BACKGROUND Excretory phase computed tomography (CT) scan is used for diagnosis of renal collecting system injuries and accurate grading of high-grade renal trauma. However, optimal timing of the excretory phase is not well established. We hypothesized that there is an association between excretory phase timing and diagnosis of urinary extravasation and aimed to identify the optimal excretory phase timing for diagnosis of urinary extravasation. METHODS The Genito-Urinary Trauma Study collected data on high-grade renal trauma (grades III-V) from 14 Level I trauma centers between 2014 and 2017. The time between portal venous and excretory phases at initial CT scans was recorded. Poisson regression was used to measure the association between excretory phase timing and diagnosis of urinary extravasation. Predictive receiver operating characteristic analysis was used to identify a cutoff point optimizing detection of urinary extravasation. RESULTS Overall, 326 patients were included; 245 (75%) had excretory phase CT scans for review either initially (n = 212) or only at their follow-up (n = 33). At initial CT with excretory phase, 46 (22%) of 212 patients were diagnosed with urinary extravasation. Median time between portal venous and excretory phases was 4 minutes (interquartile range, 4–7 minutes). Time of initial excretory phase was significantly greater in those diagnosed with urinary extravasation. Increased time to excretory phase was positively associated with finding urinary extravasation at the initial CT scan after controlling for multiple factors (risk ratio per minute, 1.15; 95% confidence interval, 1.09–1.22; p < 0.001). The optimal delay for detection of urinary extravasation was 9 minutes. CONCLUSION Timing of the excretory phase is a significant factor in accurate diagnosis of renal collecting system injury. A 9-minute delay between the early and excretory phases optimized detection of urinary extravasation. LEVEL OF EVIDENCE Diagnostic tests/criteria study, level III.

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) (MP04)1 Apr 2019MP04-02 RELIABILITY OF THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) RENAL INJURY GRADING FOR HIGH-GRADE RENAL INJURIES Sorena Keihani*, Bryn Putbrese, Douglas Rogers, Gregory Stoddard, Kaushik Mukherjee, Sarah Majercik, Joshua Piotrowski, Christopher Dodgion, Brenton Sherwood, Bradley Erickson, Ian Schwartz, Sean Elliott, Erik DeSoucy, Scott Zakaluzny, Nima Baradaran, Benjamin Breyer, Brian Smith, Brandi Miller, Richard Santucci, Matthew Carrick, Jurek Kocik, Timothy Hewitt, Frank Burks, Marta Heilbrun, Raminder Nirula, James Hotaling, and Jeremy Myers Sorena Keihani*Sorena Keihani* More articles by this author , Bryn PutbreseBryn Putbrese More articles by this author , Douglas RogersDouglas Rogers More articles by this author , Gregory StoddardGregory Stoddard More articles by this author , Kaushik MukherjeeKaushik Mukherjee More articles by this author , Sarah MajercikSarah Majercik More articles by this author , Joshua PiotrowskiJoshua Piotrowski More articles by this author , Christopher DodgionChristopher Dodgion More articles by this author , Brenton SherwoodBrenton Sherwood More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Ian SchwartzIan Schwartz More articles by this author , Sean ElliottSean Elliott More articles by this author , Erik DeSoucyErik DeSoucy More articles by this author , Scott ZakaluznyScott Zakaluzny More articles by this author , Nima BaradaranNima Baradaran More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Brian SmithBrian Smith More articles by this author , Brandi MillerBrandi Miller More articles by this author , Richard SantucciRichard Santucci More articles by this author , Matthew CarrickMatthew Carrick More articles by this author , Jurek KocikJurek Kocik More articles by this author , Timothy HewittTimothy Hewitt More articles by this author , Frank BurksFrank Burks More articles by this author , Marta HeilbrunMarta Heilbrun More articles by this author , Raminder NirulaRaminder Nirula More articles by this author , James HotalingJames Hotaling More articles by this author , and Jeremy MyersJeremy Myers More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000554954.23774.d5AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: The American Association for the Surgery of Trauma (AAST) injury scale is the most widely used grading system for renal trauma. However, reproducibility of the AAST grading is not well studied. We aimed to assess the agreement for AAST renal trauma grading between radiologists and the grades entered in a multi-center database of high-grade renal trauma. METHODS: Data on high-grade renal trauma (AAST grades III-V) was collected from 14 Level-1 trauma centers from 2014-2017. Patients with initial CT scans were included. 2 radiologists, blinded to the submitted AAST grades and outcomes, reviewed the scans and re-graded the injuries according to the 1989 original AAST grading (O-AAST). After measuring the inter-radiologist agreement, both radiologists were asked to reach consensus on the discrepancies. The reproducibility of AAST grading was evaluated using weighted Kappa analysis for ordinal variables. Inter-radiologists agreement as well as final agreement between re-graded readings (O-AAST) and the injury grades submitted by the centers (C-AAST) were measured. Agreement was interpreted based on the kappa coefficient as slight (0-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), and almost perfect (0.81-1.00). RESULTS: 322 patients met the inclusion criteria. Injuries were submitted by centers as grade III (59.8%), grade IV (33.1%), and grade V (7.1%). Upon re-grading the injuries, inter-radiologist agreement was substantial for O-AAST (Kappa: 0.76, 95% CI: 0.66-0.84). After resolving the discrepancies, injuries were re-graded using the O-AAST as non-gradable (1.2%), grade I (0.9%), grade II (4.6%), grade III (71.5%), grade IV (16.6%), and grade V (5.2%). Comparing the O-AAST re-grading and C-AAST, the agreement was moderate (Kappa: 0.50, 95% CI: 0.40-0.60). Overall, 27% of injuries were downgraded, 5% were upgraded, and 68% remained the same. CONCLUSIONS: The agreement between center-reported renal injury grades and re-grading of injuries by radiologists blinded to the outcomes was moderate and many injuries were downgraded. These findings have implications for using AAST grading for both predicting the need for interventions, as well as using administrative data, such as the National Trauma Databank for research purposes when AAST grade is an important variable. Source of Funding: none Salt Lake City, UT; Loma Linda, CA; Murray, UT; Milwaukee, WI; Iowa City, IA; Minneapolis, MN; Sacramento, CA; San Francisco, CA; Philadelphia, PA; Detroit, MI; Plano, TX; Tyler, TX; Royal Oak, MI; Atlanta, GA; Salt Lake City, UT© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e30-e30 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sorena Keihani* More articles by this author Bryn Putbrese More articles by this author Douglas Rogers More articles by this author Gregory Stoddard More articles by this author Kaushik Mukherjee More articles by this author Sarah Majercik More articles by this author Joshua Piotrowski More articles by this author Christopher Dodgion More articles by this author Brenton Sherwood More articles by this author Bradley Erickson More articles by this author Ian Schwartz More articles by this author Sean Elliott More articles by this author Erik DeSoucy More articles by this author Scott Zakaluzny More articles by this author Nima Baradaran More articles by this author Benjamin Breyer More articles by this author Brian Smith More articles by this author Brandi Miller More articles by this author Richard Santucci More articles by this author Matthew Carrick More articles by this author Jurek Kocik More articles by this author Timothy Hewitt More articles by this author Frank Burks More articles by this author Marta Heilbrun More articles by this author Raminder Nirula More articles by this author James Hotaling More articles by this author Jeremy Myers More articles by this author Expand All Advertisement PDF downloadLoading ...

Sorena Keihani, M.D., Bryn E. Putbrese, Douglas M. Rogers, Chong Zhang Raminder, Nirula Xian, Luo-Owen, Kaushik Mukherjee, Bradley J. Morris, Sarah Majercik, Joshua Piotrowski, Christopher M. Dodgion, Ian Schwartz, Sean P. Elliott, Erik S. DeSoucy, Scott Zakaluzny, Brenton G. Sherwood, Bradley A. Erickson, Nima Baradaran, Benjamin N. Breyer, Cameron N. Fick, Brian P. Smith, Barbara U. Okafor, Reza Askari, Brandi Miller, Richard A. Santucci, Matthew M. Carrick, Jurek F. Kocik, Timothy Hewitt, Frank N. Burks, Marta E. Heilbrun, Jeremy B. Myers (J Trauma Acute Care Surg. 2019;86(6):974Y982)

INTRODUCTION AND OBJECTIVES: Radiologic factors are important for predicting bleeding interventions after high-grade renal trauma (HGRT). We aimed to assess the associations between laceration size and peri-renal hematoma rim distance (HRD) with bleeding interventions after HGRT and also find the optimal cut-off points for these measurements. METHODS: The Genito-Urinary Trauma Study is a multi-center study including data on HGRT (AAST grades III-V) from 14 Level-1 trauma centers from 2014-2017. Patients with initial CT scans were included. 2 radiologists reviewed the scans to extract HRD (largest measure from the edge of the kidney to the hematoma in the axial plane) and size of the deepest laceration. Renal bleeding interventions included: angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Diagnostic accuracy was measured using the ROC analysis and the optimal cut-offs were chosen based on the Youden′s index and F-1 score. Mixed effect Poisson regression was used to assess the associations. RESULTS: 326 patients were included. Mean age was 35.0±16.6 y. Injury mechanism was blunt in 81%. Injuries were reported as AAST grades III (60%), IV (33%), and V (7%). Overall, 47 (14%) underwent bleeding interventions including 19 renal angioembolization, 16 nephrectomies, and 12 other procedures. Mean HRD was 2.1±2.0 cm and was higher in the intervention group (4.3±0.4 vs. 1.8±0.1, P<0.001). Mean laceration size was 2.0±1.0 cm and was higher in the intervention group (2.8±0.1 vs. 1.9±0.1, P<0.001). For HRD, a cut-off of 3.5 cm provided the best diagnostic accuracy (sen: 0.62, spe: 0.87, Youden: 0.49, F1 score: 0.51). An HRD ≥3.5 cm was associated with 6.3-fold increase in risk of undergoing bleeding interventions (RR: 6.3, 95% CI: 3.5-11.4). For laceration size, a cut-off of 2.5 cm provided best diagnostic accuracy (sen: 0.62, spe: 0.80, Youden: 0.42, F1 score: 0.44). A laceration ≥2.5 cm was associated with 4.4-fold increased risk of bleeding interventions (RR: 4.4, 95% CI: 2.5-8.0). CONCLUSIONS: Our findings support the use of 3.5 cm cut-off point for hematoma and 2.5 cm for laceration size. These cut-offs may be used as simpler predictors of bleeding interventions. Renal trauma grading may benefit from incorporating additional important radiologic findings. Figure. No caption available. Source of Funding: none

BACKGROUND Indications for intervention after high-grade renal trauma (HGRT) remain poorly defined. Certain radiographic findings can be used to guide the management of HGRT. We aimed to assess the associations between initial radiographic findings and interventions for hemorrhage after HGRT and to determine hematoma and laceration sizes predicting interventions. METHODS The Genitourinary Trauma Study is a multicenter study including HGRT patients from 14 Level I trauma centers from 2014 to 2017. Admission computed tomography scans were categorized based on multiple variables, including vascular contrast extravasation (VCE), hematoma rim distance (HRD), and size of the deepest laceration. Renal bleeding interventions included angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Mixed-effect Poisson regression was used to assess the associations. Receiver operating characteristic analysis was used to define optimal cutoffs for HRD and laceration size. RESULTS In the 326 patients, injury mechanism was blunt in 81%. Forty-seven (14%) patients underwent 51 bleeding interventions, including 19 renal angioembolizations, 16 nephrectomies, and 16 other procedures. In univariable analysis, presence of VCE was associated with a 5.9-fold increase in risk of interventions, and each centimeter increase in HRD was associated with 30% increase in risk of bleeding interventions. An HRD of 3.5 cm or greater and renal laceration depth of 2.5 cm or greater were most predictive of interventions. In multivariable models, VCE and HRD were significantly associated with bleeding interventions. CONCLUSION Our findings support the importance of certain radiographic findings in prediction of bleeding interventions after HGRT. These factors can be used as adjuncts to renal injury grading to guide clinical decision making. LEVEL OF EVIDENCE Prognostic and Epidemiological Study, Level III and Therapeutic/Care Management, Level IV.

BACKGROUND The management of high-grade renal trauma (HGRT) and the indications for intervention are not well defined. The American Association for the Surgery of Trauma (AAST) renal grading does not incorporate some important clinical and radiologic variables associated with increased risk of interventions. We aimed to use data from a multi-institutional contemporary cohort to develop a nomogram predicting risk of interventions for bleeding after HGRT. METHODS From 2014 to 2017, data on adult HGRT (AAST grades III–V) were collected from 14 level 1 trauma centers. Patients with both clinical and radiologic data were included. Data were gathered on demographics, injury characteristics, management, and outcomes. Clinical and radiologic parameters, obtained after trauma evaluation, were used to predict renal bleeding interventions. We developed a prediction model by applying backward model selection to a logistic regression model and built a nomogram using the selected model. RESULTS A total of 326 patients met the inclusion criteria. Mechanism of injury was blunt in 81%. Median age and injury severity score were 28 years and 22, respectively. Injuries were reported as AAST grades III (60%), IV (33%), and V (7%). Overall, 47 (14%) underwent interventions for bleeding control including 19 renal angioembolizations, 16 nephrectomies, and 12 other procedures. Of the variables included in the nomogram, a hematoma size of 12 cm contributed the most points, followed by penetrating trauma mechanism, vascular contrast extravasation, pararenal hematoma extension, concomitant injuries, and shock. The area under the receiver operating characteristic curve was 0.83 (95% confidence interval, 0.81–0.85). CONCLUSION We developed a nomogram that integrates multiple clinical and radiologic factors readily available upon assessment of patients with HGRT and can provide predicted probability for bleeding interventions. This nomogram may help in guiding appropriate management of HGRT and decreasing unnecessary interventions. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.

BACKGROUND:In 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions.METHODS:Data on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared.RESULTS:Of the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34).CONCLUSION:About one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions.LEVEL OF EVIDENCE:Prognostic and Epidemiological Study, level III.

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II1 Apr 2018MP25-18 IMAGING FINDINGS ASSOCIATED WITH RENAL BLEEDING INTERVENTIONS AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITO-URINARY TRAUMA STUDY Sorena Keihani, Rachel Moses, Yizhe Xu, Bryn Putbrese, Douglas Rogers, Xian Luo-Owen, Kaushik Mukherjee, Bradley Morris, Sarah Majercik, Joshua Piotrowski, Christopher Dodgion, Brenton Sherwood, Bradley Erickson, Ian Schwartz, Sean Elliott, Erik DeSoucy, Scott Zakaluzny, Nima Baradaran, Benjamin Breyer, Brian Smith, Brandi Miller, Richard Santucci, Matthew Carrick, Jurek Kocik, Timothy Hewitt, Frank Burks, Marta Heilbrun, James Hotaling, Angela Presson, Raminder Nirula, and Jeremy Myers Sorena KeihaniSorena Keihani More articles by this author , Rachel MosesRachel Moses More articles by this author , Yizhe XuYizhe Xu More articles by this author , Bryn PutbreseBryn Putbrese More articles by this author , Douglas RogersDouglas Rogers More articles by this author , Xian Luo-OwenXian Luo-Owen More articles by this author , Kaushik MukherjeeKaushik Mukherjee More articles by this author , Bradley MorrisBradley Morris More articles by this author , Sarah MajercikSarah Majercik More articles by this author , Joshua PiotrowskiJoshua Piotrowski More articles by this author , Christopher DodgionChristopher Dodgion More articles by this author , Brenton SherwoodBrenton Sherwood More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Ian SchwartzIan Schwartz More articles by this author , Sean ElliottSean Elliott More articles by this author , Erik DeSoucyErik DeSoucy More articles by this author , Scott ZakaluznyScott Zakaluzny More articles by this author , Nima BaradaranNima Baradaran More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Brian SmithBrian Smith More articles by this author , Brandi MillerBrandi Miller More articles by this author , Richard SantucciRichard Santucci More articles by this author , Matthew CarrickMatthew Carrick More articles by this author , Jurek KocikJurek Kocik More articles by this author , Timothy HewittTimothy Hewitt More articles by this author , Frank BurksFrank Burks More articles by this author , Marta HeilbrunMarta Heilbrun More articles by this author , James HotalingJames Hotaling More articles by this author , Angela PressonAngela Presson More articles by this author , Raminder NirulaRaminder Nirula More articles by this author , and Jeremy MyersJeremy Myers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.855AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In high-grade renal trauma (HGRT), radiologic findings including hematoma rim distance (HRD), laceration location, and intravascular contrast extravasation (ICE) are proposed to be associated with interventions for renal hemorrhage. We aimed to assess the association of multiple imaging findings with renal bleeding interventions in a prospective multi-institutional study of HGRT. METHODS The GU Trauma Study is a multi-center prospective study including data on HGRT from 13 Level-1 trauma centers from 2014-2017. Patients with CT scans at presentation were included. 2 radiologists, blinded to outcomes, reviewed the scans for ICE, laceration location (lateral, medial, complex [lateral and medial]), HRD (largest measure from the edge of the kidney to the hematoma), and hematoma extension (subcapsular, peri-renal, para-renal [beyond the aorta on the left or IVC on the right or into the pelvis]). Renal bleeding interventions included: angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Logistic regression established associations between imaging findings and bleeding interventions. RESULTS 310 patients met the inclusion criteria. 80% had blunt trauma. Mean age and ISS were 35.0±16.3 and 25.3±12.7. Injuries were AAST grades III, IV, and V in 60%, 32%, and 8%. Overall, 46 (15%) underwent bleeding interventions including: renal angioembolization (18), nephrectomy (17), and other surgical procedures (11). 68 (22%) had ICE. laceration location was lateral (93; 31%), medial (69; 23%), or complex (134; 45%). Hematoma extension was subcapsular (8; 3%), peri-renal (201; 72%), and para-renal (70; 25%). Mean HRD in all patients was 2.2±0.2 cm and was higher in patients who underwent bleeding interventions (4.3±0.3 vs. 1.8±0.2 cm). In the bleeding intervention group 54% had HRD>3.5 cm compared to 14% in the conservative group. In univariate analysis, ICE, complex laceration, para-renal hematoma, and PRD>3.5 cm were associated with bleeding intervention (Table-1). CONCLUSIONS Several radiologic factors are associated with renal bleeding interventions. These factors could be used to create a bleeding risk nomogram guiding clinical decision making for patients with HGRT. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e333-e334 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Sorena Keihani More articles by this author Rachel Moses More articles by this author Yizhe Xu More articles by this author Bryn Putbrese More articles by this author Douglas Rogers More articles by this author Xian Luo-Owen More articles by this author Kaushik Mukherjee More articles by this author Bradley Morris More articles by this author Sarah Majercik More articles by this author Joshua Piotrowski More articles by this author Christopher Dodgion More articles by this author Brenton Sherwood More articles by this author Bradley Erickson More articles by this author Ian Schwartz More articles by this author Sean Elliott More articles by this author Erik DeSoucy More articles by this author Scott Zakaluzny More articles by this author Nima Baradaran More articles by this author Benjamin Breyer More articles by this author Brian Smith More articles by this author Brandi Miller More articles by this author Richard Santucci More articles by this author Matthew Carrick More articles by this author Jurek Kocik More articles by this author Timothy Hewitt More articles by this author Frank Burks More articles by this author Marta Heilbrun More articles by this author James Hotaling More articles by this author Angela Presson More articles by this author Raminder Nirula More articles by this author Jeremy Myers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I1 Apr 2018PD02-08 THE IMPORTANCE OF THE TIMING OF EXCRETORY PHASE CT SCAN IN THE DIAGNOSIS OF URINARY EXTRAVASATION AFTER HIGH-GRADE RENAL TRAUMA Sorena Keihani, Darshan Patel, Bryn Putbrese, Douglas Rogers, Xian Luo-Owen, Kaushik Mukherjee, Bradley Morris, Sarah Majercik, Joshua Piotrowski, Christopher Dodgion, Brenton Sherwood, Bradley Erickson, Ian Schwartz, Sean Elliott, Erik DeSoucy, Scott Zakaluzny, Nima Baradaran, Benjamin Breyer, Brian Smith, Brandi Miller, Richard Santucci, Matthew Carrick, Jurek Kocik, Timothy Hewitt, Frank Burks, Marta Heilbrun, James Hotaling, Raminder Nirula, and Jeremy Myers Sorena KeihaniSorena Keihani More articles by this author , Darshan PatelDarshan Patel More articles by this author , Bryn PutbreseBryn Putbrese More articles by this author , Douglas RogersDouglas Rogers More articles by this author , Xian Luo-OwenXian Luo-Owen More articles by this author , Kaushik MukherjeeKaushik Mukherjee More articles by this author , Bradley MorrisBradley Morris More articles by this author , Sarah MajercikSarah Majercik More articles by this author , Joshua PiotrowskiJoshua Piotrowski More articles by this author , Christopher DodgionChristopher Dodgion More articles by this author , Brenton SherwoodBrenton Sherwood More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Ian SchwartzIan Schwartz More articles by this author , Sean ElliottSean Elliott More articles by this author , Erik DeSoucyErik DeSoucy More articles by this author , Scott ZakaluznyScott Zakaluzny More articles by this author , Nima BaradaranNima Baradaran More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Brian SmithBrian Smith More articles by this author , Brandi MillerBrandi Miller More articles by this author , Richard SantucciRichard Santucci More articles by this author , Matthew CarrickMatthew Carrick More articles by this author , Jurek KocikJurek Kocik More articles by this author , Timothy HewittTimothy Hewitt More articles by this author , Frank BurksFrank Burks More articles by this author , Marta HeilbrunMarta Heilbrun More articles by this author , James HotalingJames Hotaling More articles by this author , Raminder NirulaRaminder Nirula More articles by this author , and Jeremy MyersJeremy Myers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.233AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Contrast-enhanced CT of the abdomen/pelvis with delayed excretory phase is the preferred diagnostic test in renal trauma. Excretory phase allows for contrast accumulation into the collecting system to evaluate for urinary extravasation. Although usually performed at about 5 minutes, the optimal time between contrast injection and excretory phase has not been established. We hypothesized that there is an association between excretory phase timing and diagnosis of urinary extravasation. METHODS From 2014-2017, imaging data on high-grade renal trauma (AAST grades III-V) were gathered from 13 Level-1 trauma centers participating as the AAST Genito-Urinary Trauma Study Group. Patients with missing initial CT scans or those who underwent immediate surgery without imaging were excluded. Initial and follow up CT scans were reviewed by 2 radiologists to evaluate for urinary extravasation. The time between the early (portal venous) and excretory phases was recorded. Follow up images were reviewed to determine if there were cases of missed urinary extravasation diagnosis. Logistic regression was used to measure the association of excretory phase timing with diagnosis of urinary extravasation. RESULTS From 313 patients with available initial CT, 232 (74%) had excretory phase imaging for review either at the initial contrast CT (199) or at their follow up (33). Median time between portal venous and excretory phases was 4 m (IQR: 4-7 m). Overall, 66 patients (21%) were diagnosed with urinary extravasation either at the initial (51) or at follow up CT scan (15). Of the 15 urinary extravasations diagnosed at follow up, 6 did not have excretory phase imaging initially and 9 were missed despite initial excretory phase imaging. Median time to excretory phase imaging was longer in those initially diagnosed with urinary extravasation (n=51) compared to those with missed collecting system injury (n=9) [median: 7 m, IQR: 4-10 m vs. median: 4 m, IQR: 4-7 m, respectively; P=0.01; Wilcoxon ranked-sum test). In univariate regression, increased time to excretory phase was positively associated with finding urinary extravasation at the initial CT scan (OR: 1.2, 95% CI: 1.1-1.3). CONCLUSIONS The timing of excretory phase imaging in the evaluation of renal trauma is important in diagnosis of urinary extravasation. Longer delays between early and excretory phase imaging is associated with increased odds of finding a collecting system injury. Although this study shows that longer time to excretory phase is preferred, we cannot yet determine what the optimal delay time is. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e68 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Sorena Keihani More articles by this author Darshan Patel More articles by this author Bryn Putbrese More articles by this author Douglas Rogers More articles by this author Xian Luo-Owen More articles by this author Kaushik Mukherjee More articles by this author Bradley Morris More articles by this author Sarah Majercik More articles by this author Joshua Piotrowski More articles by this author Christopher Dodgion More articles by this author Brenton Sherwood More articles by this author Bradley Erickson More articles by this author Ian Schwartz More articles by this author Sean Elliott More articles by this author Erik DeSoucy More articles by this author Scott Zakaluzny More articles by this author Nima Baradaran More articles by this author Benjamin Breyer More articles by this author Brian Smith More articles by this author Brandi Miller More articles by this author Richard Santucci More articles by this author Matthew Carrick More articles by this author Jurek Kocik More articles by this author Timothy Hewitt More articles by this author Frank Burks More articles by this author Marta Heilbrun More articles by this author James Hotaling More articles by this author Raminder Nirula More articles by this author Jeremy Myers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Ventriculomegaly (VM) is a non-specific finding on fetal imaging. Identification of the specific aetiology is important, as it affects prognosis and may even change the course of current or future pregnancies. In this review, we will focus on the application of fetal MRI to demonstrate intracranial haemorrhage and ischaemic brain injury as opposed to other causes of VM. MRI is able to identify the specific aetiology of VM with much more sensitivity and specificity than ultrasound and should be considered whenever VM is identified on obstetric ultrasound. Advances in both fetal and neonatal MRI have the potential to shed further light on mechanisms of brain injury and the impact of chronic hypoxia; such information may guide future interventions.