Is Nonoperative Management the Best First-line Option for High-grade Renal trauma? A Systematic Review

Arunan Sujenthiran* (Corresponding Author), Pieter Jan Elshout, Erik Veskimae, Steven MacLennan, Yuhong Yuan, Efraim Serafetinidis, Davendra M. Sharma, Noam D. Kitrey, Nenad Djakovic, Nicolaas Lumen, Franklin E. Kuehhas, Duncan J. Summerton

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

26 Citations (Scopus)
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Context: The management of high-grade (Grade IV–V) renal injuries remains controversial. There has been an increase in the use of (NOM) but limited data exists comparing outcomes with open surgical exploration.ObjectiveTo conduct a systematic review to determine if NOM is the best first-line option for high-grade renal trauma in terms of safety and effectiveness.

Evidence acquisition: Medline, Embase, and Cochrane Library were searched for all relevant publications, without time or language limitations. The primary harm outcome was overall mortality and the primary benefit outcome was renal preservation rate. Secondary outcomes included length of hospital stay and complication rate. Single-arm studies were included as there were few comparative studies. Only studies with more than 50 patients were included. Data were narratively synthesised in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed.

Evidence synthesis: Seven nonrandomised comparative and four single-arm studies were selected for data extraction. Seven hundred and eighty-seven patients were included from the comparative studies with 535 patients in the NOM group and 252 in the open surgical exploration group. A further 825 patients were included from single-arm studies. Results from comparative studies: overall mortality: NOM (0–3%), open surgical exploration (0–29%); renal preservation rate: NOM (84–100%), open surgical exploration (0–82%); complication rate: NOM (5–32%), open surgical exploration (10–76%). Overall mortality and renal preservation rate were significantly better in the NOM group whereas there was no statistical difference with regard to complication rate. Length of hospital stay was found be significantly reduced in the NOM group. Patients in the open surgical exploration group were more likely to have Grade V injuries, have a lower systolic blood pressure, and higher injury severity score on admission.

Conclusions: No randomised controlled trials were identified and significant heterogeneity existed with regard to outcome reporting. However, NOM appeared to be safe and effective in a stable patient with a higher renal preservation rate, a shorter length of stay, and a comparable complication rate to open surgical exploration. Overall mortality was higher in the open surgical exploration group, though this was likely due to selection bias.

Patient summary: The data of this systematic review suggest nonoperative management continues to be favoured to surgical exploration in the management of high-grade renal trauma whenever possible. However, comparisons between both interventions are difficult as patients who have surgery are often more seriously injured than those managed nonoperatively, and existing studies do not report on outcomes consistently.
Original languageEnglish
Pages (from-to)290-300
Number of pages11
JournalEuropean Urology Focus
Issue number2
Early online date29 May 2017
Publication statusPublished - Mar 2019

Bibliographical note

Funding/Support and role of the sponsor: None.


  • Conservative
  • High-grade renal injury
  • Nonoperative management
  • Surgical exploration


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