Conservative... and non conservative... treatment of renal blunt injuries

Whether patients with blunt renal trauma should be managed conservatively without surgery or undergo surgery is often hard to decide. We describe three clinical cases of blunt renal trauma, all involving the left kidney. All three patients had abdominal ultrasound studies and computerized tomographic (CT) scans. In the first case, an accidental fall led to severe injury of the renal hilus causing massive retroperitoneal extravasation. The patient underwent emergency nephrectomy and survived. The second case concerned a patient who was involved in a road accident, suffered injuries mainly affecting the spleen, and underwent splenectomy. A postoperative CT scan showed left renal vein thrombosis functionally excluding the inferior pole of the kidney. The patient received conservative non surgical treatment. A follow-up imaging study showed that although the thrombosis had resolved the renal pole had failed to regain normal function. In the third case, mild apparently unimportant trauma led to a massive hemorrhage responsible for a severe shock state. Despite prompt nephrectomy, renal failure and and pulmonary complications developed and one month after the injuries the patient died. The medical history referred to a "chronic hematoma" secondary to a childhood injury. In this case, the pre-existing hematoma probably led to a permanent communication with the vascular and excretory tree thus resulting in a kind of "silent" fistula that the relatively mild injury unexpectedly disrupted. For the two left nephrectomies we used a midline approach after isolating the renal Treitz vessels; special care was taken to mobilize the left colon. Although blunt renal trauma often responds to non surgical conservative treatment, some patients should undergo prompt surgery. All patients must be scheduled for long-term clinical and imaging follow-up.