Abstract：
BACKGROUND: The kidney is the most frequently injured component of the genitourinary system, accounting for 5% of all trauma cases. Several guidelines by different societies address the management of urological trauma. However, unanswered questions remain regarding optimal use of angioembolization in hemodynamically stable patients, indications for operative exploration of stable retroperitoneal hematomas and renal salvage techniques in the setting of hemodynamic instability, and imaging practices for patients undergoing non-operative management. We performed a systematic review, meta-analysis, and developed evidence-based recommendations to answer these questions in both blunt and penetrating renal trauma.
METHODS: The working group formulated four population, intervention, comparator, outcome (PICO) questions regarding the following topics: (1) angioembolization (AE) usage in hemodynamically stable patients with evidence of ongoing bleeding; (2) surgical approach to stable zone II hematomas (exploration vs. no exploration) in hemodynamically unstable patients and (3) surgical technique (nephrectomy vs. kidney preservation) for expanding zone II hematomas in hemodynamically unstable patients; (4) frequency of repeat imaging (routine or symptom based) in high-grade traumatic renal injuries. A systematic review and meta-analysis of currently available evidence was performed. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members and concurrence was obtained for each final recommendation.
RESULTS: A total of 20 articles were identified and analyzed. Two prospective studies were encountered; the majority were retrospective, single-institution studies. Not all outcomes projected by PICO questions were reported in all studies. Meta-analysis was performed for all PICO questions except PICO 3 secondary to the discrepant patient populations included in those studies. PICO 1 had the greatest number of articles included in the meta-analysis with nine studies; yet, due to differences in study design, no critical outcomes emerged; similar differences among a smaller set of articles prevented observation of critical outcomes for PICO 4. Analyses of PICOs 2 and 3 favored a non-invasive or minimally invasive approach in-line with current international practice trends.
CONCLUSIONS: In hemodynamically stable adult patients with clinical or radiographic evidence of ongoing bleeding, no recommendation could be made regarding the role of AE vs. observation. In hemodynamically unstable adult patients, we conditionally recommend no renal exploration vs. renal exploration in stable zone II hematomas. In hemodynamically unstable adult patients, we conditionally recommend kidney preserving techniques vs. nephrectomy in expanding zone II hematomas. No recommendation could be made for the optimal timing of repeat imaging in high grade renal injury.
METHODS: Guideline; systematic review, level III.
METHODS: The working group formulated four population, intervention, comparator, outcome (PICO) questions regarding the following topics: (1) angioembolization (AE) usage in hemodynamically stable patients with evidence of ongoing bleeding; (2) surgical approach to stable zone II hematomas (exploration vs. no exploration) in hemodynamically unstable patients and (3) surgical technique (nephrectomy vs. kidney preservation) for expanding zone II hematomas in hemodynamically unstable patients; (4) frequency of repeat imaging (routine or symptom based) in high-grade traumatic renal injuries. A systematic review and meta-analysis of currently available evidence was performed. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members and concurrence was obtained for each final recommendation.
RESULTS: A total of 20 articles were identified and analyzed. Two prospective studies were encountered; the majority were retrospective, single-institution studies. Not all outcomes projected by PICO questions were reported in all studies. Meta-analysis was performed for all PICO questions except PICO 3 secondary to the discrepant patient populations included in those studies. PICO 1 had the greatest number of articles included in the meta-analysis with nine studies; yet, due to differences in study design, no critical outcomes emerged; similar differences among a smaller set of articles prevented observation of critical outcomes for PICO 4. Analyses of PICOs 2 and 3 favored a non-invasive or minimally invasive approach in-line with current international practice trends.
CONCLUSIONS: In hemodynamically stable adult patients with clinical or radiographic evidence of ongoing bleeding, no recommendation could be made regarding the role of AE vs. observation. In hemodynamically unstable adult patients, we conditionally recommend no renal exploration vs. renal exploration in stable zone II hematomas. In hemodynamically unstable adult patients, we conditionally recommend kidney preserving techniques vs. nephrectomy in expanding zone II hematomas. No recommendation could be made for the optimal timing of repeat imaging in high grade renal injury.
METHODS: Guideline; systematic review, level III.
摘要：
背景：肾脏是泌尿生殖系统中最常受损的组成部分，占所有创伤病例的5%。不同社会的一些指南解决了泌尿系统创伤的管理。然而,关于在血流动力学稳定的患者中血管栓塞的最佳使用仍未解决的问题，在血流动力学不稳定的情况下，对稳定的腹膜后血肿和肾脏抢救技术进行手术探查的指征，以及接受非手术治疗的患者的影像学实践。我们进行了系统的审查,荟萃分析，并制定了基于证据的建议来回答钝性和穿透性肾损伤中的这些问题。
方法：工作组制定了四个人口，干预，比较器,结果（PICO）关于以下主题的问题：（1）血管栓塞（AE）在有持续出血证据的血液动力学稳定患者中的使用；（2）稳定区II血肿的手术方法（探索与无探查）在血流动力学不稳定的患者和（3）手术技术（肾切除术与肾脏保存）用于血流动力学不稳定患者的II区血肿扩大；（4）高度创伤性肾损伤中重复成像（常规或基于症状）的频率。对现有证据进行系统评价和荟萃分析。使用RevMan5（Cochran协作）和GRADepro（等级工作组）软件。工作组成员对建议进行了表决，并对每项最终建议表示同意。
结果：共鉴定和分析了20篇文章。遇到了两项前瞻性研究；大多数是回顾性的，单一机构研究。并非所有研究都报告了PICO问题预测的所有结果。对所有PICO问题进行荟萃分析，但PICO3继发于这些研究中包含的不同患者群体。PICO1在9项研究的荟萃分析中纳入了最多的文章；然而，由于研究设计的差异，没有出现关键结局;在一组较小的文章中,类似的差异阻碍了对PICO4关键结局的观察.对PICOs2和3的分析支持符合当前国际实践趋势的非侵入性或微创方法。
结论：在血液动力学稳定的成年患者中，临床或影像学证据表明持续出血，没有关于AE与AE的作用的建议观察。在血流动力学不稳定的成年患者中，我们有条件地建议没有肾探查与稳定区Ⅱ血肿肾探查术。在血流动力学不稳定的成年患者中，我们有条件地推荐肾脏保存技术与II区血肿扩大的肾切除术。无法推荐在高度肾损伤中重复成像的最佳时机。
方法：指南；系统综述，三级。
方法：工作组制定了四个人口，干预，比较器,结果（PICO）关于以下主题的问题：（1）血管栓塞（AE）在有持续出血证据的血液动力学稳定患者中的使用；（2）稳定区II血肿的手术方法（探索与无探查）在血流动力学不稳定的患者和（3）手术技术（肾切除术与肾脏保存）用于血流动力学不稳定患者的II区血肿扩大；（4）高度创伤性肾损伤中重复成像（常规或基于症状）的频率。对现有证据进行系统评价和荟萃分析。使用RevMan5（Cochran协作）和GRADepro（等级工作组）软件。工作组成员对建议进行了表决，并对每项最终建议表示同意。
结果：共鉴定和分析了20篇文章。遇到了两项前瞻性研究；大多数是回顾性的，单一机构研究。并非所有研究都报告了PICO问题预测的所有结果。对所有PICO问题进行荟萃分析，但PICO3继发于这些研究中包含的不同患者群体。PICO1在9项研究的荟萃分析中纳入了最多的文章；然而，由于研究设计的差异，没有出现关键结局;在一组较小的文章中,类似的差异阻碍了对PICO4关键结局的观察.对PICOs2和3的分析支持符合当前国际实践趋势的非侵入性或微创方法。
结论：在血液动力学稳定的成年患者中，临床或影像学证据表明持续出血，没有关于AE与AE的作用的建议观察。在血流动力学不稳定的成年患者中，我们有条件地建议没有肾探查与稳定区Ⅱ血肿肾探查术。在血流动力学不稳定的成年患者中，我们有条件地推荐肾脏保存技术与II区血肿扩大的肾切除术。无法推荐在高度肾损伤中重复成像的最佳时机。
方法：指南；系统综述，三级。
