LAUSR

In their recent article, Chebbi et al. compared observation and early drainage by ureteral stenting in patients with blunt renal trauma and urinary extravasation in a multicenter cohort [1]. Based on their results, they concluded that observation was not different from early drainage in terms of persistent urinary extravasation after grade IV blunt renal trauma. Since the last few decades, non-operative management of high-grade renal trauma has become the standard of care with interventions which are mostly minimally invasive, being reserved for patients who fail non-operative management and develop symptoms in the form of persisitent urinoma or bleeding [2, 3]. In this study, the authors have explored whether early intervention in high-grade trauma can hasten the resolution of extravasation and thereby the recovery of the traumatized kidney. We appreciate the authors’ efforts in trying to answer this important question, as this is still a controversial topic in renal trauma management [4–6]. However, some methodological issues are need to be discussed. One of the biggest pitfalls we noticed in this study and in many studies focusing on timing of intervention has been the definition of early intervention which the authors have used i.e., 48 h after admission [4–6]. This is based on the assumption that all patients come to the trauma centers immediately after trauma, which is erroneous. Many a time, patient with blunt trauma abdomen do not present immediately to the hospital and sometimes they are referred from smaller centers after a trial of non-operative intervention. So, many patients who are in fact taken as “early” intervention in this study may in fact be “not so early” intervention if the time from trauma is considered. This may be a possible reason for the authors’ failure to show no significant difference in the duration of extravasation between the groups. We believe a better definition of early intervention would have been 48 h after trauma. Another point of potential criticism has to do with the fact that the authors have considered only ureteral stenting as intervention and excluded percutaneous interventions. In grade IV renal trauma, when there is a major parenchymal laceration with a large rent, sometimes a stent alone will not be beneficial in facilitating drainage and is prone to occlusion by clots from resolving hematoma; in such cases, a simultaneous percutaneous drain insertion into the urinoma would be a better option in hastening resolution of the collection [7]. Further, as the authors themselves have acknowledged putting a stent may increase the chances of reflux and increase the chance of infection leading to more morbidity as they have noticed in the present study [8]. Lastly, we observe that most of the studies on management of blunt renal trauma including the present one have focused on short-term outcomes only, with the idea of renal salvage being just avoidance of nephrectomy [9, 10]. We believe long-term functional outcomes especially in the subgroup that need interventions for salvage are also important, as we need to know whether these traumatized kidneys actually recover in function or atrophy over time. Unfortunately, most of the studies on this subject including the present one have relegated this important topic to the last few lines of This comment refers to the article available online at https ://doi. org/10.1007/s0034 5-020-03255 -3.