Renal Trauma Medscape PDF

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com/article/440811-print

emedicine.medscape.com
Renal Trauma
Updated: Apr 05, 2023
Author: Dennis G Lusaya, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS
Overview
Practice Essentials
Renal trauma may manifest in a dramatic fashion for both the patient and the clinician. The incidence of renal trauma
depends somewhat on the patient population being considered. Renal trauma accounts for approximately 1-5% of all
trauma admissions and as many as 10% of abdominal trauma admissions.[1] In addition, renal trauma may occur in
settings other than those thought of as a classic trauma setting. At most trauma centers, blunt renal trauma is more
common than penetrating trauma; indeed, blunt renal injuries are as much as 9 times more common than penetrating
injuries. Both kidneys are at equal disposition for injury.[2]
Genitourinary (GU) tract injuries, while typically not lethal, require clinical knowledge pertaining to each GU organ to avoid
unwanted outcomes (eg, loss of kidney function, urinary incontinence, difficulty voiding) and secondary psychosocial
stressors. Coordination of care among urologists, general/trauma surgeons, orthopedics, and other services can be
essential to improve overall outcomes.
The management of renal injuries has evolved over the past decade, with an increasing preference for nonsurgical
management, when clinically appropriate. The tolerance for nonoperative or expectant management has increased, even
with the most seriously injured kidneys, replacing the past tendency toward aggressive renorrhaphy.
Problem
Most traumatic renal injury occurs as a result of blunt trauma. Renal injuries may be generally divided into 3 groups:
laceration, contusion, and vascular injury. All subsets of renal trauma require a high index of clinical awareness and prompt
evaluation and management.
Epidemiology
Frequency
The frequency of renal injury somewhat depends on the patient population being considered. Renal trauma occurs in 80–
95% of urogenital trauma cases and 8–10% of abdominal blunt trauma.[3]
Using the National Trauma Data Bank, Grimsby et al reviewed data on 2213 pediatric renal injuries to determine injury
mechanism and grade, demographics, treatment, and treatment setting. Most renal trauma in children was found to be low
grade (79%) and blunt (> 90%). Mean age at injury was 13.7 years, with 94% of patients being 5 to 18 years old. Only 12%
of patients were admitted to a pediatric hospital. Although most children were treated conservatively at adult hospitals, the
rate of nephrectomy was three times higher than for those patients treated at pediatric hospitals.[4]
Similarly, a review of 20 years of a prospectively maintained trauma database found that 70.6% of pediatric renal injuries
from blunt trauma were low grade. Nephrectomy was required in only 1.4% of the 228 cases, and endoscopic interventions
or percutaneous drainage procedures were needed in 2.4%.[5]
A meta-analysis of 24 studies found that approximately 30% of patients with high-grade renal trauma are diagnosed with
urinary extravasation. The rate of extravasation was 29% after grade III-V trauma and 51% with grade IV-V injuries. Meta-
analysis of 20 studies showed that overall, 29% of patients with urinary extravasation underwent ureteral stenting.[6]
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Etiology
The mechanism of injury should alert the clinician to the possibility of renal trauma. The following list is not all-inclusive, but
it highlights the major mechanisms that generate renal injuries:
Penetrating (eg, gunshot wounds, stab wounds)

Blunt - Rapid deceleration (eg, motor vehicle crash, fall from heights); direct blow to the flank (eg, pedestrian struck,
sports injury)
Iatrogenic (eg, endourologic procedures, extracorporeal shock-wave lithotripsy, [7] kidney biopsy, percutaneous
renal procedures)
Intraoperative (eg, diagnostic peritoneal lavage [8] )
Other (eg, kidney transplant rejection, childbirth [9] [may cause spontaneous renal lacerations])
In a review by Dangle et al of pediatric blunt renal trauma cases from a trauma database, the most frequent mechanisms
of injury identified, in descending order of frequency, were as follows[5] :
Falls
Recreational motor vehicle (RMV) accidents
Bicycle accidents
Motor vehicle collisions
Sports accidents
The authors note that during the 20 years reviewed (1993 to 2013), RMV-related injuries became frequent, despite
recommendations against the use of these vehicles by this population.[5]
High-grade renal injuries have been reported as the result of electric scooter accidents.[10]
Presentation
The diagnosis of renal injury begins with a high index of clinical awareness. The mechanism of injury provides the
framework for the clinical assessment. Particular attention should be paid to complaints of flank or abdominal pain.
Urinalysis, both gross and, if necessary, microscopic, should be performed in patients who are thought to have renal
trauma. Based on these initial measures, radiographic or operative investigation may follow.
Indications
Most blunt renal injuries are low grade; therefore, they are usually amenable to treatment with observation and bed rest
alone. Penetrating trauma is more likely to be associated with more severe renal injury, thus requiring a higher index of
clinical awareness. Further, penetrating trauma is more often associated with other abdominal injuries requiring
laparotomy, thus providing the opportunity for intraoperative renal staging and/or repair.
Patients with indications for emergent exploration include those with hemodynamic instability. Expanding hematomas or
active hemorrhage suggests the possibility of high-grade renal injury. Patients with penetrating trauma who are stable and
do not require urgent laparotomy for other possible intra-abdominal injuries may be observed without immediate renal
exploration.
Unrelenting gross hematuria may require urgent exploration. However, the presence of a renal contusion does not typically
require specific intervention. Findings from imaging studies may appear quite alarming, but most renal contusions resolve,
particularly if the lesion appears to be of grade I-III.
Relevant Anatomy
In most instances, the kidneys are paired retroperitoneal structures. They lie against the psoas muscles. The superior
aspect of the kidneys is somewhat protected by the lower ribs. However, the lower poles are inferior to the 12th ribs.
The parenchyma of the kidney has a segmental arterial supply. This anatomic arrangement becomes important in the
management of renal lacerations. Blunt injuries tend to fracture along the planes between the segmental vessels, while
penetrating injuries cross the segmental vessels.
Numerous anatomic variations exist, including the following:
Pelvic kidneys
Horseshoe kidneys
Multiple renal arterial, venous, and ureteral duplications
Contraindications
For all practical purposes, no specific contraindications exist for surgical exploration of possible renal trauma. However, the
general trend is toward a more selective approach. Current (2020) guidelines on urotrauma from the American Urological
Association recommend noninvasive management strategies in hemodynamically stable patients with renal injury.[11]
Presentation
History
When possible, obtain a focused history of the injury from the patient, prehospital personnel, and available bystanders.
Important information relevant to genitourinary injury includes the mechanism of injury, prehospital care provided, and any
previous history of genitourinary injury or disease. As the genitourinary tract is seldom injured in isolation, a meticulous
physical examination is crucial to avoid missing occult injuries. The clinical clues to a potential renal injury are nonspecific,
but include: bruising, pain, or tenderness to the flank or abdomen; posterior rib or spine fractures; gross hematuria; other
organ injury; microhematuria, defined as ≥3 to 5 RBCs/HPF; and shock, defined as a systolic blood pressure ≤90 mmHg.
The degree of renal injury does not correspond to the degree of hematuria, since gross hematuria may occur in minor
trauma and only mild hematuria in major trauma. Not all patients sustaining blunt renal injuries require full imaging
evaluation. Only those with gross hematuria or microscopic hematuria with shock (systolic blood pressure < 90mmHg)
should undergo imaging and those without microscopic hematuria with shock need not.
However, in cases where there is a strong suspicion of renal injury based on physical examination or associated injuries
arise, renal imaging is warranted. This is especially true of victims of rapid deceleration injuries, who may have renal injury
without the presence of hematuria.
Workup
Laboratory Studies
Urinalysis
Urinalysis provides rapidly available information in patients who may have a renal laceration; however, the data obtained
must be viewed within a rational framework.
If gross hematuria is not present, a microscopic examination is advisable. Although in general, the degree of hematuria
correlates with the likelihood of urinary tract trauma, renal injury with no hematuria has been reported. Reliance on
urinalysis as the only modality to help diagnose renal trauma is fraught with difficulty. In fact, injuries such as renal artery
laceration or avulsion may not generate any hematuria.
One study documents that 63% of patients with multisystem trauma had hematuria, of which 12.5% had a proven injury.
[12] Other investigators have shown that as many as 11% of patients with renal gunshot wounds did not have hematuria.
[13]
Thus, the presence or absence of hematuria should be viewed in the clinical context and not used as the sole decision
point in the assessment of a patient with a possible renal laceration.
Imaging Studies
Intravenous pyelography
All penetrating renal and hemodynamically unstable blunt renal trauma patients who require immediate surgical exploration
should undergo one-shot, high-dose intravenous urography (IVU) prior to any renal exploration.[14] One-shot trauma IVU
consists of 2 mL/kg of body weight of standard 60% ionic or nonionic contrast injected intravenously, followed by a single
abdominal radiograph 10 minutes later. No scout film is necessary.
In children, 2-3 mL/kg of nonionic contrast is preferred.[15] For a satisfactory study, a systolic blood pressure above 90 mm
Hg is needed. In order to save time, the contrast can be injected at the time of the initial resuscitation. Unstable patients
who are emergently taken to the operating room, should be stabilized first and undergo one-shot IVU in the operating room
once they are stabilized. The major limitation of intravenous pyelography (IVP) is that it can seldom, by itself, define the full
extent of the injury.[16]
The purpose of the IVU is to determine the presence of two functioning renal units, the presence and extent of any urinary
extravasation, and, in penetrating injuries, the likely course of the missile. Radiopaque markers (paper clips) taped to the
skin at the bullet entrance and exit sites help predict the likelihood of the kidney being in the missile's path.
IVU is highly accurate for establishing the presence or absence of renal injury.[17] When it comes to staging parenchymal
injury, however, IVU findings are usually nonspecific and not sensitive.[18, 19] Abnormal or equivocal IVU findings warrant
further exploration or radiographic staging. For the hemodynamically stable patient, further and more accurate staging can
be achieved with CT scanning.[20, 21] For unstable patients with abnormal IVU findings, surgical exploration is warranted.
Advantages of IVP are as follows:
Allows functional and anatomic assessment of both kidneys and ureters

Establishes the presence or absence of two functional kidneys
May be performed in the emergency department or operating room
Disadvantages of IVP are as follows:
Multiple images are required for maximal information, although a one-shot technique can be used
The radiation dose is relatively high (0.007-0.0548 Gy)
A full IVP usually requires a trip to the radiology suite
Findings do not reveal the full extent of injury (one investigation of penetrating trauma showed normal findings on
six of 27 IVP examinations; all of those six patients had renal injuries)
Computed tomography
For stable patients, renal injury can be most accurately and completely imaged and staged using computed tomography
(CT).[20, 21] CT imaging is both sensitive and specific for demonstrating parenchymal lacerations and urinary
extravasations, delineating segmental parenchymal infarcts, and determining the size and location of the surrounding
retroperitoneal hematoma and/or associated intra-abdominal injury (spleen, liver, pancreas, and bowel).
CT imaging has largely replaced the once standard IVU and arteriography. In the acute setting, CT scanning has
completely replaced arteriography because it can also accurately delineate segmental and major arterial injuries. The
present role of arteriography is with delayed renal bleeding or delayed arteriovenous fistula formation, for which super-
selective arterial embolization is used.[22] Renal artery occlusion and global renal infarct are noted on CT scans by lack of
parenchymal enhancement or a persistent cortical rim sign. Although reliable for demonstrating renal infarct, the
disadvantage to using the rim sign is that it is usually not seen until at least 8 hours after injury.[23]
The advent of fast-scanning and image-reconstructing helical CT scanners has reduced turnaround times for abdominal
trauma imaging to the 10-minute range. Seventy to 90 seconds before initiating helical CT scanning, 150-180 mL of
intravenous contrast is given at 2-4 mL per second. Helical CT imaging is so quick (usually under 2 min) that only the
arterial phase (20-30 seconds) and the early cortical phase (40-70 seconds) of the kidney are obtained. Arterial-phase
imaging helps delineate any renal artery injury, while the early cortical phase still misses most parenchymal injuries.
Therefore, in order to complete the proper evaluation and staging of renal injuries, later imaging in the nephrogram phase
(>80 seconds) is needed to detect renal parenchymal and venous injury, while delayed images (2-10 min) are often
required to detect urine and blood extravasation. On delayed CT images, extravasated urine can be distinguished from
blood in that it accumulates, while extravasated arterial contrast dilutes out after the bolus of contrast is stopped.[15, 24]
In children, four-phase CT with intravenous contrast (noncontrast, arterial, nephrographic, and pyelographic phases) is the
choice for initial imaging. However, ultrasonography might also be used in children with minimal symptoms.[25]
Advantages of CT are that it (1) allows unsurpassed functional and anatomic assessment of the kidneys and urinary tract,
(2) helps establish the presence or absence of 2 functional kidneys, and (3) allows for the diagnosis of concurrent injuries.
Disadvantages are that (1) it requires intravenous contrast in order to maximize information about functionality, hematoma,
and, possibly, bleeding; (2) the patient must be stable enough to go to the scanner; and (3) full urinary assessment is
dependent on the timing of contrast and scanning in order to view the bladder and ureters.
Follow-up CT imaging is performed in high-grade injury within two to four days after trauma to minimize the risk of missed
complications. In patients with low-grade injury, repeat CT imaging is not needed in the absence of symptoms.[26]
Angiography
With the advent of accurate and quick CT imaging, the uses for arteriography with renal trauma have diminished. Renal
arteriography does provide the opportunity to stage the injury and, if necessary to embolize bleeding points at the same
time.[17] However, in the acute setting, it is rarely used (renal arteriography and embolization for renal trauma) because it
is time consuming and patients with active bleeding need to undergo immediate exploratory laparotomy. Furthermore,
during laparotomy, the kidney can be explored and surgically reconstructed. Arteriography and superselective embolization
continues to play an important role in the evaluation and treatment of symptomatic posttraumatic arteriovenous fistulas or
persistent delayed renal bleeding.[22]
Advantages are that it (1) has the capacity to aid in both the diagnosis and treatment of renal injuries and (2) may further
define injury in patients with moderate IVP abnormalities or with vascular injuries.
Disadvantages are as follows:
Invasive
Requires contrast
Requires mobilization of resources to perform the study, which may be time-consuming
Requires moving the patient to the radiology suite
Ultrasonography
Experience with the evaluation of suspected acute renal traumatic injury by ultrasonography has been primarily from
Europe.[27] In well-trained and experienced hands, renal lacerations and hematomas can be reliably identified and
delineated. Limitations of ultrasonography include an inability to distinguish fresh blood from extravasated urine and an
inability to identify vascular pedicle injuries or segmental infarcts. Only with close color and pulsed Doppler interrogation
can a vascular injury be diagnosed. Furthermore, concomitant rib fractures, bandages, intestinal ileus, open wounds, or
morbid obesity severely limit renal visualization.
In general, the accuracy of ultrasonography for evaluating the retroperitoneum is variable, time consuming, and highly
operator dependent. Therefore, the routine use of ultrasonography for screening acute renal trauma is not advocated.
However, ultrasonography has proven useful and reliable for evaluating blunt intra-abdominal injuries by detecting the
presence of hemoperitoneum. In hemodynamically unstable patients, it is used as a less invasive replacement for
diagnostic peritoneal lavage. In stable blunt trauma victims, ultrasonography is used to direct patients to CT imaging when
hemoperitoneum is noted and to observation in those with negative findings
Advantages are as follows:
Noninvasive
May be performed in real time in concert with resuscitation
May help define the anatomy of the injury
Disadvantages are as follows:
Optimal study results related to anatomy require an experienced sonographer

The focused abdominal sonography for trauma (FAST) examination does not define anatomy and, in fact, looks only
for free fluid
Bladder injuries may be missed.
Diagnostic Procedures
Operative diagnosis
Depending on the mechanism of injury, many patients who sustain renal laceration have associated intra-abdominal
injuries that require urgent exploration. The clinical situation may have precluded the opportunity to perform the
aforementioned diagnostic modalities.
The surgeon should be prepared to make the diagnosis of renal injury intraoperatively. Lateral retroperitoneal hematomas
may alert the surgeon to the presence of renal laceration. Direct evidence of penetrating trauma should also provide
evidence of renal laceration. Other renal trauma, including renal pelvis or ureteral injuries, should be sought and identified.
Although the medical consensus is not complete, evidence exists that not all perirenal hematomas discovered at
laparotomy require exploration. Theories range from simple observation to exploration with vascular control. The optimal
course depends on the physician's experience and the institution's resources. Increasingly, even severe renal injuries are
being safely managed nonoperatively.
Staging
Using the clinical information, the indications for radiographic imaging may be tailored to detect patients with a significant
chance of having a major renal laceration (considered grades 3-4).
Based on the experience at San Francisco General Hospital, Brandes and McAninch recommend imaging patients with the
following categories of injuries[28] :
Blunt trauma and gross hematuria

Blunt trauma, microscopic hematuria, and shock
Major deceleration injury
Microscopic or gross hematuria after penetrating flank, back, or abdominal trauma or missile path in line with the
kidney
Pediatric trauma patient with significant microscopic or gross hematuria
Associated injuries suggesting underlying renal injury
Blunt trauma and gross hematuria
Gross hematuria is the most reliable indicator for serious urological injury. The degree of hematuria, however, does not
correlate with the degree of injury. In fact, renal pedicle avulsion or acute thrombosis of segmental renal arteries can occur
in the absence of hematuria, while renal contusions can present as gross hematuria.
Blunt trauma, microscopic hematuria, and shock
Significant microscopic hematuria is more than five red blood cells per high-power field (RBC/hpf) in the first voided or
catheterized specimen. Shock is any presence of systolic blood pressure less than 90 mm Hg during transport or upon
arrival in the emergency department. Blunt trauma patients with microhematuria and no shock have minor renal injuries in
nearly all cases.
Miller and McAninch reviewed the records of 2254 adult patients with suspected renal trauma and found that only 3 of the
1588 blunt trauma patients with microscopic hematuria and no shock had significant injury. Those 3 patients did not
undergo renal imaging studies at first, but they were the victims of multiple trauma, and their initially missed major renal
injuries were discovered during imaging or exploratory laparotomy for associated injuries. These authors concluded that
radiographic imaging can be safely foregone in adults with blunt renal trauma who have microscopic hematuria and no
shock or major associated intra-abdominal injuries.[2]
Major deceleration injury
The kidney primarily floats free in a bed of fat contained within the envelope of the Gerota fascia. The kidney is fixed at
only two points, the ureter and the vascular pedicle. Because of poor fixation, the kidney can be easily dislocated by
sudden acceleration or deceleration.
Kidney dislocation can result in tearing of the collecting system at the ureteropelvic junction (UPJ) or tearing of renal artery
intima, resulting in partial-to-complete vessel occlusion. Such injuries can occur with major deceleration, as in head-on
motor vehicle accidents (MVA) or falls from great heights, or from marked flexion extension, as with pedestrian versus
motor vehicle collisions. Pediatric patients are particularly prone to this mechanism of injury. In general, all rapid
deceleration injuries warrant renal imaging, even in the absence of hematuria.[14, 29]
Pediatric trauma patient with significant microscopic or gross hematuria
In comparison to adults, children’s kidneys are relatively much larger for their body size. The kidneys are also not as well
protected with perirenal fat, which is usually scant, and lower ribs that are incompletely ossified. Therefore, children are
particularly prone to injury. However, the majority of blunt renal injuries are contusions that require no active therapy.
Hypotension is often an unreliable predictor of significant renal injury, as children can maintain a normal blood pressure
despite extensive blood loss.[30]
Traditionally, all children with any degree of microscopic hematuria after blunt trauma have undergone renal imaging. In a
meta-analysis of all reported series of children with hematuria and suspected renal injury,[31] Morey et al noted that only
2% (11 of 548) of patients with insignificant microscopic hematuria (< 50 RBC/HPF) had a significant renal injury.
Furthermore, these 11 patients all had other significant injuries that required abdominal and, thus, renal imaging. They
concluded that renal injury is suggested in children in stable condition with gross or significant microscopic hematuria (>50
RBC/HPF) or with moderate-to-severe multisystem trauma (regardless of the hematuria degree), and these children should
undergo renal imaging.
Patients who do not initially undergo renal imaging who have persistent or worsening hematuria should also be imaged.
Although renal pedicle injuries can occur without hematuria, they are likely to be associated with severe multisystem
trauma that requires abdominal imaging anyway. For suspected renal injury, CT scanning is the best study for staging a
solid organ injury.
Associated injuries suggesting underlying renal injury
These include blunt trauma and a flank ecchymosis, lumbar vertebral or transverse process fractures, lower rib (11th or
12th) fractures, and severe mechanism of injury. Another indication for imaging is a penetrating flank or abdominal injury
with which the entrance and exit sites (or radio-opaque density) are in the path of the kidney, regardless of the degree of
hematuria.
Also see the Medscape article Imaging in Kidney Trauma and the flow chart in the image below.
Flow chart for adult renal injuries; a guide for decision making. CT, computed tomography; IVP, intravenous pyelography;
RBC/HPF, red blood cells per high-power field; SBP, systolic blood pressure.
Injury scaling
To determine the appropriate management for a renal injury, the renal injury first needs to be accurately staged. The
American Association for the Surgery of Trauma (AAST) has defined renal trauma in five grades, as shown in the table
below.[32, 33, 34, 35]
Table. American Association for Surgery of Trauma Renal Injury Scale (Open Table in a new window)
Grade Type Description
Contusion Microscopic or gross hematuria, urologic studies normal
Hematoma Subcapsular, non-expanding without parenchymal laceration
II Hematoma Non-expanding perirenal hematoma confined to renal retroperitoneum
Laceration < 1.0 cm parenchymal depth of renal cortex
> 1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary
III Laceration
extravasation
Laceration Parenchymal laceration extending through renal cortex, medull, and collecting system
IV
Vascular Main renal artery or vein injury with contained hemorrhage
Laceration Completely shattered kidney
Vascular Avulsion of renal hilum that devascularizes kidney

Treatment
Approach Considerations
Santucci describes the contemporary approach to renal trauma as follows[36] :
1. Operate immediately if the patient has life-threatening bleeding

2. Observe initially, but step in with metered responses as necessary
3. Use ureteral stents for symptomatic or growing urinoma
4. Use angioembolization for nonemergent bleeding or for urgent bleeding if those techniques are available at your
center
5. Do open surgery when needed
Nonoperative Treatment
In the setting of blunt renal trauma and selected instances of penetrating renal trauma, a nonoperative approach may be
selected. Patient selection is the preliminary step in adopting a nonoperative management strategy. One series, with
predominantly blunt mechanisms of injury, documented that over 85% of patients were treated successfully without
surgery.[37] Ultimately, the exclusion of concurrent injury may be the key point in treating patients nonoperatively.
The anatomic structure of the kidney lends itself to nonoperative management in the setting of blunt trauma. The kidney
has an end-artery blood supply with a segmental pattern of division that supplies the renal parenchyma. When subjected to
blunt force that causes a laceration, the laceration tends to occur through the parenchyma. The resulting hematoma may
displace renal tissue, but the segmental vessels themselves often are not lacerated.
The closed retroperitoneal space around the kidney also promotes tamponade of bleeding renal injuries. Finally, the kidney
is rich in tissue factor, the molecule that activates the extrinsic coagulation cascade, further promoting hemostasis after
injury.
Interventional radiology has extended the ability to treat renal lacerations nonoperatively. Techniques have included the
following:
Percutaneous drainage of perinephric fluid collections or urinomas
Endourologic stenting
Angiography with selective embolization
For example, Wang et al reported that emergency transcatheter arterial embolization produced complete hemostasis in 80
of 83 patients with acute renal hemorrhage. Renal artery computed tomography angiography (CTA) was used to localize
the bleeding artery in 35 of their cases. Embolic agents used varied with arteriographic presentation and included gelatin
sponge, polyvinyl alcohol particles, and coils.[38]
In children with grade IV renal injury who are receiving conservative treatment, Lee et al recommend performing a follow-
up imaging study 4-5 days after the trauma when any of the following are present[39] :
Need for transfusion

Main laceration location in the antero-medial portion of the kidney
Intravascular contrast extravasation
Large perinephric hematoma (> 2.2 cm)
In their study of 26 consecutive cases of grade IV renal trauma in children, more patients with those predictive factors
required urologic intervention, typically 4-8 days after the trauma.[39]
Loftus et al studied repeat imaging, generally performed 48 to 72 hours after initial imaging, in 108 conservatively managed
patients who had grade IV renal lacerations with urinary extravasation from blunt trauma. Patients who received routine
repeat imaging were more likely to undergo a urologic procedure in the absence of symptoms and received more radiation
during their hospital stay. Patients who did not undergo repeat imaging did not experience a higher rate of urologic
complications. These authors suggest that in patients who do not have signs/symptoms, repeat imaging may be avoidable.
[40]
Operative Treatment
The goals of operative therapy for renal laceration incorporate the two basic principles of hemorrhage control and renal
tissue preservation, which must be balanced for each individual patient. Attempts to find a universal plan for this approach
have generated controversy in the medical literature. The mindset of the medical community has also been changing as
established practice patterns have been examined, challenged, and reassessed.
An additional benefit of operative therapy is the ability to address concurrent injuries. One study documented that 80% of
patients with renal laceration had other associated injuries. In that same study, 47% of the patients with renal laceration
had an associated injury that required immediate laparotomy.
Indications for renal exploration
In order to select a renal injury for nonoperative management, the injury needs to be imaged and accurately staged. An
incompletely staged renal injury requires surgical exploration. Not all penetrating renal injuries require surgical exploration.
The use of the improved imaging technique of CT has largely been responsible for the decreased rate of renal explorations
at the authors’ institution. Guidelines for the surgical exploration of the injured kidney vary.
The only absolute indication for surgical renal exploration is a patient with external trauma and persistent renal bleeding.
Signs of continued renal bleeding are a pulsatile, expanding, or uncontained retroperitoneal hematoma. Another sign is
avulsion of the main renal artery or vein as noted by CT or arteriography.
In the Genitourinary Trauma Study, a multicenter study of 326 patients with high-grade renal trauma (81% blunt trauma),
51 bleeding interventions were performed in 47 patients. Univariable analysis showed that the likelihood of intervention
was 5.9-fold higher when imaging showed vascular contrast extravasation, and increased by 30% with each centimeter
increase in hematoma rim distance (HRD). An HRD of 3.5 cm or greater and renal laceration depth of 2.5 cm or greater
were most predictive of interventions. The authors concluded that those radiographic findings can be used as adjuncts to
renal injury grading to guide clinical decision making.[37]
Relative indications include nonviable tissue. Substantial devitalized renal parenchyma (> 25%) is a relative indication for
exploration.[41] Husmann and Morris[42] noted that injuries with significant nonviable renal tissue (25-50%) associated
with parenchymal laceration that are managed nonoperatively have a high complication rate (82%).
Husmann et al further compared the results of the nonoperative and surgical management of major renal lacerations and
devitalized renal fragments after blunt trauma. Their findings demonstrated that when such renal injuries are associated
with an intraperitoneal organ injury, the postinjury complication rate is much higher unless the kidney is surgically explored
and repaired. By surgically repairing such injuries, they reduced the overall morbidity from 85% to 23%. Concomitant
pancreatic and bowel injuries were particularly associated with higher rates of infected urinomas and abscesses.
Furthermore, since nearly all blunt trauma patients with intraperitoneal organ injuries undergo celiotomy by the general
surgeon, this offers the opportunity to explore and repair the kidney with such major parenchymal injuries.
A systematic review by Chiron et al identified three risk factors that are not included in the grade 4 renal injury
classification, but are associated with hemodynamic instability and need for surgery, as follows[41] :
Perirenal hematoma >3.5 cm

Intravascular contrast extravasation
Medial renal laceration
Additional relative indications include the following:
A major devitalized segment

Injury associated with urinary extravasation
Extensive renal injury
A large retroperitoneal hematoma, even without intraperitoneal injury
Urinary extravasation
Urinary extravasation in itself does not demand surgical exploration. Extravasation confirms the diagnosis of a major renal
injury. Persistent extravasation or signs of sepsis usually require intervention. In general, urinary extravasation resolves
spontaneously in the majority of patients with blunt trauma. In select patients, expectant management does not reduce the
renal salvage rate and does not prolong hospitalization.
Nonoperative therapy may also require delayed intervention. However, the usual complications of urinoma and persistent
urinary leak can be successfully managed by either percutaneous or endoscopic techniques, thus avoiding celiotomy and
renal exploration. Matthews et al[43] reported that in patients with major renal injury and urinary extravasation who are
managed conservatively, urinary extravasation spontaneously resolved in 87%. Extravasation persisted in 13% and was
successfully managed endoscopically (eg, double-J stent). Overall hospitalization lasted 8 days and was not prolonged by
the need for delayed intervention.
Ureteropelvic junction (UPJ) injuries rarely heal spontaneously and thus are often best managed by surgical repair at the
time of injury. Conservative management of such injuries is fraught with persistent urine leakage, urinoma formation, ileus,
and infection.
Incomplete staging
Only complete definition of the renal injury by appropriate imaging studies permits the selection of nonoperative
management. Incomplete staging demands either further imaging or renal exploration and reconstruction. In the unstable
patient who requires emergent celiotomy, the kidney can only be imaged by one-shot IVU on the operating room table. The
nephrogram of the injured kidney is often poorly opacified due to the injury and is worsened by any hemodynamic
instability. In so doing, the full extent of the injury is indeterminate. In such circumstances, the kidney should be explored
after obtaining proximal vascular control.
The unexpected finding of a retroperitoneal hematoma upon celiotomy should be evaluated by on-table, one-shot IVU. If
IVU results are abnormal or indeterminate or if the kidney is persistently bleeding, then the kidney should be explored.
Arterial thrombosis
Major deceleration injuries can result in stretching on the renal artery and tearing of the vessel intima, resulting in
thrombosis of the main renal artery or its segmental branches and thus causing infarction of the renal parenchyma. Prompt
diagnosis and the time until operation of a unilateral complete arterial thrombosis is vital to salvaging the kidney. The
chance of renal salvage is remote after 12 hours of ischemia.
If the contralateral kidney is healthy, there is some controversy as to whether to attempt revascularization or to observe. If
renal ischemia exceeds 12 hours, the kidney should be allowed to slowly atrophy. Nephrectomy should be performed only
if delayed celiotomy is being performed for an associated injury or if persistent hypertension develops postoperatively.
Bilateral complete renal artery thrombosis or a solitary kidney demands more immediate exploration and revascularization.
Penetrating trauma
The only absolute indication for exploration is persistent renal bleeding. Nearly all penetrating renal injuries should be
managed surgically. The exception is stable patients with no missile penetration of the peritoneum in whom the injury is
well staged by computed tomography.
Wessels et al have shown that gunshot wound victims who have no intra-abdominal organ injury and a demonstrated
grade 1-2 renal injury, when managed conservatively, are relatively complication free. In sharp contrast, one of four
expectantly managed grade 3-4 injuries were complicated by delayed renal bleeding.[44]
A study by Bjurlin et al found that selective nonoperative management of penetrating renal injuries resulted in a lower
mortality rate, a decreased incidence of blood transfusion, and a shortened mean ICU and hospital stay compared with
nephrectomy; however, results were similar to renorrhaphy. Rates of complication were low with selective nonoperative
management and were comparable to operative management.[45]
Stab wounds posterior to the posterior axillary line are less likely to have an associated visceral injury. When the diagnostic
peritoneal lavage or CT scan is negative for intraperitoneal organ injury and the renal injury not severe, observation of the
renal injury may be appropriate. Most abdominal penetrating injuries undergo celiotomy by the general surgeons. The
presence of an unexpected retroperitoneal hematoma upon exploratory laparotomy when the renal injury has not been fully
staged radiographically usually warrants renal exploration.
Some controversy remains with the use of postoperative drains in the setting of renal trauma. The general trend has been
away from the routine use of drains in this setting, although some centers still advocate their use. Suction drains should be
avoided after renal repair.
Preoperative Details
Patients with renal injuries should be managed with initial attention to the basic ABCDEs outlined in Advanced Trauma Life
Support protocols. Because many patients have multisystem trauma with concurrent injuries, a systematic approach to the
initial assessment and resuscitation allows for identification of other injuries. The decision-making process becomes more
involved as additional injuries are found. For additional details, see Critical Care Considerations in Trauma or Initial
Evaluation of the Trauma Patient.
Intraoperative Details
Techniques for renal exploration and repair
Primary vascular control is achieved prior to all renal explorations by routinely obtaining proximal vascular control. For
vascular control, the ipsilateral renal artery and vein are isolated individually with vessel loops.
The kidney is then exposed by incising the Gerota fascia lateral to the colon. When brisk bleeding is encountered, the renal
artery is temporarily occluded with Rummel tourniquets. Warm ischemic time should not greatly exceed 30 minutes, in
order to avoid permanent renal ischemic damage. If bleeding persists, the renal vein is occluded by Rummel tourniquet
placement, in order to eliminate back bleeding. Temporary occlusion of the renal artery is needed in patients with renal
vascular injuries, those in shock, and those with large or expanding retroperitoneal hematomas.
Rostas et al have proposed that exploration of the Gerota fascia may be used selectively rather than routinely for patients
with renal gunshot wounds. Their retrospective 10-year review of 63 patients with renal gunshot wounds who underwent
exploratory laparotomy concluded that most such patients do not require exploration of the Gerota fascia. Compared with
patients (n=28) who underwent exploration of the Gerota fascia, those who did not (n=35) experienced significantly lower
mortality (14% versus 29%), had very low complication rates, and were unlikely to need surgical intervention due to renal-
associated complications.[46]
Renal reconstruction
In the absence of persistent hemodynamic instability or coagulopathy, renal reconstruction is safe and effective. The
method of kidney reconstruction is dictated by the degree and location of the injury, and not by the associated intra-
abdominal injuries. In the face of concomitant major pancreatic or colonic injuries with frank fecal contamination, renal
reconstruction is successful, with only a slightly increased complication rate. The reconstructive principles for renal injures
are as follows:
Adequate and broad exposure of the kidney and injured area
Temporary vascular occlusion for brisk renal bleeding not well controlled by manual compression of the parenchyma
Sharp excision of all nonviable parenchyma
Meticulous hemostasis (particularly, arterial)
Watertight closure of the collecting system
Parenchymal defect closure by approximation of the capsular/parenchymal edges over a Gel-foam bolster or
coverage with omentum, perinephric fat, peritoneum, or polyglycolic acid mesh
Interposition of an omental pedicle flap between any vascular, colonic, or pancreatic injury and the injured kidney
Ureteral stent placement for a renal pelvis or ureteral injury
Retroperitoneal drain placement: The authors prefer to use a Penrose drain. Unless drainage is excessive, the
Penrose drain is removed after 48 hours. Additionally, the urinary tract injury and the pancreatic injury are always
drained separately.
Indications for nephrectomy
When proximal vascular control is initially achieved, before all renal explorations, nephrectomy is required in less than 12%
of cases.[47] When primary vascular control is not achieved and massive bleeding is encountered, in the rush to control
bleeding, a kidney that could have been salvaged may be unnecessarily sacrificed. Overall, nephrectomy is required when
the patient is persistently hemodynamically unstable and, thus, is a life-saving maneuver. Other indications for
nephrectomy are as follows:
Grade 5 injuries that are deemed irreparable (eg, major vascular pedicle injury, particularly on the right side)
Shattered kidney
Multiple concurrent injuries
Uncontrolled hemorrhage
Indications for partial nephrectomy are as follows:
Avulsed fragments
Polar penetrating mechanism of injury
Collecting system repair
Adjuncts include absorbable mesh wrap, topical thrombostatic agents, and omentum.
Postoperative Details
As with all trauma patients, the postoperative course should be monitored to ensure successful hemostasis. Serial
hematocrit measurements should be considered. In patients in whom a damaged but perfused kidney is left in situ,
renovascular hypertension remains a theoretical possibility and the patient should be monitored clinically for this entity.
Complications
Complications that can follow renal trauma are dependent on the grade of the initial renal injury and the method of
management.[48] In most cases, resulting complications are usually of minimal long-term morbidity, can be successfully
managed by endourologic and percutaneous techniques, and do not significantly prolong the mean days of hospitalization.
[49, 50]
Early complications
Early complications, those that occur within 1 month of injury, are urinoma, delayed bleeding, urinary fistula, abscess, and
hypertension. Prolonged urinary extravasation is the most common complication after renal trauma.[7, 49]
Urinomas occur in less than 1% of renal trauma cases. Small, uninfected, and stable collections do not require
intervention. Larger collections are usually successfully managed by the endoscopic or percutaneous placement of a
ureteral/nephrostomy tube.
Delayed renal bleeding most commonly occurs within 2 weeks of injury. When bleeding is heavy or symptomatic,
transfusions, angiography, and superselective embolization[22] may be required.
Urinary fistulas can occur in association with an undrained collection or from large segments of devitalized renal
parenchyma.
Abscesses of the retroperitoneum are associated with ileus, high fever, and sepsis. Most collections can be easily drained
percutaneously. The extent of the abscess and the presence of loculations are well delineated by CT imaging.
Hypertension in the early postoperative period is usually renin mediated and transient, and it does not require any
treatment.
Late complications
Late complications after renal trauma are hydronephrosis, arteriovenous fistula, pyelonephritis, calculus formation, and
delayed hypertension.
Scarring in the region of the renal pelvis and ureter after renal trauma can result in urinary obstruction and, subsequently,
lead to stone formation and chronic infections.
Arteriovenous fistula more commonly occurs after a renal stab wound and can present with delayed bleeding.[22]
Angiography can help determine the size and location of the fistula. In most cases, vessel embolization can be used to
successfully close the fistula.
Long-term hypertension from renal trauma is a rare complication that is overdiagnosed. The experience at San Francisco
General Hospital is that sustained hypertension occurs in only 0.2% of cases.[2] The etiology for hypertension after renal
injury is renal ischemia stimulating the renin-angiotensin axis. Long-term follow-up of renal trauma patients is important in
order to not miss these late complications, which are often of insidious onset and silent progression.
Outcome and Prognosis

In many cases of renal trauma, the outcome and prognosis depend on the associated injuries. In situations in which
nonoperative management is used, concern exists about leaving perfused but nonviable renal tissue in situ, which may
lead to hypertension. However, the occurrence of hypertension in this setting seems to be rare. One study documents no
evidence of hypertension after 5 years of follow-up in children who had sustained renal trauma. Other series report only
isolated instances of hypertension. Therefore, the risk of hypertension alone does not seem to warrant surgical exploration
in cases with nonperfused renal segments.
A single-center review of renal injuries in 171 children found that grades II and III renal injuries carry a low risk of
complication, so repeat imaging and close follow-up are likely not necessary. However, close follow-up is warranted for
patients with grades IV and V injuries, as those carry a meaningful risk of adverse outcome (eg, need for nephrectomy or
stenting, or development of hypertension).[51]
Future and Controversies

Preoperative IVP for penetrating trauma
Proponents of the one-shot IVP point out that it can be performed as the patient is being prepared for surgery and that it
allows a quick assessment of the functionality of the contralateral kidney.
Opponents believe that preservation of renal tissue is always a goal as long as the approach is safe for the patient.
Knowledge of the functional status of the contralateral kidney does not change whether or not trying to salvage the kidney
is safe. The timing of the injection may yield suboptimal views, and often, more time is needed to obtain images than is
anticipated.
The consensus on this technique remains incomplete. Intraoperative IVP can potentially allow leaving a perinephric
hematoma unexplored if the study shows findings of a completely normal system. Some practitioners make extra efforts to
succeed with operative salvage of a damaged kidney if the contralateral kidney is known to be absent.
Operative technique (central vascular control)
Proponents believe that data demonstrate enhanced renal salvage when vascular control is obtained outside the Gerota
fascia. This technique allows controlled assessment of the nature of the renal laceration, and it may impart less trauma on
the vessels compared to more urgent control measures.
Opponents believe that not all renal injuries have sufficient bleeding to warrant central control of vessels. The technique
requires some operative time and exposes the renal vessels to potential operative trauma. Anatomic variants, such as
multiple arteries or veins, may not be recognized and may elicit a false sense of security.
Hypertension
Although concern exists that leaving perfused but nonviable renal tissue in situ potentially leads to hypertension, the
occurrence of hypertension in this setting seems to be rare. One study documents no evidence of hypertension after 5
years of follow-up in children who had sustained renal trauma. Other series report only isolated instances of hypertension.
Therefore, the risk of hypertension alone does not seem to warrant surgical exploration in cases with nonperfused renal
segments.
Nonperfused kidney
Controversy exists regarding whether to revascularize a nonperfused kidney. The incidence rate of renal salvage in the
setting of a nonperfused kidney due to trauma has been reported to be approximately 0%. Isolated case reports of success
do exist. Most centers advocate an expectant management approach.
The need for ultimate nephrectomy also remains somewhat controversial. Possible or documented renovascular injury
continues to be a controversial arena of renal injury management. Only aggressive intervention provides the opportunity for
renal salvage. However, the clinician must be aware that the salvage rate is low, and, ultimately, the life of the patient must
take priority over the life of the kidney. Continued investigation and evolution of surgical techniques may help resolve this
controversy.
Conclusion
The approach to the diagnosis and management of renal trauma continues to evolve. In the setting of significant
hemodynamic instability, operative exploration remains the diagnostic and therapeutic modality of choice. In patients with
blunt trauma and in certain cases of penetrating trauma, a progressive trend is towards nonoperative management of renal
trauma.
Continued change in the approach to renal trauma is almost a certainty. Interventional radiology and endourologic
manipulation have increased the ability to successfully treat patients without surgery and to address common
complications of renal trauma. Numerous diagnostic options exist in the setting of a stable patient. With awareness of
these modalities, the clinician can provide each patient with optimal treatment.

Guidelines
Guidelines Summary
The American Urological Association issued a guideline on urotrauma in 2014 and updated it in 2017 and 2020.[11]
Recommendations regarding renal trauma include the following:
1. In stable blunt trauma patients with gross hematuria or microscopic hematuria and systolic blood pressure < 90 mm
Hg, perform diagnostic imaging with intravenous (IV) contrast–enhanced computed tomography (CT). (Standard;
evidence strength: Grade B)
2. Perform diagnostic imaging with IV contrast–enhanced CT in stable trauma patients whose mechanism of injury or
physical exam findings raise concern for renal injury (eg, rapid deceleration; significant blow to the flank; rib
fracture; significant flank ecchymosis; penetrating injury of the abdomen, flank, or lower chest)). (Recommendation;
evidence strength: Grade C)
3. Perform IV contrast–enhanced abdominal/pelvic CT with immediate and delayed images when renal injury is
suspected. (Clinical Principle)
4. Use noninvasive management strategies in patients with renal injury who are hemodynamically stable. (Standard;
evidence strength: Grade B)
5. Hemodynamically unstable patients with no response or only transient response to resuscitation must undergo
immediate intervention (surgery, or angioembolization in selected situations). (Standard; evidence strength: Grade
B); hemodynamically unstable patients with radiographic findings of large perirenal hematoma (> 4 cm) and/or
vascular contrast extravasation in the setting of deep or complex renal laceration (American Association for the
Surgery of Trauma [AAST] Grade 3-5), should undergo immediate intervention (angioembolization or surgery).
(Recommendation; Evidence Strength; Grade C)
6. Patients with renal parenchymal injury and urinary extravasation may initially be observed. (Clinical Principle)
7. Follow-up CT imaging should be performed for renal trauma patients having either deep lacerations (AAST grade
IV-V) or clinical signs of complications (eg, fever, worsening flank pain, ongoing blood loss, abdominal distention)
(Recommendation; evidence strength: Grade C)
8. Urinary drainage should be performed in patients with complications such as enlarging urinoma, fever, increasing
pain, ileus, fistula or infection (Recommendation; evidence strength: Grade C); ureteral stenting should be used for
drainage and may be augmented by percutaneous urinoma drain, percutaneous nephrostomy, or both. (Expert
Opinion)
Guidelines on kidney and urotrauma from the World Society of Emergency Surgery (WSES) and the AAST, issued in 2019,
include the following recommendations for the use of contrast-enhanced CT with delayed urographic phase[52] :
The gold standard in hemodynamically stable or stabilized adults after blunt or penetrating trauma and in severely
injured children when kidney or urinary tract injury is suspected. (Grade 1A)
Must be performed in blunt trauma patients with gross or microscopic hematuria and hypotension, and in high-
energy deceleration trauma patients with or without hematuria. (Grade 2B)
Indicated in all hemodynamically stable or stabilized patients with penetrating trauma. (Grade 1B)
Indicated in pediatric patients with high-energy, penetrating, or decelerating trauma and/or in patients with a
decrease in hematocrit associated with any degree of hematuria. (Grade 2A)
WSES/AAST recommendations regarding other imaging systems in urotrauma include the following[52] :
Extended focused abdominal sonography for trauma (E-FAST) is effective and rapid for detecting intra-abdominal
free fluid (Grade 1A) but has low sensitivity and specificity in kidney trauma. (Grade 1B)
Ultrasound (US), contrast-enhanced US, and echo-Doppler (E-FAST excluded) are generally not recommended as
diagnostic tools for the initial evaluation of adult patients with high-energy trauma when multiple injuries and/or
injury to the urinary tract and collecting system are suspected. (Grade 1C)
US, contrast-enhanced US, and echo-Doppler can be used for the initial assessment and in follow-up evaluations in
hemodynamically stable pregnant women and pediatric patients, as an alternative to CT. (Grade 1C)
In children with mild symptoms, minimal clinical findings, hematuria < 50 red blood cells per high-power field
(RBCs/HPF), and no other indications for CT scanning, US and/or contrast-enhanced US and/or echo-Doppler may
be used for the initial evaluation. (Grade 2A)
Intravenous urography may be useful in unstable patients during surgery when a kidney injury is found
intraoperatively or when CT is not available and a urinary tract injury is suspected. (Grade 2C )
WSES/AAST recommendations regarding nonoperative management of kidney trauma include the following[52] :
Should be the treatment of choice for all hemodynamically stable or stabilized minor (AAST I-II), moderate (AAST
III), and severe (AAST IV-V) lesions. (Grade 1B)
May be considered even in patients with a transient hemodynamic response, but only in settings with immediate
availability of an operating room, surgeons, and adequate resuscitation and immediate access to blood, blood
products, and a high dependency/intensive care environment; and in the absence of other reasons for surgical
exploration. (Grade 2C)
In hemodynamically stable or stabilized patients, requires accurate classification of the degree of injury and
associated injuries with CT with intravenous contrast and delayed urographic phases. (Grade 2A)
Is feasible and effective in penetrating lateral kidney injuries, but accurate patient selection is crucial even in the
absence of other indications for laparotomy. In particular, cases without violation of the peritoneal cavity are more
suitable for nonoperative management. (Grade 2A)
Isolated urinary extravasation, in itself, is not an absolute contraindication to nonoperative management, in the
absence of other indications for laparotomy. (Grade 1B)
In low resource settings, could be considered in hemodynamically stable patients without evidence of associated
injuries, with negative serial physical examinations and negative first-level imaging and blood tests. (Grade 2C)
WSES/AAST recommendations regarding angiography and angioembolization for kidney trauma include the following[52] :
Angiography with eventual super-selective angioembolization is a safe and effective procedure; it may be indicated
in hemodynamically stable or stabilized patients with arterial contrast extravasation, pseudoaneurysms,
arteriovenous fistula, and non–self-limiting gross hematuria. (Grade 1C)
Angioembolization should be performed as selectively as possible. (Grade 1C)
Blind angioembolization is not indicated in hemodynamically stable or stabilized patients with both kidneys when
angiography is negative for active bleeding, regardless of arterial contrast extravasation on CT scan. (Grade1C)
In hemodynamically stable or stabilized patients with severe renal trauma with main renal artery injury, dissection,
or occlusion, the use of angioembolization and/or percutaneous revascularization with stent or stent/graft is
indicated in specialized centers and in patients with limited warm ischemia time (< 240 min) (Grade 2C)
Endovascular selective balloon occlusion of the renal artery could be utilized as a bridge to definitive hemostasis.
This procedure requires direct visualization by fluoroscopy where the balloon is advanced over a selectively placed
guidewire. (Grade 2B)
Angioembolization is not indicated in severe injury, with main renal vein injury without self-limiting bleeding; those
patients should undergo surgical intervention. (Grade 1C)
In hemodynamically stable or stabilized patients with solitary kidney and moderate (AAST III) or severe (AAST IV-V)
renal trauma with arterial contrast extravasation on CT-scan, angiography with eventual super-selective
angioembolization should be considered as the first choice. (Grade 1C)
In hemodynamically stable or stabilized patients with active kidney bleeding at angiography and without other
indications for surgical intervention, if the initial angioembolization fails, a repeat angioembolization should be
considered. (Grade 1C)
Angioembolization might be considered in selected adult patients who have a transient hemodynamic response and
no other indication for surgical exploration, but only in selected settings (immediate availability of operating room,
surgeon, adequate resuscitation, immediate access to blood and blood products, and to high dependency/intensive
care environment). (Grade 2C)
In children, angiography and eventual super-selective angioembolization should be the first choice, even in patients
with active bleeding and labile hemodynamics, provided there is immediate availability of an angiographic suite,
immediate access to surgery and to blood and blood products, and to a high dependency/intensive care
environment. (Grade 2C)
WSES/AAST recommendations regarding operative management for kidney trauma include the following[52] :
Indicated in hemodynamically unstable and non-responding (WSES IV) patients. (Grade 2A)
Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in hemodynamically unstable
patients as a bridge to other more definitive procedures for hemorrhage control. (Grade 2B)
Indicated in cases of severe renal vascular injuries without self-limiting bleeding. (Grade 1C)
The presence of non-viable tissue (devascularized kidney) is not an indication to operative management in the
acute setting, in the absence of other indications for laparotomy. (Grade 2A)
Delayed operative management should be considered in hemodynamic stable or stabilized patients with damage to
the renal pelvis that is not amenable to endoscopic/percutaeous techniques/stent and in absence of other
indications for immediate laparotomy. (Grade 2B)
A 2023 guideline on management of adult renal trauma from the Eastern Association for the Surgery of Trauma (EAST)
includes the following recommendations[53] :
In hemodynamically stable adult patients with renal trauma who have clinical or radiographic evidence of active
bleeding, no recommendation can be made for angioembolization versus observation to decrease mortality and risk
of surgical morbidity (delayed hemorrhage necessitating intervention and nephrectomy).
In hemodynamically unstable patients with a stable zone II hematoma diagnosed intraoperatively, EAST
conditionally recommends against renal exploration versus no renal exploration to decrease the incidence of
mortality and nephrectomy.
In hemodynamically unstable patients found to have an expanding zone II hematoma necessitating exploration,
EAST conditionally recommends against total nephrectomy versus attempted kidney-preserving surgery (partial
nephrectomy or repair) to decrease mortality, delayed hemorrhage necessitating intervention, angioembolization,
and need for long term renal replacement therapy.
In hemodynamically stable adult patients with high-grade (AAST III–V) renal injuries managed nonoperatively, no
recommendation can be made for routine follow-up abdominal CT versus symptom-based abdominal CT to
decrease the incidence of delayed hemorrhage necessitating intervention.

Questions & Answers

Overview
What is renal trauma?
What is the most common cause of renal trauma?
What is the prevalence of renal trauma?
What causes renal trauma?
How is renal trauma diagnosed?
When is surgery indicated in the treatment of renal trauma?
What is the anatomy of the kidney relevant to renal trauma?
What are the contraindications to surgery for renal trauma?
Presentation
Which clinical history findings are characteristic of renal trauma?
Workup
What is the role of urinalysis in the workup of renal trauma?
What is the role of IVP in the workup of renal trauma?
What are advantages of IVP in the workup of renal trauma?
What are disadvantages of IVP in the workup of renal trauma?

What is the role of CT scanning in the workup of renal trauma?
What are advantages of CT scanning in the workup of renal trauma?
What are disadvantages of CT scanning in the workup of renal trauma?
What is the role of angiography in the workup of renal trauma?
What are advantages of angiography in the workup of renal trauma?
What are disadvantages of angiography in the workup of renal trauma?
What is the role of ultrasonography in the workup of renal trauma?
What are advantages of ultrasonography in the workup of renal trauma?
What are disadvantages of ultrasonography in the workup of renal trauma?
When is interoperative diagnosis of renal trauma necessary?
When is imaging indicated in renal trauma?
What is the role of gross hematuria in the diagnosis of renal injury?
What is the role of microscopic hematuria and shock in the diagnosis of renal injury?
How is renal trauma diagnosed following a deceleration injury?
How is renal injury diagnosed in children?
What are associated injuries of renal trauma?
How is renal trauma graded?
Treatment
How is renal trauma treated?
When is nonoperative treatment indicated for renal trauma?
What are the nonoperative treatments for renal trauma?
When is follow-up imaging indicated in the nonoperative treatment of renal trauma in children?
What is the role of surgery in the treatment of renal trauma?
What is the role of exploratory surgery in the treatment of renal trauma?
What is the role of urinary extravasation in the treatment of renal trauma?
How is renal injury managed following incomplete staging?
How is arterial thrombosis treated in renal trauma?
How is penetrating renal trauma treated?
What is the initial treatment for renal trauma?
Which techniques are used for renal exploration and repair of traumatic injuries?
How is renal reconstruction performed following a traumatic injury?
What is the role of nephrectomy in the treatment of renal trauma?
What is the role of partial nephrectomy in the treatment of renal trauma?
What are postoperative details for renal trauma?
What are the possible complications of renal trauma?
What are the early complications after renal trauma?
What are the late complications after renal trauma?
What is the prognosis of renal trauma?
What is the role of preoperative IVP in the treatment of penetrating renal trauma?
What is the role of central vascular control in the treatment of renal trauma?
What is the prevalence of renal trauma-related hypertension?
How is a nonperfused kidney treated following renal trauma?
What is the optimal treatment for renal trauma?
Guidelines
What are the AUA guidelines on the treatment of renal trauma?
What are the WSES/AAST guidelines for imaging in renal trauma?
What are the WSES/AAST guidelines for nonoperative management of renal trauma?
What are the WSES/AAST guidelines for use of angiography and angioembolization following renal trauma?
What are the WSES/AAST guidelines for operative management of renal trauma?
Contributor Information and Disclosures
Author
Dennis G Lusaya, MD Associate Professor II, Department of Surgery (Urology), University of Santo Tomas Faculty of
Medicine and Surgery; Chairman, Institute of Urology, St Luke's Medical Center; Head of Urology Unit, Benavides Cancer
Institute, University of Santo Tomas Hospital, Philippines
Dennis G Lusaya, MD is a member of the following medical societies: American Urological Association, Philippine College
of Surgeons, Philippine Medical Association, Philippine Society of Urological Oncology, Philippine Urological Association
Disclosure: Nothing to disclose.
Coauthor(s)
Edgar V Lerma, MD, FACP, FASN, FAHA, FASH, FNLA, FNKF Clinical Professor of Medicine, Section of Nephrology,
Department of Medicine, University of Illinois at Chicago College of Medicine; Research Director, Internal Medicine
Training Program, Advocate Christ Medical Center; Consulting Staff, Associates in Nephrology, SC
Edgar V Lerma, MD, FACP, FASN, FAHA, FASH, FNLA, FNKF is a member of the following medical societies: American
Heart Association, American Medical Association, American Society of Hypertension, American Society of Nephrology,
Chicago Medical Society, Illinois State Medical Society, National Kidney Foundation, Society of General Internal Medicine
Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Astra Zeneca<br/>Author for: UpToDate, ACP
Smart Medicine, Elsevier, McGraw-Hill, Wolters Kluwer.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Chief Editor
Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology,
Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons,
American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society,
Society of Laparoscopic and Robotic Surgeons, Society of University Urologists
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society
Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a
speaker or a member of a speakers bureau for: Cook Medical.
Additional Contributors
Peter Langenstroer, MD Associate Professor, Department of Urology, Medical College of Wisconsin
Peter Langenstroer, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.
Acknowledgements
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Douglas M
Geehan, MD, and Richard A Santucci, MD, FACS,to the development and writing of this article.
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Penetrating (eg, gunshot wounds, stab wounds)

Numerous anatomic variations exist, including the following:

Advantages of IVP are as follows:

Allows functional and anatomic assessment of both kidneys and ureters

Disadvantages of IVP are as follows:

Disadvantages are as follows:

Advantages are as follows:

Disadvantages are as follows:

Optimal study results related to anatomy require an experienced sonographer

Blunt trauma and gross hematuria

Blunt trauma and gross hematuria

Blunt trauma, microscopic hematuria, and shock

Major deceleration injury

Pediatric trauma patient with significant microscopic or gross hematuria

Associated injuries suggesting underlying renal injury

Grade Type Description

Contusion Microscopic or gross hematuria, urologic studies normal

Hematoma Subcapsular, non-expanding without parenchymal laceration

II Hematoma Non-expanding perirenal hematoma confined to renal retroperitoneum

Laceration < 1.0 cm parenchymal depth of renal cortex

Vascular Main renal artery or vein injury with contained hemorrhage

Laceration Completely shattered kidney

Vascular Avulsion of renal hilum that devascularizes kidney

1. Operate immediately if the patient has life-threatening bleeding

Percutaneous drainage of perinephric fluid collections or urinomas

Need for transfusion

Indications for renal exploration

Perirenal hematoma >3.5 cm

Additional relative indications include the following:

A major devitalized segment

Adequate and broad exposure of the kidney and injured area

Sharp excision of all nonviable parenchyma

Meticulous hemostasis (particularly, arterial)

Watertight closure of the collecting system

Ureteral stent placement for a renal pelvis or ureteral injury

Indications for nephrectomy

Multiple concurrent injuries

Indications for partial nephrectomy are as follows:

Polar penetrating mechanism of injury

Collecting system repair

Outcome and Prognosis

Future and Controversies

Operative technique (central vascular control)

Questions & Answers

What is renal trauma?

What is the most common cause of renal trauma?

What is the prevalence of renal trauma?

What causes renal trauma?

How is renal trauma diagnosed?

When is surgery indicated in the treatment of renal trauma?

What is the anatomy of the kidney relevant to renal trauma?

What are the contraindications to surgery for renal trauma?

Which clinical history findings are characteristic of renal trauma?

What is the role of urinalysis in the workup of renal trauma?

What is the role of IVP in the workup of renal trauma?

What are advantages of IVP in the workup of renal trauma?

What are disadvantages of IVP in the workup of renal trauma?

What is the role of CT scanning in the workup of renal trauma?

What are advantages of CT scanning in the workup of renal trauma?

What are disadvantages of CT scanning in the workup of renal trauma?

What is the role of angiography in the workup of renal trauma?

What are advantages of angiography in the workup of renal trauma?