Optimal timing of delayed excretory phase computed tomography scan for diagnosis of urinary extravasation after high-grade renal trauma.

J Trauma Acute Care Surg

From the Division of Urology, Department of Surgery (S.K., D.P.P., J.M.H., J.B.M.), Department of Radiology (B.E.P., D.M.R.), Division of Epidemiology, Department of Internal Medicine (G.J.S.), Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; Division of Acute Care Surgery (X.L.-O., K.M.), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma and Surgical Critical Care (B.J.M., S.M.), Intermountain Medical Center, Murray, Utah; Department of Urology (J.P.), Department of Surgery (C.M.D.), University of Wisconsin, Milwaukee, Wisconsin; Department of Urology, Hennepin County Medical Center (I.S., S.P.E.,), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (E.S.D.), Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery (S.Z.), University of California Davis Medical Center, Sacramento, California; Department of Urology (B.G.S., B.A.E.), University of Iowa, Iowa City, Iowa; Department of Urology (N.B., B.N.B.), University of California-San Francisco, San Francisco, California; Division of Trauma and Surgical Critical Care (C.N.F., B.P.S.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Department of Surgery (B.U.O., R.A.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Urology (B.M., R.A.S.), Detroit Medical Center, Detroit, Michigan; Medical City Plano (M.M.C.), Plano; Department of Surgery (J.F.K.), East Texas Medical Center, Tyler, Texas; Department of Urology (T.H., F.N.B.), Oakland University William Beaumont School of Medicine, Royal Oak, Michigan; and Department of Radiology and Imaging Sciences (M.E.H.), Emory University Hospital, Atlanta, Georgia.

Published: February 2019

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.

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