Renal Trauma Management (AUA Urotrauma 2020)

Algorithm Steps

1. ▶

   Start

   Suspected Renal Trauma

   Blunt or penetrating injury with flank pain, hematuria

   1. ●

      Action

      ATLS Primary Survey

      Stabilize before urological evaluation

      • Airway, Breathing, Circulation first
      • Large bore IV access x2
      • Type and crossmatch
      • Assess mechanism: blunt vs penetrating
      • Associated injuries common (40-80%)
      1. ◆

         Decision

         Hemodynamically Stable?

         Responding to resuscitation?

         1. ⚠

            Warning

            Hemodynamically Unstable

            Immediate intervention required

            • If isolated renal injury suspected: OR vs IR
            • If multi-system trauma: damage control surgery
            • Consider angioembolization if available
            • Nephrectomy may be necessary
            • One-shot IVP if OR without CT
            1. ●

               Action

               Surgical Exploration

               When intervention fails or not available

               • Indications: Hemodynamic instability
               • Expanding/pulsatile hematoma at OR
               • Grade V hilar avulsion
               • Failed angioembolization
               • Attempt renorrhaphy if possible
               • Nephrectomy if not salvageable
               1. ●

                  Action

                  Follow-Up Care

                  Monitor for complications

                  • Repeat imaging 48-72h for Grade III-IV
                  • Blood pressure monitoring (renovascular HTN)
                  • Follow-up CT at 3 months for high-grade
                  • Monitor renal function if bilateral/solitary
                  • Watch for delayed bleeding (up to 2 weeks)
                  1. ✓

                     Outcome

                     Long-Term Outcomes

                     90%+ renal preservation with NOM

                     • NOM success: >95% for Grade I-III
                     • NOM success: 85-90% for Grade IV
                     • Nephrectomy rate <5% with modern approach
                     • HTN risk: 1-5%
                     • Monitor for AV fistula, pseudoaneurysm
         2. ●

            Action

            CT Abdomen/Pelvis with IV Contrast

            Gold standard for renal injury staging (AUA Strong Rec)

            • Arterial and delayed (10-15 min) phases
            • Assess renal perfusion
            • Identify extravasation (urine or blood)
            • Evaluate collecting system injury
            • Stage per AAST grading
            1. ◆

               Decision

               AAST Renal Injury Grade?

               Determines management pathway

               1. ●

                  Action

                  Grade I-II (Low Grade)

                  Contusion or non-expanding hematoma

                  • Grade I: Contusion or subcapsular hematoma
                  • Grade II: <1cm laceration, no extravasation
                  • Non-operative management (AUA Strong Rec)
                  • Bed rest, serial hemoglobin
                  • Discharge when stable, hematuria resolving
                  1. ●

                     Action

                     Non-Operative Management

                     Observation and supportive care

                     • Bed rest until gross hematuria resolves
                     • Serial hemoglobin every 6-8 hours initially
                     • IV fluids, transfuse PRN
                     • Antibiotics if penetrating injury
                     • VTE prophylaxis when safe
                     • Advance activity as tolerated
                     1. ●

                        Action

                        Urine Extravasation Management

                        Collecting system injury

                        • Most resolve spontaneously
                        • Consider ureteral stent for persistent leak
                        • Percutaneous drain for urinoma
                        • Repeat imaging at 48-72h
                        • Stent for >72h persistent extravasation
               2. ●

                  Action

                  Grade III-IV (High Grade)

                  Deep laceration or vascular injury

                  • Grade III: >1cm laceration into medulla
                  • Grade IV: Laceration into collecting system OR segmental vessel injury
                  • Non-operative management if stable (AUA Strong Rec)
                  • ICU admission, close monitoring
                  • Serial CT at 48-72h for high-grade
                  • Watch for delayed bleeding, urinoma
                  1. ◆

                     Decision

                     Active Bleeding on CT?

                     Contrast extravasation or expanding hematoma

                     1. ●

                        Action

                        Angioembolization

                        Selective embolization for hemorrhage (AUA Strong Rec)

                        • First-line for stable patients with active bleeding
                        • Selective embolization preserves parenchyma
                        • Success rate >90% for hemorrhage control
                        • May need repeat embolization in 5-10%
                        • Consider if pseudoaneurysm or AV fistula
               3. ⚠

                  Warning

                  Grade V (Shattered/Avulsion)

                  Shattered kidney or hilar avulsion

                  • Shattered kidney (multiple lacerations)
                  • Main renal artery/vein avulsion
                  • Often requires surgical exploration
                  • Attempt repair vs nephrectomy
                  • Warm ischemia time <30-60 min for salvage