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THE JOURNAL OF UROLOGY -vol. 136, September
Copyright © 1986 by The Williams & Wilkins Co. Printed in U.S.A.

Original Articles
COMPUTERIZED TOMOGRAPHIC STAGING OF RENAL TRAUMA: 85
CONSECUTIVE CASES
PETER N. BRETAN, JR., JACK W. McANINCH*, MICHAEL P. FEDERLE AND
R. BROOKE JEFFREY, JR.
From the Departments of Urology and Radiology, University of California School of Medicine and San Francisco General Hospital,
San Francisco, California

ABSTRACT
In 85 patients with renal trauma we compared the findings on computerized tomography with
those of excretory urography, renal surgery, intra-abdominal surgery and angiography. Patients
underwent computerized tomography because of a suspected associated thoracic or abdominal
injury, or indeterminate findings on excretory urography, nephrotomography or angiography. Blunt
trauma accounted for 87.1 per cent of the renal injuries and penetrating trauma for 12.9 per cent.
The most common findings on computerized tomography were perirenal hematoma in 29.4 per
cent, intrarenal hematoma in 24.7 per cent and parenchymal disruption in 17.6 per cent. In 33
patients who underwent laparotomy computerized tomographic staging was confirmed. In contrast,
the most common finding on excretory urography, diminished opacification (17 of 53 patients), was
found to have no correlation with the severity of renal injury as assessed by computerized
tomography or laparotomy. Angiography appreciably understaged 1 of 5 cases by failing to show
extracapsular extravasation with parenchymal disruption. All findings on angiography were depicted
by computerized tomography.
We conclude that computerized tomographic staging for renal trauma is more sensitive and
specific than excretory urography, nephrotomography and angiography, and that it should be used
primarily when multiple traumatic injuries are suspected, when excretory urography suggests major
trauma or is nonspecific and when clinical evidence of major trauma exists, regardless of what
excretory urography shows.

Of all cases of abdominal trauma 8 to 10 per cent result in
significant renal injury. Of the cases of penetrating renal
trauma 80 per cent are associated with other abdominal injuries,
as are 20 per cent of cases of blunt trauma. 1- 3 Because of these
risks, immediate assessment or staging is required to determine
appropriate therapy. (Staging is defined as the determination
of the full extent of injury through sufficient diagnostic stud-
ies.2) Inadequate staging of major renal trauma can lead to
needless morbidity and mortality from incorrect or delayed
surgical intervention. 4 • 5
At our institution the radiographic techniques currently used
for staging renal trauma are excretory urography (IVP), ne-
phrotomography, arteriography and computerized tomography
(CT). Renal trauma has been categorized previously by anatom-
ical groups according to severity (fig. 1), 6 and the sensitivity
and specificity of the aforementioned diagnostic techniques are
measured by their ability to match these stages when compared
with the gold standard of assessment by exploratory laparot-
omy. CT has a definite advantage over IVP and nephrotomog-
raphy in delineating parenchymal lacerations, extravasations,
nonviable tissue outline, the extent of hematoma and associated
Accepted for publication March 24, 1986.
Read at annual meeting of American Urological Association, Atlanta,
Georgia, May 12-16, 1985.
* Requests for reprints: Department of Urology, U-518, University
of California, San Francisco, California 94143.
561
abdominal injuries, 1' 7- 9 and it has emerged recently as the most
accurate diagnostic method. 1- 3 • 7- 9 CT is rapid and noninvasive,
and can stage renal trauma more sensitively and specifically
than IVP, nephrotomography or arteriography. It can differ-
entiate major from minor renal lacerations, assess concomitant
retroperitoneal and abdominal injuries, and enable physiologi-
cal functional assessment of the renal parenchyma.
To delineate the indications for CT staging of renal trauma
and to assess its reputed advantages, we conducted a retrospec-
tive review, comparing CT findings in 85 consecutive patients
with those of IVP, nephrotomography, arteriography and ex-
ploratory laparotomy.
PATIENTS AND METHODS
Between 1977 and 1984, 466 consecutive patients between 3
and 84 years old were evaluated for suspected renal injuries at
the San Francisco General Hospital. Evaluation was based on
microhematuria (greater than 5 red blood cells per high power
field) or gross hematuria with normal lower genitourinary tract
assessment (patients with isolated pelvic fractures and/or blad-
der ruptures thus were excluded10 ), a rapid deceleration injury,
flank tenderness or ecchymosis, or an entrance wound in the
vicinity of the kidneys in patients with less than 5 red blood
cells per high power field on urinalysis, or retroperitoneal
hematoma discovered during CT staging and/or laparotomy for
associated abdominal injuries.
562 BRETAN AND ASSOCIATES

RESULTS
Of the 85 patients with renal trauma staged with CT blunt
trauma accounted for 87.1 per cent and penetrating trauma for
12.9 per cent. Since all patients were hemodynamically stable
at the time of CT staging, there was no compromise in patient
care. Scan periods of less than 1 hour ensured the institution
of rapid surgical intervention if needed, although this situation
did not arise in our experience. The most common associated
findings were hematuria (96 per cent), abdominal tenderness
(61.2 per cent), fractures (54.1 per cent) and flank tenderness
(41.2 per cent). The grade ofhematuria was assessed by dipstick
and microscopic urinalysis, and both methods showed a general
tendency toward high grade hematuria in most patients, al-
though a precise correlation was not evident, especially in the
lower grades. Also, there was no correlation between the sever-
C ity of injury found on CT staging and the grade of hematuria.
Surgical exploration was required in 33 patients (38.8 per
cent) for renal or associated nonrenal injuries, including 11 (13
per cent) who required specific renal repair (table 1). In 57
patients (67.1 per cent) the results of CT were abnormal (table
2). The most common findings were perirenal hematoma (29.4
per cent), intrarenal hematoma (24.7 per cent) and parenchy-
mal disruption (17.6 per cent).
An IVP was done in 53 patients (62.4 per cent), of whom 32
had abnormal or indeterminate findings. Diminished opacifi-
cation (17 patients) was the most common abnormality (table
3). However, the IVP findings bore no correlation with the
severity of renal injury as assessed by laparotomy or CT staging.
In fact, a direct comparison of the CT and IVP findings revealed
that the latter often were nonspecific (table 4).
Angiography was performed in 5 patients, which enabled
direct comparison with CT staging (table 4). Severe injuries
were noted in 3 patients (1 had massive parenchymal disruption
and 2 had traumatic renal artery occlusion). CT provided as
much information as angiography in 3 of the patients and more
staging data in the remaining 2. In 1 of these patients angiog-
raphy had understaged the injury as a subcapsular hematoma

TABLE 1. Surgical staging in 33 patients with renal trauma

No. Pts.
Injury/Repair
(% of total)
N onrenal injuries: 33 (38.8)
FIG. 1. Renal injuries classified by severity. A, minor laceration. B, Head, 11
renal contusion. C, major laceration (deep medullary laceration). D, Hemopneumothorax, 9
major laceration (fractured kidney). E, major laceration (laceration Small bowel, 6
into collecting system). F, vascular injury. Liver, 5
Spleen, 5
Diaphragm, 3
Pancreas, 3
Radiological assessment was initiated by an IVP in the Cardiovascular, 2
Colon, 1
patients whose clinical status permitted. Nephrotomography, Renal repair: 11 (13)
CT, arteriography and exploratory laparotomy were performed Primary closure, 4
after an IVP if the exact extent of the injury was not defined Partial nephrectomy, 4
and the situation required further diagnostic study. CT was Nephrectomy, 3
ordered as the initial test if an associated abdominal injury was
suspected in a stable patient. Hemodynamically unstable pa-
tients or patients in whom major renal and/or intra-abdominal TABLE 2. CT staging in 85 patients with renal trauma
injury was found on the initial CT staging or physical exami- Findings
No. Pts.
(% of total)
nation immediately underwent exploratory laparotomy.
A total of 85 of the 446 patients underwent CT scanning Normal 28 (32.9)
Abnormal 57 (67.1)
with the GE CT /T 8800 or 9800 for suspected renal injury. In Observations:
these patients type of injury, associated injuries, signs and Subcapsular extravasation 5 (6.0)
symptoms at presentation, degree of hematuria and hospital Extracapsular extravasation 6 (7.1)
course were recorded accurately. Hematuria was graded in most Parenchymal disruption 15 (17.6)
Intrarenal hematoma 11 (24.7)
patients by microscopic and dipstick analysis. Comparison of Perirenal hematoma 25 (29.4)
CT staging of renal trauma (85 patients) then was correlated Chronic abnormalities* 6 (7.1)
by computerized analysis with simultaneous findings on the Associated nonrenal injuries 14 (16.5)
IVP (53), renal surgery (11), nonrenal associated intra-abdom- Vascular injuries 5 (6.0)
inal surgery (22) and angiography (5). * Medullary sponge kidney, ureteropelvic junction obstruction and so forth.
 COMPUTERIZED TOMOGRAPHIC STAGING OF RENAL TRAUMA
but CT demonstrated extracapsular hematoma with major pa-
renchymal disruption (fig. 2), which was verified at surgical
exploration.
One patient sustained a 30-foot fall 4 hours before presenting
with abdominal pain, microhematuria and hypotension (sys-
tolic blood pressure 80 mm. Hg), and an IVP revealed nonfunc-
tion of the left kidney (fig. 3, A). CT showed an intact renal
pedicle with minimal contrast material enhancement of the
renal parenchyma (fig. 3, B) and a high grade renal artery
occlusion was verified on arteriography (fig. 3, C). In addition,
there was no evidence of parenchymal disruption or extrava-
sation on CT. These findings were consistent with a high grade
intimal disruption and obstruction of the renal artery. The
patient was stable and had evidence of good renal function in
the remaining kidney. Precise CT staging spared him unnec-
essary surgical exploration that had seemed indicated by the
IVP and arteriography. Surgical repair was not attempted
because of the patient's medical status, duration of renal ische-
mia and presence of severe calcified plaques in the adjacent
aorta.
Of our 2 patients with renal artery thrombosis (table 4)
verified by arteriography 1 had evidence of a small perirenal
hematoma, while the other had no evidence of hematoma or
extravasation. The appearance of renal artery occlusion is
unique on CT, which may show a total lack of renal enhance-
ment and excretion while preserving normal renal size and
contour. 11 However, in many cases collateral perfusion from
the renal capsular vessels will show a thin rim of renal cortical
enhancement.
563
Findings on CT were verified in all 33 patients (38.8 per
cent) undergoing surgical exploration. In 22 cases only minor
renal trauma was verified at abdominal exploration to repair
major intraperitoneal injury, and no formal renal exploration
was done. Delineation of these nonrenal injuries (for example
ruptured spleen in 5, liver lacerations in 5 and bowel perfora-
tions in 7) often was predicted by preoperative CT. Especially
helpful was the differentiation of splenic from renal injuries in
left-sided trauma and hepatic from renal injuries in right-sided
trauma. With penetrating injuries, concomitant involvement of
adjacent organs also could be defined. Eleven patients were
found to have moderate to severe renal injuries that had all
been predicted accurately by CT staging, and these patients
underwent specific surgical procedures (table 4).
There were no false-negative or false-positive findings on CT
staging in these 33 patients. However, 22 patients had verifi-
cation of renal injuries during exploration of nonrenal abdom -
inal injuries and only 11 had formal surgical staging via primary
renal exploration. When these limitations are considered CT

TABLE 3. Staging by !VP and nephrotomography in 85 patients with

renal trauma
Findings No. Pts.
Nephrotomography:
Total 34
Abnormal 16
Questionable 6
IVP:
Total 53
Normal 18
Abnormal 32
Observations:
Subcapsular extravasation 1
Extracapsular extravasation 2
Nonfunction 2
Diminished opacification 17
Irregular cortical margins 6
Filling defect 3
Displaced kidney 5
FIG. 2. CT scan shows major renal parenchymal laceration (arrows).
Delayed opacification 2
K, kidney. H, hematoma.

TABLE 4. Findings on CT versus !VP, angiography and renal surgery in patients staged for renal trauma
CT Findings
Total
No. Pts. Intrarenal Subcapsular Perirenal Parenchymal Extracapsular
Hematoma Extravasation Hematoma Disruption Extravasation
!VP
Subcapsular extravasation 1 0 1 1 0 1
Extracapsular extravasation 2 0 1 2 0 2
Filling defect 3 2 1 2 1 1
Displaced kidney 5 1 1 5 2 0
Irregular cortical margins 6 1 1 3 1 0
Delayed opacification 2 2 1 1 0 1
Diminished opacification 17 10 2 7 8 2
Nonfunction or nonvisualization 2 1 1 1 1 1
Angiography
Subcapsular extravasation 1 1 1 1 1 1
Extracapsular extravasation 1 1 1 1 1 1
Parenchymal disruption 1 1 1 1 1 1
Vascular obstruction 2 0 0 1 0 0
Surgical therapy
Primary closure 4 1 1 4 2 2
Partial nephrectomy 4 1 3 4 4 2
Nephrectomy 3 0 0 3 1 0
564 BRETAN AND ASSOCIATES
FIG. 3. A, IVP shows absence of opacification of left renal collecting system. B, CT scan reveals minimal contrast material uptake in left
renal parenchyma. Renal pedicle was not avulsed and there is no evidence of parenchymal disruption, extravasation or retroperitoneal hematoma.
These are typical CT findings of high grade intimal disruption and obstruction of renal artery. C, renal digital subtraction intra-arterial
arteriography demonstrates abrupt renal artery cut-off verifying renal artery occlusion (arrowhead).
had a 100 per cent specificity and 100 per cent sensitivity for
the staging of renal trauma in our selected study group. It
follows that by direct comparison with IVP and renal arteri-
ography, CT is a much more accurate staging technique.
The final diagnosis when the patients were discharged from
the hospital revealed that the majority of renal injuries were
contusions (70.6 per cent) or minor lacerations (12.9 per cent)
that required bed rest and observation. The mean hospital stay
for patients with urological injuries only was approximately 2
days, and for those with renal and associated nonrenal injuries
it was approximately 4 days. There were no urological compli-
cations, postoperative hypertension or misdiagnoses. There was
1 perioperative death unrelated to renal injury and 1 delayed
bleeding episode that responded to bed rest and hydration.
Followup ranged from 2 to 6 months.
DISCUSSION
Hematuria traditionally has been the primary indication for
immediate radiological staging but this has come under much
scrutiny. 10-14 Computerized analysis of 359 renal trauma pa-
tients at San Francisco General Hospital revealed that the
greatest risk factors for significant renal injuries were pene-
trating abdominal trauma in the area of the kidneys in patients
with any degree of hematuria and blunt trauma with gross
hematuria or with shock (systolic blood pressure less than 90
mm. Hg) associated with microscopic hematuria (greater than
5 red blood cells per high power field) .10 If radiological staging
had been performed only in these high risk patients, unneces-
sary use of x-ray could have been avoided without missing
significant renal injuries. Although further experience is nec-
essary, preliminary evidence tends to support these conten-
tions.10
IVP with tomography will stage adequately 60 to 85 per cent
of the renal injuries but abnormal findings often are nonspe-
cific, contributing to the inadequate staging in the remaining
15 to 40 per cent in whom an IVP is the initial study. 1• 3 Most
of these patients require additional radiological assessment.
Our study demonstrates that CT is a more sensitive and
specific staging technique than IVP or nephrotomography and
in many cases arteriography. It differentiates minor from major
lacerations, and assesses associated chest and abdominal inju-
ries precisely. Because isolated traumatic renal vascular injuries
are uncommon (1 to 3 per cent), CT is more practical than
arteriography as the primary staging technique. Precise advan-
tages over arteriography are its rapidity, noninvasiveness, de-
tection of associated injuries and assessment of physiological
functional renal status (enhancement of viable renal paren-
chyma as well as the renal artery).
Our experience with angiography differs from that of others
in that we have shown it to be less accurate than CT (table 4).
In 1 patient surgical intervention would have been delayed if
not for the added staging information provided by CT. Although
angiography (during the venous phase) may localize lacerations
of the renal vein and inferior vena cava more precisely, it is
unlikely that the surgical management of these usually unstable
patients would be altered by the use of CT. The decision for
immediate open surgical exploration should be based on the
patient's clinical status. Our indications for angiography in
stabilized patients include suspected venous lacerations (renal
vein or inferior vena cava) and renal arterial injuries after
indeterminate findings on CT (usually a large perirenal hema-
toma without parenchymal disruption), and clinical evidence
of continued intra-abdominal hemorrhage. With this rationale,
the use of angiography is likely to be decreased.
Based on our experience, CT should be used to evaluate renal
injuries as a primary staging modality when multiple traumatic
injuries are suspected (in this setting a formal IVP is a waste
of valuable time but a "1-shot" IVP can be obtained by a simple
film of the kidneys, ureters and bladder immediately after the
CT scan, making use of the same contrast material), when an
IVP suggests major trauma or is nonspecific and when the
patient has clinical evidence (for example hemodynamic insta-
bility) of major trauma, regardless of what the IVP shows.
When staging renal trauma by CT cuts should be 5 to 10 mm.
in areas of question to assure an accurate representation of the
anatomy of the injured kidney.
The aforementioned indications have allowed for precise
staging of renal trauma, thus, enabling a more accurate assess-
ment of the need for surgery. The lack of significant compli-
cations and the absence of renal trauma-related deaths in our
series support all of the aforementioned advantages of staging
by CT. Of our 85 patients scanned 57 had significant renal
abnormalities on CT with the extent of injury defined clearly;
thus, the information provided was sufficient for confident
selection of appropriate management. Only 11 patients required
primary renal exploration. If CT is used in selected cases (at
our institution it is available immediately 24 hours a day), a
high yield of staging information can be expected and appro-
priate management can be selected. Delay in diagnosis, and
subsequent morbidity and mortality can be avoided.
REFERENCES
1. McAninch, J. W. and Federle, M. P.: Evaluation of renal injuries
with computerized tomography. J. Urol., 128: 456, 1982.
2. McAninch, J. W.: The injured kidney. Monogr. Urol., 4: 42, 1983.
3. Cass, A. S.: Immediate radiologic and surgical management of renal
injuries. J. Trauma, 22: 361, 1982.
4. Bierman, S. F.: Assessing blunt abdominal trauma. Hosp. Med.,
19: 13, August 1983.
 COMPUTERIZED TOMOGRP.PHIC STAGING OF RENAL TRAUMA
5. Cass, A. S., Susset, J., Khan, A. and Godec, C. J.: Renal pedicie
injury in the multiple injured patient. J. Urol., 122: 728, 1979.
6. McAninch, J. W.: Injuries to the urinary system. In: Trauma
Management: Abdominal Trauma. Edited by F. W. Blaisdell and
D. D. Trunkey. New York: Thieme-Stratton, Inc., vol. I, chapt.
11, pp. 199-227, 1982.
7. Federle, M. P., Kaiser, J. A., McAninch, J. W., Jeffrey, RB. and
Mall, J. C.: The role of computed tomography in renal trauma.
Radiology, 141: 455, 1981.
8. Lang, E. K., Sullivan, J. and Frentz, G.: Renal trauma: radiological
studies. Comparison of urography, computed tomography, an-
giography, and radionuclide studies. Radiology, 154: 1, 1985.
9. Kaufman, RA., Towbin, R, Babcock, D.S., Gelfand, M. J., Guice,
K. S., Oldham, K. T. and Noseworthy, J.: Upper abdominal
trauma in children: Imaging evaluation. Amer. J. Roentgen.,
142: 449, 1984.
10. Nicolaisen, G. S., McAninch, J. W., Marshall, G. A., Bluth, RF.,
Jr. and Carroll, P. R: Renal trauma: re-evaluation of the indi-
cations for radiographic assessment. J. UroL, 133: 183, 1985.
11. Steinberg, D. L., Jeffrey, R B., Federle, M. P. and McAninch, J.
W.: The computerized tomography appearance of renal pedicle
injury. J. Urol., 132: 1163, 1984.
12. McDonald, E. J., Korobkin, M., Jacobs, RP. and Minagi, H.: The
role of emergency excretory urography in evaluation of blunt,
abdominal trauma. Amer. J. Roentgen., 126: 739, 1976.
13. Guice, K., Oldham, K, Eide, B. and Johansen, K.: Hematuria after
blunt trauma: when is pyelography useful? J. Trauma, 23: 305,
1983.
14. Bright, T. C., White, Kand Peters, P. C.: Significance of hematuria
after trauma. J. UroL, 120: 455, 1978.
EDITORIAL COMMENT
The authors should be congratulated on an extremely lucid presen-
tation of the usefulness of CT in the management of patients with
blunt renal injury. We also use CT extensively for the staging of renal
trauma and have found it to be quite helpful.
A real objective of CT, arteriography, IVP, clinical assessment and
observation is to decide which patients with renal injuries should be
subjected to surgical management, in addition to determining the
presence or absence of renal injury. One must define the nature of the
injury so that one may decide whether a surgical approach would
shorten the convalescence or decrease the risk of hemorrhagic shock.
Rarely with blunt trauma is extravasation of urine a problem, since
these injuries are almost always intrarenal and heal spontaneously.
Avulsion of the ureterope!vic junction or intrarenal collecting system
is extremely rare.
CT offers an advantage over arteriography in defining the extent of
perirenal hematoma and it is a benign test. CT also allows for screening
of the remainder of the solid organs in the abdomen for serious injury,
as does arteriography. CT fails in its definition of the vasculature of
the kidney and it is not as useful, in our judgment, as a planning guide
for surgical repair.
Arteriography offers significant advantages over CT because one can
565
determine precisely if and how a particular injured segment is devas-
cularized. This finding helps not only in surgical planning but also in
managing patients nonoperatively. There is no question that with
injuries in which the capsule is relatively intact, and the fragments are
in close apposition and are vascularized, the patient usually will do
well. The only risk is late development of hypertension or pseudoaneu-
rysm and arteriovenous fistula. However, even if patients with major
injuries are managed by observation, one must make decisions as to
how long to observe the patient under close confinement, how long he
should remain in the hospital, when he should return to work and
whether he can participate in sports. All of these decisions are difficult
to make without a true understanding of the nature of the injury.
Our indications for surgical intervention in cases of blunt trauma
are disruption of a polar fragment, injury to major segmental vascula-
ture of the kidney and signs of instability in patients being observed
with a major renal injury, such as multiple parenchymal fractures. Our
first line of study usually is CT but we perform arteriography primarily
if vascular injury is suspected and if major parenchymal injury is noted
on CT when consideration of surgical intervention is present. We have
not had the experience of the authors in finding that the CT scan is
more accurate than arteriography in defining injury and cannot remem-
ber a case when arteriography did not provide better definition.
Both studies appear to be useful. There is no question that CT has
replaced tomography and that it may define the injury in many cases
satisfactorily, preventing needless interventional radiological studies,
but there still is a place for the arteriogram. However, arguments as to
which is better probably are of little benefit to the practicing clinician,
who should be ready to use either or both in an individual patient.
W. Graham Guerriero
Department of Urology
Baylor College of Medicine
Houston, Texas
REPLY BY AUTHORS
The diagnostic goal in renal injury is to stage the injury completely
so that appropriate management can be selected. CT achieves this goal
as well as or better than arteriography without morbidity and time
delays. CT, a noninvasive study, can be done in 30 minutes at our
center and provides a complete survey of intraperitoneal and retroper-
itoneal injuries as well as the kidney injury. There is virtually no
published experience in which arteriography revealed important find-
ings in renal trauma missed by CT; conversely, we and others have
published cases in which CT offered more useful information.
CT can demonstrate renal vascular avulsions or arterial occlusions,
albeit indirectly, by failure of the renal parenchyma to enhance
normally on a contrast-enhanced scan. These signs appear to be specific
and have been verified in at least 6 cases in our own experience as well
as that of others in the literature.
We use arteriography rarely to stage renal injuries and currently
find it unnecessary except to support the diagnosis of an arterial injury
noted on CT. In these cases intra-arterial digital subtraction angiog-
raphy is preferred. We recognize the importance of arteriography and
recommend it when CT is not available.