Pediatric Urology

Renal Trauma in Pediatrics:

A Current Review
María Fernández-Ibieta
Children are at increased risk of renal injuries from blunt trauma. Four-phase computed tomography with intravenous
contrast (noncontrast, arterial, nephrographic, and pyelographic phases) is the choice for initial imaging, although ul-
trasonography might also be used in children with minimal symptoms. The American Association for the Surgery of
Trauma developed the known system for renal injury grading, which was modified in 2011. The management of pedi-
atric renal injuries has largely shifted toward conservative means. However, as long as the child remains hemodynami-
cally unstable, renal exploration might be necessary. There is a trend toward managing high-grade injuries with interventional
radiography procedures. UROLOGY 113: 171–178, 2018. © 2017 Elsevier Inc.

M
ost literature regarding renal trauma is based on
adult case series and retrospective data. A con-
siderable amount of information on pediatric
cases has been compiled in the past 2 decades. This review
pretends to highlight the different recommendations
between adult and pediatric trauma management. For this
purpose, all information concerning specific pediatric da-
tabases, reviews, or guidelines are highlighted in italics to
better discern pediatric recommendations,
Around 5%-20% of pediatric patients with blunt ab-
dominal trauma will also have renal trauma.1 Children are
at increased risk of renal injuries from blunt trauma owing
to the relatively increased renal size (beyond the rib cage)
and mobility.2 Kidneys are only fixed by the vascular pedicle
and the ureter (more concretely, the pelviureteric junc-
tion), and are surrounded by its capsule, Gerota’s fascia and
perirenal fat, which is thinner and more flexible than in
adults. Also, lower ribs are incompletely ossified,3,4 and renal
lobulations might be naturally disposed cleavage lines to
permit the injury forces along these planes.1-5
Associated genitourinary congenital malformations are
present in 1%-23% of patients with renal trauma. Hydro-
nephrosis, ectopy, tumors, or congenital cysts also predis-
pose to a higher susceptibility of pediatric renal trauma.2
Rupture of a hydronephrotic kidney may need only initial
drainage by percutaneous nephrostomy allowing repair of
the primary urologic condition later after the effects of
trauma have subsided.2
Injuries are graded based on severity, which has been clas-
sified by the American Association for the Surgery of
Financial Disclosure: The authors declare that they have no relevant financial
interests.
This study was approved by the local ethics committee.
No animal testing was done in this study.
From the Pediatric Surgery and Urology, Hospital Clínico Universitario Virgen de la
Arrixaca, Murcia, Spain
Address correspondence to: María Fernández-Ibieta, M.D., Ph.D., Pediatric Surgery
and Urology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia 30150, Spain.
E-mail: mfndezibieta@hotmail.com
Submitted: July 15, 2017, accepted (with revisions): September 29, 2017
© 2017 Elsevier Inc.
All rights reserved.
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Trauma (AAST) Organ Injury Scale (OIS)1,6-9 and modi-
fied at its 2011 revision10 (Figure 1 and Tables 1 and 2).
The goal of management of blunt renal trauma in children is
renal preservation. Debated variables include imaging, the
conservative vs operative approaches, the length of inten-
sive care unit observation, length of bed rest, the use of
antibiotics, and follow-up protocols. Therefore, we review
recent literature to outline current evidence, the Euro-
pean Association of Urology grading scale, and recom-
mendations on Renal Trauma for management strategies
of renal trauma in children.1,8,10
Renal trauma is a disease of the young; the mean age
in large retrospective series is 20-30 years (more common
in men). This difference has been attributed to the in-
volvement of men in high-risk activities.7 The vast major-
ity of renal injuries in children result from blunt mechanisms.
CLINICAL EVALUATION
Blunt renal injuries in children are seldom isolated, and
multiorgan injury (liver, spleen, closed head, orthopedic
fractures) is the rule.2 For blunt injuries, a history of rapid
deceleration (eg, motor vehicle accident, pedestrian acci-
dent, or fall from heights) or direct blow to the flank is an
important indicator of potential renal trauma. For pen-
etrating trauma, location of entrance and exit wounds may
help determine the likelihood of renal injury.11 In pen-
etrating injuries, nearly all patients with renal gunshot
wounds and up to 60% of patients with renal stab wounds
have injury to adjacent organs. Renal vascular injury after
blunt injury is rare. In a review of 945,326 patients from
the US National Trauma Data Bank with blunt trauma,
only 517 patients (0.05%) had injuries to the renal artery.
In contrast, penetrating injury results in a much higher in-
cidence of renal vascular injury with a quoted incidence
of 15%-33%.6 Signs suggestive of possible renal injury
include hematuria, penetrating wound in the vicinity of
a kidney, flank bruising or ecchymosis, fractured ribs
https://doi.org/10.1016/j.urology.2017.09.030 171
0090-4295

Figure 1. Classification system of renal trauma based on
the appearance on computed tomography imaging accord-
ing to the American Association for the Surgery of Trauma
classification (AAST), Committee on Organ Injury Scaling. (Color
version available online.)
(10th-12th), an abdominal mass, and abdominal tender-
ness or distension. Once significant renal trauma is estab-
lished, close monitoring should be started. Monitoring urine
output and severity of hematuria is also important and is
more accurately done after insertion of a urinary cath-
eter. Blood tests in the initial assessment of patients with
renal trauma determine the hemoglobin, platelets, pro-
thrombin value, creatinine, urea, and blood urea nitro-
gen. The required frequency of these tests is less clear,
although some advocate taking samples every 4-6 hours for
the first 24 hours. A continuous bleeding, and thus, an un-
stable patient, can be assessed by the need of 3 blood con-
centrates to maintain hematocrit in the first 24-48
hours.5,12-14 Patients who remain hemodynamically un-
stable after initial resuscitation should undergo, neverthe-
less, surgical exploration.11
In adult renal trauma, the 2 most important indicators
for significant injury are hematuria, defined as more than
5 red blood cells (RBCs) per high power field (HPF) as seen
from the first aliquot of urine of a catheterized specimen,
and hypotension (systolic blood pressure less than
90 mmHg). The first aliquot of urine is important as in-
travenous resuscitation dilutes the urine. Because hypo-
tension is a late manifestation of hypovolemia in children,
blood pressure is now not considered a reliable criterion
for imaging in pediatric population. It appears that very few
(2% according to a recent meta-analysis)15 clinically signifi-
cant renal injuries would be missed if, in children with blunt
trauma, only those with >50 RBCs/HPF underwent imaging.
However, given that hematuria is not seen in up to 36%
of renal pedicle injuries (avulsions of renal pedicle and dis-
ruptions of renal pelvis) and in 24% of renal artery
occlusions,11 the recommendation is actually to investigate any
hematuria (microscopic or macroscopic) in any child with blunt
renal trauma, especially in those with a decelerating trauma
172
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or fall from heights, or direct blow to the flank (at least
with ultrasonography, see following discussion). The degree
of hematuria does not clearly correlate with the degree of
injury.16 Although renal pedicle injuries can occur without
hematuria, they are likely to be associated with multisys-
tem trauma that requires abdominal imaging anyway.
IMAGING
Although the European Association of Urology and Eu-
ropean Society of Pediatric Radiology recommend that
imaging is necessary with any amount of nonvisible he-
maturia, the Renal Trauma Subcommittee of the Societé
Internationale d’Úrologie advises that it is only necessary
if there are 50 RBCs/HPF.7 Nevertheless, awake, alert chil-
dren who have minimal symptoms or clinical findings sugges-
tive of renal injury and microhematuria less than 50 RBCs/
HPF may be observed without computed tomography (CT) scans
using only ultrasonography screens.2
The 4 main objectives of radiographic imaging of renal
trauma are to accurately stage the injury (parenchyma, vas-
culature, and collecting system), recognize preexisting pa-
thologies of the injured kidney, document the function of
the opposite kidney, and identify associated injuries to other
organs. The choice of imaging modality has undergone
radical change in the past 2 decades. Historically, intra-
venous pyelography was the standard method: this has been
replaced by ultrasound and CT.
a. Ultrasound. Ultrasound (US) with Doppler can occasion-
ally be considered in very mild pediatric trauma.17 Limita-
tions of US include an inability to distinguish fresh blood
from extravasated urine and an inability to identify vas-
cular pedicle injuries or segmental infarcts. Only with
close color and pulsed Doppler interrogation can a vas-
cular injury be diagnosed. Furthermore, concomitant rib
fractures, bandages, intestinal ileus, open wounds, or
morbid obesity will severely limit renal visualization. In
general, the accuracy of US for evaluating the
retroperitoneum is variable (as these structures are not
associated with free abdominal or pelvic fluid), time-
consuming, and highly operator-dependent.7,15 The use
of focused abdominal sonogram for trauma (FAST) evalu-
ation of children with blunt abdominal trauma has been dem-
onstrated to have a relatively high specificity of 95% but with
low and varied sensitivity (33%-89%), as well as a low nega-
tive predictive value (50%). Therefore, abdominal US or
FAST should probably not be used as the sole method of
screening hemodynamically stable pediatric patients with blunt
abdominal trauma, although it is done frequently as the initial
radiological evaluation.1,18-20
b. Computed tomography. Four-phase CT with intrave-
nous contrast medium (noncontrast, arterial,
nephrographic, and pyelographic phases) is the imaging
method of choice.2,14 CT imaging is both sensitive and
specific for demonstrating parenchymal lacerations,
urinary extravasations, delineating segmental paren-
chymal infarcts, and for determining the size and location
UROLOGY 113, 2018
Table 1. Terminology
Terms Definition
Contusion Hypodense poorly defined area of decreased enhancement on the nephrogenic phase,
with delayed or persistent enhancement.
Infarction Wedge-shaped, sharply marginal hypodense areas on the nephrogenic phase without
late enhancement.
Subcapsular hematomas Biconvex area of blood collection along the renal contour, causing depression or
flattening of the underlying renal surface.
Perinephric hematoma Extravasated blood between the renal parenchyma and the Gerota fascia may extend
over a wider area, outlining the renal contour, without producing flattening of renal
margins.
Lacerations Irregular hypodense of parenchymal defect, causing disruption of renal contour.
Shattered kidneys Multiple lacerations causing gross disruption and fragmentation of the renal
parenchyma. Fragments may or may not retain their own blood supply.
Pseudoaneurysm Accumulation of blood between the intima and the seromuscularis. In CT, it appears as
a focal rounded well-circumscribed lesion within the renal parenchyma or in the
lacerated segment. It shows intense arterial enhancement and washout synchronous
to the blood pool. No expansion on delayed phase scans.
Active arterial extravasation Focal poorly defined areas of contrast leak with different configurations. They will show
spread into the surrounding tissue on delayed film.
CT, computed tomography.
Terminologies were adapted from the American Association for the Surgery of Trauma Classification.18

of the surrounding retroperitoneal hematoma, or asso-
ciated intraabdominal injuries (spleen, liver, pancreas,
and bowel), which are seen in up to 90% of renal
trauma.21 In the acute setting, four-phase CT has com-
pletely replaced arteriography. Renal artery occlusion
and global renal infarct are noted on CT by lack of pa-
renchymal enhancement or a persistent cortical rim sign.
Although reliable for demonstrating renal infarct, the
downside of using the rim sign is that it is usually not
seen until at least 8 hours after injury. In recent years,
fast scanning and image reconstruction helical CT scan-
ners have been introduced. Turnaround time for ab-
dominal trauma imaging is now in the 10-minute range.
Seventy to 90 seconds before initiating the helical CT,
100-180 cc of iodinated solution in the adult—300-
400 mg concentration of iodine—or 2 cc/kg in the child
of intravenous contrast is given at 2-4 cc/s. Helical CT
imaging is so quick (usually less than 2 minutes) that
only the arterial phase (20-30 seconds) and the early
cortical phase (40-70 seconds) of the kidney are ob-
tained. Arterial phase imaging helps delineate any renal
arterial injury, whereas the early cortical phase will still
miss most parenchymal injuries. Therefore, to com-
plete the proper evaluation and staging of renal inju-
ries, later imaging in the nephrogram phase (>80
seconds) is needed to detect renal parenchyma and
venous injury, whereas delayed images (2-10 minutes)
are often required to detect urine and blood extrava-
sation. On delayed CT images, extravasated urine can
be distinguished from blood in that it accumulates,
whereas extravasated arterial contrast dilutes after the
bolus of contrast is stopped.15 The CT goal is to define
lesions according to the appropriate terminology
(Table 1) and establish 1 of 5 grades of the Organ Scale
System (American Association for the Surgery of Trauma
classification (AAST), Committee on Organ Injury
Scaling (Fig. 1 and Table 2).
c. Angiography. This is the second study of choice
aside from CT. It can reliably stage significant
injury and offers the possibility of embolization
(coils). In a stable patient who presents with persist-
ing bleeding, angiography may allow selective arterial
embolization, which may obviate the need for surgical
exploration. Indications for angiography include sus-
pected renal arterial thrombosis or segmental arterial
injuries (lacerations or pseudoaneurysms) for which
interventional radiological treatment (stenting or em-
bolization, respectively) is considered. See section on
treatment.
d. Intraoperative one shot IVU (intravenous urography). When
blunt or penetrating injuries cause massive hemor-
rhage and require immediate laparotomy, CT is con-
traindicated. Intraoperative one shot IVU, in
conjunction with findings at laparotomy, can be used
to exclude life-threatening renal injury and confirm the
existence of a contralateral functioning kidney. One shot
UIV depends on rapid bolus administration of con-
trast (2 mL/kg). A single plain abdominal x-ray ob-
tained 10 minutes after injection may detect delayed
excretion or urinary extravasation. In a recent study, a
normal film obviated the need for renal exploration in
32% of patients.7
e. Magnetic resonance imaging. Although providing excel-
lent anatomical detail, MRI is time-consuming, usually
requires complete sequestering of the traumatized patient
inside the MRI machine, and is not rapidly available
in many centers. One further limitation of MRI is a lesser
ability to detect urinary extravasation. However, a rare
indication for MRI in the renal trauma setting might
be severe contrast allergy.
f. Follow-up imaging. Radiographic reassessment of renal
trauma is recommended when severe renal injuries
have been managed conservatively. The purpose of
repeat imaging is to identify patients with worsening

UROLOGY 113, 2018 173

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Table 2. Organ injury scaling
Injuries Terms Definition
Grade I Contusion Contusion or nonexpanding subcapsular hematoma without parenchymal
Hematoma laceration. Other: Limited perinephric hematoma or small subsegmental infarct.
Grade II Hematoma Nonexpanding perinephric hematoma confined to the retroperitoneum or cortical
Laceration laceration <1 cm deep. No urinary extravasation.
Grade III Laceration Nonexpanding perinephric hematoma with laceration extending more than 1 cm in
depth. No urinary extravasation.
Grade IV Laceration Renal lacerations involving the collecting system.
Vascular Vascular segmental vein or artery injury. Laceration, one or more into the
collecting system with urinary extravasation. Renal pelvis laceration or complete
ureteric pelvic disruption. Shattered kidney.
Grade V Laceration Main renal artery or vein laceration or avulsion main renal artery or vein
Vascular thrombosis.
The American Association for the Surgery of Trauma (AAST) Committee on Organ Injury Scaling has developed the known system for
renal injury grading. Here, it is shown with the 2011 modification.10
Grade I injuries account for most renal injuries (50%-80%),2,22 presenting clinically with mild or gross hematuria. In grade IV injuries, in
complete ureteral avulsion, no ureter beyond the injury would be seen. In a partial tear, there would be opacification of the ureter dis-
tally. Grade V injuries now only include main vascular injury: arterial or venous, laceration, avulsion, or thrombosis. Renal pedicle avul-
sion is a complete tear of all the layers of the vessel wall, so a hematoma around the aorta and renal helium with active contrast
extravasation from the disrupted stump will be shown.
The ASST does not describe pseudoaneurysm or active bleeding in any of the grades, but other radiological grading systems classify
those into higher categories.18

urinary extravasation, ongoing significant hemor- Evidence for a Conservative Approach

rhage, and rarer complications such as pseudoaneurysm.
Repeat abdominal CT with intravenous contrast
medium and delayed contrast is recommended 2-4
days after initial scanning for high-grade lacerations
(>grade III) managed expectantly in adults.18 The Eu-
ropean Society of Pediatric Radiology, though, recommends
obtaining routine re-imaging after slightly shorter interval
(4-24 hours).7,14 Moreover, imaging is evidently recom-
mended in those cases when the patient, along the
evolution, has unexplained fever, flank pain, flank mass,
or bleeding. Both CT and US scan can be useful in these
tests. Although CT is the method of choice for early re-
imaging in adults, US with Doppler is recommended in
children.
MANAGEMENT
A growing body of retrospective evidence suggests that
conservative management in all hemodynamically stable
traumatic pediatric blunt renal injuries is reliable.21-26 Over
the past 20 years, the management of pediatric renal
injuries has largely shifted toward conservative means.22-24
If the child is hemodynamically unstable or has suffered a
severe intraabdominal penetrating injury, immediate
operative exploration is the standard of care. In hemody-
namically stable children, who do not meet trauma criteria
for immediate operative exploration, a thought medical
history and evaluation should ensue.12 Absolute indica-
tions for surgical (or interventional radiology management)
management include expanding or pulsatile renal hema-
toma, hemodynamical instability unresponsive to 3
concentrate transfusions. Relative indications are
(1) massive urinary extravasation; (2) extensive (>20%)
nonviable tissue; (3) arterial injury; and (4) incomplete
staging.
All hemodynamically stable grade I to III injuries can be
managed nonoperatively. It may be a reasonable approach
to admit all patients with grades I to III who present with
gross hematuria on strict bed rest and observation until he-
maturia clears with no additional laboratory studies or
imaging necessary. After hematuria resolves, the patient
may begin ambulation and can be discharged home, pre-
suming that hematuria does not recur. As mentioned before,
the ability of CT scan to differentiate parenchymal, vas-
cular, or collecting system injuries based on a 4-phase scan
allows accurate staging and differentiating minor injuries
(I-III) to major ones (IV to V). Nonoperative manage-
ment of grade IV renal injury has been gaining momen-
tum from many supportive studies. In a recent systematic
review25 of retrospective and prospective pediatric reports,14
up to 72%3,14,21,25 of grade IV renal injuries have been
managed nonoperatively with subsequent healing and pres-
ervation of enough renal function (greater than 50% of the
kidney) to prevent dialysis in the event of loss of the con-
tralateral kidney. Aggressive nonoperative management re-
quires close observation, bed rest, and repeat imaging at
48 hours or earlier (as mentioned before) if clinically
prompted to reassess the injury and ensure appropriate man-
agement. As long as the child remains hemodynamically un-
stable or is unresponsive to up to 3 U packed RBC transfusions,
renal exploration may be necessary. With worsening extrava-
sation on serial CT, additional drainage of the colleting
system using an internalized double-J ureteral stent may
be needed. An absolute indication for renal exploration
is hemodynamic instability in the form of an expanding
or pulsatile renal hematoma.
Retrospective studies suggest now that a strict conser-
vative protocol is safe enough to be instituted as the stan-
dard of care in pediatric IV to V blunt trauma, although
it is still controversial. Successful expectant management

174 UROLOGY 113, 2018

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rates range from 40% to 84%, likely because most pa-
tients with grade V renal injuries present with massive hem-
orrhage, a clear indication for retroperitoneal exploration.
(Indications for operative management included shat-
tered kidney, severe renal pedicle injury, delayed nephrec-
tomy after failed renal vascular repair, and persistent urinary
leak after failed stenting). When combining the most
current retrospective and prospective cohort’s data, up to
67% of grade V lesions may be managed expectantly.2,21,24
In conclusion, severe renal injuries (grade IV to V) require
careful selective management based on hemodynamically
stability, mechanism of injury, associated nonrenal inju-
ries, and clinical presentation to determine operative vs
nonoperative management.12
Renovascular Severe Injuries
Renovascular injuries involving the renal artery occur in
1%-3% of all blunt renal trauma.2,6 The mechanism of injury
is rapid deceleration of the kidney and stretching of the
renal artery. The adventitia and muscularis, both of which
are elastic, absorb this extreme stretching force to the artery.
The intima is not so compliant and tears, exposing the mus-
cularis to the rapid blood flow and raising flaps of intima,
ultimately leading to clotting of the artery and ischemia
of the kidney (it may also be dissected, forming then a
pseudoaneurysm).2 Although it would seem to be an easy
decision to move to surgical repair to salvage a kidney if
possible, this is seldom the case. The overall condition and
stability of these patients with multiple trauma fre-
quently makes immediate surgery a significant risk. If the
contralateral kidney is normal, and the patient is un-
stable, it may be wise not to attempt to salvage the isch-
emic kidney. The time since injury is important because
warm ischemia time determines the survivability of the
kidney. If the kidney has not been perfused in more than
6 hours, the kidney would not survive even with success-
ful surgical repair.2,7,8 The blood supply is not interrupted
to the kidney at the exact time of injury in every case. In
a patient with good contralateral kidney function and who
is a good surgical candidate, exploration within 12 hours
of the injury is considered reasonable. The best salvage rate
for kidneys with pedicle injuries in ideal circumstances is
only 30%.2,11-13 Other types of renovascular injuries are direct
full-thickness tears of the artery and vein. These types of
renovascular injuries are rare, require immediate surgery,
and have a very high mortality.2,6,22
Delayed Surgery
The majority of hemodynamically stable patients who
require operative intervention are best treated with a
delayed (more than 72 hours) operative approach.26 Active
bleeding has usually stopped, obviating the need to gain
initial vascular control before exploration of the
retroperitoneum. Consequently, those cases requiring in-
tervention can be managed by a more limited retroperitoneal
flank or percutaneous approach. This method allows drain-
age of urinoma and, when necessary, hematoma evacuation
and limited debridement of necrotic renal parenchyma.
UROLOGY 113, 2018
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Bleeding is minimal with this delayed operative ap-
proach, resulting in reduced intraoperative and postoperative
morbidity.26
The overall contemporary renal savage rate using
nonoperative management is 97%-99%.22
Interventional Radiology
In the last 15 years, there is a trend toward managing high-
grade injuries with interventional radiography proce-
dures. Some centers27 have developed a protocol, which
includes all patients with renal injury. If a patient re-
quires immediate laparotomy (unresponsive hemodynami-
cally unstable patients, ureteropelvic disruption, pancreatic
injury, perforation, other involved organs) or the patient
has low-grade injuries (grade I-II), it is not included in the
arteriography protocol. All patients with CT scan renal
grade III or higher entered into the protocol within 3 hours
of the initial CT. A selective embolization was performed
in cases of extravasation of contrast medium or arteriove-
nous fistula (AVF). Cases with complete occlusion of the
main renal artery were managed conservatively, but un-
derwent emergency laparotomy when a main vein was
injured. This protocol might be a future line of manage-
ment and is already the rule in many centers. Moreover,
in a well-preserved renal function, a pseudoaneurysm or
focal arterial extravasation could be effectively embolized.
Technical Aspects of Operative Management
As in the rest of trauma surgery, the best access is through
a midline laparotomy.2,28 The transverse colon and small
intestine should be mobilized upward. This exposes the root
of the mesentery and the ligament of Treitz and the un-
derlying great vessels. The principles of exploring expand-
ing retroperitoneal hematoma, proposed by Mattox (left,
pulsatile hematoma, suspected bleeding from the aorta) or
Cattell-Braasch (right, nonpulsating hematoma, sus-
pected for inferior cava vein bleeding) may apply here.28
Otherwise, a transmesocolic approach has been pro-
posed, transecting either the left or the right mesentery of
the colon.5,13 In classical trauma surgery, a posterior ap-
proach (either Mattox or Cattell-Braasch) is the classical
option, lifting all colon including its mesentery to the op-
posite site of the injury. A retroperitoneal incision is per-
formed, medial to the visualized inferior mesenteric vein,
given proximal and distal vascular control is secured. Renal
artery and vein are then secured with vessel loops, and mo-
bilization of kidney is accomplished through dissection via
the white line of Told. After reflecting it medially, Gerota
fascia is incised and kidney is exposed. Devitalized renal
parenchyma is best managed by early surgical debride-
ment. Collecting system, if correctly visualized, must be wa-
tertight closed with running 5-0 or 6-0 absorbable
monofilament. Afterward, renorraphy can be made by
careful reapproximation of the parenchymal edges, with in-
terposition of haemostatic sponge or by placing absorb-
able pledgets on the suture.13 An omental flap can be
interpositioned. A retroperitoneal drain must be left in place,
not connected to suction. If a nephrectomy is decided,
175
separate proximal and distal ligation of vessels is advised,
if possible.
Renal artery repair should be reserved for solitary kidneys,
bilaterally injured kidneys, and in the rare situation of de-
tection within 6 hours of injury, due to the high risk (50%)
of hypertension due to postrepair arterial stenosis. 13
Endovascular stenting may have a limited role, as main-
taining patency requires anticoagulation, which is rarely
possible in the traumatically injured patient, especially with
polytrauma to the spleen or liver. If detection of renal artery
thrombosis is delayed and laparotomy is otherwise indi-
cated, nephrectomy should be performed. Otherwise, the
kidney may be allowed to atrophy, with delayed nephrec-
tomy performed if hypertension develops.
Segmental arteries or veins may be safely ligated, with
few complications arising from the subsequently
devascularized renal parenchyma. A partially lacerated seg-
mental artery or vein may be alternatively repaired with
5-0 or 6-0 nonabsorbable monofilament suture after ap-
propriate vascular clamping.2,13,28 Left vein can be safely
ligated, as gonadal vein may drain left kidney appropriately.
Predicting Nomograms
Recently, some experts have tested the possibility of de-
veloping a nomogram predicting the need for renal ex-
ploration, based on a large cohort of patients with renal
trauma.29-31 Based on the need for platelet transfusion within
the first 24 hours, blood urea nitrogen, hemoglobin, and
heart rate, the accuracy of predicting the need for surgi-
cal exploration (including arterial embolization) in modern
nomograms is high. Currently, the probability of surgical
exploration according to these nomograms are 0%
(grade I and II), 1% (grade III), 23% (grade IV), and 67%
(grade V), respectively.31 Most of grade V (67%) injuries
can, according to these very recent results, be managed with
selective embolization alone.
COMPLICATIONS AND FOLLOW-UP
Return to Activity
Most authors recommend intensive care monitoring as long
as the patient is unstable, but hospital admission has no
clear consensus: many studies and guidelines do not docu-
ment admission level of care time lapse.1,17 According to
a practical guideline,17 “Prescribing bed rest for 3 weeks dates
from the 60s, before the era of CT.” The degree of hema-
turia does not appear to correlate with either symptom im-
provement or mobility, and it leads to prolonged admissions.
Reports of average lengths of stay of >1 week in low-
grade trauma (<IV) do seem excessive. Apart from hema-
turia, other general discharge criteria apply in renal trauma:
being afebrile, tolerating a regular diet, adequate pain
control, and maintaining stable hemoglobin are not con-
tentious criteria. Anyhow, bed rest should continue until
hematuria is light or disappears. Avoiding sports for 2-3
weeks may be reasonable.
a. Extravasation of urine.2,7,8,17,22,23,32,33 Most common com-
plication of renal trauma from stage IV and also may
176
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be caused by forniceal rupture after lesser trauma. The
prevalence of extravasation is higher after penetrating
injury (10%-30%) than after blunt trauma (2%-18%),
and also more frequent if devascularized segments exist.
A lack of ureteral filling differentiates between uretero-
pelvic junction avulsion (no ureteral filling seen) and
renal pelvis laceration. In only 13%-26% of cases urinary
leakage persists for longer than a few days of expect-
ant management, and even extensive extravasation is
likely to subside without intervention (with an appro-
priate use of analgesics, bed rest, and antimicrobials).
If not, most patients are cured durably by the place-
ment of a ureteral stent by cystoscopy or antegrade after
percutaneous nephrostomy.
b. Urinoma.2,32-34 It is seen in 1%-7% of patients with renal
trauma (rising up to 30% in penetrating trauma) and
may be suspected of pain, low-grade fever, ileus, or a
palpable mass. Most are acute, but can present from 3
weeks to several months after injury. Most urinomas are
observed and there is no need to intervene. Indica-
tions to intervene are relative and include increasing
size after several days, development of fever, and urinoma
that separates renal fragments. In this cases, antero-
grade (nephrostomy) or retrograde (double-J stenting)
draining usually solves the collection, although the latter
is not recommended in cases with renal pelvis lacera-
tion. In rare extreme refractory cases, selective embo-
lization of the affected parenchyma (that prevents urinary
filling) or open surgery can be employed.
c. Perinephric abscess.33 This is a rare complication (2%-
5%). Abscesses usually develop in patients with devi-
talized parenchyma, or bowel or pancreatic lacerations,
5-7 days after renal injury. Treatment may start with an-
tibiotic alone, and percutaneous drainage may be needed
if no resolution is shown on US.
d. Coincident organ injury.1-3,33 Associated organ injury is
reported in 61%-100% of reported cases of penetrat-
ing renal trauma, and 35%-65% of reported blunt renal
trauma. Hepatic injury, splenic lesions, associated pan-
creatic injury, and bowel perforations must be taken into
account.
e. Impaired renal function.2,32,35,36 A recent series reported
that renal function by radionuclide scan was 39% after
renal reconstruction in 52 patients. Nineteen percent
of the patients had less than 33% function in the injured
side, and only 1 patient had renal insufficiency after a
bilateral trauma. A more recent report showed that renal
function was preserved in children with grade II-IV
injury after conservative treatment, but those chil-
dren with grade V injures had a mean of 29% function.
f. Hypertension.7,8,12,33,35 Developing hypertension after renal
trauma is a controversial issue. Reports range widely from
0.2% to 55%, although recent reports find lower rates
(5%). Transient hypertension is sometimes seen after
injury, occurring in 6%-10% of patients with renal
trauma. This temporary condition reverts to normal
usually in 12-50 days. Nevertheless, chronic hyperten-
sion after renal trauma develops in a period ranging from
UROLOGY 113, 2018
 2 days to 32 years. It is theoretically caused by several
mechanisms (Goldblatt kidney, acutely or chronically
Page-compressed kidney, and AVF). All mechanisms are
similar in that they lead to reduction in renal blood flow,
which stimulates the kidney to produce renin. The gold
standard for the diagnosis of posttraumatic renovascu-
lar hypertension is selective angiography and renal vein
rennin measurements. Before this, it is always advis-
able to start with conservative management.33
g. Secondary hemorrhage. This is more common in cases of
deep cortical lacerations, especially in stab wound pa-
tients treated conservatively. Some series have re-
ported delayed bleeding in 13%-25% of patients with
grade III-IV blunt renal trauma who are treated con-
servatively and in 18%-23% of patients with penetrat-
ing renal trauma who are treated conservatively. It must
be noted, however, that a bleeding rate of 0% is seen
in other similar reports. Delayed hematuria can occur
in 3%-15% of patients after primary surgical explora-
tion after renal trauma. Most causes of delayed bleed-
ing are believed to be caused by a traumatic
pseudoaneurysm or AVF. Other bleeds may be caused
by segmental renal artery bleeding. Acutely, this bleed-
ing usually is stopped by tamponade of hematoma for-
mation, but after hematoma resolution (hematoma
liquefaction takes 5-14 days), the artery may rebleed.
Bleeding may be into the collecting system or into the
perirenal space and may be life-threatening. Timing of
this bleeding most commonly is in the first 2-3 weeks
of renal trauma (range 2-45 days).
h. Arteriovenous fistula. AVF is most commonly seen as a
result of renal biopsy. Posttraumatic AVF is rare and
almost exclusively of stab wounds (0%-7%). Clinical
manifestations of AVF depend on size and location. It
is the result of simultaneous vein and artery injury, which
hematoma resolves as the injured vein drains the artery
tear. It causes hematuria (micro or macro), with or
without clot retention, and cardiovascular problems such
as diastolic hypertension, cardiomegaly, or even con-
gestive heart failure. Suspected AVF requires emboli-
zation or ablation (sometimes superselective ablation),
except for small AVF that causes only microhematuria
and resolves with time.7,8,12,33,35
i. Pseudoaneurysm. Although more frequent in open
trauma, pseudoaneurysm is also rarely described in blunt
renal injury, as previously described. This usually pres-
ents with one or more of the following symptoms: gross
hematuria, flank pain, mass, abdominal bruit, or hy-
pertension. Doppler ultrasound or arterial CT can be
used to diagnose it. Currently, superselective emboli-
zation techniques decrease the risk of postembolization
syndrome (parenchymal infarction).7,8,12,33,35
According to recent series, a total nephrectomy rate of
11%-17% in grades IV and V and a rate of 27% of sig-
nificant parenchyma loss (>50%) are reported.36,37 Never-
theless, the risk of ultimate nephrectomy is consistently decreased
in children with high-grade renal trauma managed conservatively
UROLOGY 113, 2018
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regardless of injury characteristics: in a multicenter report from
the US National Trauma Data Bank with 419 pediatric pa-
tients with injuries IV to V, nephrectomy was performed ulti-
mately less often in patients treated conservatively. This decreased
risk of nephrectomy was more marked among children with grade
IV vs grade V renal injuries. Among those 419 patients, 11%
still underwent nephrectomy.37
In conclusion, and according to the AUA 2014 Rec-
ommendations, the following tips are to be followed:
1. The rule has shifted to nonoperative management in
the vast majority of cases.
2. Percutaneous angioembolization is increasingly ac-
cepted for treating ongoing bleeding without surgical
exploration.
3. Although nonoperative management of the vast ma-
jority of blunt renal injuries is now firmly established,
nonoperative management of penetrating and high-
grade renal injuries continues to inspire debate. (In the
hemodynamically stable patient, even a grade V injury
must be currently managed conservatively, according to
the 2014 AUA trauma guidelines.8)
4. The surgical team must perform immediate interven-
tion (surgery or angioembolization in selected situa-
tions) in hemodynamically unstable patients with no
or transient response to resuscitation.
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