1台北慈濟醫院 泌尿科，2彰濱秀傳紀尿醫院 泌尿科
The American Association F
for the Surgery of Trauma Association Grade V Renal Blunt Trauma Successfully Treated Conservatively: A Case Report and Imaging Sharing
Tze-Chen Chao1, Yi-Sheng Chen 2
1 Division of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan; 2 Division of Urology, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
Case Presentation: The 19-year-old healthy man had fallen down with left loin blunt trauma and was sent to our hospital on the same day due to persistent left flank pain and gross hematuria. He had stable vital sign on arrival of emergency department. Physical examination revealed evident left costovertebral angle knocking tenderness, no peritoneal sign nor rebounding tenderness. Laboratory data disclosed leukocytosis with left shift and normal serum hemoglobin level. Abdominal computerized tomography (CT) scan with contrast showed left shattered kidney, the American Association for the Surgery of Trauma (AAST) grade V (Table 1), with perirenal and pararenal hematoma, non-visualization of left urinary collecting system and possible left renal vein injury. No prominent extravasation of contrast media from the CT scan. The patient was sent to intensive care unit for close monitoring and conservative treatment. Because of intermittent high grade fever and dropped serum hemoglobin level after few times of blood transfusion, abdominal CT scan with contrast was arranged on hospital day 4 for re-evaluation. There was still no evidence of contrast media extravasation from the CT scan nor visible renal vein for evaluation, so we kept conservative treatment. The fever subsided and hematuria, left flank pain improved gradually. Therefore, the patient started daily activity and oral diet. On hospital day 13, CT urogram showed two split left urinary collecting systems, wedge shape and poor enhancement of left upper pole (Table 2). Because of improved clinical condition, the patient was discharged on hospital day 15. The patient has been followed up at clinic for more than one month without major complication.
Discussion: Reviewing the literature, AAST grade V renal blunt trauma (RBT) accounted for 9 % of all renal trauma. Immediate surgery due to hemodynamic instability would be carried out in 11% of these cases. Among the patient who initially managed conservatively, 42% and 54% of the patients underwent transarterial angioembolization and surgery separately in the following days of injury because of unstable vitals. Conservative management was successful in only 52% AAST grade V RBT. We believe that intact or limited injury of the renal vein is the main reason that our patient could be treated conservatively. However, it is hard to assess from the initial CT scan. Thus, serial abdominal CT scan were performed for further evaluation of renal vein. Due to the limited case report of high grade RBT and paucity of comprehensive imaging study, we presented the case of AAST grade V RBT treated with only conservative management successfully, and demonstrated a series of follow-up abdominal CT scan images in a short time