As stated above, adult patients with a history of blunt trauma, microscopic or dipstick haematuria, no shock, and no history of acceleration/deceleration do not require renal imaging and can be discharged from the emergency department. Those with macroscopic haematuria should undergo a staging CT and be admitted for bed rest and observation, until the macroscopic haematuria resolves. Most such patients will have injuries of stage (grade) I to III.
High-grade (IV and V) injuries can be managed nonopera-tively, as long as the patient is cardiovascularly stable. Urinary extravasation is not in itself necessarily an indication for exploration. Almost 90% of these injuries can heal spontaneously (Matthews et al. 1997).
Traditionally, a large volume of nonviable renal tissue is a relative indication for renal exploration and repair, as is urinary extravasation, and the finding of an expanding retroperitoneal haematoma at operation (Husmann and Morris 1990). However, a recent report from Los Angeles suggests that outcome is favourable even in patients with a devitalised segments of kidney and with urinary extravasation (Toutouzas et al. 2002). Small degrees of urinary extravasation from a minor laceration into the
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collecting system of the kidney will usually resolve spontaneously. If the degree of extravasation is greater, consider placing a JJ stent. Repeat the renal imaging if the patient develops a prolonged ileus or a fever, since these signs may indicate the development of a urinoma, which can be drained percutaneously.
The Approach to Renal Exploration
The principal reason for renal exploration will be persistent bleeding causing shock. For this reason, most surgeons will elect to approach the renal pedicle first, to allow control of the renal artery and vein. This is most easily achieved by a midline incision. Such an incision has the advantage that it can be done quickly and it can also be extended up and down to allow access to the entire abdominal and pelvic cavities, for repair of injuries to other organs.