What every urologist should know about managing renal trauma

Some urologists routinely manage patients with renal trauma, but many may only sporadically see patients with traumatic kidney injuries. Most renal trauma is the result of motor vehicle accidents or other blunt or penetrating injuries, and patients are usually seen in an emergency room setting and admitted to a trauma hospital.

However, even falls from standing or sports injuries can lead to renal trauma, and these patients might present to urgent care or to an outpatient practice.

“We’ve had patients transferred to us who presented to a private practice clinic with hematuria after they had a fall a day or two earlier,” said Judith C. Hagedorn, MD, MHS, FACS, assistant professor of urology at the University of Washington in Seattle.

Dr. Hagedorn added that urologists may be consulted for renal trauma while on call or be asked to manage complications from renal trauma during a patient’s hospital admission.

“The reality,” she said, “is that every urologist should know about managing renal trauma no matter what your specialty is or where you practice.”

Dr. Hagedorn will moderate the panel discussion “Renal Trauma Management” on Monday from 7:45-8:05 a.m. to review current recommendations on managing traumatic kidney injuries. The case-based discussion will focus on factors that may merit a more conservative management approach and those that suggest the need for more invasive procedures.

Renal angioembolization (RAE) was developed in the 1970s and is used in a variety of applications from renal trauma to iatrogenic injuries, angiomyolipoma and cancer care. RAE has become the standard recommended by the AUA urotrauma guidelines for renal trauma with ongoing bleeding, Dr. Hagedorn said.

“Angioembolization is an interventional radiology procedure to control bleeding rather than going to the operating room and repairing or removing the kidney, which still happens nationwide,” she explained. “We will highlight the use of the well-validated nomogram to predict bleeding risk and the need for interventions after high-grade renal trauma. Minimally invasive options have become more commonly used in recent years. We will emphasize that noninvasive and minimally invasive management should be the go-to rather than heading straight to the operating room.”

However RAE is not always the treatment of choice, nor is it always successful. Some patients who are hemodynamically unstable may be rushed to the operating room with nephrectomy as the life-saving intervention of choice.

“Yes, it’s okay to take the patient to the operating room for open surgery in some circumstances,” Dr. Hagedorn said. “There are scenarios when that can—and even should—happen. We hope to incorporate operative management into the discussion as well.”

Follow-up imaging is another key area. Most guidelines recommend follow-up imaging for any high-grade renal injury, but some high-grade injuries may not warrant repeat imaging.

“There are some high-grade injuries, especially segmental infarcts, that don’t have any bleeding risk and may not need to be re-imaged,” Dr. Hagedorn said. “We will be talking about situations in which it could be okay to forego repeat imaging.”