What is the recommended management for patients with renal hematomas?

Management of Renal Hematomas

In hemodynamically stable patients with renal hematomas, non-invasive management strategies should be used, while hemodynamically unstable patients require immediate intervention with surgery or angioembolization. 1

Initial Assessment and Hemodynamic Stratification

The management of renal hematomas is fundamentally determined by hemodynamic status, which dictates whether conservative or interventional approaches are appropriate.

Hemodynamically Stable Patients

• Non-operative management is the standard of care for hemodynamically stable patients with renal injury and perirenal hematomas 1
• Obtain IV contrast-enhanced CT with immediate and delayed images to assess injury grade, hematoma size, and presence of active bleeding 1, 2
• Monitor blood pressure closely, as external renal compression from hematomas can activate the renin-angiotensin-aldosterone system causing severe hypertension (Page kidney) 2
• Check renal function (creatinine, eGFR) and electrolytes, particularly potassium levels 2
• Provide adequate fluid resuscitation with normal saline to maintain renal perfusion 3

Hemodynamically Unstable Patients

• Immediate intervention is mandatory for patients with no or transient response to resuscitation 1
• The surgical team must perform surgery or angioembolization in selected situations 1
• For patients with large perirenal hematoma (>4 cm) and/or vascular contrast extravasation in the setting of deep or complex renal laceration (AAST Grade 3-5), immediate intervention with angioembolization or surgery is required 1

Specific Indications for Intervention in Stable Patients

While most stable patients are managed conservatively, certain radiographic and clinical findings warrant intervention:

• Angioembolization should be performed for stable patients with evidence of ongoing arterial bleeding, such as arterial contrast extravasation on CT imaging, pseudoaneurysm formation, or arteriovenous fistula 2
• Embolization should be performed as super-selectively as possible to preserve renal parenchyma 2
• Percutaneous drainage is indicated when medical management fails to control hypertension or when renal function deteriorates 2
• Isolated urinary extravasation is not an absolute contraindication to non-operative management in the absence of other indications for laparotomy 1

Surgical Considerations for Unstable Patients

When operative intervention is required, the approach should prioritize renal preservation when feasible:

• In hemodynamically unstable patients with stable zone II hematomas, renal exploration should be avoided 4
• For expanding zone II hematomas in unstable patients, kidney-preserving techniques are preferred over nephrectomy when technically feasible 4
• Consider REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) as a temporizing bridge to definitive hemorrhage control in unstable patients 2

Follow-Up and Monitoring

Conservative management requires vigilant monitoring for complications:

• Monitor blood pressure periodically for up to one year after treatment, as hypertension can develop or persist 2
• Perform follow-up CT imaging at 48 hours for high-grade injuries to assess for complications 2
• Serial ultrasound examinations can track hematoma resolution; most hematomas gradually decrease in size over 40-50 days 5
• Check renal function recovery after intervention and monitor for late complications including chronic hypertension 2

Risk Factors and Special Considerations

Certain patient characteristics increase the risk of hematoma formation and complications:

• Hypertension is a significant risk factor for renal hematoma development and should be aggressively controlled 6, 7
• Higher body mass index and larger stone size (in post-lithotripsy hematomas) are predisposing factors 6
• Patients with clotting disorders or on anticoagulation require special attention 7
• In patients with renal dysfunction, meticulous attention must be given to proper dosing of antithrombotic medications 3

Common Pitfalls to Avoid

• Do not routinely explore stable zone II hematomas in unstable patients, as this increases morbidity without improving outcomes 4
• Do not assume all large hematomas require immediate intervention; hematoma size alone (even >4 cm) in a stable patient without contrast extravasation can be managed conservatively 1
• Do not perform nephrectomy reflexively in unstable patients with expanding hematomas; attempt renal preservation techniques first 4
• Do not delay angioembolization in stable patients with documented arterial extravasation, as this can prevent progression to hemodynamic instability 1, 2