SECTION 5

GENITOURINARY TRAUMA
39 Renal Injury
J. Patrick Spirnak, MD, FACS
Trauma is currently the leading cause of death and mor-
bidity in young Americans. Approximately 10 to 15% of
all patients with abdominal trauma have an associated uro-
logic injury. It has been estimated that 1.1% of all trauma
will involve the upper urinary tract.1 Blunt urologic injury
is the most common form of trauma seen by practicing
urologists and is responsible for 80 to 90% of all urologic
injuries.2 The most common causes of injury are motor
vehicle accidents, falls from heights, and direct blows to
the flank. The kidney is the most commonly involved
organ, followed by the bladder, urethra, and ureter.3
Although penetrating injuries account for only about 20%
of all traumatic injuries, they represent 80 to 90% of all
renal trauma cases that require exploration. Renal injury
accounts for about 1 in 3,000 hospital admissions and
should be suspected in anyone sustaining blunt or pene-
trating trauma to the lower chest, back, or abdomen. Over
the past two decades we have seen a continued evolution
in the diagnosis, evaluation, and treatment of urologic
injuries. Urologic evaluation is no longer necessary in
all patients sustaining blunt abdominal trauma because
a subset of patients who are likely to have sustained a
urologic injury have been well defined. Similarly, we
have seen continued changes in the way patients with
urologic injuries are being treated.4 With improved stag-
ing techniques, even patients with penetrating renal
injuries are being selectively managed in a nonoperative
manner.5–10
A Renal trauma should be suspected in anyone sustaining
blunt or penetrating trauma to the lower chest, back, or
abdomen. Emergency room evaluation includes the
128
determination of cardiopulmonary status and the pres-
ence of life-threatening injuries. Once hemodynamic
stability has been ensured and the pulmonary status sta-
bilized, a detailed history, physical examination, and uri-
nalysis are obtained. Falls from great heights or
high-speed motor vehicle accidents with associated
deceleration-type injuries may result in renal pedicle
injuries in the absence of hematuria.11 Individuals with
renal injuries may demonstrate costovertebral angle
(CVA) or flank tenderness, a palpable flank mass, or
flank ecchymosis. The presence of fractured ribs, pneu-
mothorax, or vertebral body fractures suggests the pos-
sibility of renal injury. Patients presenting with the
above findings undergo radiographic evaluation regard-
less of the findings on urinalysis. In patients who sustain
penetrating trauma, it is helpful to determine the type of
weapon used. Lacerations and entrance and exit wounds
are also noted. Urinalysis is obtained in all trauma vic-
tims. It is well known that the degree of hematuria does
not correlate with the severity of renal injury.1,12 Renal
artery thrombosis, which may result in complete loss of
renal function, may occur in the presence of a normal
urinalysis. Gross hematuria may occur after a mild renal
contusion. All patients with gross hematuria require
radiographic evaluation. Patients with isolated micro-
scopic hematuria determined by dipstick or by micro-
scopic urinalysis do not require radiographic imaging.
All patients with microscopic hematuria who present
with shock (systolic blood pressure < 90 mm Hg) or who
have multisystem injuries require urologic evalua-
tion.12–15 Patients sustaining severe deceleration-type
injuries are also evaluated.16
 Renal Injury

Patient with SUSPECTED RENAL TRAUMA

Physical examination
A Urinalysis

Stable Unstable

Abdominal Renal artery Exploratory

B CT scan
E thrombosis Unilateral F laparotomy; IVP

Abnormal Normal

Minor renal injury Major renal injury

C D Observation
(Grades I, II) (Grades III, IV, V)

Bilateral injury
Solitary kidney

Observation G Renal exploration Observation

Attempted
revascularization
G Unstable

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SECTION 5 Genitourinary Trauma
B Computed tomography (CT) is the most accurate imag-
ing study available to evaluate and stage the extent of
renal trauma.17,18 CT scanners are readily available in all
trauma centers. The study is noninvasive and has
replaced intravenous pyelography (IVP) and renal arte-
riography as the gold standard in identifying and staging
renal injuries. CT clearly defines parenchymal lacera-
tions, hematomas, and the presence of urinary extrava-
sation; it also allows accurate assessment for the
presence of other associated injuries.19 CT is also highly
accurate in identifying arterial injuries (Figure 39-1).20,21
The presence of the cortical rim sign signifies an acute-
ly devascularized kidney with persistent capsular perfu-
sion and is diagnostic of a renal artery thrombosis. The
use of three-dimensional CT has been reported to be a
noninvasive technique to accurately diagnose renal
artery injuries. It provides image quality similar to that
provided with angiography and may someday replace
angiography as the imaging study of choice in patients
with suspected renal artery trauma.22 Current helical CT
scanners have been shown to occasionally under-
estimate the full extent of the injury. Modern-day scan-
ners obtain images before intravenous contrast is
excreted into the collecting system. To avoid understag-
ing, it has been recommended that either a repeat scan be
performed after completing the initial study or the initial
scan be delayed for 5 to 20 minutes after contrast injec-
tion.23,24 The purpose of the CT scan is to not only iden-
tify the presence of a renal injury but also to help
classify the extent of the injury using a system estab-
lished by the Organ Injury Scaling Committee of the
American Association for the Surgery of Trauma.25 This
system classifies the renal injury into five groups. Grade
I: contusion and nonexpanding subcapsular hematoma
without laceration. Grade I injuries comprise 75 to 80%
of all renal injuries. Grade II: nonexpanding perirenal
hematoma confined to the retroperitoneum or a lacera-
Figure 39-1 Trauma CT scan showing classic findings of left
renal artery thrombosis. Note the abrupt cut-off of the left renal
artery and nonfunction of the left kidney.
130
tion less than 1 cm without urinary extravasation. Grade
III: greater than a 1 cm laceration extending into the
renal parenchyma without collection-system rupture or
extravasation. Grade IV: a renal parenchymal laceration
extending through the corticomedullary junction and
into the collecting system (Figure 39-2). (Urinary
extravasation may or may not be present.) A Grade IV
vascular injury consists of a main renal artery or vein
injury with contained hemorrhage. Grade V: complete-
ly shattered kidney with multiple lacerations through the
renal parenchyma or avulsion of the renal hilum with a
devascularized kidney.
C Eighty-five to 90% of all renal trauma will be classified
as either Grade I or Grade II renal injuries. These
patients are best treated with observation. Patients with
gross hematuria are hospitalized and placed on bed rest
until the urine becomes grossly clear. Complications are
rare.
D Treatment of major renal trauma is controversial.
Opinion is divided between those who favor immediate
operative intervention and those who favor observation
with exploration reserved for instances where compli-
cations arise or hemodynamic instability develops.26–30
Patients at risk for the development of complications
include those with urinary extravasation and/or devital-
ized renal segments. Advancements in endourologic
and percutaneous techniques have lessened the morbid-
ity of these complications. Retroperitoneal urine collec-
tions and persistent urinary extravasation may be
successfully managed endourologically with stents
and/or drainage tubes negating the need for renal explo-
ration in the majority of patients.31 In our experience,
no patient who has initially stabilized has required sur-
gical exploration for complications related to nonoper-
ative management. We have found that patients with
persistent hemodynamic instability require prompt sur-
Figure 39-2 Trauma CT scan showing a Grade IV renal injury.
Note the large right pleural hematoma and the presence of uri-
nary extravasation.
 Renal Injury

gical intervention and are usually found to have either

avulsion of the renal pedicle or a shattered kidney asso-
ciated with major vascular injuries (Figure 39-3).

All stable patients with major renal trauma are treat-

ed nonoperatively. Patients with gross hematuria are
kept on bed rest until the urine clears. Vital signs and
serial hematocrits are obtained. Broad-spectrum antibi-
otics are prescribed. Once the urine clears, the patient is
allowed to ambulate. If the urine remains clear for 24
hours, the patient is discharged. A follow-up CT scan is
obtained in 4 to 6 weeks. Complications are rare, and
surgical exploration is reserved for those patients who
manifest hemodynamic instability in spite of aggressive
resuscitative efforts.

E Traumatic renal artery thrombosis is an uncommon

complication of blunt abdominal trauma and should be
suspected in any patient presenting with severe deceler-
ation-type injury. Since the initial description by von
Recklinghausen in 1861, approximately 200 cases of
traumatic renal artery occlusion have been reported in
the literature.32–35 Traumatic renal artery thrombosis
results from excessive stretching of the renal artery with
subsequent tearing of the inelastic renal intima and
occlusion of the renal artery. When the condition is
bilateral, immediate surgical exploration and attempted
revascularization are warranted (Figure 39-4). Treatment
of unilateral renal artery thrombosis is controversial.
Advocates of surgical exploration believe renal func- Figure 39-4 Renal arteriogram showing the classic findings of
tion can be preserved by prompt revascularization; bilateral renal artery thrombosis. Note the bilateral cut-off of the
however, in fact, renal function is rarely preserved and renal arteries.
nephrectomy usually results. Recently, successful trans-
luminal angioplasty with stent placement has been
described as an alternative to open revascularization formed if hypertension develops. It is our recommenda-
techniques.36 Advocates of the nonoperative approach tion that all patients with either a solitary kidney or
believe that adequate renal function can rarely be bilateral injuries undergo prompt surgical exploration
restored and that elective nephrectomy can be per- and attempted revascularization. Patients with unilater-
al injuries are observed with nephrectomy performed if
hypertension develops.33–35

F Unstable patients require emergent laparotomy. Once

the patient has been stabilized and life-threatening
injuries have been repaired, an emergent single-shot
excretory urogram is obtained on the operating table. A
high-dose bolus infusion of 2 mL/kg of radiographic
contrast is injected. A simple, plain abdominal radi-
ograph is obtained 10 minutes after injection.
Additional delayed studies may be obtained as deemed
necessary.37 One goal of the trauma IVP is to determine
the presence or absence of two functioning kidneys.

G Patients with an expanding or pulsatile hematoma,

absence of a nephrogram on the intraoperative IVP,
(Figure 39-5) or a gunshot wound to the kidney undergo
renal exploration. Scott and Selzman, in 1966, first
Figure 39-3 Pathologic appearance of a shattered kidney. described the technique of preliminary vascular control

131
SECTION 5 Genitourinary Trauma
Figure 39-5 Emergency one-shot IVP showing a bullet over a
nonfunctioning right kidney. Note the normal appearance of the
left collecting system.
before opening Gerota’s fascia.38 Carroll and associates
described excellent results using this technique.39
Proponents of early vascular control believe nephrecto-
my rates can be reduced by limiting the blood loss and
transfusion requirements. Others have found the
technique to be time consuming, tedious, and rarely nec-
essary.39 Once Gerota’s fascia has been opened, all devi-
talized tissue is débrided, the renal parenchyma is
approximated, the collecting system is closed, and hemo-
stasis is obtained. The kidney is drained. Follow-up
imaging studies are obtained prior to patient discharge.
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