Unexpected High Rates of Angiography and Angioembolization for Isolated Low-grade Renal Trauma: Results From a Large, Statewide, Trauma Database.

OBJECTIVE: To evaluate usage of diagnostic angiography (DA) and renal angioembolization (RAE) for isolated renal injuries while assessing differences in utilization based on trauma-level designation. METHODS: Isolated renal injuries from 2000 to 2013 were identified in the prospectively maintained Pennsylvania Trauma Outcome Study database and stratified by the American Association for the Surgery of Trauma kidney injury grade. Therapeutic intervention and International Classification of Diseases-9 codes identified DA and/or RAE performance, whereas renal injury was designated through Abbreviated Injury Scale codes. Univariate and multivariate models identified factors associated with utilization of DA or RAE. RESULTS: Of 449,422 patients entered into the Pennsylvania Trauma Outcome Study from 2000 to 2013, 1628 (0.4%) isolated kidney injuries were identified. The majority of patients (1190/1628, 73.1%) experienced low-grade (American Association for the Surgery of Trauma I-III) renal trauma. Although isolated grade IV (41/350, 11.7%) or grade V (10/88, 11.4%) renal trauma patients underwent DA or RAE at a greater rate (P < .001), low-grade patients still underwent DA or RAE 4.3% (51/1190) of the time. Patients with grade I injuries were significantly more likely to undergo DA or RAE at level 1 trauma centers (odds ratio 5.4, 95% confidence interval 1.2-23.8, P = .03). CONCLUSION: Despite overwhelming evidence supporting conservative management for patients with isolated, low-grade traumatic renal injuries, contemporary utilization of DA and RAE in such patients treated at trauma centers is surprisingly high. Factors accounting for a significant increase in utilization at Level 1 trauma centers need to be further elucidated.

Collecting Duct Renal Cell Carcinoma Found to Involve the Collecting System During Partial Nephrectomy: A Case Report.

Collecting duct carcinoma (CDC) is a rare and aggressive form of renal cell carcinoma (RCC) arising from the principal cells of the collecting duct. One third of cases present with metastatic disease, but many present in a manner similar to conventional RCC or urothelial carcinoma (UC). We discuss a case of CDC which presented as a small mass at the cortico-medullary junction, and was discovered at robotic partial nephrectomy (RPN) to be grossly involving the collecting system. A 62-year-old man presented with a small renal mass suspicious for RCC, which was found on computed tomography (CT) after an episode of gross hematuria. After thorough workup, RPN was attempted; however, intraoperatively the mass was found to be involving the collecting system. Radical nephroureterectomy was performed, and the pathology report revealed CDC. CDC is a rare and aggressive form of RCC. While many cases are metastatic at diagnosis, most patients present with the incidental finding of a small renal mass. There are no reports of a CDC involving the collecting system at RPN after negative ureteroscopy preoperatively. The adjuvant therapeutic options for CDC are limited, and long term survival is poor.