The absolute indications for immediate surgical exploration include but are not limited to life-threatening hemorrhage from a renal vessel laceration that may not be managed by interventional radiological procedure, expanding or pulsatile hematoma, shock, and usually patients that suffered penetrating trauma. In cases of patients that require immediate laparotomy without prior imaging, a “one-shot” IVP may be completed with injection of 1–2 mL/kg (maximum of 150 cc) of iodine contrast to evaluate presence of two renal units in case of nephrectomy is needed.

The midline laparotomy is recommended to allow complete exposure of all abdominal organs. The use of self-retaining retractors is often helpful. Renal vascular control may be performed by two distinct methods: (1) via an incision through the mesentery, just proximal to the inferior mesenteric artery identifying the renal vessels isolating with vessel loops, or (2) by incision of the line of Toldt, rapid mobilization and medial rotation of the colon, and manual control of the renal vessels with anterior and posterior bimanual control [5]. The method of choice will depend on surgeon’s experience, and it remains controversial whether one method is superior to the other to prevent total nephrectomy rates. There have been several studies evaluating selective angiography, stent placement, and embolization in patients with grade V renal lacerations who otherwise would not require a laparotomy (Fig. 15.1) [6, 7].

Blast effect from missile injuries may cause severe tissue damage mandating debridement and repair of the renal parenchyma and use of omental wrap to cover the injured site. The omental wrap must be always considered to prevent delayed complications such as urinoma or abscess in areas that are devascularized.

Renal injury patients with urinary extravasation can be observed provided there are no other associated injuries. Up to 90 % of these injuries will resolve spontaneously. But if electrolyte or creatinine levels increase and signs of peritoneal irritation and ileus are evident, one may consider ipsilateral ureteral stent placement and Foley catheter drainage until extravasation resolves. Imaging may be recommended when continued extravasation is suspected with no resolution [8].

In cases of persistent or infected urinoma, percutaneous drain placement must be considered until the process is resolved.

Although long-term effects of renal trauma have been studied, follow-up is often difficult. Renal function may decrease 15, 30, and 65 % in patients with grades 3, 4, and 5 lacerations, respectively [9]. Nuclear renal scan are not helpful to evaluate renal function post-acute injury. Also, no difference in functional outcomes was seen between surgical and nonoperative patients [10]. Hypertension can also exist following trauma and may occur within the first 6 months post-trauma. Mechanisms for postrenal trauma hypertension include stenosis of main or segmental renal artery branch (Goldblatt kidney) or prolonged subcapsular compression from a hematoma on the kidney (Page kidney). These often resolve and rarely require curative nephrectomy. One may also follow-up with urine analysis to detect proteinuria.

Acute traumatic ureteral injuries are rare and occur in less than 1 % of overall trauma and less than 5 % of abdominal trauma. More than 80 % of these injuries are from gunshot wounds. The rest are split between stab wounds and blunt abdominal trauma [11]. However, the majority of ureteral trauma cases are due to intraoperative injury. The injuries range from sharp transection or suture ligation to thermal damage from energy devices. A common location for intraoperative injury is the distal ureter. The most common setting for this occurrence is abdominal hysterectomy, in which up to 3–12 % of cases involve distal ureteral injury. During emergent caesarean sections when there is lateral extension of the incision, distal ureteral injury is an adverse event due to low visibility if bleeding ensues from the uterine artery that is located anterior to the distal ureter. Low anterior or abdominoperineal resections, as well as vascular procedures such as aortoiliac bypass, can also lead to ureteral injury. The number one ureteral injury or perforation is done by urologists performing ureteroscopy. The risk of ureteral avulsion during ureteroscopy has been reported at 0.3 %, while perforation is reported in up to 2–6 % of cases [12] and may have delayed diagnosis in up to 50–70 % of cases [13].

Over 85 % of bladder injuries are due to blunt trauma, and only approximately 10 % are isolated. Ninety percent of traumatic bladder injuries are related to pelvic fractures and most often also present with hematuria [15]. Bladder injuries are often classified as extraperitoneal (60 % of cases) or intraperitoneal. Extraperitoneal bladder rupture is usually caused by a pelvic fracture and occurs on the anterolateral portion of the bladder.