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Conservative management for an isolated grade V renal injury

A 48-year old presented as an emergency with a history of frank haematuria and left flank pain following a fall down the stairs. His medical history included learning difficulty, poorly-controlled epilepsy, multiple fractures and asthma. He was haemodynamically stable and tender in the left flank. A contrast enhanced computed tomography (CT) was performed (Figure 1). This revealed rupture of the left kidney with lacerations, resulting in several separate fragments, mostly hypo-perfused. There was a 10.5 cm retroperitoneal haematoma. Due to this large haematoma, calyces were not well visualized. There were no other intra-abdominal or intra-thoracic injuries on CT. The patient was haemodynamically stable at presentation and his significant co-morbidities made him a very high risk case for anaesthesia. Following an extended discussion with the anaesthetist, a decision was taken to treat him conservatively with a view to carry out exploratory laparotomy only in the case of haemodynamic instability. He was put on strict bed rest, hourly monitoring of vitals, daily bloods, antibiotics for three weeks, optimization of his otherwise uncontrolled epilepsy, and daily physical examination. Gross haematuria was monitored throughout. A follow-up CT two days later did not show further expansion of the haematoma. On delayed images (Figure 2), a urinoma measuring 34 mm × 78 mm × 90 mm was seen. Surgical intervention, including drainage of the urinoma, was not considered, as the patient remained stable and apyrexial. He was discharged and able to resume normal activities 14 days after his admission. He did not require blood transfusion. The kidney functions were normal at presentation and remained stable throughout. Haematuria settled down on the fourth day of initial presentation. Conservative management for an isolated grade V renal injury