PENETRATING
RONALD NORMAN
RENAL INJURIES
F. WHITNEY, E. PETERSON,
M.D. M.D.
From the Division of Urology, University of Colorado School of Medicine, and Department of Urology, Denver General Hospital, Denver, Colorado
ABSTRACT - A retrospective analysis of 81 penetrating renal injuries revealed a need fin- surgical exploration in only 39 per cent, and the following conclusions are made: (1) Criteria fn- classifying a traumatic renal injury as major and therefore requiring further evaluation (arteriography) or appropriate urgent surgery, include urographic nonfunction or extravasation, persistent or severe hematuria orretroperitoneal hemorrhage, and deteriorating clinical status. (2) Preoperative urologic assessment is mandatory to avoid needless renal exploration; 58 per cent of patients with minor injuries were in this series operated on. (3) It is doubtful that late sequelae of penetrating renal injury occur so frequently that immediate surgery to prevent them is advisable.
injury, encouraged prompt surgical intervention in all such cases based on their observation of a 5 per cent complication rate with such management compared with a 17 per cent complication rate with conservative management. Other reports supporting aggressive management of such lesions imply the advisability of immediate surgery for most penetrating renal injuries.1°-14 We have undertaken a retrospective analysis of 81 penetrating renal injuries that were operated on at the Denver General Hospital between 1967 and 1974 to determine whether surgery was necessary or not, and to establish clinical criteria for surgical intervention in penetrating renal injuries.
Surgical intervention in the management of traumatic renal injuries was generally advocated until 1950, when Sargent and Marquardt’ suggested that the majority of such injuries could be managed conservatively. Their indications for intervention were limited to deteriorating clinical status, evidence of renal fragmentation, or total loss of renal architecture. Similarly, Glenn and Harvard2 reported satisfactory spontaneous healing in 80 to 90 per cent of such injuries, suggesting that the reparative capacity of the kidney was generally grossly underrated. Their indications for exploration included progressive shock, leukocytosis, falling hematocrit, and radiographic evidence of functional deterioration. These experiences and attitudes have been shared by others.3-g Conversely, immediate surgical intervention for penetrating renal injuries has been advocated by others. Hodges et al. lo warned that a conservative philosophy hazarded several risks such as missing the optimal time to operate, failure to recognize unassociated renal disease, protracted convalescence with the creation of “renal cripples,” and an increased incidence of late complications secondary to extravasated blood and urine. Scott, Carlton, and Goldman” citing their experience with 181 cases of penetrating renal
UROLOGY
/ JANUARY 1976 / VOLUME
VII, NUMBER
Material
and Methods
Many schemes for classification of renal injuries have been suggested to clarify degree of injury, prognosis, and most appropriate management. The majority of these ascribe major significance to penetrating renal injuries and imply the need for more aggressive management. In our analysis of 81 penetrating renal injuries that were operated on, a retrospective classification into major or minor types was done. Injuries were considered minor if surgical nonintervention
1
7
would not have compromised the patient’s survival or convalescence or caused a decrement in renal function. Similarly, injuries were classified as major if surgical intervention proved essential. These commonly comprised pedicle involvement or parenchymal damage requiring nephrectomy or heminephrectomy. Results There were 32 major and 49 minor injuries. Table I summarizes the sex incidence, type, and laterality. Gunshot injuries were most frequent with only six knife wounds in the entire series. Minor injuries involved the right and left kidneys
TABLE I.
Sex incidence,
type, and luterality
Major (32) No. Per Cent
Data Sex Males Females
Minor (49) No. Per Cent
31
97
42
3
7
85 15
(bilateral) 9 Left (bilateral) 22 Type 31 Gunshot 1 Stab
28 69
21
42
28
58
97 3
41
89 11
1
Site Right
TABLE II.
Classification Laceration Perforation Shattered Pedicle
Extent
ofinjury
Major (32) No. Per Cent 15 2 6 9
5
47 2 18
28
Minor (49) No. Per Cent 28 21 0
0
58 42 0
0
with equal frequency, while major injuries occurred slightly more often on the left. Table II tabulates the extent of the injury. The 49 minor injuries consisted of parenchymal lacerations (58 per cent) or perforations (42 per cent) that could have predictably resolved spontaneously. Of the 32 major injuries, 47 per cent were lacerations, 18 per cent shattered kidneys, and 28 per cent pedicle injuries. Table III lists the operations performed. In the minor injury group a total of 28 operations (58 per cent) were performed. All were deemed unnecessary by the authors in light of the degree and nature of the injury encountered; these in-
8
cluded debridement and drainage and wedge resection. Of the major injuries, there were 28 operations with nephrectomy or heminephrectomy the most common (71 per cent). Hematuria occurred in 93 per cent of major injuries and in 90 per cent of minor injuries. Hematuria was absent in 7 per cent of major injuries and 10 per cent of minor injuries. This latter group consisted of either pedicle or peripheral parenchymal injuries. No correlation could be made between the degree of hematuria and extent of injury. Sixty-two per cent of patients with initial urograms (22 per cent major and 40 per cent minor) demonstrated delayed or diminished dye excretion. Nonfunction was present only in the major injuries (22 per cent). Segmental functional alteration was noted only in minor injuries (26 per cent). Urinary extravasation was detectable in 33 per cent of the major injuries and in only 2 per cent of the minor injuries. Normal urograms were present in 22 per cent of the major injuries and in 20 per cent of the minor injuries. Arteriography was performed in only 16 per cent of major injuries and 17 per cent of minor injuries, reflecting its infrequent indication in minor injuries in which interpretable urograms are available, and the urgency for action and no time for arteriography in the presence of severe injury. No studies were performed in 14 patients with major injuries and 15 with minor injuries. Associated injuries are outlined in Table IV. Ninety-one per cent of major renal injuries had associated injury to other structures, involving primarily colon, bowel, liver, and spleen. Eightysix per cent of minor injuries had associated trauma of a similar nature. Data pertaining to delayed hemorrhage and mortality were tabulated. In the minor group, 1 case of delayed hemorrhage not requiring surgical repair occurred. There were three deaths in the minor group, all related to severe associated injury. Two cases had coexisting cardiac and hepatic injury and died in shock, and a third suffered cardiac arrest secondary to massive pulmonary embolization. No deaths were directly attributable to renal injury. A 9 per cent incidence of delayed hemorrhage occurred in the major subgroup. One patient underwent nephrectomy and 1 heminephrectomy for delayed bleeding. A third patient experienced hemorrhage from the renal arterial stump eighteen days following nephrectomy. Of six deaths in the major subgroup, five were due to shock secondary to liver or aortic injury accompanying either a shattered
UROLOGY / JANUARY1976 / VOLUME VII, NUMBER
1
kidney or pedicle injury. A sixth death of gramnegative sepsis occurred postnephrectomy in a patient with associated liver and colon injuries. Over-all mortality was seven deaths in 32 major injuries (19 per cent).
Other reports suggest a 50 to 60 per cent diagnostic accuracy with standard urographic techniques and a 93 per cent accuracy with infusion l-5 Chovnick and Newman5 nephrotomography. also observed a 50 per cent initial accuracy with standard urography and improvement in 82 per cent on repeat urography at seventy-two hours. Contrast medium extravasation was present in 33 per cent of major and only 2 per cent of minor injuries. Although reflecting a more severe degree of parenchymal trauma (capsular-parenchymalcollecting system injury), extravasation per se was not a de novo indicator for surgical interven-
Comment Classij%ation
of injuries
Of 81 penetrating renal injuries analyzed, 39 per cent (32 of 81) were of a major degree. The remaining 61 per cent (49 of 81) were considered minor, but 58 per cent were subjected to unnecessary renal exploration. There is an obvious need to establish criteria for surgical intervention. While the presence of hematuria is a reliable indicator of traumatic urinary tract involvement, the degree of hematuria correlates poorly with the extent of renal injury. Ninety-three per cent of major and 90 per cent of minor renal injuries presented with hematuria with 15 per cent of major injuries demonstrating only microscopic hematuria and 74 per cent of minor injuries presenting with gross hematuria. Previous reports relate hematuria to renal trauma in 71 to 100 per cent of cases.2~4~5*8,11,12 Morrow and Mendez4 reported absence of hematuria in all pedicle injuries in their series, underscoring the unreliability of hematuria as a criterion of severity of injury. Of ten pedicle injuries in our study, hematuria was absent in two, microscopic in two, and unreported in one, with the remaining 5 cases presenting with gross hematuria. Delayed or diminished urographic function is a poor criterion for distinguishing major from minor injuries; 22 per cent of major and 40 per cent of minor injuries demonstrated these findings. Urologic
Surgery perjbt-med
TABLE III.
Procedure
Major (32) No. Per Cent
4* No repair Debridement plus drainage 5 Wedge resection 0 Heminephrectomy 9 Nephrectomy 14
Minor (49) No. Per Cent
12.5
21
42
15 0 28 43
26 2 ... ...
53 5 ... ..,
*All deferred or died on table.
Associated injuries
TABLE IV.
Site of Injury None Colon Bowel Liver Spleen Stomach Pancreas Diaphragm
Major (32) Per Cent No. 3 12
9 37
10
29
9 8 6 6 4
28 25 18 18 13
Minor (49) No. Per Cent 7 19 12 15 5 4 1 4
14 38 24 30 10 8 2 8
assessment
The most reliable urographic findings in our series were nonfunction and extravasation. Urographic nonfunction occurred in 22 per cent (4 of 18) of the major injuries but in none of the minor Persistent urographic nonfunction will injuries. most often reflect severe parenchymal fragmentation (shattered) or significant pedicle injury (avulsion or thrombosis). Such cases demand arteriographic assessment when permissible or prompt renal exploration. Morrow and Mendez4 correlated high dose urography with renal angiography and noted an 87 per cent correlation, suggesting that angiography infrequently alters management except in pedicle injury.
UROLOGY /
JANUARY
1976
/
VOLUME
VII,
NUMBER
tion and drainage. Urinary extravasation may be classified according to degree: (1) intraparenchymal (confined within the renal capsule), (2) extracapsular (escaping the renal capsule but confined within Gerota’s fascia), and (3) retroperitoneal (escaping Gerota’s fascia and staining the entire hemiretroperitoneum). In the absence of urinary infection or urinary outflow obstruction, types 1 and 2 extravasation have proved to be of little permanent consequence, tending to subside spontaneously with time. Type 3 extravasation and any infected urinary extravasation demand definitive management including drainage.
1
Over-all clinical stability or instability is of maximum importance since it reflects the extent of renal trauma and/or associated injury, and determines whether urographic procedures can be done or immediate surgery undertaken.“j13 In our series associated injuries occurred in 91 per cent of the major and 86 per cent of the minor renal injuries, establishing surgical priority and often interdicting thorough urologic assessment. The presence of hematuria, nondiagnostic urographic abnormalities, or a retroperitoneal hematoma detected at laparotomy poses the dilemma of whether or not to proceed with retroperitoneal exploration. Factors supporting such exploration include an expanding or pulsatile hematoma, absence of associated injuries to explain clinical instability or deterioration, or the suspicion of associated nonrenal retroperitoneal injury (great vessels, duodenum, pancreas, colon). In circumstances other than these, such exploration may represent needless dissection, unnecessary prolongation of operative time, and a potential threat to renal viability. Approximately 40 per cent of major injuries in our series were in clinical shock on admission and only 8 per cent of the minor group. Forty-three per cent of major injuries had no preoperative urographic evaluation because of the patient’s clinical instability or deterioration. However, despite only an 8 per cent incidence of clinical shock in the minor injury group, 30 per cent of these patients received no prelaparotomy urographic evaluation, undoubtedly contributing to unnecessary renal exploration and underscoring the importance of preoperative renal assessment whenever allowable to prevent needless renal exploration. Serious
late sequelae
Another reason commonly given for advising immediate surgical intervention in penetrating renal trauma is the increased incidence of serious late sequelae reported following conservative management; also should intervention become necessary the optimal time for operation may have passed. Close observation should obviate the latter objection to conservatism, but the frequency of late sequelae is not definite. Sargent and Marquardtl reported late sequelae in less than 3 per cent of their series, stating further, “As a matter of truth, the literature does contain reports of a variety of important sequelae following renal injury. However, the authors fail to find any impressive studies warranting the contention
10
that they are common, or that they are particularly liable to occur in those cases managed conservatively.” Glenn and Harvard2 tabulated a significant list of potential post-traumatic renal complications, but observed such complications in only 5 per cent of their series, also stating that 80 to 90 per cent of traumatic renal injuries will heal with conservative treatment, and further that 75 per cent of patients with positive radiographic evidence of injury were normal on subsequent examination. Morrow and Mendez4 related that 70 per cent of severely lacerated kidneys were managed successfully by nonoperative intervention. McCague* reported late sequelae in only 1 of 67 cases of renal trauma, represented by hypertension cured by nephrectomy. Chovnick and Newman5 suggested that post-traumatic renal complications were of such a minor incidence to allow their being dealt with as they arose. Although Hodges et al. lo opposed conservatism because of their reported 85 per cent incidence of late sequelae, that percentage figure is perhaps skewed since their series was composed in part by patients referred secondary to their complications. Similarly, Scott, Carlton, and Goldman12 opposed conservatism on the basis of their experience suggesting a 5 per cent complication rate in surgically managed cases in contrast to a 17 per cent incidence in those managed conservatively. Follow-up evaluation is difficult in a municipal hospital population by virtue of transience and related factors peculiar to our patient population, so that long-term corroboration of the absence of delayed complications is generally unavailable. However, such patients do tend to return if there is recurrence of their symptoms, but such has not occurred in our patients who were managed conservatively. Furthermore, it appears unlikely that a urogram having returned to normal prior to the patient’s being lost to follow-up would ultimately deteriorate. Silent late sequelae threatening renal function or hazarding the patient would appear to be uncommon, while symptomatic late sequelae would be expected to effect the return of the patient for evaluation and treatment. A conservative conclusion would be that late sequelae appear to occur infrequently and can be evaluated and treated as they arise and are detected.
Littleton,
UROLOGY
/
JANUARY
1976
/
6 Waring Lane Colorado 80121 (DR. WHITNEY)
VOLUME
VII,
NUMBER
1
References 1. SARGENT,J. C., and MARQUARDT,C. R.: Renal injuries, J. Urol. 63: 1 (1950). 2. GLENN, J. F., and HARVARD, B. M.: The injured kidney, J.A.M.A. 173: 1189 (1960). 3. KAZMIN, M. H., BROSMAN, S. A., and CORKETT, A. T. K.: Diagnosis and early management of renal trauma, J. Urol. 101: 783 (1969). 4. MORROW, J. W., and MENDEZ, R.: Renal trauma, ibid. 104: 649 (1970). 5. CHOVNICK, S. D., and NEWMAN, H. R.: Management of renal injuries, &cl. 83: 330 (1960). 6. MAHONEY, S. A., and PERSKY, L.: Intravenous drip nephrectomography as an adjunct in the evaluation of renal injury, ibid. 99: 513 (1968). Renal 7. PETERSON, N. E., and KIRACOFE, H. L.: trauma - when to operate, Urology 3: 537 (1974).
UROLOGY
I JANUARY 1976 / VOLUME VII, NUMBER 1
8. MCCAGUE, E. J.:
Renal trauma;
conservative
man-
agement, J. Ural. 63: 773 (1950). 9. COLSTON, J. A. C., and BAKER, W. W.: Late effects of various types of tiauma to the kidney, Arch. Surg. 34: 99 (1937). 10. HODGES, C. V., et al. : Renal trauma; a study of 71 cases, J. Urol. 66: 627 (1951). 11. SCOTT, R., CARLTON, C. E., and GOLDMAN, M.: Penetrating injuries of the kidney: an analysis of 181 patients, ibid. 101: 247 (1969). 12. NATION, E. F., and MASSEY, B. D.: Renal trauma: experience with 258 cases, ibid. 89: 775 (1963). 13. PETERSON, N. E., and NORTON, L.: Injuries associated with renal trauma, ibid. 109: 766 (1973). 14. CASS, A. S., and IRELAND, G. W.: Comparison of the conservative and surgical management of the more severe degrees of renal trauma in multiple injured patients, ibid. 109: 8 (1973).
11
RONALD NORMAN
RENAL INJURIES
F. WHITNEY, E. PETERSON,
M.D. M.D.
From the Division of Urology, University of Colorado School of Medicine, and Department of Urology, Denver General Hospital, Denver, Colorado
ABSTRACT - A retrospective analysis of 81 penetrating renal injuries revealed a need fin- surgical exploration in only 39 per cent, and the following conclusions are made: (1) Criteria fn- classifying a traumatic renal injury as major and therefore requiring further evaluation (arteriography) or appropriate urgent surgery, include urographic nonfunction or extravasation, persistent or severe hematuria orretroperitoneal hemorrhage, and deteriorating clinical status. (2) Preoperative urologic assessment is mandatory to avoid needless renal exploration; 58 per cent of patients with minor injuries were in this series operated on. (3) It is doubtful that late sequelae of penetrating renal injury occur so frequently that immediate surgery to prevent them is advisable.
injury, encouraged prompt surgical intervention in all such cases based on their observation of a 5 per cent complication rate with such management compared with a 17 per cent complication rate with conservative management. Other reports supporting aggressive management of such lesions imply the advisability of immediate surgery for most penetrating renal injuries.1°-14 We have undertaken a retrospective analysis of 81 penetrating renal injuries that were operated on at the Denver General Hospital between 1967 and 1974 to determine whether surgery was necessary or not, and to establish clinical criteria for surgical intervention in penetrating renal injuries.
Surgical intervention in the management of traumatic renal injuries was generally advocated until 1950, when Sargent and Marquardt’ suggested that the majority of such injuries could be managed conservatively. Their indications for intervention were limited to deteriorating clinical status, evidence of renal fragmentation, or total loss of renal architecture. Similarly, Glenn and Harvard2 reported satisfactory spontaneous healing in 80 to 90 per cent of such injuries, suggesting that the reparative capacity of the kidney was generally grossly underrated. Their indications for exploration included progressive shock, leukocytosis, falling hematocrit, and radiographic evidence of functional deterioration. These experiences and attitudes have been shared by others.3-g Conversely, immediate surgical intervention for penetrating renal injuries has been advocated by others. Hodges et al. lo warned that a conservative philosophy hazarded several risks such as missing the optimal time to operate, failure to recognize unassociated renal disease, protracted convalescence with the creation of “renal cripples,” and an increased incidence of late complications secondary to extravasated blood and urine. Scott, Carlton, and Goldman” citing their experience with 181 cases of penetrating renal
UROLOGY
/ JANUARY 1976 / VOLUME
VII, NUMBER
Material
and Methods
Many schemes for classification of renal injuries have been suggested to clarify degree of injury, prognosis, and most appropriate management. The majority of these ascribe major significance to penetrating renal injuries and imply the need for more aggressive management. In our analysis of 81 penetrating renal injuries that were operated on, a retrospective classification into major or minor types was done. Injuries were considered minor if surgical nonintervention
1
7
would not have compromised the patient’s survival or convalescence or caused a decrement in renal function. Similarly, injuries were classified as major if surgical intervention proved essential. These commonly comprised pedicle involvement or parenchymal damage requiring nephrectomy or heminephrectomy. Results There were 32 major and 49 minor injuries. Table I summarizes the sex incidence, type, and laterality. Gunshot injuries were most frequent with only six knife wounds in the entire series. Minor injuries involved the right and left kidneys
TABLE I.
Sex incidence,
type, and luterality
Major (32) No. Per Cent
Data Sex Males Females
Minor (49) No. Per Cent
31
97
42
3
7
85 15
(bilateral) 9 Left (bilateral) 22 Type 31 Gunshot 1 Stab
28 69
21
42
28
58
97 3
41
89 11
1
Site Right
TABLE II.
Classification Laceration Perforation Shattered Pedicle
Extent
ofinjury
Major (32) No. Per Cent 15 2 6 9
5
47 2 18
28
Minor (49) No. Per Cent 28 21 0
0
58 42 0
0
with equal frequency, while major injuries occurred slightly more often on the left. Table II tabulates the extent of the injury. The 49 minor injuries consisted of parenchymal lacerations (58 per cent) or perforations (42 per cent) that could have predictably resolved spontaneously. Of the 32 major injuries, 47 per cent were lacerations, 18 per cent shattered kidneys, and 28 per cent pedicle injuries. Table III lists the operations performed. In the minor injury group a total of 28 operations (58 per cent) were performed. All were deemed unnecessary by the authors in light of the degree and nature of the injury encountered; these in-
8
cluded debridement and drainage and wedge resection. Of the major injuries, there were 28 operations with nephrectomy or heminephrectomy the most common (71 per cent). Hematuria occurred in 93 per cent of major injuries and in 90 per cent of minor injuries. Hematuria was absent in 7 per cent of major injuries and 10 per cent of minor injuries. This latter group consisted of either pedicle or peripheral parenchymal injuries. No correlation could be made between the degree of hematuria and extent of injury. Sixty-two per cent of patients with initial urograms (22 per cent major and 40 per cent minor) demonstrated delayed or diminished dye excretion. Nonfunction was present only in the major injuries (22 per cent). Segmental functional alteration was noted only in minor injuries (26 per cent). Urinary extravasation was detectable in 33 per cent of the major injuries and in only 2 per cent of the minor injuries. Normal urograms were present in 22 per cent of the major injuries and in 20 per cent of the minor injuries. Arteriography was performed in only 16 per cent of major injuries and 17 per cent of minor injuries, reflecting its infrequent indication in minor injuries in which interpretable urograms are available, and the urgency for action and no time for arteriography in the presence of severe injury. No studies were performed in 14 patients with major injuries and 15 with minor injuries. Associated injuries are outlined in Table IV. Ninety-one per cent of major renal injuries had associated injury to other structures, involving primarily colon, bowel, liver, and spleen. Eightysix per cent of minor injuries had associated trauma of a similar nature. Data pertaining to delayed hemorrhage and mortality were tabulated. In the minor group, 1 case of delayed hemorrhage not requiring surgical repair occurred. There were three deaths in the minor group, all related to severe associated injury. Two cases had coexisting cardiac and hepatic injury and died in shock, and a third suffered cardiac arrest secondary to massive pulmonary embolization. No deaths were directly attributable to renal injury. A 9 per cent incidence of delayed hemorrhage occurred in the major subgroup. One patient underwent nephrectomy and 1 heminephrectomy for delayed bleeding. A third patient experienced hemorrhage from the renal arterial stump eighteen days following nephrectomy. Of six deaths in the major subgroup, five were due to shock secondary to liver or aortic injury accompanying either a shattered
UROLOGY / JANUARY1976 / VOLUME VII, NUMBER
1
kidney or pedicle injury. A sixth death of gramnegative sepsis occurred postnephrectomy in a patient with associated liver and colon injuries. Over-all mortality was seven deaths in 32 major injuries (19 per cent).
Other reports suggest a 50 to 60 per cent diagnostic accuracy with standard urographic techniques and a 93 per cent accuracy with infusion l-5 Chovnick and Newman5 nephrotomography. also observed a 50 per cent initial accuracy with standard urography and improvement in 82 per cent on repeat urography at seventy-two hours. Contrast medium extravasation was present in 33 per cent of major and only 2 per cent of minor injuries. Although reflecting a more severe degree of parenchymal trauma (capsular-parenchymalcollecting system injury), extravasation per se was not a de novo indicator for surgical interven-
Comment Classij%ation
of injuries
Of 81 penetrating renal injuries analyzed, 39 per cent (32 of 81) were of a major degree. The remaining 61 per cent (49 of 81) were considered minor, but 58 per cent were subjected to unnecessary renal exploration. There is an obvious need to establish criteria for surgical intervention. While the presence of hematuria is a reliable indicator of traumatic urinary tract involvement, the degree of hematuria correlates poorly with the extent of renal injury. Ninety-three per cent of major and 90 per cent of minor renal injuries presented with hematuria with 15 per cent of major injuries demonstrating only microscopic hematuria and 74 per cent of minor injuries presenting with gross hematuria. Previous reports relate hematuria to renal trauma in 71 to 100 per cent of cases.2~4~5*8,11,12 Morrow and Mendez4 reported absence of hematuria in all pedicle injuries in their series, underscoring the unreliability of hematuria as a criterion of severity of injury. Of ten pedicle injuries in our study, hematuria was absent in two, microscopic in two, and unreported in one, with the remaining 5 cases presenting with gross hematuria. Delayed or diminished urographic function is a poor criterion for distinguishing major from minor injuries; 22 per cent of major and 40 per cent of minor injuries demonstrated these findings. Urologic
Surgery perjbt-med
TABLE III.
Procedure
Major (32) No. Per Cent
4* No repair Debridement plus drainage 5 Wedge resection 0 Heminephrectomy 9 Nephrectomy 14
Minor (49) No. Per Cent
12.5
21
42
15 0 28 43
26 2 ... ...
53 5 ... ..,
*All deferred or died on table.
Associated injuries
TABLE IV.
Site of Injury None Colon Bowel Liver Spleen Stomach Pancreas Diaphragm
Major (32) Per Cent No. 3 12
9 37
10
29
9 8 6 6 4
28 25 18 18 13
Minor (49) No. Per Cent 7 19 12 15 5 4 1 4
14 38 24 30 10 8 2 8
assessment
The most reliable urographic findings in our series were nonfunction and extravasation. Urographic nonfunction occurred in 22 per cent (4 of 18) of the major injuries but in none of the minor Persistent urographic nonfunction will injuries. most often reflect severe parenchymal fragmentation (shattered) or significant pedicle injury (avulsion or thrombosis). Such cases demand arteriographic assessment when permissible or prompt renal exploration. Morrow and Mendez4 correlated high dose urography with renal angiography and noted an 87 per cent correlation, suggesting that angiography infrequently alters management except in pedicle injury.
UROLOGY /
JANUARY
1976
/
VOLUME
VII,
NUMBER
tion and drainage. Urinary extravasation may be classified according to degree: (1) intraparenchymal (confined within the renal capsule), (2) extracapsular (escaping the renal capsule but confined within Gerota’s fascia), and (3) retroperitoneal (escaping Gerota’s fascia and staining the entire hemiretroperitoneum). In the absence of urinary infection or urinary outflow obstruction, types 1 and 2 extravasation have proved to be of little permanent consequence, tending to subside spontaneously with time. Type 3 extravasation and any infected urinary extravasation demand definitive management including drainage.
1
Over-all clinical stability or instability is of maximum importance since it reflects the extent of renal trauma and/or associated injury, and determines whether urographic procedures can be done or immediate surgery undertaken.“j13 In our series associated injuries occurred in 91 per cent of the major and 86 per cent of the minor renal injuries, establishing surgical priority and often interdicting thorough urologic assessment. The presence of hematuria, nondiagnostic urographic abnormalities, or a retroperitoneal hematoma detected at laparotomy poses the dilemma of whether or not to proceed with retroperitoneal exploration. Factors supporting such exploration include an expanding or pulsatile hematoma, absence of associated injuries to explain clinical instability or deterioration, or the suspicion of associated nonrenal retroperitoneal injury (great vessels, duodenum, pancreas, colon). In circumstances other than these, such exploration may represent needless dissection, unnecessary prolongation of operative time, and a potential threat to renal viability. Approximately 40 per cent of major injuries in our series were in clinical shock on admission and only 8 per cent of the minor group. Forty-three per cent of major injuries had no preoperative urographic evaluation because of the patient’s clinical instability or deterioration. However, despite only an 8 per cent incidence of clinical shock in the minor injury group, 30 per cent of these patients received no prelaparotomy urographic evaluation, undoubtedly contributing to unnecessary renal exploration and underscoring the importance of preoperative renal assessment whenever allowable to prevent needless renal exploration. Serious
late sequelae
Another reason commonly given for advising immediate surgical intervention in penetrating renal trauma is the increased incidence of serious late sequelae reported following conservative management; also should intervention become necessary the optimal time for operation may have passed. Close observation should obviate the latter objection to conservatism, but the frequency of late sequelae is not definite. Sargent and Marquardtl reported late sequelae in less than 3 per cent of their series, stating further, “As a matter of truth, the literature does contain reports of a variety of important sequelae following renal injury. However, the authors fail to find any impressive studies warranting the contention
10
that they are common, or that they are particularly liable to occur in those cases managed conservatively.” Glenn and Harvard2 tabulated a significant list of potential post-traumatic renal complications, but observed such complications in only 5 per cent of their series, also stating that 80 to 90 per cent of traumatic renal injuries will heal with conservative treatment, and further that 75 per cent of patients with positive radiographic evidence of injury were normal on subsequent examination. Morrow and Mendez4 related that 70 per cent of severely lacerated kidneys were managed successfully by nonoperative intervention. McCague* reported late sequelae in only 1 of 67 cases of renal trauma, represented by hypertension cured by nephrectomy. Chovnick and Newman5 suggested that post-traumatic renal complications were of such a minor incidence to allow their being dealt with as they arose. Although Hodges et al. lo opposed conservatism because of their reported 85 per cent incidence of late sequelae, that percentage figure is perhaps skewed since their series was composed in part by patients referred secondary to their complications. Similarly, Scott, Carlton, and Goldman12 opposed conservatism on the basis of their experience suggesting a 5 per cent complication rate in surgically managed cases in contrast to a 17 per cent incidence in those managed conservatively. Follow-up evaluation is difficult in a municipal hospital population by virtue of transience and related factors peculiar to our patient population, so that long-term corroboration of the absence of delayed complications is generally unavailable. However, such patients do tend to return if there is recurrence of their symptoms, but such has not occurred in our patients who were managed conservatively. Furthermore, it appears unlikely that a urogram having returned to normal prior to the patient’s being lost to follow-up would ultimately deteriorate. Silent late sequelae threatening renal function or hazarding the patient would appear to be uncommon, while symptomatic late sequelae would be expected to effect the return of the patient for evaluation and treatment. A conservative conclusion would be that late sequelae appear to occur infrequently and can be evaluated and treated as they arise and are detected.
Littleton,
UROLOGY
/
JANUARY
1976
/
6 Waring Lane Colorado 80121 (DR. WHITNEY)
VOLUME
VII,
NUMBER
1
References 1. SARGENT,J. C., and MARQUARDT,C. R.: Renal injuries, J. Urol. 63: 1 (1950). 2. GLENN, J. F., and HARVARD, B. M.: The injured kidney, J.A.M.A. 173: 1189 (1960). 3. KAZMIN, M. H., BROSMAN, S. A., and CORKETT, A. T. K.: Diagnosis and early management of renal trauma, J. Urol. 101: 783 (1969). 4. MORROW, J. W., and MENDEZ, R.: Renal trauma, ibid. 104: 649 (1970). 5. CHOVNICK, S. D., and NEWMAN, H. R.: Management of renal injuries, &cl. 83: 330 (1960). 6. MAHONEY, S. A., and PERSKY, L.: Intravenous drip nephrectomography as an adjunct in the evaluation of renal injury, ibid. 99: 513 (1968). Renal 7. PETERSON, N. E., and KIRACOFE, H. L.: trauma - when to operate, Urology 3: 537 (1974).
UROLOGY
I JANUARY 1976 / VOLUME VII, NUMBER 1
8. MCCAGUE, E. J.:
Renal trauma;
conservative
man-
agement, J. Ural. 63: 773 (1950). 9. COLSTON, J. A. C., and BAKER, W. W.: Late effects of various types of tiauma to the kidney, Arch. Surg. 34: 99 (1937). 10. HODGES, C. V., et al. : Renal trauma; a study of 71 cases, J. Urol. 66: 627 (1951). 11. SCOTT, R., CARLTON, C. E., and GOLDMAN, M.: Penetrating injuries of the kidney: an analysis of 181 patients, ibid. 101: 247 (1969). 12. NATION, E. F., and MASSEY, B. D.: Renal trauma: experience with 258 cases, ibid. 89: 775 (1963). 13. PETERSON, N. E., and NORTON, L.: Injuries associated with renal trauma, ibid. 109: 766 (1973). 14. CASS, A. S., and IRELAND, G. W.: Comparison of the conservative and surgical management of the more severe degrees of renal trauma in multiple injured patients, ibid. 109: 8 (1973).
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