Urine leaks in children sustaining blunt renal trauma

Abstract

BACKGROUND:Few consensus statements exist to guide the timely diagnosis and management of urine leaks in children sustaining blunt renal trauma (BRT). The aims of this study were to characterize kidney injuries among children who sustain BRT, evaluate risk factors for urine leaks, and describe the negative impact of urinoma on patient outcomes and resource consumption. METHODS:A retrospective review was performed of 347 patients, younger than 19 years, who presented with BRT to a single American College of Surgeons-verified Level I Pediatric Trauma Center between 2005 and 2020. Frequency of and risk factors for urine leak after BRT were evaluated, and impact on patient outcomes and resource utilization were analyzed. RESULTS:In total, 44 (12.7%) patients developed urine leaks, which exclusively presented among injury Grade 3 (n = 5; 11.4%), Grade 4 (n = 27; 61.4%), and Grade 5 (n = 12; 27.3%). A minority of urine leaks (n = 20; 45.5%) were discovered on presenting CT scan but all within 3 days. Kidney-specific operative procedures (nephrectomy, cystoscopy with J/ureteral stent, percutaneous nephrostomy) were more common among urine leak patients (n = 17; 38.6%) compared with patients without urine leaks (n = 3; 1.0%; p = 0.001). Patients with urine leak had more frequent febrile episodes during hospital stay (n = 24; 54.5%; p = 0.001) and showed increased overall 90-day readmission rates (n = 14; 33.3%; p < 0.001). Independent risk factors that associated with urine leak were higher grade (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.6-24.3; p < 0.001), upper-lateral quadrant injuries (OR, 2.9; 95% CI, 1.2-7.1; p = 0.02), and isolated BRT (OR, 2.6; 95% CI, 1.0-6.5; p = 0.04). CONCLUSION:In a large cohort of children sustaining BRT, urine leaks result in considerable morbidity, including more febrile episodes, greater 90-day readmission rates, and increased operative or image-guided procedures. This study is the first to examine the relationship between kidney quadrant injury and urine leaks. Higher grade (Grade 4-5) injury, upper lateral quadrant location, and isolated BRT were independently predictive of urine leaks.

Management of Pediatric Solid Organ Injuries

“…In the setting of devitalized tissue, partial or total nephrectomy is indicated depending on the extent of the damage, ensuring a watertight closure of the collecting system via an omental pedicle flap or renal fat bolster if a partial nephrectomy is performed [ 96 ]. Urine leaks secondary to renal injury are overall uncommon [ 97 ]; only half require some sort of intervention, which is most commonly stent placement, but the presence of a urine leak is a risk factor for requiring surgical intervention and is associated with increased morbidity [ 97 , 98 ]. Renal artery occlusion is another rare complication of renal trauma, and while data are overall limited, there have been reports of successful management with endovascular intervention [ 99 , 100 ].…”

Pediatric renal trauma: 17 years of experience at a major Scandinavian trauma center

“…Moreover, the average annual number of pediatric renal injuries more than doubled from P1 to P2 accompanied by an increase in renal injury severity which is likely an effect of the maturation of the trauma system with adherence to triage and transfer criteria implemented in 2010 as described in a previous publication from our institution. 17 Isolated blunt renal trauma is rarer and often presumed to represent a minor injury leading potentially to less timely evaluation as suggested by Ghani et al 1 They found that this group of patients had a higher risk of urine leaks and suspected that these injuries result from greater focal energy transfer (eg, sports-related injury) than multisystem scenarios in which the energy transfer is more diffuse (eg, motor vehicle crash). These speculations are supported by our observations that isolated renal injury was more common in high-grade compared with low-grade injury (table 5).…”

“…1 5 To diagnose urine leaks in a timely fashion, routine on-arrival delayed CT in children with grade 3 injury and above has been recommended. 1 Such a strategy will reduce the need for repeat imaging and excess radiation. 5 Although many of these urine leaks heal spontaneously, kidney interventions and procedures are more common in this category of patients compared with those without leaks.…”

“…5 Although many of these urine leaks heal spontaneously, kidney interventions and procedures are more common in this category of patients compared with those without leaks. 1 Minimal interventions (eg, cystoscopy with ureteral stent placement or…”

“…Children are at increased risk of renal injuries from blunt trauma due to their anatomic constitution; a larger relative size of the kidney, less perirenal fat, and a more pliable rib cage. [1][2][3][4] The kidney is injured in 5-20% of pediatric patients with blunt abdominal trauma. [5][6][7][8][9] During the last decades, the management of pediatric renal injuries has evolved toward nonoperative management (NOM) unless the patient is hemodynamically compromised.…”