Non-operative management of penetrating renal injury: a retrospective observational study

Background Non-operative management (NOM) is established for blunt renal injury, but its place in penetrating injury is less clearly defined, and published series define success inconsistently. We report the selection criteria, management protocol and outcomes of NOM for penetrating renal injury. Methods The records of all patients admitted with penetrating renal injury to a tertiary-care centre in 2000–2020 were reviewed retrospectively. Gunshot injuries, deaths before admission and major thoracic, cardiac or neurosurgical trauma were excluded. Injuries were graded with the 2018 American Association for the Surgery of Trauma (AAST) scale. NOM was defined as management without operative exploration of the kidney; angioembolization was regarded as an adjunct to NOM, and laparotomy for an associated injury with Gerota’s fascia left unopened was reported separately. Results Of 46 patients, 19 underwent immediate laparotomy (three nephrectomies) and 27 (25 men; mean age 43.6 ± 18.2 years; 16 stab wounds) were selected for NOM. Twenty-one (77.8%) were managed by observation alone. Four transient responders (two grade III, two grade IV) became non-responders during observation and were treated successfully by angioembolization instead of surgery. Two patients (7.4%) underwent laparotomy for splenic and mesenteric injuries not seen on the initial computed tomography; the kidney was not explored. All six transient responders needed an intervention. No kidney in the NOM group was explored or removed (renal NOM success 27/27; 25/27, 92.6%, counting any laparotomy as failure), and kidneys were preserved in 43 of all 46 patients (93.5%). Median hospital stay was 7 days after observation alone and 9 days after angioembolization. There were no deaths. During follow-up of 8–60 months, six of the 22 patients without previous hypertension (27.3%) developed new-onset hypertension, and two of the four embolized kidneys decreased in size. Conclusions In selected patients with non-gunshot penetrating renal injury, NOM with close monitoring and access to angioembolization avoided renal exploration in every case. Transient responders and patients with a possible associated intra-abdominal injury need particular vigilance. These results apply only to centres with immediate access to theatre, blood, high-dependency care and interventional radiology.