Due to improvements in computed tomography imaging and resuscitation methods, operative intervention for renal injuries has been significantly reduced. Currently 36 % of penetrating and less than 5 % of blunt kidney injuries require operative intervention In addition, about 30 % of penetrating and 45 % of blunt grade IV and V injuries are managed nonoperatively. With the broadening criteria for nonoperative management of renal injury, even in penetrating trauma including some gunshots, the only absolute indications for operative management are hemodynamic instability, expanding or pulsatile perirenal hematoma, incomplete renal injury staging, renal pelvic injury, or non-visualization of the injured kidney on IVP. AAST stage I–III renal injuries are usually hemodynamically stable and are managed nonoperatively. Isolated stage IV renal injuries may be managed nonoperatively when hemodynamically stable but must be continually reassessed and re-imaged by CT scan at 48 h or sooner if there is clinical decompensation. Superselective embolization may be attempted for certain patients with stage IV renal injuries who fail conservative management due to persistent bleeding from segmental arteries. Stage V renal injuries nearly always require operative intervention. With these guidelines in mind however, renal injuries suffered from penetrating trauma are almost always associated with other injuries that dictate the decision to operate.

Almost all ureteral injuries require immediate operative repair. In the event a ureteral injury is initially unrecognized and consequently not repaired immediately, reconstruction should be deferred for 3–6 months to allow inflammation to resolve. All bladder neck and intraperitoneal bladder injuries mandate repair, while most extraperitoneal bladder injuries can be observed unless the patient undergoes laparotomy for other injuries.

Once committed to operative management, a standard transabdominal midline incision is best for assessing renal injury because both kidneys can be inspected through this approach and midline incision allows access to the remainder of the abdominal cavity. Abdominal packing, in typical trauma laparotomy fashion, will help control bleeding. Attention should first be turned to the destabilizing injury, urologic or otherwise.

When the time comes to assess the bleeding kidney, vascular exposure is the first priority. Lift the transverse colon to the chest with a moist laparotomy pad and move the small bowel to the right in order to expose the retroperitoneum. Carefully incise the retroperitoneum over the aorta at the inferior mesenteric artery and extend superiorly to the ligament of Treitz (Fig. 50.1). The left renal vein can be identified where it crosses the aorta anteriorly, noting that the vein rarely crosses posteriorly and when it does it may be duplicated. Sometimes a large retroperitoneal hematoma distorts the anatomy. In this case, make the incision just medial to the inferior mesenteric vein and proceed to identify the left renal vein. Wrap a vessel loop around the vein without occluding it, unless bleeding from this vessel is heavy. The remaining renal vessels should be identified in order: left renal artery, right renal vein, and right renal artery. The left and right renal arteries are posterior and superior to the left renal vein on either side of the aorta. Apply vessel loops to the renal arteries and veins, but only occlude the vessels if severe bleeding must be controlled (Fig. 50.2).