The conservative management of renal trauma:
a literature review and practical clinical
guideline from Australia and New Zealand
Steve P. McCombie*, Isaac Thyer, Niall M. Corcoran, Christopher Rowling,
John Dyer, Anton Le Roux**, Melvyn Kuan, D. Michael A. Wallace and
Dickon Hayne*
*School of Surgery, University of Western Australia, Crawley, Departments of Urology, Infectious Diseases, **Radiology,
Fremantle Hospital, Fremantle, Department of Urology, Sir Charles Gairdner Hospital, Nedlands, WA, and Departments
of Urology and Surgery, Royal Melbourne Hospital and University of Melbourne, Parkville, VIC, Australia
Objective
To review the literature and make practical
recommendations regarding the conservative management
of renal trauma.
Patients and Methods
Relevant articles and guidelines published between 1980 and
2014 were reviewed.
Graded recommendations were constructed by a
multi-disciplinary panel consisting of urologists,
radiologists, and infectious disease physicians.
These recommendations underwent formal review and
debate at the Western Australian USANZ 2013 state
conference, and were presented at the USANZ 2014 annual
scientic meeting.
Results
The literature on the conservative management of renal
trauma is reviewed within the framework of the American
Introduction
The conservative management of blunt renal trauma was rst
proposed in the 1940s [1]. Since then the benets of this
approach have become increasingly apparent with reductions in
nephrectomy rate, complications, and hospital stay all being
reported [13]. This has resulted in a paradigm shift towards
managing increasingly severe blunt renal trauma with a
conservative approach [1,49]. The selective application of this
approach to penetrating renal injuries has also been gaining
momentum since this was rst recommended in the 1980s
[1,4,5,8,10]. This evolution in the management of renal trauma
has been made possible by advances in both imaging and
minimally invasive techniques [1,4,5,8,10]. The widespread
availability of CT allows clinicians to be much more informed
about the injuries they are treating, while the ability to use
2014 The Authors
BJU International 2014 BJU International | doi:10.1111/bju.12902
Published by John Wiley & Sons Ltd. www.bjui.org
Association for the Surgery of Trauma (AAST) kidney
injury severity scale.
Graded recommendations are made regarding several key
topics including: imaging, inpatient management,
antibiotics, return to activity, and follow-up.
Grade IV injuries and intraoperative consults are examined
separately in view of the diculties these groups cause in
making appropriate treatment decisions.
Conclusion
A practical clinical guideline is provided regarding the
conservative management of renal trauma.
Keywords
renal trauma, non-operative management, review, guideline,
diagnostic imaging, follow-up
ureteric stenting, percutaneous drainage, and embolisation
within a conservative approach has increased the range of
injuries to which conservative management can be applied
[1,4,5,8,10].
However, while several studies have shown a conservative
approach to be successful, very few have addressed what
specically this conservative approach should entail. The
EAU [4], AUA [9], and Socit Internationale dUrologie
International Consultation on Urological Diseases renal
trauma subcommittee (renal trauma subcommittee) [5] have
provided some recommendations; however, there remains
a hiatus on specic guidance about certain aspects of
conservative management. As such there seems to be a wide
variation in practice regarding issues such as repeat imaging,
inpatient monitoring, thromboprophylaxis, antibiotics,
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McCombie et al.
Table 1 The American Association for the Surgery of Trauma (AAST)
kidney injury severity scale [11].
Grade* Type Description
I Contusion Normal imaging, non-visible or visible haematuria present
Haematoma Non-expanding subcapsular haematoma with no
parenchymal lacerations
II Haematoma Non-expanding peri-renal haematoma conned to
retroperitoneum
Laceration Cortical laceration <1 cm without urinary extravasation
III Laceration Cortical laceration >1 cm without urinary extravasation
IV Laceration (a) Laceration through corticomedullary junction into
collecting system
Vascular (b) Renal artery or vein injury with contained
haemorrhage, or partial vessel laceration, or
vessel thrombosis
V Laceration (a) Completely shattered kidney
Vascular (b) Avulsion of renal hilum with devascularised kidney
*Advance one grade for bilateral injuries up to grade III.
discharge criteria, advice on activity restriction, and
follow-up.
Methods
A literature search was conducted utilising MedLine, Embase,
and AustHealth; articles published between 1980 and 2012 were
included. Search terms used included: renal trauma, kidney
injuries, complications, bed rest, discharge criteria, follow-up,
and aftercare. Recommendations were then constructed by a
multi-disciplinary panel of experienced clinicians, based on the
available literature and their collective experience. The panel
included urologists, radiologists, and infectious disease
physicians. These recommendations were then modied after a
formal review and debate at the Western Australian USANZ
2013 state conference, and were subsequently presented at the
USANZ 2014 annual scientic meeting.
This guideline is designed for patients who remain stable,
without developing complications, on conservative
management. The management of patients who require initial
or delayed intervention has been described extensively
elsewhere [25,11]. The American Association for the Surgery
of Trauma (AAST) kidney injury severity scale [12] is used to
classify renal trauma (Table 1) [11]; this scale has been both
validated [13] and widely accepted [4,5,9]. Recommendations
are graded according to the EAU grading scale [4], which
closely resembles the grading scale used by the AUA [9]:
A. Based on clinical studies of good quality and consistency
addressing the specic recommendations and including at
least one randomised trial
B. Based on well-conducted clinical studies, but without
randomised clinical trials
C. Made despite the absence of directly applicable clinical
studies of good quality
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14 BJU International 2014 BJU International
Results
Treatment Selection
While increasing numbers of patients are being managed
conservatively for renal trauma, criteria for identifying patients
who are suitable for this approach remains controversial
[4,5,9,14]. Some appear to base treatment decisions largely on
injury grade or radiological ndings [13], whereas others
appear to rely more heavily on assessment of the patients
clinical status [14]. Nonetheless, absolute contraindications for
initiation of conservative management include life-threatening
bleeding, renal pedicle avulsion, and the presence of a large,
expanding, pulsatile haematoma [4,5,8]. However, debate
surrounds other relative indications for intervention such as
penetrating injury, high-grade injury, renovascular injury,
non-pulsatile retroperitoneal haematoma, devitalised
segments, urinary extravasation, and injuries to other organs
[35,8,9]. Additionally, the threshold for intervention may be
lower in cases of a solitary functioning kidney or bilateral
injuries [3]. The recently released AUA guideline recommends
initiation of conservative management in all patients as long
as they are haemodynamically stable [9].
Grade V injuries [14,15] and the need for platelet transfusion
[14], which reects activation of a massive transfusion
protocol, have been identied as good predictors of the
need for intervention. Additionally, nomograms have been
developed that are able to predict the need for renal
exploration with >95% accuracy [16,17]. One such nomogram
incorporates a combination of radiological (injury grade),
serological (admission haemoglobin, blood urea nitrogen), and
clinical variables (heart rate, platelet transfusion within 24 h),
and is even able to predict the need for renal exploration in
the context of a unit that oers embolisation as an alternative
to surgery [17].
Grade IV Injuries
Whereas low-grade injuries rarely require intervention
and grade V injuries usually require exploration, the
management of patients with grade IV injuries can be
particularly challenging [18]. Not only does a dicult
decision need to be made between renal exploration and
conservative management, but the use and timing of other
interventions, e.g. ureteric stenting, percutaneous drainage,
and embolisation, must also be considered. In one study,
even when grade IV injuries were initially managed
non-operatively 11% of patients ultimately required renal
exploration, 27% required ureteric stenting, and 25%
required embolisation [19].
Decision-making for these injuries can be approached in a
sequential manner. Firstly, it must be determined if the patient
requires intervention to control bleeding; if they do then
embolisation appears preferable to renal exploration if it is
immediately available and the patient is stable enough for this

[5,9]. While it is obvious that a haemodynamically unstable
patient requires intervention to control bleeding, serious
consideration must also be given to intervening early in
patients who are haemodynamically stable but at high-risk of
ongoing blood loss. These patients appear to include those
with a penetrating injury, and those with particular ndings
on CT (extravasation of intravascular contrast, medial
laceration, peri-renal haematoma with a diameter of >3.5 cm)
[9,18,20]. Next it must be determined if the patient requires
intervention for urine leak; this may be in the form of ureteric
stenting or renal exploration depending on the circumstances
[9]. The AUA recommend that this is only required if injury to
the renal pelvis or ureter is suspected based on the presence of
a large medial urinoma, or urinary extravasation associated
with an absence of contrast in the distal ureter [9]. If the
patient does not require immediate intervention for bleeding
or urine leak then conservative management can be initiated,
although the need for delayed intervention should be regularly
reviewed. The indication for delayed embolisation or
exploration is evidence of ongoing bleeding (haemodynamic
instability, falling haemoglobin, ongoing transfusion
requirements). The indications for delayed intervention for
urine leak are sepsis, pain, increasing urinoma, ileus, and
stula [2,5,9,19]. The AUA state that ureteric stenting is
preferable to percutaneous drainage in the delayed
management of urine leak, and recommend that it is
combined with an initial period of catheterisation to assist
resolution [9]. Figure 1 shows a suggested algorithm for
managing grade I to IV renal trauma.
The Intraoperative Consult
The ideal management of renal injury in the context of a
patient undergoing laparotomy for severe bleeding or
intraperitoneal injuries is another dicult and highly
controversial scenario. While exploration is mandated in the
presence of a large, expanding, pulsatile retroperitoneal
haematoma [4,5,8], or a persistently unstable patient despite
exclusion of other abdominal causes, optimum management
in other situations is less clear. If preoperative imaging is not
available then a one-shot IVU is a useful tool in assisting
decision making [4,5,9,11,21,22]. An abnormal IVU is
considered an indication for renal exploration, and a normal
IVU (or absence of a contralateral kidney) may discourage
renal exploration due to the risk of unnecessary
nephrectomy [4,5,11,22]. If preoperative imaging is available,
algorithms produced by both the EAU and renal trauma
subcommittee suggest proceeding to renal exploration at
laparotomy in the presence of a grade III renal injury [4,5].
However, the belief that renal injuries should only be
explored on their own merits, regardless of the patient
undergoing laparotomy, is felt to be a commonly used and
sensible approach [18]. This approach avoids the potential
consequences of renal exploration, which include
Conservative management of renal trauma
destabilising the patient and unnecessary nephrectomy [18].
Finally, while some of the renal injuries encountered at
laparotomy may ordinarily be amenable to embolisation,
the delay involved with organising this in theatre may be
unjustied.
Initial Imaging
Four-phase CT of the abdomen and pelvis with non-contrast,
arterial-, nephrographic-, and pyelographic-phased images is
generally considered the gold standard initial imaging method
in renal trauma [46,9,11,21,23]. The American College of
Radiology has made useful recommendations as to when other
imaging methods may be appropriate [21]; importantly, in the
event wherein CT is unavailable then combined assessment
with IVU and focused abdominal sonography for trauma
(FAST) is considered acceptable [21]. There appears to be a
reasonable consensus in the literature that suitable criteria for
initial imaging in adults are: visible haematuria, non-visible
haematuria with shock, penetrating injury, signicant
associated injuries, and high-risk injury mechanisms
[4,5,9,21].
Although four-phase CT is also the initial imaging choice in
children [4,9,23], the European Society of Paediatric Radiology
(ESPR) recommend that ultrasonography (US) with Doppler
can be considered in mild or moderate paediatric trauma
if a low threshold for proceeding to CT is maintained [23].
Although adult criteria for initial imaging are generally
applicable to children, shock is an unreliable sign [4,5,9].
There is conicting guidance about the amount of
non-visible haematuria required to merit imaging in the
haemodynamically stable child [4,5,23]. While the EAU
and ESPR recommend that imaging is necessary with any
amount of non-visible haematuria [4,23], the renal trauma
subcommittee advise that it is only necessary if there are >50
red cells/high-power eld [5].
Unfortunately, renal trauma is uncommonly an isolated injury
and usually occurs along with injuries to other organ systems
[14,24]. This can result in competing imaging and treatment
priorities, resulting in the gold standard initial imaging not
always being readily available. The EAU recommends that
patients with multiple injuries should be evaluated on the
basis of the most threatening injury [4]. This supports the
prioritisation of obtaining gold standard initial imaging in
patients in whom renal trauma is suspected to be the most
signicant injury, which may include patients with severe
haematuria or penetrating ank trauma, that are stable enough
for CT. Intraoperative IVU is a useful adjunct to ndings at
laparotomy for assessing the need for renal exploration in
patients too unstable for preoperative imaging [5,9,21]. If
inadequate initial renal imaging is available, a low threshold
must be maintained for obtaining early re-imaging in the form
of a four-phase CT.
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McCombie et al.

Fig. 1 Algorithm for managing grade I to IV renal trauma.

Grade I Grade II or III Grade IV

Consider Stable
early Stable Unstable
discharge

Low-grade conservative management:
- Twice daily bloods initially
- Twice daily examinations initially
- No antibiotics unless febrile/risk factors
- Bed rest until haematuria is light
- No routine early re-imaging
Are ALL of the following true?
- Stable enough for embolisation
- Injury amenable to embolisation
- Not requiring laparotomy
- Embolisation readily available
Is intervention required for BLEEDING? Consider:
- Penetrating injury mechanism
Yes - Extravasation of intravascular contrast
- Medial laceration
- Peri-renal haematoma diameter > 3.5 cm
No

Yes No

Is intervention required for URINE LEAK? Consider:

Embolisation Renal exploration - Large medial urinoma

- Absence of contrast in the distal ureter

Yes No

Ureteric stenting or High-grade conservative

renal exploration management:
- Bloods every six hours initially
- Examinations every six hours
initially
- Prophylactic antibiotics (48-72
hours intravenous, 5 days oral)
- Bed rest until haematuria is light
- Routine early re-imaging at about
48 hours

management in three out of 177 patients, and each of these

Early Re-imaging
While there is a consensus that patients who deteriorate
clinically should either undergo intervention or re-imaging
[35,9], it is less clear whether certain patients who remain
stable on conservative management may benet from routine
early re-imaging. Blankenship et al. [25] initially proposed that
routine early re-imaging was necessary in all renal trauma of
grade III, based on the high complication rate in this group.
This recommendation was subsequently rationalised by
Malcolm et al. [26], who recommended that routine
re-imaging in grade III and IV vascular injuries was
unnecessary. This was because routine re-imaging was only
found to contribute to a decision to deviate from conservative
had an injury involving the collecting system [26]. Shirazi
et al. [27] went even further in concluding that even injuries
involving the collecting system do not require routine
re-imaging. In a cohort of 94 patients with a grade III or
IV injury, they found that all patients who developed
complications had clinical manifestations that would have
prompted re-imaging in any case [27]. Finally, Bukur et al.
[28] reported on a series of 120 patients in whom re-imaging
was only performed in patients with concerning clinical
features. Using this policy repeat imaging was limited to 18
of 120 patients, with no adverse events reported in those
not re-imaged [28]. Although some of these studies were
published after the release of their guidelines, the EAU

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Table 2 Recommendations on initial imaging and early re-imaging.
1. Criteria for initial imaging in adults are: visible haematuria, non-visible
haematuria with shock, penetrating injury, signicant associated injuries, and high-
risk injury mechanisms (B)
2. Criteria for initial imaging in children are: any haematuria, penetrating injury,
signicant associated injuries, and high-risk injury mechanisms (B)
3. Four-phase CT is the imaging method of choice for initial imaging. US with
Doppler can occasionally be considered in very mild paediatric trauma (B)
4. Clinical deterioration should prompt consideration of re-imaging or intervention.
Examples of deterioration may include: fever, a falling haemoglobin, new or
persistent haemodynamic instability, or worsening pain or abdominal signs (C)
5. If initial imaging is adequate then routine early re-imaging is not required in
grade IIII renal trauma. Routine re-imaging is recommended for all grade IV or
V renal trauma at 48 h (B)
6. US with Doppler is recommended for early re-imaging in children, whereas
four-phase CT is recommended in adults (B)
currently recommends routine early re-imaging after any
signicant renal trauma, whereas the AUA and renal trauma
subcommittee recommend it only for grade IV or V
lacerations [4,5,9]. If routine early re-imaging is ever
indicated, the guidance for the ideal timing of it is unclear
[4,5,9,23]. The ESPR (424 h), renal trauma subcommittee
(3648 h), AUA (>48 h), and EAU (24 days) all recommend
obtaining routine early re-imaging after slightly dierent
intervals [4,5,9,23].
CT is regarded as the method of choice for early re-imaging in
adults [4,5,9]; however, US with Doppler is recommended in
children [23]. In 71 children sustaining renal trauma, US
proved sucient in detecting four enlarging perinephric
collections and a pseudoaneurysm, and CT was only required
in two patients to better dene a urological complication [29].
Given the good experience with US in children [29], the low
yield of routine early re-imaging [26,27], and the radiation
risks of CT [30], it may be that US has a useful role in the
early re-imaging of adult trauma that has yet to be dened
(Table 2).
Initial Monitoring
While it is common practice to admit all patients sustaining
renal trauma for a period of observation, discharge from the
emergency department may be considered for patients with
grade I injuries without visible haematuria [31]. Routine
admission of patients with high-grade injuries to the intensive
care unit (ICU) is rarely described for adults; however, appears
more common for children [6,31]. This practice has been
questioned in view of the reductions in ICU admissions that
have been safely achieved in paediatric hepatosplenic trauma
[32,33], when these patients are considered to have a higher
risk of uncontrollable haemorrhage than those with renal
trauma [6]. Monitoring of paediatric patients sustaining renal
trauma on surgical wards is thought to be an under-reported
phenomenon [6].
Monitoring should include regular observations, blood tests
and clinical examinations. The frequency of observations
Conservative management of renal trauma
should be tailored to the patients clinical status but should
include heart rate, blood pressure, respiratory rate, oxygen
saturation and temperature measurements. Monitoring urine
output and severity of haematuria is also important and is
most accurately done after insertion of a urinary catheter.
Although some patients may require this to manage their
haematuria in any case, placement of a urinary catheter for
monitoring purposes is particularly useful in patients with
haemodynamic instability, high-grade or multiple injuries, or
signicant co-morbidities. The most important blood tests
in the initial assessment of patients with renal trauma are
haemoglobin and creatinine [4]; ensuring the patient has a
valid cross-match or group and hold is also paramount. After
initial assessment, serial haemoglobins are a useful tool in
assessing for ongoing bleeding [4]; the required frequency of
these is less clear, although some advocate taking samples
every 6 h for the rst 24 h [26,27]. Initial and subsequent
clinical examinations should aim to detect both the presence
and progression of renal injuries and injuries to other organ
systems. Signs suggestive of possible renal injury include:
haematuria, penetrating wound in the vicinity of a kidney,
ank bruising, fractured ribs, an abdominal mass, and
abdominal tenderness or distension [4,5,9]. Assessing for
developing peritonitis is particularly important given this is a
common cause for failure of conservative management and
hollow visceral injuries are not always readily apparent on
initial imaging [34]. The required frequency of clinical
examinations is not clear, although some advocate repeating
this up to every 4 h initially [27]. Reducing the intensity of
monitoring after 24 h seems reasonable, as 87% of patients
who fail a trial of conservative management do so within this
time frame [34].
Thromboprophylaxis
Trauma patients are known to be at high-risk of venous
thromboembolism (VTE), and this risk can be reduced
signicantly with mechanical and pharmacological
thromboprophylaxis [35]. Small dierences between the
ecacy of dierent methods of thromboprophylaxis make
drawing absolute conclusions dicult; however, it appears as
though low-molecular-weight heparin may be superior to
either unfractionated heparin or mechanical prophylaxis in
reducing the risk of VTE after trauma [35]. However, while
mechanical prophylaxis in the form of anti-embolism
stockings and intermittent pneumatic compression devices
appears relatively safe and eective, many clinicians do not
feel comfortable with prescribing unfractionated or
low-molecular-weight heparin in the context of known renal
injury due to the considered increased bleeding risk [35].
Providing specic guidance on thromboprophylaxis in renal
trauma is dicult because there is a lack of evidence specic
to renal trauma on which to base recommendations currently.
Additionally, decisions about thromboprophylaxis have to
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McCombie et al.
consider multiple dierent factors including: haematuria,
other injuries, medications, and risk factors for VTE.
Trauma-specic risk-factors for VTE that should be
considered include: age, need for major surgery, specic
injuries (pelvic or lower extremity fracture, head or spinal
cord injury, venous injury), and markers of being critically
unwell (shock on admission, >3 ventilator days) [35].
Bed Rest and Discharge Criteria
Prescribing bed rest after renal trauma dates back to an era
before CT; the original paper advocating it is from 1968 and
recommends 3 weeks of bed rest, with the rst of these
occurring in hospital [36]. Yet despite the advent of CT,
meaning that we now know much more about the injuries
we manage, assigning bed rest is still very common practice
[4,5,11,14,31]. Most of those who advocate bed rest
recommend continuing it until the resolution of visible
haematuria [3,4,11,31]; however, this policy has been
challenged for two reasons [6,24]. Firstly, the degree of
haematuria does not appear to correlate with either symptom
improvement or mobility [24]. Secondly, it leads to
prolonged admissions [6] with the associated risks of VTE
and hospital-acquired infections of this. Reports of average
lengths of stay of >1 week in low-grade trauma [37,38] are
probably a consequence of this policy, and do seem
excessive. This is particularly so when other studies report
safely achieving an average length of stay of <4 days in
isolated renal injuries across all trauma grades, using a more
liberal policy on mobilisation [24]. Equally, reports of an
average length of stay of <2 days in hepatosplenic trauma,
with no re-admissions [33], suggests periods of prescribed
bed rest may be able to be safely reduced in renal trauma.
Results of a prospective study examining the eect of
allowing early mobilisation and discharge, regardless of
ongoing visible haematuria, are eagerly awaited [6]. Apart
from haematuria, other general discharge criteria apply in
renal trauma; being afebrile, tolerating a regular diet,
adequate pain control, and maintaining a stable haemoglobin
are not contentious criteria (Table 3).
Antibiotics
Prophylactic antibiotics are often advocated after renal
trauma [4,6,10,27]; however, it is agreed that there is
minimal evidence to support this practice [2,6]. The most
suitable agents and duration of treatment have yet to be
dened, and few specic recommendations exist. Equally, it
is not clear whether all patients require antibiotics; some
have suggested limiting their use to injuries involving the
collecting system [2,8,11,14], or those with an associated
large haematoma [2]. In one study of grade IV injuries,
patients were not given prophylactic antibiotics and 5%
ultimately required nephrectomy for sepsis [19]. The
rationale behind their use is to reduce the incidence of UTI
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18 BJU International 2014 BJU International
Table 3 Recommendations on inpatient management.
1. Admission of all patients for at least 24 h observation, except those with grade I
injuries without visible haematuria (C)
2. Admission of patients to ICU should be based on factors such as haemodynamic
instability and other injuries, as opposed to routinely admitting patients based on
trauma grade (C)
3. Regular observations, blood tests and clinical examinations are required. The
frequency of these must be tailored to both the patient and injury; however, serial
examinations and haemoglobin concentrations up to every 6 h may be
appropriate in grade IV or V trauma for the rst 24 h (C)
4. Thromboprophylaxis must be decided on a case-by-case basis. Unless
contraindications exist, anti-embolism stockings are recommended throughout
admission and intermittent pneumatic compression devices are recommended
while the patient is immobile. Routine use of low-molecular-weight or
unfractionated heparin is not recommended currently (C)
5. Bed rest should continue until haematuria is light without the need for bladder
irrigation or manual bladder washouts (C)
6. General discharge criteria such as being afebrile, tolerating a normal diet,
adequate pain management, and stable blood tests apply (C)
Table 4 Recommendations on antibiotics.
1. In the absence of fever and risk factors (e.g. devitalised segments, signicant soft
tissue loss, bowel or pancreatic injury, immunosuppression):
Injuries of grade IIII do not require antibiotics (C)
Injuries of grade IV and V should receive i.v. antibiotics for 4872 h, followed
by a 5-day course of oral antibiotics (C)
2. In the presence of fever or risk factors, injuries of any grade should receive i.v.
antibiotics for at least 4872 h, followed by a 5-day course of oral antibiotics (C)
3. Unless contraindicated, our preference is for the i.v. or oral antibiotic to be
a rst-generation cephalosporin. These agents generally have good
anti-staphylococcal cover, reasonable gram-negative cover, an excellent safety
prole, and a low risk of selecting multi-resistant organisms if used for a short
duration. Alternative options include ciprooxacin or combined treatment with
ampicillin and gentamycin (C)
4. Any concomitant bowel injury requires additional anaerobic cover in the form of
metronidazole. An alternative option is clindamycin (C)
and perinephric abscess, which have reported incidences of
511% [25,38] and 05% [2] respectively, and an associated
increased mortality risk. Devitalised segments, signicant
soft tissue loss, and concomitant bowel or pancreatic injury
appear to increase these risks [39]. Patient factors including
age, co-morbidities and immunosuppression must also be
considered (Table 4).
Return to Activity
Neither the EAU, AUA, or renal trauma subcommittee provide
recommendations about timing of return to normal activities
or sport after conservatively treated renal trauma [4,5,9].
Concerns related to return to activity are mainly related to a
considered increased risk of secondary haemorrhage while the
injured kidney is still healing, although this has never been
proven. Secondary haemorrhage occurs in up to 25% of
conservatively managed injuries of grade III [2,5], and
it is usually caused by a ruptured pseudoaneurysm or an
arteriovenous stula [5,11,40]. It usually occurs within the rst
6 weeks, with patients seemingly most susceptible in the rst 2
weeks [2,5,10,40]; it does not therefore seem unreasonable to

Table 5 Recommendations on return to activity.
1. Long-haul travel and return to remote areas is not recommended for 2 weeks
after renal trauma (C)
2. Patients should be allowed to return to normal everyday activities, such as school
and work, as tolerated after discharge (C)
3. Patients should be advised against sports for at least 6 weeks after grade I injuries,
and at least 3 months after injuries of grade II. Radiological resolution should
also be conrmed before permitting return to sports, in all but grade I injuries (C)
4. Patients should be counselled about the risks of dierent sporting activities after
renal trauma, particularly if they have a residual poorly- or non-functioning
kidney. However, advising against ongoing participation in sports for patients
with residual poorly- or non-functioning kidneys does not appear warranted (C)
recommend patients avoid long-haul travel and return to
remote areas during this 2-week period.
Prescribed periods of activity restriction are very common after
any solid abdominal organ trauma; about three-quarters of
paediatric surgeons recommend 23 weeks o of school and
23 months o of sports after an injury [41]. Some advocate
using radiological resolution of the injury as a guide to allowing
return to sporting activities [4143]. While guidance after renal
trauma is limited, the American Paediatric Surgical Association
has made clear recommendations for hepatosplenic trauma
[44]; the suggested period of activity restriction in weeks equals
the grade of the injury plus two [44]. Furthermore, studies have
reported no re-admissions when allowing patients with
hepatosplenic trauma to return to non-contact activities on
discharge, and contact sports at 46 weeks [33,43].
The incidence of sport-related traumatic kidney injury is
6.9/million people [45]. However, the incidence of
catastrophic injury, resulting in nephrectomy, is very low at
0.4/million people [45]. Studies agree that the likelihood of
sustaining a traumatic brain injury is signicantly higher;
relative risks of ve and 67 have been reported [46,47].
Additionally, the risk of sustaining a traumatic kidney injury
during a road trac accident is up to three-times higher than
the risk of sustaining one during sport [47]. While most
consider contact sports to be most risky, the evidence suggests
cycling, equestrian, and snow sports are more commonly
responsible [47,48]. There have been no documented cases of
kidney loss due to sport-related trauma in patients with a
solitary functioning kidney [47,48]. Although most clinicians
may advise patients with a solitary functioning kidney against
participation in certain sports [48], numerous studies conclude
that restricting exposure to sports is not justied in this group
[4648] (Table 5).
Follow-up Imaging
The purposes of follow-up imaging are to exclude
development of new pathologies, and to show adequate
healing of known injuries. Pathologies of particular
importance include pseudo-aneurysms, arteriovenous stulae,
and hydronephrosis. Pseudo-aneurysms and arteriovenous
Conservative management of renal trauma
stulae are the commonest causes of secondary haemorrhage
[2,5,40], and occur almost exclusively in injuries of grade III
[2,40]. Patients usually present with haematuria [2,40], often
within 2 weeks of the injury [2,10,40]; however, reports of
detection up to 20 years after renal trauma suggests they can
progress asymptomatically [2,10,40,49]. Although commonly
diagnosed on CT, Doppler US has successfully detected both
[2,29,40]. Hydronephrosis can progress asymptomatically after
renal trauma, and have a deleterious eect on kidney function
[2]; US is equivalent to CT for its detection.
For healing of known injuries, healing time has been shown to
be proportional to the size of associated haematoma [50].
While 6080% of injuries have completely healed by 1 month,
up to 3 months may be required for higher grade injuries
[42,51]. Ensuring adequate healing of a renal injury may
enable clinicians to better counsel patients on issues such as
return to sporting activities, although radiological healing may
not equate to physiological healing.
Follow-up imaging in the absence of concerning clinical
manifestations has been shown to result in the need for
intervention in <1% of patients [51]. It is for this reason that
some authors have recommended restricting its use to
collecting system injuries [6] or grade V injuries [51]; others
have proposed abandoning follow-up imaging altogether [28].
Although US with Doppler is recommended for follow-up
imaging in children [23], the ideal method in adults is less
clear. The low incidence of signicant abnormalities
developing asymptomatically after the rst 48 h [51],
combined with the radiation risks of CT [30], make it dicult
to justify using CT for follow-up imaging routinely.
In addition, radionuclide scintigraphy is useful for monitoring
functional recovery of a traumatised kidney, and DMSA scans
seem to be the preferred option [4,5,11,52,53]. Results of
radionuclide scans correlate well with the grade of injury, with
low-grade injuries rarely resulting in signicant dysfunction
[52,53]. In addition to grade IV and V injuries [5,52,53], new
hypertension appears to be a useful indication for obtaining
this investigation [29]. The timing of radionuclide scans
appears unimportant: serial split functions remain almost
identical at 8 days and 6 months [53], or 3 months and 1 year
[52]. Results do not necessarily aect management; however,
may be useful when counselling patients and in guiding need
for nephrological follow-up [52].
Clinical Follow-up
Clinical follow-up after renal trauma allows symptoms,
examination ndings, blood pressure, serological renal
function, and resolution of non-visible haematuria to be
monitored [4]; it also prompts the clinician to review any
follow-up imaging that has been obtained.
The pathophysiology of post-traumatic hypertension is
thought to relate to the increased production of renin in
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BJU International 2014 BJU International 19
McCombie et al.
Table 6 Recommendations on follow-up.
1. Except patients with grade I injuries, all patients should be oered outpatient
follow-up at 46 weeks; earlier appointments may be appropriate in some
instances (C)
2. Except patients with grade I injuries, US with Doppler is recommended for all
patients before outpatient follow-up at 46 weeks. If adequate healing is not
demonstrated, further US every 46 weeks should be considered until adequate
healing is achieved (C)
3. If examination ndings, radiology, blood pressure, and serum renal function are
all normal at rst outpatient appointment, further urological follow-up is not
mandated but the patient should be followed up by their GP (C)
4. A DMSA scan at 612 weeks should be considered for all patients sustaining
grade IV or V renal trauma (B), or those who develop hypertension (C)
5. GP follow-up after renal trauma should involve:
Twice yearly blood pressure checks for 2 years, followed by lifelong annual
blood pressure checks (C)
Conrmation of resolution of non-visible haematuria at 6 months (C)
6. Non-visible haematuria that persists beyond 6 months should be investigated in
the usual way (C)
response to renal ischaemia [5]. This ischaemia may be caused
by post-traumatic arterial occlusion or stenosis (Goldblatt
kidney), pressure on the kidney from haematoma or scar
tissue (Page kidney), or an arteriovenous stula [2]. The
incidence, risk factors, and natural history of post-traumatic
hypertension remain unclear [6]. The high incidence of
hypertension generally, along with long latent periods between
the injury and the occurrence of hypertension, which average
34 months [54], make determining these factors very dicult.
Although an average incidence of 5.2% has been reported,
results from individual studies vary widely (0.633%) [55];
several studies have failed to observe hypertension after renal
trauma at all [2]. Patients thought to be at particular risk are
those sustaining high-grade injuries, particularly vascular
injuries or those with renal artery occlusion [2,5].
Although the incidence of serological renal dysfunction
after conservatively managed renal trauma is extremely low
[42,52], monitoring for it is recommended by the EAU [4].
Radionuclide scintigraphy is a much more sensitive and
informative test for renal dysfunction; however, it does not
appear necessary for most patients [52,53].
While the EAU recommends monitoring for resolution of
non-visible haematuria in all patients [4], the renal trauma
subcommittee only specify checking this in those not imaged
for their renal trauma [5]. Presumably the purpose of
monitoring non-visible haematuria is two-fold: as a crude
marker of injury healing, and to alert the clinician to the
possibility of an underlying urological malignancy if it
persists. However, it remains unclear when and how persistent
non-visible haematuria should be investigated after a
traumatic renal injury (Table 6).
Conclusion
There is a paucity of high-level evidence and specic guidance
about precisely what conservative management of renal trauma
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20 BJU International 2014 BJU International
should involve. The available literature has been reviewed and
consensus recommendations made by a multi-disciplinary team
consisting of experienced urologists, radiologists, and infectious
disease physicians. These recommendations have undergone
formal review and debate at the Western Australian USANZ
2013 state conference, and have been presented at the USANZ
2014 annual scientic meeting. They therefore reect both
best-available evidence, and a consensus of expert opinion. It is
hoped that these recommendations may help standardise the
conservative management of renal trauma, and provide
stimulus for debate and further research.
Conflict of Interest
None declared.
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Correspondence: Dickon Hayne, PO Box 480, Fremantle, WA
6959, Australia.
e-mail: dickon.hayne@uwa.edu.au
Abbreviations: ESPR, European Society of Paediatric
Radiology; ICU, intensive care unit; US, ultrasonography/
ultrasound; VTE, venous thromboembolism.
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BJU International 2014 BJU International 21