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Difficulty: Very hardUrologic Surgery

A 2424-year-old man is brought to the emergency department after colliding with a tree while downhill skiing. He reports severe, continuous pain in his right flank and right upper quadrant. His temperature is 37.1∘37.1^\circ C (98.8∘98.8^\circ F), blood pressure is 118/76118/76 mmHg, pulse is 9292/min, and respirations are 1616/min. Physical examination reveals a 1515-cm area of ecchymosis over the right flank with marked tenderness to palpation. The abdomen is soft without rebound tenderness or guarding. Urinalysis demonstrates gross hematuria. A focused assessment with sonography for trauma (FAST) is negative for intraperitoneal free fluid. Computed tomography of the abdomen and pelvis with intravenous contrast reveals a 3.53.5-cm laceration of the right kidney that extends deep into the renal medulla and collecting system. Delayed-phase imaging demonstrates pooling of contrast medium in the perirenal space. There is a moderate, non-expanding perirenal hematoma, but no evidence of active arterial extravasation (blush). Which of the following is the most appropriate next step in management?

  1. Hospital admission for bed rest and serial hemodynamic monitoringAnswer
  2. B
    Immediate exploratory laparotomy with primary renorrhaphy
  3. C
    Cystourethroscopy with retrograde ureteral stent placement
  4. D
    Renal angiography with selective arterial embolization
  5. E
    Initiation of intravenous broad-spectrum antibiotics and percutaneous urinoma drainage

Answer

The most appropriate next step is hospital admission for bed rest and serial hemodynamic monitoring.
The correct management is hospital admission for bed rest and serial hemodynamic monitoring. This patient has sustained a blunt Grade IV renal injury, characterized by a parenchymal laceration extending into the collecting system with resulting urinary extravasation. A high-yield and frequently tested principle in urologic trauma is that hemodynamic stability—not the grade of the injury—drives the decision for surgery. In the absence of hemodynamic instability, expanding/pulsatile hematoma, or active arterial extravasation, even high-grade renal injuries (Grades III-V) with urinary leaks are managed conservatively. The contained retroperitoneal space allows most urinary extravasations to heal spontaneously without surgical or endoscopic intervention.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and overall trauma survey.
The patient is hemodynamically stable (BP 118/76118/76, HR 9292) with a negative FAST exam, ruling out immediate life-threatening intraperitoneal hemorrhage.
Hemodynamic stability dictates whether a trauma patient proceeds to immediate surgical exploration or advanced imaging.
2
Interpret the CT scan findings to grade the renal injury.
The CT shows a 3.53.5-cm laceration extending into the collecting system with urinary extravasation but no active arterial bleeding, classifying this as an AAST Grade IV renal injury.
Accurate grading of the renal injury determines the specific management algorithm.
3
Select the appropriate intervention based on stability and injury grade.
Because the patient is stable and lacks active arterial hemorrhage, conservative management is indicated despite the presence of urinary extravasation.
Over 90%90\% of blunt renal injuries, including Grade IV injuries with urinary leaks, resolve spontaneously with conservative management (bed rest, observation, serial hematocrits).

Key Concept

Hemodynamically stable blunt renal trauma, including high-grade injuries with urinary extravasation, should initially be managed conservatively with bed rest and observation.
Estimated Time:1m 30s
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Urologic Surgery

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