Urological evaluation and management of renal-proximity stab wounds

The urological evaluation and management of renal-proximity stab wounds remain controversial. Questions regarding the 'best' first radiographic study and the indications for nonoperative management are still unanswered. At the Los Angeles County-University of Southern California Medical Center we retrospectively reviewed the charts of 244 patients evaluated between January 1985 and December 1990 for renal-proximity stab wounds. There were 184 patients who presented without hematuria, 46 who presented with microscopic hematuria and 14 who presented with gross hematuria. When used as the first diagnostic study, an excretory urogram was 96% accurate in establishing the presence or absence of injury. In 34 patients additional evaluation was done with computerized tomography and/or angiography. A total of 43 injuries (17.6%) was found, of which 27 were successfully managed nonoperatively and 16 were managed surgically (1 nephrectomy). One patient had significant postoperative hemorrhage after partial nephrectomy, which was successfully managed with angiographic embolization. We conclude that although the degree of hematuria was a good indication of renal injury, the absence of hematuria did not preclude injury. In addition, excretory urography appears to be an acceptably reliable first study at our institution. We advocate a renal angiogram as the second radiographic study of choice because it reliably stages significant injuries and offers the possibility of therapeutic transcatheter embolization. Most renal injuries, when accurately staged, can safely be managed nonoperatively.