0022-534 7/91/1455-0932$03.

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THE JOURNAL OF UROLOGY Vol. 145, 932-937, May 1991
Copyright© 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC. Printed in U.S.A.

RENAL RECONSTRUCTION AFTER INJURY

JACK W. McANINCH,* PETER R. CARROLL, PAUL W. KLOSTERMAN, CHRISTOPHER M. DIXON
AND MICHAEL N. GREENBLATT
From the Department of Urology, University of California School of Medicine and San Francisco General Hospital, San Francisco, California

ABSTRACT
During an 11-year period 1,363 patients presented to our institution with renal trauma. Renal
exploration was performed in 127 patients (133 renal units). Most patients had multiple organ
injuries, as indicated by a mean blood loss of 4,160 ml. and a mean injury severity score of 25.8.
Absolute indications for exploration were bleeding and pulsatile perirenal hematoma and relative
indications included urinary extravasation, nonviable renal tissue and incomplete staging. Renal
surgery was required in 2.4% of the blunt injuries, 45% of the stab wounds and 76% of the gunshot
wounds. Salvage was successful in 88. 7% of the kidneys explored and total nephrectomy was required
in 11.3%. The success rate was based on early vascular control and reconstructive techniques of
"renorrhaphy," partial nephrectomy, vascular repair and coverage with omental pedicle flaps.
Complications occurred in 9.9% of the cases but none resulted in renal loss. When indicated, renal
exploration after trauma is safe and in a high percentage of cases reconstruction will be successful.
KEY WORDS: kidney, wounds and injuries, nephrectomy

Renal exploration after trauma has often resulted in total
nephrectomy, most likely owing to renal bleeding. For recon-
struction to be successful appropriate preoperative assessment,
patient selection and surgical techniques must be used. Any
renal exploration for trauma should have as its primary objec-
tive salvage of sufficient parenchyma for the patient to avoid
dialysis should the contralateral kidney be lost (that is approx-
imately 30% function of 1 normal kidney). The decision to
salvage these traumatized kidneys requires an armamentarium
of diagnostic skills, surgical techniques and personal commit-
ment. Few studies provide detailed information on the compli-
cations and results of renal reconstructive procedures. We
describe our surgical approach and demonstrate that renal
salvage after trauma can be successful in a high percentage of
patients.
METHODS
From September 1977 through September 1988, 1,363 pa-
tients presented to San Francisco General Hospital with trau-
matic renal injuries. Patient data were recorded and entered
into a computer database prospectively. Criteria to establish
the presence of injury included gross or microscopic hematuria
(greater than 5 red blood cells per high power field), suggestive
physical findings, positive findings on imaging studies and/or
confirmation of injury at laparotomy. Patients with pelvic
fracture and normal findings on renal imaging studies, even in
the presence of hematuria, were excluded so that those with
bladder and urethral injury might be eliminated.
Throughout the data collection period the indications for
renal exploration were standard. Absolute indications included
evidence of persistent renal bleeding, expanding perirenal ret-
roperitoneal hematoma and pulsatile perirenal hematoma. Rel-
ative indications were urinary extravasation, nonviable renal
tissue and incomplete staging of the renal injury. A combination
of absolute and relative indications usually was the reason for
renal exploration.
During the 11 years 127 patients underwent renal exploration
(133 renal units). Detailed information was obtained for cause
of injury, physical findings, presence and degree of hematuria,
results of imaging studies, type and classification of renal
injury, associated organ, skeletal and soft tissue injury, opera-
Accepted for publication September 19, 1990.
* Requests for reprints: Department of Urology, University of Cali-
fornia, San Francisco, California 94143-0738.
932
tive findings, reconstructive technique, blood transfusion re-
quirements, complications, and followup imaging and renal
function studies. In addition, the extent of total body trauma
was determined by the injury severity score. Computer analysis
of the data provided the basis for this report.
RESULTS
Table 1 shows the total number of patients included in the
study and the management of each group based on the cause
of injury. Blunt trauma accounted for 87.5% of the renal
injuries but only 2.5% of these nonpenetrating injuries required
renal surgery. Stab wounds represented 7.8% of the total, with
45% requiring surgery. Gunshot wounds were seen in 4.7% of
the cases and 76.6% required renal surgery. Six patients with
bilateral injury required surgery, bringing the total number of
renal units explored to 133 (table 2). In patients with multiple
injuries a mean of 2.5 abdominal organs was affected (±0.1
standard error). Also indicative of the large number of patients
with associated injuries were the mean blood transfusion re-
quirement (4,160 ± 606 ml.) and the mean injury severity score
(25.8 ± 1.1). The latter was significantly higher in patients with
blunt trauma and gunshot wounds than in those with stab
wounds (p <0.001). Figure 1 depicts the classification of injury
used in this series. Table 3 demonstrates the findings, classifi-
cations and cause of injury in the individual renal units ex-
plored. Injuries are tabulated by occurrence: 24 renal units
(18%) had multiple injuries, with parenchymal laceration as-
sociated with renal vascular injury being the most common
(16).
All renal explorations were performed via a transabdominal
approach (fig. 2), which provided the opportunity to diagnose
and manage the associated intra-abdominal injuries noted in
86% of the patients (109 of 127) (table 4). The renal vessels
were isolated before renal exploration and clamping was only
done to control heavy bleeding. The retroperitoneal hematoma
was entered after reflecting the colon. Complete renal exposure
TABLE 1. Cause and management of renal trauma in 1,363 patients
Blunt Trauma Stab Wound Gunshot
(1,193 pts.) (106 pts.) (64 pts.)
Discharge from the emergency room 362 0 0
Admit only 801 58 15
Explore only (kidney) 5 4 7
Surgery (kidney) 25 44 42
 REI.,.JAL RECOt-ISTR,UC l.'lOt~ AFTER ~:NJURY
1

r:I'ABLE 2, Injured r2nal units requiring surgical expiorction

Cause
Totals
Blunt Trauma Stab Wound Gunshot
No. pts. 30 48 49 127
Bilat. injuries 1 1 4 6
Total renal units(%) 31 (23) 49 (37) 53 (40) 133

C
d

FIG. 1. Classification of renal injuries. a, minor parenchymal lacerations involve only renal cortex. b, contusion has evidence of injury without
parenchymal laceration. c, major parenchymal lacerations extend through cortex and into renal medulla (d) and include lacerations of collecting
system (e). /, vascular injuries include injuries to main renal artery or vein or their segmental branches.
934 MCANINCH AND ASSOCIATES

TABLE 3. Classification and cause of injury in 133 surgically explored renal units
Cause
Totals
Classification Blunt Trauma Stab Wound · Gunshot (157 pts.)*
(38 pts.) (57 pts.) (62 pts.)
Contusion 2 2 3 7
Minor laceration 2 8 6 16
Major laceration 15 33 38 86
Vascular 13 12 12 37
Renal pelvis 6 2 3 11
* Multiple injuries were present in 24 kidneys.

Fm. 2. Surgical approach to injured kidney. A, inferior mesenteric vein is major landmark in patients with large retroperitoneal hematomas.
B, retroperitoneal incision is just medial to this vessel, followed by dissection on anterior aortic surface to left renal vein. Each renal vessel can
then be isolated easily.

TABLE 4. Associated abdominal injuries*

Cause
Totals
Blunt Trauma Stab Wound Gunshot
Liver 9 11 16 36
Spleen 14 6 9 29
Small bowel 3 5 20 28
Colon 4 7 16 27
Mesentery 4 8 8 20
Stomach 0 4 16 20
Pancreas 6 1 12 19
Ureter 0 1 3 4
Adrenal 0 1 3 4
Gallbladder 0 2 2 4
Bladder 0 0 1 1
Ovary 1 0 0 1
None 3 14 1 18
* Noted in 109 of the 127 patients.

was necessary to detect multiple m1uries. Renal salvage was
possible in 88.7% of the kidneys surgically explored and total
nephrectomy was required in 11.3% (table 5). The cause of
injury had no statistically significant bearing on surgical man -
agement. No patients undergoing renal exploration for the
purpose of complete staging at the time of laparotomy required
nephrectomy.
"Renorrhaphy." "Renorrhaphy" was the most common recon-
structive technique (45.9%) and was more likely to be per-
formed for stab wounds than for blunt trauma (p = 0.033) and
gunshot wounds (p = 0.038). After hemostasis and complete
removal of all nonviable tissue a variety of techniques may be
used, including primary closure of the parenchymal laceration
with capsule alone or in combination with a hemostatic collagen
bolster, coverage with a pedicle flap of omentum for large
parenchymal defects when the capsule has been destroyed and
reconstruction with synthetic mesh, free peritoneal grafts or
free fat grafts.
Partial nephrectomy. Partial nephrectomy was required in
17.3% of the injuries (table 5). All nonviable tissue was sharply
excised and hemostasis was obtained with 4-zero chromic su-
ture ligation of individual bleeding vessels. When possible
capsule was preserved for coverage and if absent an omental
pedicle flap was most often used. Watertight closure of the
collecting system is imperative, and in many instances micro-

TABLE 5. Results of renal exploration and type of renal reconstruction

Blunt Trauma Stab Wound Gunshot (53 Totals (133
(31 pts.) (%) (49 pts.) (%) pts.) (%) pts.) (%)
"Renorrhaphy" 11 (35.5) 29 (59.2) 21 (39.6) 61 (45.9)
Partial nephrectomy 4 (12.9) 7 (14.2) 12 (22.7) 23 (17.3)
Nephrectomy 4 (12.9) 4 (8.2) 7 (13.2) 15 (11.3)
Vascular repair only 3 (9.7) 4 (8.2) 4 (7.5) 11 (8.2)
Pelvis repair only 4 (12.9) 1 (2.0) 0 5 (3.7)
Vascular and pelvis only 0 0 1 (1.9) 1 (0.8)
Exploration only 5 (16.1) 4 (8.2) 8 (15.1) 17 (12.8)
 RENAL RECONSTRUCTION AFTER INJURY
collagen or gelatin hemostatic agents were applied to the pa-
renchymal surface before coverage.
Vascular repairs. Vascular repair alone was required in 11
renal units (8%), with no statistical differences in incidence
among the various causes of injury. Another 19 vascular injuries
occurred in association with parenchymal or renal pelvic inju-
ries (a major parenchymal laceration was present in 16). Tem-
porary clamping of the renal vessels was required in 12% of the
renal units (16), with mean warm ischemia time of 36 minutes.
Venous injury was repaired (after control of bleeding to visu-
alize the area) with running 5-zero vascular silk sutures for
main renal vein injury or total ligation for segmental venous
injuries. Lacerations of the main renal artery were closed with
fine vascular sutures. Thrombosis or avulsion of the main renal
artery consequent to blunt trauma was repaired in 5 patients,
none of whom regained normal renal function after repair.
Repair of segmental renal artery lacerations was unsuccessful.
These injuries, when associated with deep parenchymal lacer-
ations, were most often managed by partial nephrectomy.
Repair of parenchymal defects. Large deep lacerations of the
parenchyma were managed with a variety of "renorrhaphy"
techniques (table 6) and by partial nephrectomy. After debride-
ment, coverage of the remaining defect was considered essential
to prevent complications. Primary closure, including suture
approximation with capsule only or in combination with a
bolster of hemostatic collagen (fig. 3), was used on 46 occasions
(54.8%) either for "renorrhaphy" or partial nephrectomy. Ped-
icle flaps of omentum were used on 29 occasions (34.5%), most
often for gunshot wounds (17 units) (p = 0.00086). All omental
flaps had viable blood supply at the time of repair. To approx-
imate the omentum to the capsule margin interrupted absorb-
able sutures were used. When capsule loss was extensive the
omentum was approximated superficially with monofilament
sutures (fig. 4), which avoids significant parenchymal ischemia.
When capsule and omentum were not available (9 occasions)
the parenchymal defect was covered by synthetic mesh, free
peritoneal or fat grafts.
Followup. Eleven patients died. One death was directly re-
lated to a delay in diagnosis of a renal vein injury, while all
others were unrelated to renal injury. Followup evaluation was
available in 82 of the 116 surviving patients (71%). Postoper-
ative renal imaging was performed in 39% of the cases. Serum
creatinine was measured in 100 patients and 5 had values
greater than 1.5 mg./dl., of whom 2 with bilateral injuries had
levels greater than 3.0. Renal complications are shown in
table 7. Hypertension in only 3 patients resolved spontaneously
in 2 and was successfully treated in the other. Delayed bleeding
in 2 patients required reoperation in 1 and resulted in preser-
vation of the kidney. Perinephric abscesses in 2 patients were
drained, with resulting renal salvage in both. Urinomas were
small and did not require drainage. Partial ureteral obstruction
was noted in 2 patients but it did not require intervention. The
arteriovenous fistula and prolonged urinary drainage seen in 1
patient each resolved spontaneously without operative inter-
vention.
DISCUSSION
The ultimate goal of renal exploration after trauma is renal
salvage. In this 11-year prospective study 88. 7% of 133 explored
renal units were salvaged sufficiently to obviate dialysis should
the contralateral kidney be lost. No statistically significant
TABLE 6. Reconstructive methods for "renorrhaphy" and partial nephrectomy
Blunt Trauma
Technique (15 pts.) (%)
Primary* 8 (53.3)
Omental flap 7 (46.7)
Peritoneum, fat or polyglycolic acid 0 6 (16.7)
* Suture approximation only or in combination with a collagen bolster.
935
differences between salvage rates were evident on the basis of
cause of injury: 87.1% blunt trauma, 91.8% stab wounds and
86.8% gunshot wounds.
Sagalowsky et al reported an over-all total nephrectomy rate
of 26.5% in 185 patients undergoing renal surgery, and rates of
36% and 30%, respectively, for blunt trauma and gunshot
wounds. 1 Total nephrectomy is more likely to be required when
a vascular injury is present. In our series 10 of the 15 patients
requiring nephrectomy had vascular injury either alone or in
combination with a parenchymal laceration. Cass et al reported
a 65% nephrectomy rate (11 of 17 kidneys) in the presence of
vascular injury and a 39% rate in another report. 2• 3 Bleeding is
the most common cause of nephrectomy after trauma, and the
incidence of both will be greatly reduced by early control of the
renal vasculature. 4 In a previous report5 we showed that a
standardized transperitoneal approach originally advocated by
Scott and Selzman6 can significantly reduce renal loss. Tem-
porary occlusion of the renal vessels is required at our institu-
tion in approximately 12% of the patients but they cannot be
reliably identified before renal inspection. 7 Therefore, we iso-
late the renal vessels in all patients before exploration, and as
a result no renal loss or complication has occurred in these
patients.
In this series of 1,363 patients careful staging of the extent
of injury was emphasized. Excretory urography (IVP) and
computerized tomography (CT), either alone or in combination,
were the most common imaging studies. Arteriography was
occasionally used. In hemodynamically unstable patients with
critical injuries or in those with a retroperitoneal hematoma at
laparotomy a "single-shot" IVP was performed in the operating
room. Based on nonvisualization or indeterminate findings
renal exploration was performed in 17 patients without repair
being required (table 5), none of whom suffered renal tissue
loss or damage. In our experience renal exploration is safe with
the technique described. Selection of patients for renal explo-
ration depends on multiple factors. The single absolute indi-
cation is persistent renal bleeding requiring transfusions to
maintain hemodynamic stability. Our patients usually had ma-
jor parenchymal and/or vascular injury. Relative indications
for renal exploration included urinary extravasation, nonviable
renal parenchyma and incomplete preoperative staging. Uri-
nary extravasation alone does not necessitate exploration (for
example fornical rupture of the collecting system) but large
lacerations of the renal pelvis or avulsion of the ureteropelvic
junction do. Some cases of major lacerations with urinary
extravasation can be followed expectantly if they have been
adequately staged (CT or arteriography), there is no active
bleeding and no exploratory laparotomy is needed. However,
one must bear in mind that these patients are at increased risk
for complications and renal repair should be strongly consid-
ered if abdominal laparotomy is being performed by the trauma
surgeon.
We plan renal exploration in all cases of penetrating renal
injury, except when related to preoperative staging of the injury.
Patients with penetrating renal injuries who are hemody-
namically stable should undergo complete staging to define the
full extent of the renal abnormality. In most of our cases IVP,
CT and occasionally arteriography were performed. Superficial
parenchymal lacerations with little or no nonviable tissue were
safely observed, even in the presence of a penetrating injury.
In some cases with complete staging deep parenchymal lacera-
Stab Wounds Gunshot (33 Totals (84
(36 pts.) (%) pts.) (%) pts.) (%)
25 (69.4) 13 (39.4) 46 (54.8)
5 (13.9) 17 (51.5) 29 (34.5)
3 (9.1) 9 (10.7)
936 MCANINCH AND ASSOCIATES

FIG. 3. "Renorrhaphy" reconstruction in 25-year-old patient with multiple blunt abdominal injuries. A, deep posterior renal laceration in mid
portion of kidney. B, after debridement and collecting system closure absorbable sutures (3-zero) are placed through capsule only. C, sutures tied
over absorbable gelatin sponge bolster.

FIG. 4. Omental pedicle flap reconstruction in 32-year-old patient with self-inflicted gunshot wound in mid portion of kidney. A, large
hematoma and nonviable tissue on lateral margin of kidney. B, large parenchymal defect noted after debridement and collecting system closure.
C, omental pedicle flap, easily covering complete defect, sutured into place with interrupted 3-zero absorbable sutures.

TABLE 7. Postoperative complications segment overlying the injured kidney). Although these injuries
Complication No. Pts. result in fecal contamination of the abdomen and the retro-
Hypertension 3 (1 treated) peritoneum, we have nevertheless continued to perform recon-
Delayed bleeding 2 structive renal surgery. We found this aggressive approach to
Perinephric abscess 2 be quite satisfactory, with only 2 perinephric abscesses in the
Urinoma 2 entire series and in both cases renal salvage was accomplished.
Obstruction 2
Prolonged urinary drainage 1 Diverting colostomy and retroperitoneal drainage are recom-
Arteriovenous fistula 1 mended. Renal repair was likewise performed in patients with
associated pancreatic injury and our 19 such patients did not
suffer significant complications. We recommend drainage of
tions were selectively managed without renal exploration. Stab the ipsilateral retroperitoneum to provide an outlet for any
wounds of the kidney often have a posterior position and the temporary urinary drainage that might occur after repair. As-
peritoneal cavity is not violated. In such cases abdominal sociated colon, stomach and pancreatic injuries require the
exploration is avoided and the renal injury is staged, which renal area to be well drained. We prefer the Penrose drain
resulted in the selection of the nonoperative approach in 55% (closed suction may create too much positive pressure), which
of our patients. This method did not result in delayed nephrec- should be left in place only until a serum creatinine measure-
tomy in any patient, and delayed renal exploration was rarely ment of the fluid is not elevated to the value of urine. Because
necessary. This same conceptual approach was used in gunshot of the great danger that bacteria along the drain tract might
wounds of the kidney, and renal exploration was not necessary contaminate the retroperitoneal hematoma, retroperitoneal
in 24 %. The absence of complications in these carefully selected drains were not left in place in selected patients (approximately
patients makes this approach acceptable in small numbers. 50%) with no collecting system violation or in whom collecting
Delayed renal exploration after major renal injury often system closure was well controlled. No complications resulted
results in total nephrectomy. 3 •8 During exploration nonviable from this management. Our over-all results of only 2 perineph-
renal parenchyma associated with a laceration should be de-
ric abscesses confirm the importance of appropriate drainage.
brided and removed. The extent of the laceration and the site
Partial nephrectomy was performed on 23 occasions (17.3%)
of nonviable tissue will be evident on CT or arteriography by a
lack of contrast material enhancement. In the exposed kidney and "renorrhaphy" on 61 (45%). These extensive reconstructive
nonviable tissue will be dark black and will not bleed during procedures resulted in relatively few complications and no total
debridement. Tissue should be debrided until active bleeding renal loss. More than 70% of the patients were seen at followup,
occurs. As noted previously, complications are frequent when and renal imaging was performed in approximately 40%. Al-
major lacerations with associated nonviable tissue are managed though these rates may appear low, they are high for this
nonoperatively. 9 However, we continue to take a conservative population seen at the trauma center of a large, inner city
approach in patients with segmental arterial injuries from blunt hospital.
trauma who have no associated renal laceration. The intact Based on our experience with this series, we believe that
renal capsule provides coverage during the healing process and aggressive staging of renal trauma by IVP, CT or arteriography
the incidence of hypertension appears to be low. The success when possible provides the definition of injury that allows
of this approach has been previously reported. 10 selective management in each individual. Renal bleeding ne-
Table 4 indicates the high (75 over-all) incidence of associ- cessitates surgery but in the hemodynamically stable patient a
ated bowel injury, including 27 to the colon (most often to the more selective approach can be taken. When renal exploration
 RENAL RECONSTRUCTION AFTER INJURY
is required, reconstruction can be successful in a high percent-
age of patients.
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