Grade I and II renal injuries (I§ble254-2) are usually managed nonoperatively. If there are no other medical considerations, such patients can be treated similarly to those with isolated hematuria. Renal contusions almost always resolve without sequelae unless there is a preexisting renal lesion, such as hydronephrosis, cyst, or tumor. Almost all minor lacerations heal without sequelae with conservative management.
Patients with grade III and IV injuries should be admitted to the hospital. Most of these patients will have other compelling reasons to be admitted or be taken to the operating room. Many stable adult patients with clearly delineated grade III and even grade IV injuries can still be managed nonoperatively. ™2! Many centers attempt nonoperative management for all stable children unless the renal injury is particularly severe or the child fails conservative therapy. 822 Exploration itself is not without consequence, since it may accentuate considerable hemorrhage. Neither the volume of blood replacement nor the degree of extravasation is an indication for exploration in itself.3 However, if exploration is undertaken for the evaluation of other injuries, repair of renal injuries is usually undertaken. If conservative management is attempted, frequent reassessment is required, and there should be a low threshold for ordering reimaging studies. Conservative management includes bed rest, hydration, serial hematocrit determinations, monitoring of vital signs, and serial urine specimens to assess the degree of hematuria. Patients with gross hematuria remain at bed rest until the gross hematuria resolves and remain at limited activity until microscopic hematuria resolves.
Indications for operative management are listed in Iable...2.5.4.-5.3 Renal rupture is usually explored and nephrectomy usually required. Most, but not all, penetrating injuries are explored. Ihe only widely accepted absolute indication for surgical exploration of a renal injury is persistent retroperitoneal bleeding with hemodynamic instability. As noted, CI may allow adequate staging even for penetrating injuries.18 If the patient has other injuries warranting abdominal exploration, an intraoperative IVP may assist in determining the necessity for retroperitoneal exploration while also giving information regarding function of the contralateral kidney.
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