INTRODUCTION AND OBJECTIVES: There is limited data on conservative management of penetrating renal trauma. The aim of this study was to review the management and outcome of a large patient cohort presenting with penetrating renal trauma to a tertiary center in South Africa. METHODS: All patients presenting with penetrating abdominal trauma and hematuria admitted to the Trauma Center at Groote Schuur Hospital over a 19 month period [Jan 2008 e July 2009] were prospectively evaluated. Mechanism of injury, micro vs macrohematuria, grade of injury(AAST), management decision(non surgical, surgical for other reasons without renal exploration and true renal surgery with Gerotas fascia opened), non-surgical success rate, complications and nephrectomy rate were analysed. RESULTS: Ninety-two patients (84 male and 8 female) presented with haematuria following penetrating abdominal trauma. There were 74 (80.4%) renal injuries proved with imaging or intraoperatively. Median age was 26 years(range 14–51 years). Trauma mechanism was stab wounds in 50(54.3%) and gunshot wounds in 42 cases (45.7%). Microscopic hematuria diagnosed in 39 cases was associated with grade I, II, III, IV and V renal trauma in 5 (12.8%), 16 (41.0%), 12 (30.8%), 5 (12.8%) and 1(2.6%) patients, respectively. Overall, 18/39 patients (46.2%) with microscopic hematuria had grade III injury or worse. A total of 48 patients with 49 proven renal injuries (66.2%) were treated conservatively. Renal injuries were graded I, II, III, IV, and V in 6 (12.2%), 18 (36.7%), 17 (34.7%), 9 (18.4%), and 0 (0%) cases, respectively. 4 patients(8.3%) in this group presented with delayed hematuria. 3 patients had successful angioembolisation of an arteriovenous fistula(2) and a false aneurysm(1), while one patient had a normal angiogram. None of the patients who were elected to undergo conservative management had any delayed surgical intervention during follow-up. In the cohort of 25 patients with renal exploration, there were 18 nephrectomies performed for uncontrollable bleeding (11), hilar injuries (2), ‘shattered’ kidney(3). The nephrectomy conversion rate in all patients surgically explored was 72% with the overall nephrectomy rate being 24.3%. 13 nephrectomies were due to gunshotwounds (72.2%). CONCLUSIONS: If the decision for renal exploration is made, the nephrectomy conversion rate is as high as 72%. Conservative management leads to a high organ preserving success rate (100%) with minimal morbidity. This information is crucial for clinical decision making as aggressive surgical management with renal exploration leads to high rate of potentially preventable nephrectomies.