MANAGEMENT OF SEVERE BLUNT RENAL TRAUMA IN ADULT PATIENTS: A 10-YEAR RETROSPECTIVE REVIEW FROM AN EMERGENCY HOSPITAL

Authors


Sir,

Aragona et al. [1] report the trend towards successful conservative management of high-grade renal injury witnessed elsewhere [2]. Over the 5-year period from 2006 to 2010, only one patient with American Association for the Surgery of Trauma (AAST) grade III or IV blunt renal trauma required open surgery in their level I trauma centre. Nevertheless, emergency nephrectomy remains a life-saving treatment for unstable grade V renal injuries. From 2004 to 2008, there were only 62 nephrectomies performed for renal trauma in England [3]. This is a slight reduction compared with the previous 5-year period (1999–2003), when there were 71 cases. This small and reducing number of cases ultimately means that most urologists are lacking regular exposure to such emergency procedures. Additionally, the laparoscopic approach for elective nephrectomy is now the established procedure for most benign and malignant cases, and intradepartmental subspecialisation has resulted in many urologists being on-call who do not regularly perform open nephrectomies. Furthermore, a recent study has highlighted a significant decline in the number of open radical nephrectomies performed by UK urological trainees [4].

The lack of exposure to renal trauma surgery, in addition to the reducing experience in open nephrectomies, inevitably raises the question of whether future urologists would be able to carry out emergency renal exploration competently. The transperitoneal approach directly towards the aorta to achieve early vascular control before entering Gerota's fascia is recommended by the European Association of Urology guidelines [5] and is a critical step in minimising mortality. While this surgical approach may be unfamiliar to many urologists because of the aforementioned reasons, it is commonly used by vascular surgeons in haemodynamically unstable patients with ruptured aortic aneurysms. It would therefore make sense that, when necessary, emergency surgical explorations for renal trauma are performed jointly with a vascular surgeon.

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