A 32-year-old man sustains a blunt abdominal trauma from a motor vehicle collision. On examination, he has left-sided flank tenderness and haematuria. Imaging confirms a Grade III renal laceration with contained perinephric haematoma. Regarding the management of blunt renal trauma, all of the following statements are TRUE EXCEPT:

Question

Accepted Answer

C. Gross haematuria alone is an absolute indication for immediate surgical exploration and nephrectomy. ## Blunt Renal Trauma Management

**Key Point:** The vast majority of blunt renal injuries are managed conservatively, regardless of grade or haematuria status. Surgical intervention is reserved for haemodynamic instability, expanding haematoma, or loss of renal function.

### Conservative Management Criteria

Blunt renal injuries from Grade I to IV are managed non-operatively in haemodynamically stable patients:
- Bed rest and analgesia
- Serial clinical assessment
- Imaging surveillance (ultrasound or CT) for delayed complications
- Prophylactic antibiotics if there is concern for infected urine extravasation

**High-Yield:** Gross haematuria is NOT an indication for surgery. The presence of haematuria (gross or microscopic) indicates urinary tract involvement but does not mandate operative intervention in stable patients. Indications for surgery include:
  1. Haemodynamic instability despite resuscitation
  2. Expanding or pulsatile perinephric haematoma
  3. Renal artery thrombosis with loss of renal perfusion
  4. Complete renal pedicle avulsion
  5. Collecting system disruption with uncontrolled urine extravasation

### Delayed Complications

| Complication | Timing | Management |
|---|---|---|
| Pseudoaneurysm | Days to weeks | Angiographic embolization |
| Arteriovenous fistula | Weeks to months | Angiographic intervention |
| Infected urine collection | Variable | Percutaneous drainage + antibiotics |
| Hypertension (post-traumatic) | Months to years | Medical management |

**Clinical Pearl:** Serial imaging (ultrasound or contrast-enhanced CT) is standard to detect pseudoaneurysm, which can present with recurrent haematuria or haemodynamic deterioration days after the initial injury.

**Warning:** Do not confuse blunt renal trauma with penetrating renal injury. Penetrating injuries have a much higher rate of operative intervention (~50%) because of associated vascular and collecting system damage.

[cite:ATLS 10e Ch 8]
[cite:Sabiston Textbook of Surgery 21e Ch 50]

Answer

A. Serial ultrasound or CT imaging is recommended to monitor for delayed complications such as pseudoaneurysm formation

Answer

B. Most blunt renal injuries (>90%) can be managed conservatively with bed rest, analgesia, and serial imaging

Answer

D. Ureteric injuries are rare in blunt trauma and are more commonly associated with penetrating injuries

Explanation

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