Guideline sources The following summarized guidelines for the evaluation and management of kidney trauma are prepared by our editorial team based on guidelines from the Eastern Association for the Surgery of Trauma (EAST 2023; 2019), the European Association of Urology (EAU 2022), the Society of Interventional Radiology (SIR 2020), the World Society of Emergency Surgery (WSES/AAST 2019), and the American Urological Association (AUA 2014). 1 2 3 4 5 6 Guidelines 1. Diagnostic investigations Clinical assessment: Assess hemodynamic stability upon admission of patients with suspected kidney trauma. A Record past renal surgery, and known preexisting renal abnormalities (ureteropelvic junction obstruction, solitary kidney, kidney stone disease). A Urinalysis: test for hematuria in patients with suspected kidney trauma. A https://web.pathway.md/diseases/rec5tP6my1WrODZ18 1/7 6/29/23, 5:44 AM Kidney trauma Pathway Ultrasound: obtain extended FAST to detect intra-abdominal free fluid. A Recognize that extended FAST has low sensitivity and specificity in kidney trauma. B Show 2 more Computed tomography: As per EAU 2022 guidelines, obtain multiphase CT in patients with traumatic injury and: visible hematuria non-visible hematuria and one episode of hypotension history of rapid deceleration injury and/or significant associated injuries penetrating trauma clinical signs suggesting kidney trauma, such as flank pain, abrasions, fractured ribs, abdominal distension, and/or a mass and tenderness. A As per WSES 2019 guidelines: Obtain contrast-enhanced CT with delayed urographic phase as the gold standard in hemodynamically stable or stabilized adult patients after blunt or penetrating trauma with suspected kidney or urinary tract injury. A Obtain contrast-enhanced CT with delayed urographic phase in patients with: blunt trauma with macro- or microhematuria with hypotension B blunt high-energy deceleration trauma regardless of the presence of hematuria B penetrating trauma with stable or stabilized hemodynamic condition. B As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images in patients with suspected renal injury. B Show 2 more Intravenous urography: consider obtaining IV urography in unstable patients during surgery when a kidney injury is found intraoperatively or when CT is not available and a urinary tract injury is suspected. C 2. Medical management Non-operative management: As per EAU 2022 guidelines: Offer nonoperative management with close monitoring and repeat imaging as required in stable patients with blunt kidney trauma. A Offer nonoperative management in stable patients with isolated grade 1-4 stab or low-velocity gunshot wounds. A As per WSES 2019 guidelines, offer nonoperative management as the treatment of choice in all hemodynamical stable or stabilized minor (AAST I-II), moderate (AAST III), or severe (AAST IV- V) lesions. B Show 5 more https://web.pathway.md/diseases/rec5tP6my1WrODZ18 2/7 6/29/23, 5:44 AM Kidney trauma Pathway As per AUA 2014 guidelines, offer nonoperative management in hemodynamically stable patients with renal injury. B Show 2 more 3. Therapeutic procedures Angioembolization: As per EAST 2023 guidelines, insufficient evidence to recommend for or against angioembolization versus observation to decrease mortality, risk of surgical morbidity (delayed hemorrhage necessitating intervention and nephrectomy), and need for long-term RRT in hemodynamically stable adult patients with renal trauma and clinical or radiographic evidence of active bleeding. I As per EAU 2022 guidelines, perform selective angioembolization for active renal bleeding if there are no other indications for immediate surgical exploration. A As per SIR 2020 guidelines, consider performing angioembolization in patients with grade III/IV renal injuries when surgical exploration is not warranted as a result of other indications. B As per WSES 2019 guidelines, consider performing angiography with eventual super-selective (as selective as possible) angioembolization in hemodynamically stable or stabilized patients with arterial contrast extravasation, pseudoaneurysms, arteriovenous fistula, and non-self- limiting gross hematuria. B Show 5 more As per AUA 2014 guidelines, perform immediate intervention (surgery or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation. B Endovascular balloon occlusion of the renal artery: consider performing endovascular selective balloon occlusion of the renal artery as a bridge to definitive hemostasis, using direct visualization by fluoroscopy where the balloon is advanced over a selectively placed guidewire. C Resuscitative endovascular balloon occlusion of the aorta: consider performing REBOA as a bridge to other more definitive procedures for hemorrhage control in hemodynamically unstable patients. C 4. Surgical interventions Indications for surgery: As per EAST 2023 guidelines: Avoid performing renal exploration to decrease the incidence of mortality and nephrectomy in hemodynamically unstable adult patients with a stable zone II hematoma diagnosed intraoperatively. D Avoid performing total nephrectomy to decrease mortality, delayed hemorrhage necessitating intervention, angioembolization, and need for long-term RRT in hemodynamically unstable https://web.pathway.md/diseases/rec5tP6my1WrODZ18 3/7 6/29/23, 5:44 AM Kidney trauma Pathway adult patients with an expanding zone II hematoma necessitating exploration. D As per EAU 2022 guidelines: Perform renal exploration in the presence of: persistent hemodynamic instability grade 5 vascular or penetrating injury expanding or pulsatile peri-renal hematoma. A Attempt renal reconstruction if the hemorrhage is controlled and there is sufficient viable renal parenchyma. B As per WSES 2019 guidelines, perform surgery in hemodynamically unstable and non- responder patients (WSES IV). B Show 3 more As per AUA 2014 guidelines, perform immediate intervention (surgery or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation. B 5. Specific circumstances Pediatric patients: obtain contrast-enhanced CT with delayed urographic phase as the gold standard in severely injured pediatric patients with suspected kidney or urinary tract injury. A Show 5 more Patients with ureteral injury: As per EAU 2022 guidelines, suspect ureteral injury in all cases of abdominal penetrating trauma, and in deceleration-type blunt trauma. A Show 3 more As per WSES 2019 guidelines, suspect ureteral injury in patients with high-energy blunt trauma, particularly in deceleration injuries with multi-system involvement and in all cases of penetrating abdominal trauma. B Show 9 more As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with delayed imaging (urogram) in stable patients with trauma with suspected ureteral injuries. B Show 10 more Patients with bladder injury: As per EAU 2022 guidelines, obtain cystography with active retrograde filling of the bladder with dilute contrast (300-350 mL) in the presence of visible hematuria and pelvic fracture. A Show 5 more As per EAST 2019 guidelines, obtain CT cystography for the diagnosis of bladder rupture in moderate-risk (gross hematuria) and high-risk (gross hematuria and pelvic fracture) patients. B Show 7 more https://web.pathway.md/diseases/rec5tP6my1WrODZ18 4/7 6/29/23, 5:44 AM Kidney trauma Pathway As per WSES 2019 guidelines, recognize that IV contrast-enhanced CT with delayed phase is less sensitive and specific than retrograde cystography in detecting bladder injuries. B Show 14 more As per AUA 2014 guidelines, obtain retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture. B Show 5 more Patients with urethral injury: As per EAU 2022 guidelines, obtain flexible cystourethroscopy and/or retrograde urethrography for the evaluation of male patients with urethral injuries. A Show 10 more As per WSES 2019 guidelines, evaluate patients with post-traumatic urethral hemorrhage for urethral injuries. B Show 11 more As per AUA 2014 guidelines, obtain retrograde urethrography in patients with blood at the urethral meatus after pelvic trauma. B Show 5 more 6. Follow-up and surveillance Serial imaging assessment: As per EAST 2023 guidelines, insufficient evidence to recommend for or against routine follow- up abdominal CT versus symptom-based abdominal CT to decrease the incidence of delayed hemorrhage necessitating intervention in hemodynamically stable adult patients with high-grade (AAST III-V) renal injuries managed nonoperatively. I As per EAU 2022 guidelines, repeat imaging in high-grade and penetrating injuries and in cases of fever, worsening flank pain, or falling hematocrit. A As per WSES 2019 guidelines, do not obtain follow-up imaging in patients with minor (AAST I-II) renal injuries managed nonoperatively. D Show 2 more As per AUA 2014 guidelines, obtain follow-up CT in patients with renal trauma having either deep lacerations (AAST grade IV-V) or clinical signs of complications (such as fever, worsening flank pain, ongoing blood loss, abdominal distention). B Return to sport activities: advise returning to sport activities only after microscopic hematuria is resolved. B Long-term follow-up: Follow-up approximately 3 months after major kidney trauma with: physical examination urinalysis individualized radiological investigation including nuclear scintigraphy https://web.pathway.md/diseases/rec5tP6my1WrODZ18 5/7 6/29/23, 5:44 AM Kidney trauma Pathway BP measurement renal function tests. B Measure BP annually to diagnose renovascular hypertension. A Clinical findings Symptoms Past medical history Difficulty urinating Abdominal trauma Dysuria Bladder injury Flank pain Pelvic fracture Hematuria Pelvic trauma Rib fracture Past events Sepsis Traumatic injury Motor vehicle accident Ureteral injury Abdominal exam Vital signs Abdominal distension Signs of shock Abdominal tenderness Ascites Genitourinary exam Flank ecchymosis Palpable abdominal mass urine output Peritoneal findings Hematological findings Lab findings Hgb serum creatinine hematocrit serum urea References 1. Siddharth A Padia, Christopher R Ingraham, John M Moriarty et al. Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol. 2020 Mar;31 3 363 369.e2. Open 2. Federico Coccolini, Ernest E Moore, Yoram Kluger et al. Kidney and uro-trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 2;14 54. Open 3. N.D. Kitrey Chair), F. Campos-Juanatey, P. Hallscheidt et al. EAU Guidelines on Urological Trauma. EAU. 2022. Open 4. Morey AF, Brandes S, Dugi DD rd et al. Urotrauma: AUA guideline. J Urol. 2014 Aug;192 2 327 35. Open 5. Hiba Abdel Aziz, Nikolay Bugaev, Gerard Baltazar et al. Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma. BMC Surg. 2023 Jan https://web.pathway.md/diseases/rec5tP6my1WrODZ18 6/7 6/29/23, 5:44 AM Kidney trauma Pathway 27;23 1 22. Open 6. Lawrence L Yeung, Amy A McDonald, John J Como et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019 Feb;86 2 326 336. Open https://web.pathway.md/diseases/rec5tP6my1WrODZ18 7/7