
Grade IV Injury
Twenty-seven studies reported information specific to
patients with Grade IV injury. In these studies, 0% to 38.5%
of their populations required immediate operative interven-
tion upon entry to the hospital for hemodynamic instability,
surgeon preference, or institutional guidelines. Seventeen
studies required emergent intervention in less than 15% of the
population with a mode of 0 patients who required interven-
tion.5,9,20Y22,24Y27,29,30,33,36,38Y41
In the remainder of the stud-
ies, patients were initially treated using conservative measures.
Twenty-two of these studies had a success rate of at least 80%
when treating patients conservatively.5,9,16,20Y24,26Y31,33,36Y42
The studies with the three largest patient populations accom-
plished success rates of 88.6%, 93.8%, and 100%, respec-
tively.22,24,37
Two studies that present as outliers with success
rates less than or equal to 50% had small patient populations,
and one did not discuss operative indications.6,25
Overall, renal
salvage rate was high with a conservative approach. Eighteen
studies reported renal salvage rates greater than 90%, with
sixteen studies reporting renal salvage rates greater than 95%
(Table 3).9,12,20Y22,24Y29,31,33,36Y38,40,41
Grade V Injury
Indications for the use of conservative management
in the patient population with Grade V injury remain highly
controversial. The reviewed data show a wide range of success
rates when using conservative management with renal salvage
of 0% to 100%. Only 5 of the 15 studies for which success
rates of conservative management could be calculated had
success rates of 50% or less.6,17,23,31,42
Overall, renal salvage
rate for 10 of the 20 studies that reported this information
was greater than 80%. One challenge in interpreting this in-
formation is the small patient population size. Few patients
presented with Grade V injuries, and even fewer were hemo-
dynamically stable and eligible for conservative therapy. Eassa
et al.18
had the largest analysis with 18 patients. This study used
hemodynamic instability, progressive urinoma, and persistent
bleeding as operative criteria. Conservative management suc-
cess rate was 70.6%, and overall renal salvage rate was 78%.
Of the six studies that presented Grade IV and V injuries in
aggregate, success of conservative management was overall
high, 79.7% to 100%, with overall renal salvage rates of 69%
to 100% (Table 4).7,16,19,32,34,42
Minimally Invasive Therapy
Adjunct therapies including stent placement, percuta-
neous drainage, and angioembolization serve as minimally
invasive alternatives to operative intervention. In the reviewed
studies, these three interventions were largely successful in
obviating the need for surgery. Indications for these procedures
are as yet without consensus.
Seventeen studies used stenting and/or drainage pro-
cedures as adjunct measures for the treatment of urinary
extravasation or expanding urinoma.5,7,9,17Y20,24,29,31Y34,36Y39
Nearly all studies cited ongoing urinary extravasation or
J Trauma Acute Care Surg
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6. expanding urinoma as cause for stenting. Urinomas associated
with fever, tachycardia, ileus, nausea, or flank pain are de-
scribed indications.29,31,36,39
Eight studies reported 100%
success rate at avoiding laparotomy with these measures.17,20,
24,29,31Y33,36,39
Patients in three studies required ureteral stenting
after percutaneous drainage for persistent collection, with sub-
sequent resolution of symptoms.24,29,39
Timing of drainage remains controversial. In the study
populations, drainage and/or stenting was performed as early
as 48 hours and as late as 5 weeks after injury. Two studies
specifically commented on timing of stenting and/or percuta-
neous drainage. In the study of Rogers et al.,38
where patients
were stented after 20 days of nonresolving urinoma, sponta-
neous resolution was not seen after 14 days. Reese et al.37
described 16 patients initially managed conservatively, 7 of
whom required stenting or percutaneous drainage, which was
performed at a mean of 11 days. Reese et al. additionally ex-
amined initial radiographic findings associated with patients
who required stenting and/or percutaneous drainage versus
those who did not. Statistically significant predictors of need
for minimally invasive therapy were renal pelvic hematoma
and large urinoma. Average urinoma sizes for the failed and
successful conservatively managed groups were 4.29 cm and
1.45 cm, respectively.
Angioembolization was used in seven studies.18Y20,22,
28,31,37
Six studies report successful management of ongoing
hemorrhage or pseudoaneurysm with angioembolization and
no further intervention.18Y20,28,31,37
One patient with a hilar
bleed eventually required nephrectomy due to devasculariza-
tion after embolization.22
Outcomes
Preservation of renal function after hospitalization
was investigated in seven studies using Technetium-99m-
dimercaptosuccinic acid (DMSA) scans.18,19,24Y26,32,34
Nerli
et al. reported good renal function in all individuals who re-
ceived follow-up. The remaining six studies reported variable
success at function preservation. Eassa et al.,18
Impellizzeri
et al.,25
and Keller and Green27
reported follow-up DMSA data
on 9, 9, and 17 patients, respectively, and found that greater
than 40% of patients retained normal renal function in the
traumatized kidney. In four studies, a moderate dysfunction
was reported in 22% to 56% of study participants.18,24Y26
Severe to complete dysfunction was detected in 11%, 24%,
TABLE 3. Management of Grade IV Injury
Author
Grade IV
Injury
(No. Patients)
Patients
Requiring
Emergent
Surgery, n (%)
Patients With
Initial Attempt
at Nonoperative
Management, n (%)
Success of
Conservative,
Nonoperative
Therapy, n (%)
Patients Requiring
Minimally Invasive
Intervention, n (%)
Success of Minimally
Invasive Intervention at
Avoiding Surgery, n (%)
Renal
Salvage,
n (%)
Barsness16
7 2 (28.6) 5 (71.4) 5 (100) 0 (0) na Unknown
Bartley9
10 0 (0) 10 (100) 8 (80) 2 (20) 1 (50) 9 (90)
Broghammer5
10 0 (0) 10 (100) 8 (80) 2 (25) 0 (0) 8 (80)
Buckley12
11 Unknown Unknown 8 (72.7) Unknown na 11 (100)
Ceylan17
7 Unknown Unknown 4 (57.1) 1 (14.3) 1 (100) 6 (85.7)
El-Sherbiny20
4 0 (0) 4 (100) 4 (100) 2 (50) 2 (100) 4 (100)
Fitzgerald21
6 0 (0) 6 (100) 5 (83.3) 1 (16.7) 0 (0) 6 (100)
Gerstenbluth42
17 Unknown Unknown 16 (94.1) Unknown na Unknown
Graziano22
21Y24 0 (0) 21Y24 21Y24 (100%) 0 (0) na 21Y24 (100)
He23
10 2 (20) 8 (80) 7 (88) 0 (0) na 7 (70)
Henderson24
35 0 (0) 35 (100) 31 (88.6) 1 (3.2) 1 (100) 34 (97.1)
Impellizzeri25
2 0 (0) 2 (100) 1 (50) 0 (0) na 2 (100)
Keller26
9 0 (0) 9 (100) 9 (100) 0 (0) na 9 (100)
Keller27
9 0 (0) 9 (0) 9 (100) Unknown Unknown 9 (100)
Kiankhooy28
Unknown Unknown Unknown Unknown (100) 3 (Unknown) 3 (100) Unknown (100)
Manikandan29
2 0 (0) 2 (100) 2 (100) 2 (100) 2 (100) 2 (100)
Margenthaler30
14 2 (14.3) 12 (85.7) 10 (83.3) 0 (0) na 11 (78.6)
Mohamed31
14 4 (28.6) 10 (71.4) 10 (100) 5 (50) 5 (100) 14 (100)
Moog32
5
Nance33
11 1 (9.1) 10 (90.9) 10 (100) 4 (40) 4 (100) 10 (90.9)
Ozturk35
2 2 (100) 0 (0) na 0 (0) na 0 (0)
Philpott36
2 0 (0) 2 (100) 2 (100) 2 (100) 2 (100) 2 (100)
Reese37
26 10 (38.5) 16 (61.5) 15 (93.8) 7 (43.8) 6 (85.7) 25 (96.1)
Rogers38
10 0 (0) 10 (100) 9 (90.0) 2 (25) 1 (50) 10 (100)
Russell39
15 1 (0.6) 14 (93.3) 13 (92.9) 5 (38.5) 4 (80) 13 (86.7)
Tsui40
2 0 (0) 2 (100) 2 (100) 0 (0) na 2 (100)
Wan41
3 0 (0) 3 (100) 3 (100) 0 (0) na 3 (100)
Wessel6
5 1 (20) 4 (80) 0 (0) 0 (0) na 3 (75)
Operations performed for nonrenal trauma or nontraumatic reasons were not included as ‘‘surgery.’’
J Trauma Acute Care Surg
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7. TABLE4.ManagementofGradeVInjuryandAggregateGradeIV/VInjury
Author
TypeV
Injury
(No.
Patients)
Patients
Requiring
Emergent
Surgery,
n(%)
Patients
WithInitial
Attemptat
Nonoperative
Management,
n(%)
Successof
Conservative,
Nonoperative
Therapy,
n(%)
Patients
Requiring
Minimally
Invasive
Intervention,
n(%)
Successof
Minimally
Invasive
Intervention
atAvoiding
Surgery,
n(%)
Renal
Salvage,
n(%)
Combined
TypeIV
andV,
(No.
Patients)
Patients
Requiring
Emergent
Surgery,
n(%)
Patients
WithInitial
Attemptat
Nonoperative
Management,
n(%)
Successof
Conservative,
Nonoperative
Therapy,
n(%)
Patients
Requiring
Minimally
Invasive
Intervention,
n(%)
Successof
Minimally
Invasive
Intervention
atAvoiding
Surgery,
n(%)
Renal
Salvage,
n(%)
Barsness16
65(83)1(20)1(100)0(0)naUnknown137(53.8)6(46.1)6(100)0(0)na9(69)
Bartley9
11(100)0(0)na0(0)na0(0)
Broghammer5
2
Buckley12
1UnknownUnknownUnknown1(100)
Ceylan17
53(60)2(40)0(0)0(0)na1(20)
Eassa18
181(5.6)17(94.4)12(70.6)5(27.8)3(60)14(78)
Eeg19
222(10)20(90.9)19(95)4(20)3(75)19(86.3)
El-Sherbiny20
30(0)3(100)3(100)2(66.6)2(100)3(100)
Fitzgerald21
10(0)1(100)1(100)0(0)na1(100)
Gerstenbluth42
8UnknownUnknown4(50)UnknownnaUnknown25UnknownUnknown20(80)Unknownna22(88)
Graziano22
2Y31(30Y50%)UnknownUnknown1(30Y50%)1(100)Unknown
He23
83(37.5)5(62.5)0(0)0(0)na0(0)
Henderson24
152(13.3)13(86.7)11(84.6)0(0)na12(80)
Impellizzeri25
0
Jacobs7
41981(19.3)338(80.6)334(79.7)47(13.9)Unknown373(89)
Keller26
40(0)4(100)4(100)0(0)4(100)
Keller27
30(0)3(100)3(100)UnknownUnknown3(100)
Kiankhooy28
UnknownUnknownUnknownUnknown0(0)naUnknown
(100)
Manikandan29
0
Margenthaler30
53(60)2(40)2(100)0(0)na2(40)
Mohamed31
107(70)3(30)1(33.3)0(0)na8(80)
Moog32
5100(0)10(100)9(90)4(40)4(100)10(100)
Nance33
20(0)2(100)2(100)1(50)1(100)2(100)
Nerli34
4310(23.3)33(76.7)29(87.9)6(18.2)4(66.7)41(95.3)
Ozturk35
11(100)0(0)na0(0)na0(0)
Philpott36
0
Reese37
21(50)1(50)Notstated0(0)na1(50)
Rogers38
1010(100)0(0)na3(30)
Tsui40
10(0)1(100)1(100)0(0)0(0)1(100)
Wan41
11(100)0(0)na0(0)na0(0)
Wessel6
10(0)1(1)0(0)0(0)na0(0)
*Operationsperformedfornonrenaltraumaornontraumaticreasonswerenotincludedas‘‘surgery.’’
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8. and 15% of scanned patients in the studies performed by
Impellizzeri et al.,25
Keller and Green,27
and Henderson et al.,24
respectively. At 6 months after trauma, Moog et al.32
calculated
an average 48% loss of function in the injured kidney.
Both Keller and Green and Henderson et al. described
worse functional outcomes in those with Grade V injury. Keller
and Green27
demonstrated severe dysfunction in 50% of
children with Grade V injury compared with 20% of children
with Grade IV injury (p G 0.05). Henderson et al.24
reported
less than 23% function in 3 (15%) of 20 with Grade IV injury
and 3 (50%) of 6 with Grade V injury. Of note, on repeat scan at
1 year for eight patients, the study of Keller and Green27
demonstrated equivalent results at the time of radiographic
healing.
Secondary hypertension is a feared complication of re-
nal trauma; there is concern that conservative management
may increase the likelihood of this adverse outcome. Our re-
view of the recent literature does not find evidence to strongly
substantiate this fear. Ten studies reported no hypertension
discovered in the follow-up of their patient population.16,20,
25Y27,30,31,34,36,40
Nine studies list 5% to 15% of patients with
transient or long-term hypertension.17Y19,21,23,24,28,32,39
Ceylan
et al., Fitzgerald et al., and Kiankhooy et al. presented 1 (0.5%),
2 (5%), and 2 (66%) patients, respectively, with self-limited
hypertension. He et al. presented three patients (3.6%) with
hypertension that was treated medically. Eeg et al. reported
five patients (7%) who developed hypertension, but treatment
regimen was not discussed. Five studies report hyperten-
sion cured by subsequent operation.17,18,24,32
These included
the studies of Eassa et al. with one (5%), Henderson et al.
with one (3%), Moog et al. with one (5%), and Russell et al.
with one (6.6%).
Length of Stay
The effect of conservative management on length of stay
is not well understood. The six studies that analyzed length of
stay reach differing conclusions, and there is no evidence to
suggest that any particular management course is associated
with reduced length of stay.5,12,21,37,38
Rogers et al.38
reported
an increased length of stay in patients undergoing conserva-
tive therapy compared with operative therapy of 23 days versus
11 days, respectively. Reese et al.37
reported no statistically
significant difference between early and late intervention
groups but found that patients who had successful conserva-
tive management required the shortest stay. Buckley and
McAninch12
reported longer stay for operatively managed
patients compared with nonoperatively managed patients. In-
cluded studies do report that presence of nonrenal injury sub-
stantially affects lengthof stay.5,21
In studies thatcomparedgrade
of renal injury, they determined it had no significant effect on
length of stay.5,33
DISCUSSION
As management of high-grade renal injury trends to-
ward conservative protocols, it is increasingly important to
devise a pathway that optimizes recovery and minimizes length
of stay and unnecessary intervention. There are currently no
randomized control trials that assess the utility of ICU
admission, urinary catheter drainage, antibiotics, bed rest, or
routine imaging. Based on the findings of this review, there is
minimal evidence to support routine ICU care for high-grade
renal trauma patients. Patients should be maintained in the
ICU based on daily assessment of monitoring needs. Although
no studies directly compare outcomes for patients cared for in
the ICU versus the floor, the five studies that reported routine
ICU admission based on the presence of high-grade renal in-
jury did not demonstrate improved renal salvage rates com-
pared with studies that did not use this criterion.12,30,31,33,35
Although prospective comparative studies are lacking,
indicating the need for urinary catheter placement, prophylac-
tic antibiotics, and mandatory bed rest, there is insufficient evi-
dence to recommend the routine use of these measures. Studies
that did not routinely use these measures as part of a conserva-
tive protocol did not have worse outcomes.5,6,9,12,18Y21,23,25,30,38
Given that catheter drainage increases risk of infection, we do
not recommend routine placement.12
Antibiotic therapy may
have a role after minimally invasive intervention but should
otherwise be reserved for use when signs or symptoms of in-
fection emerge. Failure of compliance with bed rest may be
related to recurrence of gross hematuria,23
but studies that did
not use this measure did not demonstrate inferior therapeutic
success.22
In addition, there is minimal evidence to support the use
of routine imaging, especially in patients with Grade IV injury,
as part of a conservative protocol. Ultrasound is an adequate
tool for the assessment of signs and symptoms of injury pro-
gression.19
CT should be considered if ultrasound is equivocal
or demonstrates worsening injury or is necessary for thera-
peutic intervention.18
Reducing routine CT use will help re-
duce cost and radiation exposure.
The initial use of a conservative protocol should be
used for all patients, and immediate surgical intervention for
both Grade IV and V injury should be based exclusively on
hemodynamic stability, as studies demonstrate that immediate
surgical intervention is associated with higher nephrectomy
rates.7
Although several studies identified findings including
medial extravasation of contrast, nonopacification of ureter,
and interpolar contrast extravasation as associated with higher
rates of surgical intervention, many patients with these in-
jury patterns were successfully treated with conservative man-
agement with or without minimally invasive therapy.9,18,37,38
These patients merit close monitoring, and further studies are
necessary to identify optimal timing of surgical intervention
when indicated.
Minimally invasive therapy including percutaneous drain-
age, stenting, and angioembolization are often successful at
preventing the need for more extensive surgical intervention.
Because up to two thirds of urinomas resolve spontaneously,39
intervention should be reserved for urinomas that are symp-
tomatic, are large, or persist for an excessive amount of time.
Although there are very limited data to suggest optimal size
criteria, we recommend intervention for urinoma greater than
4 cm.37
Several studies reported failure of isolated percuta-
neous drainage alone, with subsequent success with ureteral
stenting.24,29,39
This finding in addition to practical consider-
ations including the cumbersome nature of external drain-
age systems and potential for dislodgement leads to the
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9. recommendation of stenting as the initial choice of urinoma
management. Therapeutic intervention should not be delayed for
greater than 2 weeks because urinoma is likely to resolve after
this time point. Angioembolization is a very useful tool and,
where available, should be used for renal artery pseudoaneurysm
and hemorrhage amenable to intervention.
Although resolution of gross hematuria was commonly
used in conservative protocols as a criterion for discharge,
there are limited data to support this claim. As a result, we
recommend discharge on the basis of symptomatic control and
assessment of stability. Patients require follow-up in the out-
patient setting with special attention paid to worsening symp-
toms, but routine use of imaging is not recommended. Overall
functional outcomes are good with most individuals experi-
encing only mild-to-moderate ipsilateral renal dysfunction.18,19,
24Y26,32,34
Although monitoring is required for the development
of hypertension, it is a relatively uncommon sequelae of renal
trauma.16,20,25Y27,30,31,34,36,40
LIMITATIONS
The review was limited by the retrospective nature of
the studies included and the relatively small sample size be-
cause of the infrequency with which pediatric renal trauma
occurs. Further limitations include the lack of uniformity in
reporting timing of intervention, definition of failure of con-
servative therapy, and reasoning behind operative intervention.
CONCLUSION
This review synthesizes the past 15 years of literature
regarding blunt pediatric renal trauma. The primary limitation
to the analysis is the small size and the retrospective nature
of the available literature. Based on the analysis of the avail-
able literature, we recommend implementation of conservative
management protocols to treat high-grade blunt pediatric renal
trauma. It is not recommended that protocols routinely re-
quire bed rest, serial imaging, and ICU admission, although
prospective comparative data are lacking to support specific
management strategies. Early operative intervention should
be implemented for hemodynamic instability. Intervention due
to CT findings alone is not recommended. Minimally invasive
interventions including angioembolization, stenting, and per-
cutaneous drainage should be used when indicated and do
not qualify as a failure of conservative therapy. Short- and long-
term outcomes are favorable when using conservative manage-
ment approaches to high-grade renal injuries. Further studies
including prospective, randomized studies and cost-benefit
analyses are essential to develop a comprehensive, standard-
ized approach to the management of pediatric renal trauma,
which will improve outcomes and maximize resource use.
AUTHORSHIP
E.L.V., O.Z., F.C., R.V.B., and J.S.U. designed this study. E.L.V., O.Z., and
F.C. conducted the literature search. E.L.V., F.C., and R.V.B. contributed
to the data collection. E.L.V. performed the data analysis and wrote the
manuscript. R.V.B., J.Z., and J.S.U. participated in the critical revision.
DISCLOSURE
The authors declare no conflicts of interest.
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