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Primary ureteral stent vs. observation in pediatric high-grade renal trauma: a multicenter, retrospective analysis from the traumatic renal injury collaborative in kids (TRICK) consortium
Tyler Gaines, MD¹, Jacob Lucas, DO², Jeffrey Ellis, MD³, Ching Man Carmen Tong, DO⁴, Albert Lee, DO⁵, Christopher Long, MD⁶, Vinaya Bhatia, MD⁷, Benjamin Abelson, MD⁸, Douglass Clayton, MD⁹, Gabriella Crane, MD⁹, Jonathan Gerber, MD¹⁰, Harold N. Lovvorn, MD⁹, Ming Hsien Wang, MD¹¹, David M. Kitchens, MD⁴, Christina Ho, MD¹², Michael Nance, MD⁶, Dana Weiss, MD⁶.
¹Einstein Healthcare Network, Philadelphia, PA, USA, ²Baylor Scott & White, Temple, TX, USA, ³Loyola University Medical Center, Chicago, IL, USA, ⁴Children's of Alabama, Birmingham, AL, USA, ⁵Texas Children's Hospital, Houston, TX, USA, ⁶Children's Hospital of Philadelphia, Philadelphia, PA, USA, ⁷University of Wisconsin - Madison, Madison, WI, USA, ⁸Phoenix Children's Hospital, Phoenix, AZ, USA, ⁹Vanderbilt Children's Hospital, Nashville, TN, USA, ¹⁰University of Texas Medical Branch, Webster, TX, USA, ¹¹Johns Hopkins University, Baltimore, MD, USA, ¹²Children's National, Washington D.C., DC, USA.

INTRODUCTION
While nonoperative treatment of pediatric low grade renal injuries is standard of care, management of high-grade renal trauma remains variable, as no universally accepted pediatric urogenital trauma guidelines exist. However, there is emerging evidence to support conservative management in select patients. We sought to evaluate clinical outcome differences in patients with high grade renal injuries (AAST III-V) who underwent primary ureteral stenting compared to patients managed conservatively with observation.
METHODS
A retrospective review of a multi-institutional database was performed of pediatric patients ≤ 18 years old who sustained high grade renal injuries (AAST III-V) and underwent either expectant management or primary ureteral stent placement. Data regarding patient demographics, mechanism of injury, associated injuries, and complications was collected. Logistic regression analysis was performed on unmatched data to identify risk factors associated with complications. Propensity score matching was performed to compare both cohorts after adjusting for grade of renal injury and concomitant injuries.
RESULTS
A total of 325 pediatric patients met eligibility criteria, of whom 289 patients underwent primary ureteral stent placement and 36 patients were managed with observation. Before propensity matching, multivariate analysis identified two independent risk factors for complication: ureteral stent procedure and concomitant spleen injury. Thirty-six patients per cohort (stent v. observation) were matched revealing no statistical difference in complication rate (24% v. 18%, p 0.12) or readmission (15% v. 12%, p 0.67). There was no difference in rate of urologic procedure at time of readmission (3% v. 6% p 0.34).
CONCLUSIONS
Our data supports the conservative management of high-grade renal injuries in appropriately selected patients.

	Before PSM			After PSM
	Stent (n= 36)	Observation (n= 289)	p-value	Stent (n=34)	Observation (n=34)	p-value
Complications (during hospitalization), n (%)	10 (28)	42 (15)	0.003	8 (24)	6 (18)	0.12
Ileus	2 (6)	0	-	1 (3)	0	-
Persistent GH	3 (8)	3 (1)	0.02	3 (9)	0	-
Fevers	5 (14)	27 (9)	0.73	5 (15)	4 (12)	0.67
Uncontrolled Pain	1 (3)	1 (0.3)	0.07	1	0	-
Intractable N/V	0	1 (0.3)	-	0	0	1.00
Acute blood loss anemia	2 (6)	8 (3)	0.65	2 (6)	0	-
Urinary Tract Infection	1 (3)	8 (3)	0.84	1 (3)	2 (6)	0.74
Days to Complication, median [IQR]	2 [1-4]	3 [2-6]	0.3	2 [1-4]	2 [2-5]	0.23
Length of Stay, median [IQR]	4 [2-8]	6 [4-9]	0.15	3 [2-7]	6 [4-8]	0.06
Readmission, n (%)	5 (14)	27 (9)	0.67	5 (15)	4 (12)	0.67
Ileus	0	1 (0.3)	-	0	0	1.00
Persistent GH	3 (8)	12 (4)	0.47	3 (9)	4 (12)	0.57
Fevers	1 (3)	4 (1)	0.52	0	0	1.00
Uncontrolled Pain	0	0	-	0	0	1.00
Intractable N/V	2 (6)	7 (2)	0.28	1 (3)	0	-
Acute blood loss anemia	0	1 (0.3)	-	0	0	1.00
Urinary Tract Infection	1 (3)	1 (0.3)	0.07	1 (3)	0	-
Days to Readmission, median [IQR]	10 [6-21]	13 [5-22]	0.83	11 [6-20]	11 [5-16]	0.54
Readmission Urologic Procedure, n (%)	2 (6)	7 (3)	0.42	1 (3)	2 (6)	0.34
PSM, Propensity Score Matching; IQR, Interquartile Range.

	Univariate			Multivariate
Variables	OR	95% CI	P-value	OR	95% CI	P-value
Grade of Renal Injury	1.96	1.28-3.02	0.02	1.40	0.87- 2.25	0.17
Concomitant Bowel Injury	1.54	0.58-4.09	0.38	1.64	0.57-4.68	0.36
Concomitant Liver Injury	1.07	0.57-1.97	0.86	1.12	0.57-2.20	0.73
Concomitant Spleen Injury	1.79	0.99-3.21	0.05	2.37	1.25-4.51	0.01
Ureteral Stent Procedure	7.35	3.52-15.31	<0.01	7.62	3.37-17.25	<0.01

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