Treatment

The management of SPH is similar to that of renal trauma wherein conservative measures are first-line and nephrectomy is reserved as an option of last resort (Santucci and Fisher 2005). Initial steps are directed toward maintaining hemodynamic support through i.v. hydration and blood and blood product replacement as necessary. Bed rest is instituted along with periodic monitoring of vital statistics and serum hemoglobin in those patients who are hemodynamically stable. Unstable patients or those in whom the hemoglobin continues to decrease despite repeated transfusions require diagnostic arteriography and selective embolization. Only patients who remain unstable or continue to bleed despite embolization need undergo open nephrectomy. Partial nephrectomy remains an option in the early period but should be restricted to patients with a solitary kidney or those with a small (<4 cm), easily identifiable exophytic mass whose hemodynamic parameters do not prohibit an extended procedure. Seven percent of patients with a renal mass in available series have undergone early partial nephrectomy in the setting of SPH (Zhang et al. 2002). Unfortunately, no data on local recurrence is available at this time.

Patients with hemodynamic stability including those responding to conservative measures, including embolization, require inpatient monitoring and symptomatic treatment only. Ambulation and subsequent hospital discharge can be initiated when vital signs and hemoglobin remain stable for 24 h and gross hematu-ria, if present, has resolved. Given the 25% risk of underlying malignancy, repeat abdominal imaging with

CT scan should be performed in 1 - 3 months (Zhang et al. 2002; Yip et al. 1998). If a mass suggestive of RCC is identified at presentation or in follow-up, definitive treatment can be performed on an elective basis.

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