Renal trauma

General principles

Renal trauma commonly accompanies blunt or penetrating injury to the abdomen and retroperitoneum.

Management begins with assessment and stabilization of vital functions, not a urological intervention. In polytrauma, control of life-threatening bleeding takes priority.

When to suspect renal injury

• Gross hematuria.
• Microscopic hematuria with at least one episode of hypotension after blunt trauma.
• Lower back pain, flank hematoma.
• Lower rib fractures.
• Penetrating injury.
• Associated abdominal injury.
• A high-energy mechanism, rapid deceleration, a fall from height, or significant associated injuries.

The absence of hematuria does not exclude serious renal injury.

Diagnosis

• In a hemodynamically stable patient, contrast-enhanced CT with a delayed phase is indicated for gross hematuria, microscopic hematuria with hypotension, penetrating injury, a high-energy mechanism, or clinical signs of renal injury.
• In an unstable patient, investigations must not delay resuscitation and hemorrhage control.
• Laboratory tests: hemoglobin, creatinine, blood group, coagulation profile.

Conservative management

• Most blunt renal injuries in hemodynamically stable patients can be managed nonoperatively.
• Monitor hemodynamics, hemoglobin, pain, urine output, and interval imaging findings.
• Selective angioembolization may be used for ongoing bleeding.

When intervention is required

Absolute priorities:

• Uncontrolled bleeding.
• Hemodynamic instability.
• Injuries requiring surgical exploration.

In urinary extravasation:

• Management depends on the clinical course.
• Persistent symptomatic leakage → stenting, nephrostomy, or drainage.

When considering nephrectomy, prioritize renal preservation whenever this is safe.

Observation

• Monitor kidney function and blood pressure.
• Individualize treatment of complications (urinoma, bleeding, infection, post-traumatic hypertension).

Algorithm