Who Is at Risk of Death after Renal Trauma? An Analysis of Thirty-Day Mortality after 1,799 Cases of Renal Trauma.

INTRODUCTION: The aim of the study was to report the 30-day mortality (30DM) after renal trauma and identify the risk factors associated with death. METHODS: The TRAUMAFUF project was a retrospective multi-institutional study including all patients with renal trauma admitted to 17 French hospitals between 2005 and 2015. The included population focused on patients of all age groups who underwent renal trauma during the study period. The primary outcome was death within 30 days following trauma. The multivariate logistic regression model with a stepwise backward elimination was used to identify predictive factors of 30DM. RESULTS: Data on 1,799 renal trauma were recorded over the 10-year period. There were 59 deaths within 30 days of renal trauma, conferring a 30DM rate of 3.27%. Renal trauma was directly involved in 5 deaths (8.5% of all deaths, 0.3% of all renal trauma). Multivariate stepwise logistic regression analysis revealed that age >40 years (odds ratio [OR] 2.18; 95% confidence interval [CI]: 1.20-3.99; p = 0.01), hemodynamic instability (OR 4.67; 95% CI: 2.49-9; p < 0.001), anemia (OR 3.89; 95% CI: 1.94-8.37; p < 0.001), bilateral renal trauma (OR 6.77; 95% CI: 2.83-15.61; p < 0.001), arterial contrast extravasation (OR 2.09; 95% CI: 1.09-3.96; p = 0.02), and concomitant visceral and bone injuries (OR 6.57; 95% CI: 2.41-23.14; p < 0.001) were independent predictors of 30DM. CONCLUSION: Our large multi-institutional study supports that the 30DM of 3.27% after renal trauma is due to the high degree of associated injuries and was rarely a consequence of renal trauma alone. Age >40 years, hemodynamic instability, anemia, bilateral renal trauma, arterial contrast extravasation, and concomitant visceral and bone lesions were predictors of death. These results can help clinicians to identify high-risk patients.

Impact of Hospital Volume on the Outcomes of Renal Trauma Management.

BACKGROUND: Some health care systems have set up referral trauma centers to centralize expertise to improve trauma management. There is scant and controversial evidence regarding the impact of provider's volume on the outcomes of trauma management. OBJECTIVE: To evaluate the impact of hospital volume on the outcomes of renal trauma management in a European health care system. DESIGN SETTING AND PARTICIPANTS: A retrospective multicenter study, including all patients admitted for renal trauma in 17 French hospitals between 2005 and 2015, was conducted. INTERVENTION: Nephrectomy, angioembolization, or nonoperative management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Four quartiles according to the caseload per year: low volume (eight or fewer per year), moderate volume (nine to 13 per year), high volume (14-25/yr), and very high volume (≥26/yr). The primary endpoint was failure of nonoperative management defined as any interventional radiology or surgical procedure needed within the first 30 d after admission. RESULTS AND LIMITATIONS: Of 1771 patients with renal trauma, 1704 were included. Nonoperative management was more prevalent in the very-high- and low-volume centers (p = 0.02). In a univariate analysis, very high hospital volume was associated with a lower risk of nonoperative management failure than low (odds ratio [OR] = 0.54; p = 0.05) and moderate (OR = 0.48; p = 0.02) hospital volume. There were fewer nephrectomies in the high- and very-high-volume groups (p = 0.003). In a multivariate analysis, very high volume remained associated with a lower risk of nonoperative management failure than low (OR = 0.48; p = 0.04) and moderate (OR = 0.42; p = 0.01) volume. Study limitations include all the shortcomings inherent to its retrospective multicenter design. CONCLUSIONS: In this multicenter study, management of renal trauma varied according to hospital volume. There were lower rates of nephrectomy and failure of nonoperative management in very-high-volume centers. These results raise the question of centralizing the management of renal trauma, which is currently not the case in our health care system. PATIENT SUMMARY: In this study, management of renal trauma varied according to hospital volume. Very-high-volume centers had lower rates of nephrectomy and failure of nonoperative management.

Factors Predictive of Selective Angioembolization Failure for Moderate- to High-grade Renal Trauma: A French Multi-institutional Study.

BACKGROUND: Angiography with selective angioembolization (SAE) is safe and effective in addressing bleeding in patients with renal trauma. However, there are no validated criteria to predict SAE efficacy. OBJECTIVE: To evaluate factors predictive of SAE failure after moderate- to high-grade renal trauma. DESIGN, SETTING, AND PARTICIPANTS: TRAUMAFUF was a retrospective multi-institutional study including all patients who underwent upfront SAE for renal trauma in 17 French hospitals between 2005 and 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was SAE efficacy, defined as the absence of repeat SAE, salvage nephrectomy, and/or death for each patient. RESULTS AND LIMITATIONS: Out of 1770 consecutive patients with renal trauma, 170 (9.6%) with moderate- to high-grade renal trauma underwent SAE. Overall upfront SAE was successful in 131 patients (77%) and failed in 39 patients: six patients died after the embolization, ten underwent repeat SAE, 22 underwent open nephrectomy, and one underwent open surgical exploration. In multivariate logistic regression analysis, gross hematuria (odds ratio [OR] 3.16, 95% confidence interval [CI] 1.29-8.49; p=0.015), hemodynamic instability (OR 3.29, 95% CI 1.37-8.22; p=0.009), grade V trauma (OR 2.86, 95% CI 1.06-7.72; p=0.036), and urinary extravasation (OR 3.49, 95% CI 1.42-8.83; p=0.007) were predictors of SAE failure. The success rate was 64.7% (22/34) for patients with grade V trauma and 59.6% (31/52) for those with hemodynamic instability. The study was limited by its retrospective design and the lack of a control group managed with either surgery or surveillance. CONCLUSIONS: We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure. However, success rates in these subgroups remained relatively high, suggesting that SAE might be appropriate for those patients as well. PATIENT SUMMARY: Selective angioembolization (SAE) is a useful alternative to nephrectomy to address bleeding in patients with renal trauma. Currently, there are no validated criteria to predict SAE efficacy. We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure.

Study of Renal and Kidney Tumor Vascularization Using Data from Preoperative Three-dimensional Arteriography Prior to Partial Nephrectomy.

BACKGROUND: In a cadaveric model with healthy kidneys, it has recently been highlighted that a single renal segment could be supplied by one or more arterial branches originating from an artery supplying another segment. OBJECTIVE: To demonstrate occurrences of anatomical variations of renal vascularization and to analyze vascularization of renal tumors. DESIGN, SETTING, AND PARTICIPANTS: This prospective monocentric study included all patients treated for a renal tumor between May 2015 and June 2017 by laparoscopic partial nephrectomy after superselective tumor embolization in a hybrid operating room. INTERVENTION: Three-dimensional renal and tumoral arteriography with cone-beam computed tomography scan was performed, coupled with preoperative cross-sectional imaging. This procedure provided an accurate vascular anatomical mapping of the kidney and allowed further analysis of tumor vascularization. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Relation between anatomical variations of the vascularization and perioperative data was assessed. A χ2 test or Fisher's test was used for qualitative variables, and a Student t test was used for quantitative variables. RESULTS AND LIMITATIONS: Out of the 60 patients included, only 25 (42%) presented a standard vascular subdivision. In 26 patients (43%), tumors were supplied by more than one branch and in 20 patients (33%), there was a branch supplying the tumor from another segment. In these cases of multiple or multi-segmental tumor vascularization, tumor size, operative duration, and duration of embolization were significantly higher than in the case of standard vascularization. These complex tumors were more often located at the upper pole of the kidney or at the junction of the anterior and posterior vascular territories of the kidney. Limitations of this study include the low number of patients and its monocentricity. CONCLUSIONS: This study confirms that renal vascularization frequently differs from Graves' reference model and that tumor vascularization can depend on several segmental branches. This vascular complexity explains surgical difficulties and must be taken into consideration when segmental arterial clamping is considered during partial nephrectomy. PATIENT SUMMARY: We studied renal and tumor vascularization using three-dimensional preoperative arteriography data on tumor kidneys. We have shown that there is great variability in renal vascularization and that tumors can be vascularized branches that originate from an artery leading to another segment. This vascular complexity explains surgical difficulties and must be taken into consideration when segmental arterial clamping is considered during partial nephrectomy.

Laparoscopic Partial Nephrectomy After Selective Embolization and Robot-Assisted Partial Nephrectomy: A Comparison of Short-Term Oncological and Functional Outcomes.

BACKGROUND: Partial nephrectomy (PN) is the standard treatment for localized renal tumors. Laparoscopic PN (LPN) after selective embolization of tumor (LPNE) in a hybrid operating room has been developed to make LPN easier and safer. The aim of this study was to compare outcomes of LPNE and robot-assisted PN (RAPN). PATIENTS AND METHODS: All patients who underwent an LPNE at Angers University Hospital between May 2015 and April 2017, and a RAPN at Diaconesses Croix Saint Simon hospital between October 2014 and April 2017 were prospectively included. The functional outcomes were evaluated using the change of estimated glomerular filtration rate (eGFR) at 1 month, and the oncological outcomes were evaluated using the positive surgical margin (PSM) rate. RESULTS: Fifty-seven patients underwent LPNE and 48 underwent RAPN. There was no difference between oncological and functional outcomes, with 2 PSM (4.4%) in the LPNE group and 4 PSM (10.3%) in the RAPN group (P = .32), and a mean change in eGFR at 1 month of -5.5% for LPNE and -8.3% for RAPN (P = .17). The mean surgical time was shorter in the LPNE group (150 vs. 195 minutes; P < .001), and mean estimated blood loss was less in the LPNE group (185 vs. 345 mL; P = .04). CONCLUSION: The short-term oncological and functional outcomes for LPNE were comparable with those for RAPN. A longer follow-up and a larger cohort of patients would be necessary to verify the benefits of LPNE, which appears to be a very interesting alternative to RAPN.

Laparoscopic partial nephrectomy following tumor embolization in a hybrid room. Feasibility and clinical outcomes.

PURPOSE: In order to limit ischemia and operative bleeding during and after partial nephrectomy we developed a clampless laparoscopic technique, in a hybrid operating room, immediately after super-selective arterial embolization of the renal tumor. We evaluated feasibility and morbidity of this new approach of zero ischemia in partial nephrectomy. METHODS: We included prospectively 50 consecutive patients treated in a hybrid operating room by this new technique for a localized renal tumor in a university hospital between May 2015 and January 2017. We evaluated perioperative data, postoperative complications, surgical margin and modification of renal function one month after surgery. Renal tumor complexity was evaluated by the R.E.N.A.L. score. RESULTS: We included 30 (60%) men and 20 (40%) women with a median age of 61 years (32-84) and a median BMI of 26.85 kg/m2 (20.1-46.4). Tumors were at low, median and high complexity in respectively 11 (22%), 32 (64%) and 7 (14%) cases. Median endovascular and surgical procedures durations were 43 min (16-120) and 80 min (32-150). Median blood loss was 100 mL (10-850). Two Clavien II complications occurred. Median length of hospital stay was 3 days (2-7). Renal function was not modified one month after partial nephrectomy. Median tumor size was 3 cm (1.2-8). Forty tumors (80%) were malignant and surgical margins were positive in one (2%). CONCLUSIONS: Clampless laparoscopic partial nephrectomy in a hybrid operating room without pedicular dissection after previous tumoral embolization is a technically safe and carcinologically efficient mini-invasive alternative for the management of localized renal tumors.

Safety and Feasibility of Laparoscopic Nephrectomy for Big Tumors (≥ 10 cm): A Retrospective Multicentric Study.

OBJECTIVE: Evaluate the feasibility of laparoscopic nephrectomy for big tumors. MATERIAL AND METHODS: Data from 116 patients were retrospectively collected from 16 tertiary centres. Clinical and operative parameters, tumor characteristics, pre- and postoperative parameters, and renal function before and after surgery were analyzed. RESULTS: Mean age and body mass index were 61 years and 27.8 kg/m(2), respectively. Males represented 63.8% of patients, and 54.4% presented symptoms at diagnosis. Median tumor size was 11 cm, and 75% of the cases were performed by expert surgeons. Median operative time and blood loss were 180 minutes and 200 mL respectively. Conversion to open surgery was necessary in 20.7% of cases. Intraoperative complications related to massive hemorrhage occurred in 16.4% of patients, resulting in open conversion in 62.5%. Major postoperative complications occurred in only 10 patients (8.6%). In univariate analysis, intraoperative complications, age, and blood loss were predictive factors of conversion to open surgery. Positive surgical margins occurred in 6 patients (5.2%). None of them presented a local recurrence. Predictive factors of recurrence or progression were lymph node invasion, metastases, and Furhman grade. CONCLUSION: Laparoscopic nephrectomy for tumors > 10 cm can be performed safely. Complication rate and positive surgical margins are similar to open surgery. In experienced hands, the benefit of a mini invasive surgery remains evident.

Partial nephrectomy after selective embolization of tumor vessels in a hybrid operating room: A new approach of zero ischemia in renal surgery.

It is established that partial nephrectomy is the standard of care for tumors confined to the kidney. Achieving a partial nephrectomy without renal ischemia and limiting operative bleeding is the subject of numerous researches. Since 2010, hybrid operating rooms have been used to perform both interventional radiology and surgical procedures at the same place and time. We used this latest technology to treat 3 patients with localized kidney tumors. The tumors were of moderate complexity and all were treated after immediate hyperselective embolization by laparoscopic surgery without dissection and clamping of the renal pedicle. The embolization of tumor vessels could be performed using image-stitching software. After embolization, operative time was 50, 70 and 80 minutes and blood loss was less than 100 ml for each case. Postoperative control 3D arteriography confirmed the respect of the vascularization of the healthy renal parenchyma. No postoperative complications occurred. Combined approach including hyperselective embolization and partial nephrectomy in the same time in a dedicated operating room is a new approach of zero ischemia during partial nephrectomy which reduces the difficulty of the surgery, limits injury to the kidney and increases patient safety.

Acute renal colic during pregnancy: management and predictive factors.

INTRODUCTION: The aim of this study was to identify predictive factors of urolithiasis etiology for acute renal colic (ARC) during pregnancy. MATERIALS AND METHODS: We performed a retrospective review of all pregnant women hospitalized for an ARC between January 2007 and October 2012 in the department of Obstetrics and Gynecology of a University Hospital. Univariate and multivariate regression models were used to assess potential predictive factors of urolithiasis etiology. RESULTS: We included 82 patients. A urolithiasis was identified in 24 (29.3%) patients. In univariate analysis, we identified the following predictive factors for a urolithiasis etiology: primiparity (p = 0.017), leukocyturia (p = 0.021), left hydronephrosis > 10 mm and > 15 mm (p = 0.009; p = 0.02) and right hydronephrosis > 15 mm (p = 0.019). In multivariate analysis, only left hydronephrosis > 10 mm remained predictive for a urolithiasis etiology (p = 0.036; HR 7.45). A ureteral stenting was necessary for 23 patients (28.0%). Three patients (3.7%) had a premature membrane rupture and two patients (2.4%) delivered prematurely. After delivery, 10 patients (12.2%) required surgical treatment. CONCLUSION: Left hydronephrosis was related to urolithiasic etiology for ARC. Obstetrical consequences of ARC were minor.