High-grade renal injuries in children - Is conservative management possible?

Objectives. To review our experience with the management of high-grade (grade IV and V) renal injuries to clarify the role of conservative management. Methods. From 1991 to 2003, 79 consecutive patients (age range 2 to 14 years) with renal injuries were treated in an urban level I pediatric trauma center. Twenty children were identified as having high-grade renal injury (grade IV, 10 children and grade V, 10 children). The mechanism of injury was blunt trauma in 17 patients (85%) and penetrating trauma in 3 (15%). Results. Of the 10 patients with grade IV injury, 8 (80%) were successfully treated conservatively with bedrest and catheter drainage. Two patients with persistent urine leaks required ureteral stenting, and one subsequently required open operative repair. The initial radiographic findings in both patients demonstrated complete renal fracture with retained vasculature to both renal segments. All 10 patients with grade V injury required open operative management and only 3 (30%) achieved long-term renal salvage. Conclusions. Most children with grade IV renal injury can be treated conservatively. Patients with complete renal fracture or significant urinary extravasation on initial radiographic imaging may be less likely to undergo spontaneous resolution. Patients with a persistent urinary leak can be successfully treated with internal drainage. Grade V injuries are associated with an increased risk of requiring open operative intervention, and the renal preservation rates are low.