Coexisting injuries are identified in 14 % - 34 % of blunt trauma and in 50%-80% of penetrating renal trauma cases, mostly involving the liver with right-sided injury and the spleen in the left-sided cases (Krieger et al. 1984; McAninch and Santucci 2002; Peterson 2000). The urologist might therefore be involved with renal trauma as a consultant in a shared abdomen at laparot-omy performed by the general surgeons for associated injuries or because of hemodynamic instability.
The ultimate goal of all renal explorations in the setting of major traumatic renal injury is to control bleeding and to preserve the maximal amount of viable renal parenchyma. In a stable patient, primary proximal vascular control, broad surgical exposure of the injured area, and the use of strict reconstructive principles have made it possible to achieve successful reconstructive outcome of the kidney in up to 87% of renal injuries (Brandes and McAninch 1999; Wessells 2002). Yet it requires temporary vascular occlusion, extensive de-bridement of nonviable parenchyma, meticulous he-mostasis, closure of the collecting system, approximation of the parenchymal margins, and omental interposition. Altogether, these steps are time-consuming and only the reported mean arterial occlusion time exceeds 39 min (Brandes and McAninch 1999), rendering these techniques inapplicable in the context of an unstable multitrauma patient with associated injuries of other organs or in the scenario of mass casualties when the operating room cannot be and should not be saturated with time-consuming reconstructive procedures.
Whenever major active hemorrhage of renal origin can be ruled out it is probably wise not to explore the injured kidney even if a secondary delayed laparotomy will eventually be needed. The surgeon's approach should be especially selective with exploration of contained perirenal hematomas that are clinically considered unlikely to involve the renal pedicle, unless the patient is considered unstable (Brandes and McAninch 2006) or the procedure needs to be terminated as quickly as possible in order to move the patient forward and make the operating room available for the next patient in the mass casualty event. Selection of patients according to strict criteria is the key of success for this conservative approach (Wessells et al. 1997). Brandes and McAninch (1999) report an exploration rate of 77% in renal gunshot wounds and 45% in renal stab wounds. According to these authors, the only absolute indication for surgical exploration is a patient with external trauma and persistent renal bleeding. Can these recommendations be extrapolated to the operating room in the setup of an unstable, multitrauma patient or in situations of mass casualties? The answer is certainly yes. Packing the renal fossa with laparotomy pads and transferring the patient to the surgical intensive care unit until a planned second-look laparotomy becomes possible is probably a viable alternative to heroic and time-consuming nephrectomy or reconstruction (Coburn 1977).
Other techniques that were initially applied in hepatic surgery and for splenic trauma can be considered as auxiliary applicable damage control measures for controlling renal parenchymal bleeding, including application of mattress sutures, fibrin glue, absorbable mesh tamponade, and firing a stapler line over the lacerated kidney parenchyma (Chaabouni and Bittard 1996; Feliciano et al. 2000; McAninch 2003; Nadu et al., unpublished data; Shekarris and Stoller 2002).
Urinary extravasation may be ignored during the acute phase and will be drained through retroperitone-al drains, while stents or insertions of percutaneous nephrostomies are to be deferred. The abdomen is temporarily closed with towel clips or other temporizing measures (Feliciano et al. 2000). Following the urgent primary exploration, the patient is carefully monitored in an intensive care unit and only when he is sufficiently stable should radiological assessment of the injuries be undertaken in order to plan the definitive operative management accordingly (Feliciano et al. 2000; Hirs-hberg and Walden 1997; Hirshberg et al. 1994).
CT is advocated as the most useful imaging modality in patients who are stable enough and transportable. If the extent of renal injury has not been clearly defined at the initial laparotomy (by choosing not to explore the retroperitoneal hematoma), the CT scan performed in the interim time before the second laparotomy can provide information and help in further decision making. Data regarding existence and function of the contralateral kidney is documented, the kidney injury is graded according to traditional protocols, and therapeutic strategies are delineated concerning operative or nonoperative management of the renal trauma or whether nephrectomy or reconstruction are to be attempted.
In patients who do not stabilize after the initial acute damage control laparotomy or in patients with deteriorating hemodynamic parameters (ongoing or delayed bleeding), the management options are angiographic embolization of the bleeding kidney or reoperation. The decision should be made according to the general status of the patient and the associated injuries that have also been treated according to damage control principles (bowel injuries, packed liver, or splenic injuries) and need reoperation regardless of the renal injury. Exploration of the kidney should be approached according to the principles of renal trauma: initial control of the renal pedicle and only then opening Gerota's fascia and the perinephric space. This approach has been proved to lower the nephrectomy rates due to bleeding from the renal parenchyma. (McAninch and Santucci 2002; Peterson 2000)
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