Purpose <p>This study aimed to investigate the long-term outcomes of non-operative, operative, and minimally invasive surgery management of high-grade renal injuries (Grades III–V) in an underserved population at a high-volume trauma center.</p> Methods <p>We conducted a retrospective chart review of 93 patients who sustained high-grade renal trauma and presented to University Hospital, a Level 1 trauma center, between 2017 and 2022. The patients were categorized by initial management strategy: non-operative, operative, or minimally invasive surgery (endoscopic urologic and interventional radiologic procedures). Outcome variables included length of hospital stay, complications, mortality, long-term renal function, and the need for additional procedures. We analyzed associations between management strategies and outcomes, adjusting for injury mechanism and severity.</p> Results <p>Non-operative management was the most common strategy (60%), followed by operative (20%) and minimally invasive surgery (20%). Operative management was associated with a higher rate of complications and reoperations (<i>p</i> = 0.007) and significantly longer hospital stays (<i>p</i> &lt; 0.001). Non-operative management demonstrated similar long-term renal function compared to operative and minimally invasive approaches (<i>p</i> = 0.087), with fewer complications. No non-operative patients required subsequent procedural management, while 32% of those initially managed operatively or minimally invasively required additional interventions.</p> Conclusions <p>Non-operative management is a safe and effective approach for hemodynamically stable patients with high-grade renal trauma, leading to fewer complications and similar long-term renal outcomes compared to operative and minimally invasive strategies. These findings support renal preservation through non-operative management, especially in underserved populations.</p>