Symposium on Advances in Small Hospital Care
Management of Genitourinary Trauma Richard D. Shanrwn, M.D., F A.C.S. *
In a small hospital setting, genitourinary tract injuries seem to occur often enough to be a management problem, and yet, not so frequently as to be routine. Consequently, the managing physician may have a degree of uncertainty in evaluating a urinary tract injury. Several factors may change the management of such injuries from that of a university or metropolitan hospital; specifically, the limitations of a small blood bank, the lack of emergency aortography and, perhaps, the absence of urological expertise. However, these factors do not necessarily compromise the care of the patient with an injured urinary tract. In this article, eight illustrative cases of urinary tract injuries will be presented. These injuries occurred in a three year period from 1975 to 1978 and were treated at Montrose Memorial Hospital. Despite a lack of extensive experience, these cases show the advantages of conservative management in such a rural setting. Adequate radiographic diagnosis is the key to satisfactory management of genitourinary injuries whatever the location. In the excitement of treating an acutely injured patient, the urinary tract is frequent overlooked and satisfactory x-ray films are not obtained. Any standard surgical text describes injuries associated with the urinary tract. However for a brief review, penetrating upper abdominal or lower chest injuries, injuries to the flank, fractured ribs, and fractured spine, particularly fractures of the transverse processes of the lower thoracic or lumbar spine as seen in x-ray films, are findings frequently associated with renal injuries. Injuries to the lower abdomen, particularly penetrating or crush injuries, should alert one to the possibility of a bladder injury. Posterior m:ethral injuries are commonly seen with a fractured pelvis. Blood coming from the urethral meatus is usually a sign of injury to the urethra. However, it is hematuria, either gross or microscopic, thl',l.t is the key finding. This alerts the physician to the probability of a genitourinary tract injury. Absence of blood in the urine does not absolutely exclude a genitourinary injury, however. *Urologist, Montrose Memorial Hospital, Montros~. Colorado
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In a review of injuries at Parkland Hospital, 5 of 109 patients did not have hematuria with a renal injury. If a renal injury is suspected, further x-ray examination should proceed. All patients with blood in the urine require further x-ray evaluation. An intravenous pyelogram can be rapidly performed in the emergency room as soon as the patient is stabilized and out of shock. An infusion intravenous pyelogram, involving rapid infusion of 1 ml per lb of a 30 per cent iodinated solution of contrast material, is preferred in most trauma units. However, a double-dose, single shot injection will usually give adequate films, using 100 cc of Renografin-60 or 50 per cent Hypaque solutions (standard intravenous pyelogram contrast material). The single shot technique has been found to be more practical, since it is fast and the contrast material is usually readily available. Films should be taken at 1, 5, 15, and 20 minutes after injection of the contrast material. If the patient is unstable, a single abdominal film can be taken 10 minutes after the injection of contrast material to evaluate overall renal function and to estimate the extent of damage. Nonfunction is the most common indicator of a major renal injury. A cystogram should also be obtained at this time. A Foley catheter is inserted into the bladder and a 15 per cent iodine-containing contrast material (Cystografin) is instilled into the bladder under gravity flow. Approximately 250 to 300 cc of contrast material is instilled into the bladder, the catheter is clamped, and a film is taken. Oblique films are helpful here if the patient's condition permits. If the patient has a fractured pelvis or blood coming from the urethra, or if the catheter cannot be easily ihserted, a retrograde urethrogram is needed. This study is obtained by slowly injecting 20 cc of Renografin-60 or 50 per cent Hypaque solution into the urethral meatus and taking a film as the injection is ending. A Christmas-tree adapter is useful to obtain an adequate seal while injecting the contrast material. If possible, the patient should be in an oblique position when this film is taken. These three x-ray examinations can be obtained in a 20 minute period as the patient is being stabilized and prepared for possible surgery. It is important to keep in mind the possibility of a genitourinary injury and to perform these examinations without fail. In the heat of the emergency room battle, this is not always easy. Further evaluation with emergency aortography, renal scan, and an echogram are normally not available in the average small hospital. Retrograde pyelograms are rarely useful.
RENAL INJURIES Renal injuries may be penetrating or blunt. Most penetrating injuries in a small hospital setting are the result of gunshot wounds. Blunt injuries are seen most commonly after automobile accidents, and occasionally after falls or horseback injuries. Most urologists find it useful to divide renal injuries into three types: minor, intermediate, and major. A minor injury is a contusion or SUp(;!rficiallaceration of the parenchyma. A major injury is a "shattered" kidney or a pedicle injury
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Minor renal trauma
Major renal trauma
Intermediate Renal Trauma
Figure 1. Minor renal injuries. A, Simple laceration. B, Subcapsular hematoma. C, Renal contusion. Major renal injuries. A, Renal rupture. B, Laceration of renal artery and vein. Intermediate renal trauma. C, Perirenal hematoma. D, Laceration through collecting system. (From Peters, P. C., and Bright, T. C., III: Blunt renal injuries. Urol. Clin. North Am., 4:19, 1977, with permission.)
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(Fig. 1, bottom, A and B). An intermediate injury is a significant renal laceration and/or an injury to the collecting system (Fig. 1, bottom, C and D).
PENETRATING RENAL I:r-uuRIES
Case 1 A 17 year old white man was shot in the abdomen with a high velocity deer rifle at close range. On arrival in the emergency room, blood pressure was 90/60, pulse was llO, and respiration was 16. Physical examination showed a 1 em entrance wound in the right upper quadrant with a large 10 em exit wound in the right lumbar area. The urine was blood-tinged. After stabilization with intravenous fluids, a double-dose, single-film intravenous pyelogram was obtained which showed marked extravasation in the right flank. The right renal outline could not be seen, but the left kidney appeared to be normal. After transfusion, exploration of the abdomen revealed multiple shrapnel perforations of the transverse colon and the ileum, and a large perforation of the second portion of the duodenum. The right renal artery and vein were cross-clamped with a vascular clamp and Gerota's fascia completely opened. The renal pelvis was completely blown away. However, the kidney appeared to be grossly normal. After much discussion, nephrectomy was elected, followed by resection of the transverse colon with colostomy, and a small bowel resection with reanastomosis. A drainage tube was placed in the doudenum, and a gastrostomy tube was inserted. Postoperatively, the patient did well and eventually recovered. The colostomy was closed several months after the injury.
Discussion Penetrating renal injuries are associated with intra-abdominal visceral injuries in 80 per cent of cases, and are almost routinely explored. It may not be necessary to explore the kidney, however, if the preliminary intravenous pyelogram shows only a minor injury. In a retrospective review of penetrating renal injuries, Whitney and Peterson felt that 61 per cent of the injuries were minor and did not require retroperitoneal exploration at the time of abdominal exploration.9 Nonfunction on the intravenous pyelogram is usually seen with a major renal injury. Diminished function is usually seen with a minor injury. As a general rule, if the intravenous pyelogram suggests only a minor injury and there is no significant bleeding in the retroperitoneum at the time of abdominal exploration, retroperitoneal exploration is not needed and the surgeon can direct his attention elsewhere. If the intravenous pyelogram indicates a major or intermediate injury or if there is a large retroperitoneal hematoma at the time of exploration, concomitant retroperitoneal exploration should be performed to stop bleeding and to drain the retroperitoneum. Prior control of the renal vascular pedicle must be obtained before opening the Gerota's fascia. Failure to do so will allow significant bleeding to occur and, most likely, result in a need for nephrectomy to stop the bleeding. The repair of a major injury consists of a water-tight closure of a collecting system injury, oversewing of major lacerations and bleeding sites, and debridement of devascularized tissue. If the patient has a polar injury, a partial nephrectomy can be performed (Fig. 2).
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Figure 2. Repair of polar rupture. A, Guillotine amputation of macerated or devitalized renal parenchyma. B, Suture of collecting system with continuous interlocking suture, and individual arcuate artery ligation. C, Closure of renal capsule over operative defect. (From Peters, P. C., and Bright, T. C., III: Blunt renal injuries. Urol. Clin. North Am., 4:23, 1977, with permission.)
In this particular patient, it was elected to remove the kidney rather than repair it. Several factors entered into this decision, specifically, the large duodenal injury, the two bowel anastomoses, and particularly, the inability to determine the exact demarcation of i..J.jury to the renal pelvis, upper ureter, and kidney. Combined renal and pancreatic, or duodenal injuries can be managed with repair and concomitant use of a nephrostomy tube with a ureteral stent and adequate drainage. Guerriero et al. have managed these injuries in this manner. 3 They have not had to perform a secondary nephrectomy in spite of a 20 per cent rate of pancreatic fistula. Had this same injury in the above patient been produced by a low caliber bullet or knife, then repair with a nephrostomy tube would probably have been the procedure of choice. BLUNT RENAL I~URIES
Case 2 A 25 year old white woman was thrown off a motorcycle after colliding with a car. She was transported 80 miles to the hospital by way of ambulance and was in severe shock upon arrival in the emergency room. There was no obtainable blood pressure and the pulse was 140. On examination, the patient was comatose. The abdomen was mildly distended. She had an obvious fracture of the left femur. There was no evidence of a head injury. Upon insertion of a Foley catheter, the urine was grossly bloody. She was resuscitated with intravenous fluids and typed-specific uncrossmatched blood. After the patient was out of shock and arrangements were being made for surgery, an emer-
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gency cystogram and intravenous pyelogram were obtained. The intravenous pyelogram showed a nonfunctioning left kidney and a normal right kidney. An abdominal peritoneal lavage was performed and the fluid was grossly bloody. The patient was taken to the operating room 50 minutes after arrival in the emergency room. A xyphoid to pubis incision was made. There was a copious amount of blood in the abdominal cavity. A ruptured speen was removed. She had a massive right-sided retroperitoneal hematoma. The kidney was essentially shattered and could not be repaired, and was therefore removed. Postoperatively, the patient did well.
Discussion In our setting the management of blunt renal injuries depends upon the clinical condition of the patient. If the patient is clinically unstable, then bleeding is occurring and must be stopped. Major bleeding is usually associated intra-abdominal bleeding. Norton and Peterson found a 25 per cent incidence of splenic injuries with left-sided renal injury and a 40 per cent incidence of hepatic injury with rightsided renal injury. 7 Such an associated injury can usually be anticipated in the unstable patient with demonstrable renal trauma. The intravenous pyelogram was useful in this patient to assess the presence of a normally functioning right kidney and to indicate a major injury to the left kidney. It is not possible in our hospital to perform aortography in less than two to three hours, thus making it impractical in an unstable patient. The management of a major renal injury in an unstable patient consists of abdominal exploration through a xyphoid to pubis incision, control of abdominal bleeding, and vascular clamping of the appropriate renal artery and vein. Exactly what to do with the injured kidney will depend upon the type of injury. As with penetrating injuries, devascularized tissue should be debrided, and major lacerations and bleeders oversewn. Polar injuries can be treated with a partial nephrectomy. The collecting system must be closed in a water-tight fashion. A shattered kidney should be removed. An injury to the renal pedicle can also be repaired. Early control of the vascular pedicle is the key to avoiding major bleeding and to intelligent management of any renal injury. Whereas intermediate or major blunt renal injuries in the unstable patient must be managed operatively to stop bleeding, such injuries in the stable patient can be managed "expectantly." This means close observation with frequent monitoring of the blood pressure, pulse, and hematocrit, and evaluation of the size and change of any flank mass. If the condition of the patient deteriorates, with a persistent fall in blood pressure or if more than 2,000 cc of blood must be given within a 24 hour period in order to maintain a stable hematocrit, then surgery should be performed to stop the bleeding. Considerable controversy exists in the literature regarding the management of intermediate renal injury. In many major medical centers, traumatologists employ emergency aortography to define the extent of injury and advocate operative intervention to debride and repair the kidney. They point out that such management leads to earlier recovery and fewer complications.
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The conservative camp of noninterventionists believes that many of these renal injuries are needlessly explored and have a higher rate of nephrectomy than if they had been left alone and managed expectantly. They point out that deaths from isolated renal injury are rare, that kidney bleeding is usually tamponaded in the retroperitoneum, and that the kidney has an amazing ability to repair itself. For example, in Thompson's series of 43 patients with major parenchymal injury who were managed conservatively, only two patients subsequently required surgical exploration, one at three weeks and one at six weeks after injury. 8 These patients subsequently did well. The 41 patients managed nonoperatively and expectantly did well without major problems or hypertension in the late postoperative period. Since this type of patient can be demonstrated to do well with conservative management, I believe that the clinically stable patient with an intermediate renal injury should be managed expectantly and nonoperatively in a small hospital setting. Major injuries will usually require nephrectomy.
Case 3 A 78 year old white man was hit by a pick-up truck while crossing the street. Initial examination in the emergency room revealed an alert elderly man who was short of breath and complaining of left-sided chest pain. There was crepitance to palpation on the left chest wall. The lungs sounded clear. The abdomen was slightly distended and there was an abrasion over the left flank. A catheter was inserted and the urine was grossly bloodly. Peritoneal lavage was bloody. An emergency intravenous pyelogram showed diminished function of the left kidney with poor visualization of the upper pole collecting system and renal outline. Exploratory laparotomy disclosed a lacerated spleen which was removed. There was no visible hematoma in the retroperitoneum and the kidney felt normal to palpation. It was elected to leave the kidney alone and retroperitoneal exploration was not done. Postoperatively, the urine gradually cleared. On the fourth postoperative day the urine was grossly clear. The patient was eventually discharged from the hospital. Two months after the injury, an intravenous pyelogram was normal and the patient was normotensive.
Discussion In this patient, surgery was performed because of a bloody abdominal tap. The patient was found to have a coexistent renal injury with bleeding into the collective system. The intravenous pyelogram was consistent with a minor injury to the left kidney. This information coupled with a normal appearing retroperitoneum led us to classify the injury as minor and to the decision to leave the kidney alone. This case illustrates that renal exploration is not absolutely necessary in every renal injury and that the kidney can recover from such trauma if left alone.
Case 4 A 25 year old white man was involved in an automobile accident and sustained multiple injuries, including multiple facial lacerations, a fractured rib with pneumothorax, a dislocated hip, a pelvic separation, and laceration of the knee joint. A Foley catheter was inserted in the emergency room with ease. The urine was grossly clear but showed microscopic hematuria. After stabilization the multiple facial lacerations were repaired, the wound was debrided, and
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the dislocated hip was reduced in the operating room. Because of microscopic hematuria, an intravenous pyelogram and cystogram were obtained. The cystogram was normal but the intravenous pyelogram showed a nonfunctioning right kidney. At this point, the patient was clinically stable. An arteriogram was performed which showed a thin, attenuated renal artery with branching, typical of a hydronephrotic kidney. The patient was managed conservatively with frequent monitoring of the hematocrit and vital signs. He recovered uneventfully. At a later date, a retrograde pyelogram disclosed a high grade congenital obstruction of the ureteropelvic junction with a hydronephrotic shell. This was eventually removed because of pain and infection.
Discussion In our institution, emergency aortography is not available. However, with encouragement a study can usually be obtained two to three hours after admission. Since the decision to operate or not to operate is made on the clinical condition of the patient, the study is not usually performed. However, if the intravenous pyelogram shows lack of function, an injury to the renal pedicle must be considered, specifically, disruption of the intima of the renal artery with thrombosis of the renal artery. This situation is rare. Arteriographic films will typically show the renal artery ending abruptly 1 to 2 em from its aortic origin. Correction of this problem requires the skill of someone with expertise in vascular surgery. Usually the clot is removed and a vein patch-graft is placed in the region of the injury. Aortography can also be used to help evaluate a major renal injury in a stable patient, but arteriographic findings should not be used as the sole criteria to decide whether or not to operate. Case 5 A 22 year old white woman fell off a horse. There were no obvious injuries other than an abrasion over the flank, although the patient struck her head when she fell and was knocked unconscious. She was admitted to the hospital for observation. Initial urinalysis showed microscopic hematuria. An intravenous pyelogram was normal. The patient was discharged from the hospital the following day, and was followed as an outpatient. The urine was clear five days after the injury.
Discussion Minor injuries constitute 80 to 85 per cent of all genitourinary injuries, and can be safely managed conservatively. The intravenous pyelogram may appear normal, show a small amount of extravasation, or show diminished function as in Case 3. If the patient has only microscopic hematuria, he may be discharged and followed as an outpatient. If the urine is grossly bloody, he should be treated with bed rest and followed closely with serial hematocrits, urinalyses, and frequent monitoring of the vital signs. The patient may be discharged when the urine is seen to be grossly clear. Summary Most variations of renal injury will be seen even in a small hospital setting. Minor injuries can be treated conservatively. Intermediate injuries in the stable patient can be watched closely. Surgery is not nee-
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Unstable Patient
Normal IVP
~
~ ~
Abnormal IVP
Minor Changes (Case 3)
~
Nonvisualization or Major Extravasation
I
Conservative (Leave Retroperitoneum Alone)
Renal Exploration
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Nephrectomy or Repair (Cases 1 and 2)
Stable Patient
Gross Hematuria
Microscopic Hematuria
/
I Normal IVP
I Home and Follow as Outpatient
Abnormal IVP Minor
ExLavasa~onvisualization
or Major Extravasation (Case 4)
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Arteriogram
~I
Conservative Management
Intact Vasculaturc
I
Conservative Management (Case 4)
Vasculature Interrupted
I Exploration
Figure 3. Blunt renal injuries. (Modified from Peters, P. C., Bright, T. C., III: Blunt renal injuries. Urol. Clin. North Am., 4:22, 1977.)
essary unless the patient's clinical condition deteriorates and he later develops infections or a large urinoma. If the patient's initial clinical condition is unstable and the intravenous pyelogram suggests a major or intermediate injury, then renal exploration and repair are performed with control of the renal pedicle prior to the opening of Gerota's fascia. Aortography is useful in evaluating a stable patient with a nonfunctioning kidney and may diagnose thrombosis of the renal artery (Fig. 3)
URETERAL INJURIES Ureteral injuries are uncommon in the small hospital. We have seen only one in the last four years. The management of such injuries, if they do occur, is no different from management in the metropolitan
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Figure 4. Technique of primary spatulated watertight ureteral anastomosis. (From Carlton, C. E.: Injuries to the ureter. Urol. Clin. North Am., 4:43, 1977, with permission.)
hospital. If possible, primary realignment with spatulation of both ends and a water-tight closure of the ureter should be accomplished (Fig. 4). Stents are not necessary unless there is an underlying abnormality of the ureter caused by prior radiation or severe infection, or unless there is possible ischemia of the severed ends. The area of injury should be adequately drained. If the injury occurs in the distal ureter near the ureterovesical junction, as usually occurs in gynecologic surgery, it is frequently easier to reimplant the ureter into the bladder than to attempt primary realignment to a small and usually shredded distal ureter. Another option available to the surgeon if the ureter cannot be realigned or reimplanted into the bladder is to connect it to the opposite ureter. A tunnel is made beneath the posterior
Figure 5. Technique of transureteroureterostomy. (From Carlton, C. E.: Injuries to the ureter. Urol. Clin. North Am., 4:41, 1977, with permi~sion.)
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peritoneum above the bifurcation of the aorta and the injured ureter is sutured in a water-tight fashion to the opposite ureter (Fig. 5). This should be performed only if other options are not available as there is a risk of damage to the contralateral ureter.
Case 6 A 34 year old white woman, gravida IV, para III, required an emergency cesarean section because of fetal distress. The uterus failed to contract normally, and the patient bled extensively postoperatively. Because of significant persistent bleeding, she was taken back to the operating room where an emergency hysterectomy was performed. In the course of performing this procedure, the right ureter was transected below the iliac vessels. The injury was repaired with a running stitch of 4-0 chromic suture and a Penrose drain was brought up laterally to drain the area. A stent was not used. Postoperatively, urine drained through the Penrose drain for four to five days and then stopped. A follow-up intranvenous pyelogram at six weeks showed partial obstruction at the area of repair. A repeat intravenous pyelogram at three months after the repair was normal.
BLADDER INJURIES Bladder injuries are diagnosed with a cystogram. This study should be performed in the emergency room at the time of initial radiographic evaluation of the patient suspected of having a genitourinary injury, as previously discussed. Bladder injuries are managed in a standard fashion with repair of the injury, insertion of a suprapubic tube, and drainage of the perivesical space. Healing generally takes seven to 10 days.
Case 7 A 17 year, old white man fell from a haystacker onto a steel pole which entered the rectum. In the emergency room, blood was coming from the rectum. A cathe~r was inserted and the urine was grossly bloody. A cystogram showed a large amount of air in the bladder and a small amount of extravasation. The intravenous pyelogram was normal. Exploration showed a bladder perforation immediately behind the trigone, which was closed in two layers. A suprapubic tube was inserted. The injury to the anterior rectal wall was repaired and omentum was interposed between the rectum and the bladder. A loop colostomy was also performed and the pelvis was drained with a Penrose drain. Postoperatively, the patient did well. The catheter was removed 10 days postoperatively. His colostomy was closed two and one half months later. A follow-up cystogram and intravenous pyelogram were completely normal.
POSTERIOR URETHRAL INJURIES Injuries to the posterior urethra usually occur in association with a pelvic fracture. Any patient with an obvious pelvic fracture or blood coming from the urethral meatus should be suspected of having a torn posterior urethra. If such an injury is suspected, a retrograde urethrogram should be performed prior to attempted insertion of a Foley catheter. Blind catheterization may enlarge a partial urethral tear into a complete one.
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If the clinical condition of the patient does not permit this x-ray study, a single attempt at catheterization should be made by an experienced physician. If the catheter does not easily enter the bladder, then a retrograde urethrogram must be performed to evaluate the problem further. A urethrogram is easily performed by injecting 20 cc of any radiographic contrast material into the urethral meatus as described previously. The management of such an injury is controversial. The classical management has been an attempt at primary realignment. However more recently, McKinnon and coworkers in Montreal have suggested simple insertion of a suprapubic tube, leaving the urethra and pelvic hematoma alone. 4 Their argument is that many urethral tears are only partial initially and attempts at primary reconstruction may further damage the urethra. Furthermore, they point out that the incidence of urinary incontinence or impotency is greater in a series of patients in whom attempts at primary reconstruction were made than in patients who simply had a suprapubic tube inserted. In their series of 41 patients treated by insertion of a suprapubic tube, 39 had complete tears of the posterior urethra. After a urethroplasty was performed three to four months later, 40 of these patients were continent without stricture and one patient had stress incontinence. Thirty-six patients had satisfactory potency after the urethroplasty. Since satisfactory results can be obtained with conservative management, I think that there is little doubt that this injury should be treated conservatively in a small community hospital, that is, by simple insertion of a suprapubic tube. Further repair of the stricture, when necessary, may be performed three to four months later by a urologist with expertise in this type of injury.
Case 8 A 33 year old white man fell off the roof of a two-story house, fracturing both arms and sustaining a pelvic fracture with mild separation of the pubic symphysis. The patient was unable to void during the first 10 hours of hospitalization and became uncomfortable with a distended bladder. An attempt to catheterize the patient was not successful. A suprapubic cystocatheter was inserted. Urologic consultation was requested. A retrograde urethrogram showed mild extravasation of the posterior urethra. A cystogram showed the bladder in normal position. Upon rectal examination, the prostate felt normal and was in normal position. A suprapubic tube was inserted. Three months after the injury a short stricture of the membranous urethra was repaired and the patient did well. He had no voiding or potency problems six and 12 months after the repair.
SUMMARY The spectrum of genitourinary injuries seen in a small community hospital over the past three years is presented. With the exception of the obvious ureteral injury, the key factor in management is adequate x-ray diagnosis. This allows the physician to estimate the type and extent of injury. In the clinically stable patient, renal injuries can be managed conservatively. However, in our experience a major renal
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injury is usually associated with major intra-abdominal injury and these patients require exploration. Bladder injuries may be diagnosed with a cystogram, and repaired. Posterior urethral injuries may be managed initially by simple insertion of a suprapubic tube.
REFERENCES J., and Leadbetter, G. W.: Traumatic renal artery thrombosis. J. Urol., 109:769, 1973. Carlton, C. E.: Injuries to the ureter. Urol. Clin. North Am., 4:33, 1977. Guerriero, W. C.: Penetrating renal injuries and management of renal pedicle injury. Urol. Clin. North Am., 4:3, 1977. . Morehouse, D. G., and MacKinnon, K. J. Posterior urethral injury: Etiology, diagnosis, initial management. Urol. Clin. North Am., 4:69, 1977. Peters, P. C., and Bright, T. C. III: Blunt renal injuries. Urol. Clin. North. Am., 4:17, 1977. Peterson, N. E., and Kiracofe, L. N.: Renal trauma-when to operate. Urology, 3:537, 1974. Peterson, N. E., and Norton, L. W.: Injuries associated with renal trauma. J. Urol., 109:766, 1973. Thompson, I. A.: Expectant management of blunt renal trauma. Urol. Clin. North Am., 4:29, 1977. Whitney, R. F., and Peterson, N. E.: Penetrating renal injuries. Urology, 7:7, 1976.
1. Caponegro, P.
2. 3. 4. 5. 6. 7. 8. 9.
Montrose Memorial Hospital 800 South Third Street Montrose, Colorado 81401
CoMMENTARY
Norman Peterson, M.D.* Dr. Shannon's discussion underscores the value and importance of pragmatism and practicality in such matters, and he is to be congratulated. The frenetic atmosphere surrounding the multiply traumatized patient too often results in obscurement of urologic injury or deliberate assignment of lesser priority; Dr. Shannon has suggested this to be unnecessary, and further emphasizes the relative simplicity of adequate evaluation and optimum management. Appreciation of a general classification scheme allows effective triage, particularly when reliable classification is possible on the basis of only three factors: degree of hemorrhage, radiographic features, and overall clinical status. Mild or transient hematuria and urographic function characterize minor injuries consisting of renal contusions and minor lacerations (70 per cent); intermediate injuries (20 per cent) are similar; laceration (100 per cent) and extravasation (40 to 60 per cent) are the major distinguishing radiographic features. Both groups respond favorably to nonoperative management. Major injuries (10 per cent) are generally urographically functionless, while hemorrhage in the urine or retroperitoneum may be excessive (from parenchymal shattering) or slight (from pedicle interruption); further diagnostic studies or operative *Denver General Hospital, Denver, Colorado
Management of Genitourinary Trauma Richard D. Shanrwn, M.D., F A.C.S. *
In a small hospital setting, genitourinary tract injuries seem to occur often enough to be a management problem, and yet, not so frequently as to be routine. Consequently, the managing physician may have a degree of uncertainty in evaluating a urinary tract injury. Several factors may change the management of such injuries from that of a university or metropolitan hospital; specifically, the limitations of a small blood bank, the lack of emergency aortography and, perhaps, the absence of urological expertise. However, these factors do not necessarily compromise the care of the patient with an injured urinary tract. In this article, eight illustrative cases of urinary tract injuries will be presented. These injuries occurred in a three year period from 1975 to 1978 and were treated at Montrose Memorial Hospital. Despite a lack of extensive experience, these cases show the advantages of conservative management in such a rural setting. Adequate radiographic diagnosis is the key to satisfactory management of genitourinary injuries whatever the location. In the excitement of treating an acutely injured patient, the urinary tract is frequent overlooked and satisfactory x-ray films are not obtained. Any standard surgical text describes injuries associated with the urinary tract. However for a brief review, penetrating upper abdominal or lower chest injuries, injuries to the flank, fractured ribs, and fractured spine, particularly fractures of the transverse processes of the lower thoracic or lumbar spine as seen in x-ray films, are findings frequently associated with renal injuries. Injuries to the lower abdomen, particularly penetrating or crush injuries, should alert one to the possibility of a bladder injury. Posterior m:ethral injuries are commonly seen with a fractured pelvis. Blood coming from the urethral meatus is usually a sign of injury to the urethra. However, it is hematuria, either gross or microscopic, thl',l.t is the key finding. This alerts the physician to the probability of a genitourinary tract injury. Absence of blood in the urine does not absolutely exclude a genitourinary injury, however. *Urologist, Montrose Memorial Hospital, Montros~. Colorado
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In a review of injuries at Parkland Hospital, 5 of 109 patients did not have hematuria with a renal injury. If a renal injury is suspected, further x-ray examination should proceed. All patients with blood in the urine require further x-ray evaluation. An intravenous pyelogram can be rapidly performed in the emergency room as soon as the patient is stabilized and out of shock. An infusion intravenous pyelogram, involving rapid infusion of 1 ml per lb of a 30 per cent iodinated solution of contrast material, is preferred in most trauma units. However, a double-dose, single shot injection will usually give adequate films, using 100 cc of Renografin-60 or 50 per cent Hypaque solutions (standard intravenous pyelogram contrast material). The single shot technique has been found to be more practical, since it is fast and the contrast material is usually readily available. Films should be taken at 1, 5, 15, and 20 minutes after injection of the contrast material. If the patient is unstable, a single abdominal film can be taken 10 minutes after the injection of contrast material to evaluate overall renal function and to estimate the extent of damage. Nonfunction is the most common indicator of a major renal injury. A cystogram should also be obtained at this time. A Foley catheter is inserted into the bladder and a 15 per cent iodine-containing contrast material (Cystografin) is instilled into the bladder under gravity flow. Approximately 250 to 300 cc of contrast material is instilled into the bladder, the catheter is clamped, and a film is taken. Oblique films are helpful here if the patient's condition permits. If the patient has a fractured pelvis or blood coming from the urethra, or if the catheter cannot be easily ihserted, a retrograde urethrogram is needed. This study is obtained by slowly injecting 20 cc of Renografin-60 or 50 per cent Hypaque solution into the urethral meatus and taking a film as the injection is ending. A Christmas-tree adapter is useful to obtain an adequate seal while injecting the contrast material. If possible, the patient should be in an oblique position when this film is taken. These three x-ray examinations can be obtained in a 20 minute period as the patient is being stabilized and prepared for possible surgery. It is important to keep in mind the possibility of a genitourinary injury and to perform these examinations without fail. In the heat of the emergency room battle, this is not always easy. Further evaluation with emergency aortography, renal scan, and an echogram are normally not available in the average small hospital. Retrograde pyelograms are rarely useful.
RENAL INJURIES Renal injuries may be penetrating or blunt. Most penetrating injuries in a small hospital setting are the result of gunshot wounds. Blunt injuries are seen most commonly after automobile accidents, and occasionally after falls or horseback injuries. Most urologists find it useful to divide renal injuries into three types: minor, intermediate, and major. A minor injury is a contusion or SUp(;!rficiallaceration of the parenchyma. A major injury is a "shattered" kidney or a pedicle injury
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Minor renal trauma
Major renal trauma
Intermediate Renal Trauma
Figure 1. Minor renal injuries. A, Simple laceration. B, Subcapsular hematoma. C, Renal contusion. Major renal injuries. A, Renal rupture. B, Laceration of renal artery and vein. Intermediate renal trauma. C, Perirenal hematoma. D, Laceration through collecting system. (From Peters, P. C., and Bright, T. C., III: Blunt renal injuries. Urol. Clin. North Am., 4:19, 1977, with permission.)
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(Fig. 1, bottom, A and B). An intermediate injury is a significant renal laceration and/or an injury to the collecting system (Fig. 1, bottom, C and D).
PENETRATING RENAL I:r-uuRIES
Case 1 A 17 year old white man was shot in the abdomen with a high velocity deer rifle at close range. On arrival in the emergency room, blood pressure was 90/60, pulse was llO, and respiration was 16. Physical examination showed a 1 em entrance wound in the right upper quadrant with a large 10 em exit wound in the right lumbar area. The urine was blood-tinged. After stabilization with intravenous fluids, a double-dose, single-film intravenous pyelogram was obtained which showed marked extravasation in the right flank. The right renal outline could not be seen, but the left kidney appeared to be normal. After transfusion, exploration of the abdomen revealed multiple shrapnel perforations of the transverse colon and the ileum, and a large perforation of the second portion of the duodenum. The right renal artery and vein were cross-clamped with a vascular clamp and Gerota's fascia completely opened. The renal pelvis was completely blown away. However, the kidney appeared to be grossly normal. After much discussion, nephrectomy was elected, followed by resection of the transverse colon with colostomy, and a small bowel resection with reanastomosis. A drainage tube was placed in the doudenum, and a gastrostomy tube was inserted. Postoperatively, the patient did well and eventually recovered. The colostomy was closed several months after the injury.
Discussion Penetrating renal injuries are associated with intra-abdominal visceral injuries in 80 per cent of cases, and are almost routinely explored. It may not be necessary to explore the kidney, however, if the preliminary intravenous pyelogram shows only a minor injury. In a retrospective review of penetrating renal injuries, Whitney and Peterson felt that 61 per cent of the injuries were minor and did not require retroperitoneal exploration at the time of abdominal exploration.9 Nonfunction on the intravenous pyelogram is usually seen with a major renal injury. Diminished function is usually seen with a minor injury. As a general rule, if the intravenous pyelogram suggests only a minor injury and there is no significant bleeding in the retroperitoneum at the time of abdominal exploration, retroperitoneal exploration is not needed and the surgeon can direct his attention elsewhere. If the intravenous pyelogram indicates a major or intermediate injury or if there is a large retroperitoneal hematoma at the time of exploration, concomitant retroperitoneal exploration should be performed to stop bleeding and to drain the retroperitoneum. Prior control of the renal vascular pedicle must be obtained before opening the Gerota's fascia. Failure to do so will allow significant bleeding to occur and, most likely, result in a need for nephrectomy to stop the bleeding. The repair of a major injury consists of a water-tight closure of a collecting system injury, oversewing of major lacerations and bleeding sites, and debridement of devascularized tissue. If the patient has a polar injury, a partial nephrectomy can be performed (Fig. 2).
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Figure 2. Repair of polar rupture. A, Guillotine amputation of macerated or devitalized renal parenchyma. B, Suture of collecting system with continuous interlocking suture, and individual arcuate artery ligation. C, Closure of renal capsule over operative defect. (From Peters, P. C., and Bright, T. C., III: Blunt renal injuries. Urol. Clin. North Am., 4:23, 1977, with permission.)
In this particular patient, it was elected to remove the kidney rather than repair it. Several factors entered into this decision, specifically, the large duodenal injury, the two bowel anastomoses, and particularly, the inability to determine the exact demarcation of i..J.jury to the renal pelvis, upper ureter, and kidney. Combined renal and pancreatic, or duodenal injuries can be managed with repair and concomitant use of a nephrostomy tube with a ureteral stent and adequate drainage. Guerriero et al. have managed these injuries in this manner. 3 They have not had to perform a secondary nephrectomy in spite of a 20 per cent rate of pancreatic fistula. Had this same injury in the above patient been produced by a low caliber bullet or knife, then repair with a nephrostomy tube would probably have been the procedure of choice. BLUNT RENAL I~URIES
Case 2 A 25 year old white woman was thrown off a motorcycle after colliding with a car. She was transported 80 miles to the hospital by way of ambulance and was in severe shock upon arrival in the emergency room. There was no obtainable blood pressure and the pulse was 140. On examination, the patient was comatose. The abdomen was mildly distended. She had an obvious fracture of the left femur. There was no evidence of a head injury. Upon insertion of a Foley catheter, the urine was grossly bloody. She was resuscitated with intravenous fluids and typed-specific uncrossmatched blood. After the patient was out of shock and arrangements were being made for surgery, an emer-
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gency cystogram and intravenous pyelogram were obtained. The intravenous pyelogram showed a nonfunctioning left kidney and a normal right kidney. An abdominal peritoneal lavage was performed and the fluid was grossly bloody. The patient was taken to the operating room 50 minutes after arrival in the emergency room. A xyphoid to pubis incision was made. There was a copious amount of blood in the abdominal cavity. A ruptured speen was removed. She had a massive right-sided retroperitoneal hematoma. The kidney was essentially shattered and could not be repaired, and was therefore removed. Postoperatively, the patient did well.
Discussion In our setting the management of blunt renal injuries depends upon the clinical condition of the patient. If the patient is clinically unstable, then bleeding is occurring and must be stopped. Major bleeding is usually associated intra-abdominal bleeding. Norton and Peterson found a 25 per cent incidence of splenic injuries with left-sided renal injury and a 40 per cent incidence of hepatic injury with rightsided renal injury. 7 Such an associated injury can usually be anticipated in the unstable patient with demonstrable renal trauma. The intravenous pyelogram was useful in this patient to assess the presence of a normally functioning right kidney and to indicate a major injury to the left kidney. It is not possible in our hospital to perform aortography in less than two to three hours, thus making it impractical in an unstable patient. The management of a major renal injury in an unstable patient consists of abdominal exploration through a xyphoid to pubis incision, control of abdominal bleeding, and vascular clamping of the appropriate renal artery and vein. Exactly what to do with the injured kidney will depend upon the type of injury. As with penetrating injuries, devascularized tissue should be debrided, and major lacerations and bleeders oversewn. Polar injuries can be treated with a partial nephrectomy. The collecting system must be closed in a water-tight fashion. A shattered kidney should be removed. An injury to the renal pedicle can also be repaired. Early control of the vascular pedicle is the key to avoiding major bleeding and to intelligent management of any renal injury. Whereas intermediate or major blunt renal injuries in the unstable patient must be managed operatively to stop bleeding, such injuries in the stable patient can be managed "expectantly." This means close observation with frequent monitoring of the blood pressure, pulse, and hematocrit, and evaluation of the size and change of any flank mass. If the condition of the patient deteriorates, with a persistent fall in blood pressure or if more than 2,000 cc of blood must be given within a 24 hour period in order to maintain a stable hematocrit, then surgery should be performed to stop the bleeding. Considerable controversy exists in the literature regarding the management of intermediate renal injury. In many major medical centers, traumatologists employ emergency aortography to define the extent of injury and advocate operative intervention to debride and repair the kidney. They point out that such management leads to earlier recovery and fewer complications.
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The conservative camp of noninterventionists believes that many of these renal injuries are needlessly explored and have a higher rate of nephrectomy than if they had been left alone and managed expectantly. They point out that deaths from isolated renal injury are rare, that kidney bleeding is usually tamponaded in the retroperitoneum, and that the kidney has an amazing ability to repair itself. For example, in Thompson's series of 43 patients with major parenchymal injury who were managed conservatively, only two patients subsequently required surgical exploration, one at three weeks and one at six weeks after injury. 8 These patients subsequently did well. The 41 patients managed nonoperatively and expectantly did well without major problems or hypertension in the late postoperative period. Since this type of patient can be demonstrated to do well with conservative management, I believe that the clinically stable patient with an intermediate renal injury should be managed expectantly and nonoperatively in a small hospital setting. Major injuries will usually require nephrectomy.
Case 3 A 78 year old white man was hit by a pick-up truck while crossing the street. Initial examination in the emergency room revealed an alert elderly man who was short of breath and complaining of left-sided chest pain. There was crepitance to palpation on the left chest wall. The lungs sounded clear. The abdomen was slightly distended and there was an abrasion over the left flank. A catheter was inserted and the urine was grossly bloodly. Peritoneal lavage was bloody. An emergency intravenous pyelogram showed diminished function of the left kidney with poor visualization of the upper pole collecting system and renal outline. Exploratory laparotomy disclosed a lacerated spleen which was removed. There was no visible hematoma in the retroperitoneum and the kidney felt normal to palpation. It was elected to leave the kidney alone and retroperitoneal exploration was not done. Postoperatively, the urine gradually cleared. On the fourth postoperative day the urine was grossly clear. The patient was eventually discharged from the hospital. Two months after the injury, an intravenous pyelogram was normal and the patient was normotensive.
Discussion In this patient, surgery was performed because of a bloody abdominal tap. The patient was found to have a coexistent renal injury with bleeding into the collective system. The intravenous pyelogram was consistent with a minor injury to the left kidney. This information coupled with a normal appearing retroperitoneum led us to classify the injury as minor and to the decision to leave the kidney alone. This case illustrates that renal exploration is not absolutely necessary in every renal injury and that the kidney can recover from such trauma if left alone.
Case 4 A 25 year old white man was involved in an automobile accident and sustained multiple injuries, including multiple facial lacerations, a fractured rib with pneumothorax, a dislocated hip, a pelvic separation, and laceration of the knee joint. A Foley catheter was inserted in the emergency room with ease. The urine was grossly clear but showed microscopic hematuria. After stabilization the multiple facial lacerations were repaired, the wound was debrided, and
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the dislocated hip was reduced in the operating room. Because of microscopic hematuria, an intravenous pyelogram and cystogram were obtained. The cystogram was normal but the intravenous pyelogram showed a nonfunctioning right kidney. At this point, the patient was clinically stable. An arteriogram was performed which showed a thin, attenuated renal artery with branching, typical of a hydronephrotic kidney. The patient was managed conservatively with frequent monitoring of the hematocrit and vital signs. He recovered uneventfully. At a later date, a retrograde pyelogram disclosed a high grade congenital obstruction of the ureteropelvic junction with a hydronephrotic shell. This was eventually removed because of pain and infection.
Discussion In our institution, emergency aortography is not available. However, with encouragement a study can usually be obtained two to three hours after admission. Since the decision to operate or not to operate is made on the clinical condition of the patient, the study is not usually performed. However, if the intravenous pyelogram shows lack of function, an injury to the renal pedicle must be considered, specifically, disruption of the intima of the renal artery with thrombosis of the renal artery. This situation is rare. Arteriographic films will typically show the renal artery ending abruptly 1 to 2 em from its aortic origin. Correction of this problem requires the skill of someone with expertise in vascular surgery. Usually the clot is removed and a vein patch-graft is placed in the region of the injury. Aortography can also be used to help evaluate a major renal injury in a stable patient, but arteriographic findings should not be used as the sole criteria to decide whether or not to operate. Case 5 A 22 year old white woman fell off a horse. There were no obvious injuries other than an abrasion over the flank, although the patient struck her head when she fell and was knocked unconscious. She was admitted to the hospital for observation. Initial urinalysis showed microscopic hematuria. An intravenous pyelogram was normal. The patient was discharged from the hospital the following day, and was followed as an outpatient. The urine was clear five days after the injury.
Discussion Minor injuries constitute 80 to 85 per cent of all genitourinary injuries, and can be safely managed conservatively. The intravenous pyelogram may appear normal, show a small amount of extravasation, or show diminished function as in Case 3. If the patient has only microscopic hematuria, he may be discharged and followed as an outpatient. If the urine is grossly bloody, he should be treated with bed rest and followed closely with serial hematocrits, urinalyses, and frequent monitoring of the vital signs. The patient may be discharged when the urine is seen to be grossly clear. Summary Most variations of renal injury will be seen even in a small hospital setting. Minor injuries can be treated conservatively. Intermediate injuries in the stable patient can be watched closely. Surgery is not nee-
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Unstable Patient
Normal IVP
~
~ ~
Abnormal IVP
Minor Changes (Case 3)
~
Nonvisualization or Major Extravasation
I
Conservative (Leave Retroperitoneum Alone)
Renal Exploration
I
Nephrectomy or Repair (Cases 1 and 2)
Stable Patient
Gross Hematuria
Microscopic Hematuria
/
I Normal IVP
I Home and Follow as Outpatient
Abnormal IVP Minor
ExLavasa~onvisualization
or Major Extravasation (Case 4)
I
Arteriogram
~I
Conservative Management
Intact Vasculaturc
I
Conservative Management (Case 4)
Vasculature Interrupted
I Exploration
Figure 3. Blunt renal injuries. (Modified from Peters, P. C., Bright, T. C., III: Blunt renal injuries. Urol. Clin. North Am., 4:22, 1977.)
essary unless the patient's clinical condition deteriorates and he later develops infections or a large urinoma. If the patient's initial clinical condition is unstable and the intravenous pyelogram suggests a major or intermediate injury, then renal exploration and repair are performed with control of the renal pedicle prior to the opening of Gerota's fascia. Aortography is useful in evaluating a stable patient with a nonfunctioning kidney and may diagnose thrombosis of the renal artery (Fig. 3)
URETERAL INJURIES Ureteral injuries are uncommon in the small hospital. We have seen only one in the last four years. The management of such injuries, if they do occur, is no different from management in the metropolitan
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Figure 4. Technique of primary spatulated watertight ureteral anastomosis. (From Carlton, C. E.: Injuries to the ureter. Urol. Clin. North Am., 4:43, 1977, with permission.)
hospital. If possible, primary realignment with spatulation of both ends and a water-tight closure of the ureter should be accomplished (Fig. 4). Stents are not necessary unless there is an underlying abnormality of the ureter caused by prior radiation or severe infection, or unless there is possible ischemia of the severed ends. The area of injury should be adequately drained. If the injury occurs in the distal ureter near the ureterovesical junction, as usually occurs in gynecologic surgery, it is frequently easier to reimplant the ureter into the bladder than to attempt primary realignment to a small and usually shredded distal ureter. Another option available to the surgeon if the ureter cannot be realigned or reimplanted into the bladder is to connect it to the opposite ureter. A tunnel is made beneath the posterior
Figure 5. Technique of transureteroureterostomy. (From Carlton, C. E.: Injuries to the ureter. Urol. Clin. North Am., 4:41, 1977, with permi~sion.)
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peritoneum above the bifurcation of the aorta and the injured ureter is sutured in a water-tight fashion to the opposite ureter (Fig. 5). This should be performed only if other options are not available as there is a risk of damage to the contralateral ureter.
Case 6 A 34 year old white woman, gravida IV, para III, required an emergency cesarean section because of fetal distress. The uterus failed to contract normally, and the patient bled extensively postoperatively. Because of significant persistent bleeding, she was taken back to the operating room where an emergency hysterectomy was performed. In the course of performing this procedure, the right ureter was transected below the iliac vessels. The injury was repaired with a running stitch of 4-0 chromic suture and a Penrose drain was brought up laterally to drain the area. A stent was not used. Postoperatively, urine drained through the Penrose drain for four to five days and then stopped. A follow-up intranvenous pyelogram at six weeks showed partial obstruction at the area of repair. A repeat intravenous pyelogram at three months after the repair was normal.
BLADDER INJURIES Bladder injuries are diagnosed with a cystogram. This study should be performed in the emergency room at the time of initial radiographic evaluation of the patient suspected of having a genitourinary injury, as previously discussed. Bladder injuries are managed in a standard fashion with repair of the injury, insertion of a suprapubic tube, and drainage of the perivesical space. Healing generally takes seven to 10 days.
Case 7 A 17 year, old white man fell from a haystacker onto a steel pole which entered the rectum. In the emergency room, blood was coming from the rectum. A cathe~r was inserted and the urine was grossly bloody. A cystogram showed a large amount of air in the bladder and a small amount of extravasation. The intravenous pyelogram was normal. Exploration showed a bladder perforation immediately behind the trigone, which was closed in two layers. A suprapubic tube was inserted. The injury to the anterior rectal wall was repaired and omentum was interposed between the rectum and the bladder. A loop colostomy was also performed and the pelvis was drained with a Penrose drain. Postoperatively, the patient did well. The catheter was removed 10 days postoperatively. His colostomy was closed two and one half months later. A follow-up cystogram and intravenous pyelogram were completely normal.
POSTERIOR URETHRAL INJURIES Injuries to the posterior urethra usually occur in association with a pelvic fracture. Any patient with an obvious pelvic fracture or blood coming from the urethral meatus should be suspected of having a torn posterior urethra. If such an injury is suspected, a retrograde urethrogram should be performed prior to attempted insertion of a Foley catheter. Blind catheterization may enlarge a partial urethral tear into a complete one.
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If the clinical condition of the patient does not permit this x-ray study, a single attempt at catheterization should be made by an experienced physician. If the catheter does not easily enter the bladder, then a retrograde urethrogram must be performed to evaluate the problem further. A urethrogram is easily performed by injecting 20 cc of any radiographic contrast material into the urethral meatus as described previously. The management of such an injury is controversial. The classical management has been an attempt at primary realignment. However more recently, McKinnon and coworkers in Montreal have suggested simple insertion of a suprapubic tube, leaving the urethra and pelvic hematoma alone. 4 Their argument is that many urethral tears are only partial initially and attempts at primary reconstruction may further damage the urethra. Furthermore, they point out that the incidence of urinary incontinence or impotency is greater in a series of patients in whom attempts at primary reconstruction were made than in patients who simply had a suprapubic tube inserted. In their series of 41 patients treated by insertion of a suprapubic tube, 39 had complete tears of the posterior urethra. After a urethroplasty was performed three to four months later, 40 of these patients were continent without stricture and one patient had stress incontinence. Thirty-six patients had satisfactory potency after the urethroplasty. Since satisfactory results can be obtained with conservative management, I think that there is little doubt that this injury should be treated conservatively in a small community hospital, that is, by simple insertion of a suprapubic tube. Further repair of the stricture, when necessary, may be performed three to four months later by a urologist with expertise in this type of injury.
Case 8 A 33 year old white man fell off the roof of a two-story house, fracturing both arms and sustaining a pelvic fracture with mild separation of the pubic symphysis. The patient was unable to void during the first 10 hours of hospitalization and became uncomfortable with a distended bladder. An attempt to catheterize the patient was not successful. A suprapubic cystocatheter was inserted. Urologic consultation was requested. A retrograde urethrogram showed mild extravasation of the posterior urethra. A cystogram showed the bladder in normal position. Upon rectal examination, the prostate felt normal and was in normal position. A suprapubic tube was inserted. Three months after the injury a short stricture of the membranous urethra was repaired and the patient did well. He had no voiding or potency problems six and 12 months after the repair.
SUMMARY The spectrum of genitourinary injuries seen in a small community hospital over the past three years is presented. With the exception of the obvious ureteral injury, the key factor in management is adequate x-ray diagnosis. This allows the physician to estimate the type and extent of injury. In the clinically stable patient, renal injuries can be managed conservatively. However, in our experience a major renal
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injury is usually associated with major intra-abdominal injury and these patients require exploration. Bladder injuries may be diagnosed with a cystogram, and repaired. Posterior urethral injuries may be managed initially by simple insertion of a suprapubic tube.
REFERENCES J., and Leadbetter, G. W.: Traumatic renal artery thrombosis. J. Urol., 109:769, 1973. Carlton, C. E.: Injuries to the ureter. Urol. Clin. North Am., 4:33, 1977. Guerriero, W. C.: Penetrating renal injuries and management of renal pedicle injury. Urol. Clin. North Am., 4:3, 1977. . Morehouse, D. G., and MacKinnon, K. J. Posterior urethral injury: Etiology, diagnosis, initial management. Urol. Clin. North Am., 4:69, 1977. Peters, P. C., and Bright, T. C. III: Blunt renal injuries. Urol. Clin. North. Am., 4:17, 1977. Peterson, N. E., and Kiracofe, L. N.: Renal trauma-when to operate. Urology, 3:537, 1974. Peterson, N. E., and Norton, L. W.: Injuries associated with renal trauma. J. Urol., 109:766, 1973. Thompson, I. A.: Expectant management of blunt renal trauma. Urol. Clin. North Am., 4:29, 1977. Whitney, R. F., and Peterson, N. E.: Penetrating renal injuries. Urology, 7:7, 1976.
1. Caponegro, P.
2. 3. 4. 5. 6. 7. 8. 9.
Montrose Memorial Hospital 800 South Third Street Montrose, Colorado 81401
CoMMENTARY
Norman Peterson, M.D.* Dr. Shannon's discussion underscores the value and importance of pragmatism and practicality in such matters, and he is to be congratulated. The frenetic atmosphere surrounding the multiply traumatized patient too often results in obscurement of urologic injury or deliberate assignment of lesser priority; Dr. Shannon has suggested this to be unnecessary, and further emphasizes the relative simplicity of adequate evaluation and optimum management. Appreciation of a general classification scheme allows effective triage, particularly when reliable classification is possible on the basis of only three factors: degree of hemorrhage, radiographic features, and overall clinical status. Mild or transient hematuria and urographic function characterize minor injuries consisting of renal contusions and minor lacerations (70 per cent); intermediate injuries (20 per cent) are similar; laceration (100 per cent) and extravasation (40 to 60 per cent) are the major distinguishing radiographic features. Both groups respond favorably to nonoperative management. Major injuries (10 per cent) are generally urographically functionless, while hemorrhage in the urine or retroperitoneum may be excessive (from parenchymal shattering) or slight (from pedicle interruption); further diagnostic studies or operative *Denver General Hospital, Denver, Colorado
