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EUROPEAN UROLOGY 59 (2011) 10651070

Re: Revision of Current American Association for the

Surgery of Trauma Renal Injury Grading System
Buckley JC, McAninch JW
J Trauma 2011;70:357
Experts summary:
A review of the large renal trauma database from San
Francisco General Hospital (San Francisco, CA, USA) was performed with the goal of updating the existing American Association for the Surgery of Trauma (AAST) renal trauma
grading system to make it more compatible with contemporary management protocols [1]. Improvements in computed
tomography (CT) imaging have been particularly important
in directing the shift from the surgical management of renal
injury to a mostly conservative management, and the
changes proposed by Buckley and McAninch reflect both
the significant improvements in imaging technology and
the resulting contemporary understanding of the natural
history of renal trauma.
No changes were proposed for grade 1 (renal contusion),
grade 2 (<1 cm laceration), or grade 3 (>1 cm laceration
without collecting system injury) renal trauma. The most
significant changes were made regarding grade 4 injuries,
which now comprise all collecting system injuries, including ureteropelvic junction (UPJ) injury of any severity and
segmental arterial and venous injuries, which had not been
previously classified. Grade 5 injuries, which before had
included shattered kidneys, loosely meaning multiple
grade 4 renal injuries in the ipsilateral kidney and complete
UPJ disruption, now include only renal hilar injuries,
including thrombotic events. Using this new grading
system, the authors then regraded all of their 3580 renal
trauma cases and found statistically similar numbers of
grade 4 and 5 injuries as well as nephrectomy and renal
salvage rates.

validated to predict outcomes such as mortality and the

need for nephrectomy [3], many authors have acknowledged that the current scale does not adequately classify
certain subtypes of injuries within grades 4 and 5,
specifically segmental vascular injury, and outcomes
differences within each grade have been shown to exist
[1,4]. Experience with renal trauma since 1989 has taught
us that renal hilar injuries more often than not need to be
managed surgically, whereas most injuries involving the
renal parenchyma and/or segmental vessels can safely be
managed conservatively. The new scale is a product of this
interval clinical knowledge and should be a more useful tool
with modern CT imaging when predicting the need for
surgical intervention. Its simplicity should also facilitate
needed clinical study of conservative management protocols and the utility of angioembolization for renal trauma.
Conicts of interest: The author has nothing to disclose.

References
[1] Santucci RA, Wessells H, Bartsch G, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma
subcommittee. BJU Int 2004;93:93754.
[2] Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling:
spleen, liver, and kidney. J Trauma 1989;29:16646.
[3] Santucci RA, McAninch JW, Sar M, Mario LA, Service S, Segal MR.
Validation of the American Association for the Surgery of Trauma
organ injury severity scale for the kidney. J Trauma 2001;50:
195200.
[4] Dugi III DD, Morey AF, Gupta A, Nuss GR, Sheu GL, Pruitt JH. American
Association for the Surgery of Trauma grade 4 renal injury substratication into grades 4a (low risk) and 4b (high risk). J Urol
2010;183:5927.

Bradley A. Erickson
Department of Urology, University of Iowa, Iowa City, IA, USA

Experts comments:
The changes made by the authors represent a welcome modification to the existing AAST grading scale that was adopted
in 1989 [2]. Although the current AAST grading scale has been

Re: An International Urogynecological Association

(IUGA)/International Continence Society (ICS) Joint Terminology and Classification of the Complications Related
Directly to the Insertion of Prostheses (Meshes, Implants,
Tapes) and Grafts in Female Pelvic Floor Surgery
Haylen BT, Freeman RM, Swift SE, et al
Neurourol Urodyn 2011;30:212
Experts summary:
This publication is a first attempt to systematically classify the
complications of synthetic prostheses that are used to correct
pelvic organ prolapse (POP) and stress urinary incontinence
(SUI). The CTS system is used for Category of complication
(eg, vaginal, urinary tract, or bowel compromise), Time of

E-mail address: brad-erickson@uiowa.edu

DOI: 10.1016/j.eururo.2011.03.043

complication (eg, early or late), and Site of complication

(eg, skin, musculoskeletal, or intra-abdominal complication).
This classification is an aid for use in clinical practice and
research.
Experts comments:
What do we tell our patients who choose to undergo vaginal
surgery for SUI or POP? In 2011 we know a few things about
meshes but especially about suburethral slings. Suburethral
slings are effective, they have long-term durability, and the
relative number of complications is low. We went from retropubic tapes to transobturator tapes. The latest development is
the single-incision sling, invented because this procedure can
be done under a local anesthetic. Of course, we do not have
randomized controlled trials with 5-yr follow-up for most