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Management of severe blunt renal trauma in

adult patients: a 10-year retrospective review
from an emergency hospital

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Francesco Aragona, Pietro Pepe, Domenico Patan*, Pierantonio Malfa*,

Letterio DArrigo and Michele Pennisi
*Urology Unit and Imaging Department and Cannizzaro Emergency Hospital, Catania, Italy
Accepted for publication 30 September 2011

Study Type Therapy (case series)

Level of Evidence 4

OBJECTIVE
To review retrospectively the
management of major blunt renal truma in
adult patients admitted to our level I
trauma centre.

Whats known on the subject? and What does the study add?
Immediate surgery for major renal trauma has led to a high rate of nephrectomy in
comparison with an expectant management.
We reviewed our case material on the management of severe blunt renal trauma in
adults with emphasis on conservative management. Only shattered kidneys and pedicle
avulsion required immediate surgery.

RESULTS
PATIENTS AND METHODS
Among 1460 blunt abdominal trauma
cases collected from January 2001 to
December 2010, 221 (15%) affected the
kidneys.
All patients, except seven who needed
immediate laparotomy, underwent a
computed tomography scan to stage the
injuries.
Renal injuries were graded according to
the American Association for the Surgery
of Trauma Grading System; grade 4 and 5
injuries were subclassified based on
vascular or parenchymal injury.

INTRODUCTION
Blunt traumas (BTs) account for 8090% of
renal injuries and are most commonly
caused in Western countries by motor
vehicle acc dents, pedestrian accidents and
falls. On the basis of CT findings, the Organ
Injury Scaling Committee of the American
Association for the Surgery of Trauma
(AAST) has classified five grades of renal
injuries [1]; a revision of the original 1989
grading system, which includes segmental
vascular injuries and pelvi-ureteric ruptures,

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Only 45/221 patients (20%) suffered

major blunt renal trauma (21 grade 3, 18
grade 4 and six grade 5); 43% of the
patients had associated lesions and 77%
had gross haematuria.
Nephrectomy rates were 9% for grade 3,
22% for grade 4 and 83% for grade 5 with
an exploration rate of 26% for major renal
trauma.

stable patients yields more favourable

results with high renal salvage rate.
Grade 5 injuries still result in a
nephrectomy rate of more than 80%.
The absence of data on long-term
outcomes and a potential inclusion bias
due to the retrospective nature of the
data represent major limitations of this
review.

CONCLUSIONS

KEYWORDS

Conservative management of grade 35

blunt renal trauma in haemodynamically

renal trauma, renal injury, helical CT,

angioembolization

was recently proposed by Buckley and

McAninch [2].

December 2010. In 221 cases (15%), the type

of trauma and the clinical picture prompted
a suspicion of renal trauma. A CT scan was
performed to stage the renal and associated
organ system injuries in all but seven
patients, whose haemodynamic instability
despite resuscitation manoeuvres needed
immediate exploration.

We reviewed the management of adult

patients at our level I trauma centre
suffering major renal BT (i.e. grade 35) with
emphasis on conservative management.
PATIENTS AND METHODS
A retrospective analysis was conducted of
1460 abdominal BTs in adult patients (aged
18 years) collected from January 2001 to

Grade 12 renal BTs were found in 176

patients (80%) and were managed
conservatively (bed rest, haematocrit
monitoring) unless the coexistence of other

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MANAGEMENT OF SEVERE RENAL TRAUMA IN ADULTS

TABLE 1 Patient demographics

No. (%)
Gender
Female
Male
Age
Younger than 30 years
Older than 30 years
Renal trauma grade
3
4
5
Side
Left
Right
Gross haematuria
No
Yes
Shock
No
Yes

8 (18%)
37 (82%)
32 (72%)
13 (28%)
21 (47%)
18 (40%)
6 (13%)

FIG. 1.
Grade 5 blunt renal trauma in a
20-year-old man following a car
accident. Axial (a) and coronal
(b) CT scans show a shattered
right kidney that required
immediate nephrectomy.
Intraoperatively, the kidney
appeared to be broken in two
pieces (c) with a wide laceration
of the renal pelvis (d).

26 (58%)
19 (42%)
10 (23%)
35 (77%)
25 (55%)
20 (45%)

FIG. 2. Grade 4 blunt renal trauma in a 22-year-old man from a sports accident. CT scan during the
venous phase (a) shows a left perirenal haematoma with extravasation of contrast medium. A
conservative management by ureteral stenting was planned and the immediate result was apparently
satisfactory (b). However, the patient was readmitted 3 months later for flank pain and fever. An infected
urinoma was diagnosed at CT scan. The patient underwent a partial nephrectomy for debridement of
non-viable tissue and persistent urinary extravasation; a Nelaton tube is inserted into the leakage point
(c). Complete recovery at 6 months follow-up (d).

lesions required a surgical intervention. A

total of 45 patients (20%) sustained major
renal BT (21 grade 3, 18 grade 4 and six
grade 5 injury) and constitute the subject of
this report.
Motor vehicle accidents accounted for 38
injuries (86%), falls for six (14%) and a
sports accident for one case. Patient age,
gender, AAST renal injury grade, side of
injury, presence of shock and gross
haematuria are listed in Table 1.
Associated injuries were found in 19
severely traumatized patients (43%): liver
laceration (nine), lower and/or upper limb
fractures (six), splenic rupture (five), head
injuries (four), rib fractures (three),
pneumothorax (two), pelvic fracture (two)
and bowel injury (one). Of the 18 grade 4
BTs, three were due to vascular injury
(segmental artery or contained injury to the
main hilar vessels) isolated or in conjunction
with a parenchymal laceration and urine
extravasation. Of the six grade 5 trauma,
two were due to pedicle lesion (one arterial
thrombosis, one complete avulsion) and the
other four injuries were completely
shattered kidneys.
RESULTS
There were no deaths related to the renal
injuries. Among six patients with grade 5 BT,

five underwent an immediate nephrectomy

because of life-threatening bleeding,
shattered kidney, massive urinary
extravasation and vascular injury (Fig. 1);
in one case of arterial thrombosis an
endovascular prosthesis was positioned in
an attempt to avoid the removal of a
solitary renal unit (the patient subsequently
died of unrelated complications).
Among 21 grade 3 BTs, five were surgically
explored (three nephrectomies, three
renorrhaphies) and 16 were managed
conservatively (11 bed rest/transfusion,
five selective embolization). Among 18
grade 4 BTs, seven were explored (four
nephrectomies, two renorrhaphies and one
partial nephrectomy, Fig. 2), five healed with

ureteral stenting, five required selective

embolization and in one case a
percutaneous drainage of a perinephric
abscess was needed.

DISCUSSION
Helical CT has overcome the limitations of a
conventional CT scan in the evaluation of
renal trauma (less than 1 min scanning time,
fewer artifacts) [3]; furthermore, a threedimensional postprocessing modality allows
the assessment of the renal pedicle and
improves the demonstration of complex
parenchymal lacerations [4]. Because of the
short scanning time, a rupture of the
collecting system can be missed as images

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ARAGONA ET AL.

TABLE 2 Management of 39 grades 3 and 4 blunt renal trauma

Years
20015

AAST grade
of injury
3
4

No. of
patients
9
7

200610

12

Open surgery
Five patients: two nephrectomy, three renorrhaphy
Six patients: four nephrectomy, two renorrhaphy
+ suture of collecting system
None

11

One patient: partial nephrectomy (failed stenting)

39

12 (30%)

Total

are obtained before contrast medium is

excreted. Thus, it is mandatory to obtain
delayed scans to rule out urinary
extravasation.
In trauma patients the haemodynamic
situation is the benchmark for the
diagnostic and therapeutic algorithm.
Haemodynamically unstable patients require
immediate laparotomy; traditionally, in these
cases a one-shot intravenous pyelogram
(IVP) before renal exploration is
recommended to assess the viability of the
contralateral kidney [5]. However, the quality
of a one-shot IVP is usually not good
enough to change the decision making and,
if an unstable patient needs to be rushed to
the operating room, wasting precious time
for renal imaging makes no sense. Whenever
the patient is stable enough to undergo
imaging, a helical CT scan is the best option
to stage the trauma.
In our experience, only seven cases
necessitated immediate laparotomy and in
no case was the renal lesion alone
responsible for the emergency (five liver
lacerations, two splenic ruptures with
massive haemoperitoneum). Thus, when
major associated injuries are ruled out, an
accurate assessment of renal trauma can be
done for a timely management plan.
More than 80% of renal BTs are of minor
grade (12) and do not require treatment;
on the other hand, grade 5 lesions (except
for renal thrombosis) require immediate
treatment. The management of grades 3 and
4 BT has been a subject of controversy
(conservative vs surgical management), the
goal of either regimen being preservation of
renal function while minimizing morbidity.

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MANAGEMENT OF GRADE 5 RENAL TRAUMA

Pedicle avulsion and completely shattered
kidneys require mandatory surgery as they
cause haemodynamic instability with an
enlarging retroperitoneal haematoma and
are often associated with other lifethreatening lesions. Predictors for
nephrectomy are haemodynamic instability,
45 AAST grade injury and associated
intra-abdominal injuries [68].
An isolated renal artery thrombosis is best
managed conservatively, provided the
patient is stable and has a normal renal
function. Attempts at artery repair have a
modest 1020% success rate even when the
intervention is performed within 56 h [9];
open revascularization remains an extreme
resource in cases of solitary kidneys or
bilateral thrombosis. An endovascular
stenting is a very tempting solution
[10]; however, the necessity of full
anticoagulation to decrease the potential for
postoperative thrombosis and the risk of
artery rupture when attempting to place a
stent in an injured vessel make these
procedures impractical for the majority of
trauma patients.
A conservative management of shattered
kidneys has been proposed in selected
patients with parenchymal lacerations
without pedicle vessel injury who are
haemodynamically stable at presentation
[11].
MANAGEMENT OF GRADE 34 RENAL
TRAUMA
In the past, these injuries were managed by
immediate surgery, resulting in a high risk of

Conservative management
Four patients: bed rest/transfusions
One ureteral stenting
Twelve patients: five selective embolization, seven
bed rest/transfusions
Ten patients: four ureteral stenting, five selective
embolization, one percutaneous drainage
(perinephric abscess)
27 (70%)

renal loss. Advocates of immediate surgery

argued that a conservative approach
increases the likelihood of complications
(persistent urinary extravasation and/or
delayed haemorrhage from tissue necrosis);
these are nowadays amenable to endoscopic
or percutaneous procedures, including
transcatheter selective embolization (TSE).
The consensus is that, in the stable patient,
all grade 34 renal injuries should be
managed conservatively [12]. The same
recommendation applies to the
haemodynamically stable patient who is
explored for associated injuries: a nonpulsatile, contained perinephric haematoma
should be left alone.
Persistent or delayed bleeding in a stable
patient is managed successfully with TSE in
up to 80% of cases [1216]. After its
introduction in 2006, none of our patients
with grade 34 BT needed a laparotomy for
uncontrolled bleeding. In contrast, between
2001 and 2005, five grade 3 and six grade 4
lesions were surgically explored (Table 2).
Figure 3 illustrates a case of BT in a
horseshoe kidney for which a successful
TSE spared the patient a troublesome
intervention, whose outcome is frequently a
nephrectomy.
Except for PUJ avulsion and laceration of
the renal pelvis (both requiring surgical
repair), urinary extravasation without major
associated vascular or abdominal injuries is
not an indication for surgery. The algorithm
of expectant management is bed rest until
the urine clears, and serial haematocrits
followed by repeat CT scan 45 days after
the initial injury. Extravasation that is stable
or worse warrants ureteral stenting for 46

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FIG. 3. Blunt renal trauma of grade 3 in a 66-year-old man with a horseshoe kidney with pyelic stone and
right hydronephrosis. CT angiography during the arterial and venous phases shows a haematoma with
active bleeding from the isthmus (a); maximun intensity projection reconstruction in the arterial phase
shows active bleeding from the artery supplying the isthmus and originating from the abdominal aorta
(b); selective angiography of the artery supplying the isthmus localizes the bleeding site in two of its
branches (c). Final angiograms after placement of Gianturco microcoils show complete occlusion of the
bleeding arterial branches while the superior branch of the artery is spared (d). At 6 months follow-up,
axial (e) and coronal (f) CT angiography shows the coils in place and a small area of hypotrophic
parenchyma as the only sequela of the renal injury.

bias for drawing a definite conclusion. The

absence of data on the incidence of
long-term outcomes from renal injuries
represents a further limitation of the study.

CONFLICT OF INTEREST
None declared.

REFERENCES
1

weeks; leakage that improves on subsequent

CT should be followed. A delayed
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significant urinoma persists or a perinephric
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In conclusion, the widespread use of helical
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techniques, the improved quality of
embolizing agents and the high success rate
of TSE as the primary treatment option
for active bleeding have promoted the
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concluded that open surgery was necessary
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Some limitations of our study deserve
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comparing the results obtained in a
population of patients admitted over a
10-year period for renal BT. However, the
decision of conservative vs operative
management resulted from the availability
of interventional techniques rather than as a
consequence of enrolment in a randomized
prospective trial. This introduces a source of

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Correspondence: Francesco Aragona,
Cannizzaro Hospital Urology, Via Messina
829, Catania 95126, Italy.
e-mail: frank.aragona@virgilio.it
Abbreviations: BT, blunt trauma; AAST,
American Association for the Surgery of
Trauma; IVP, intravenous pyelogram; TSE,
transcatheter selective embolization.

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