0022-5347 /79/1226-0772$02.00/0 Vol. 122, December
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
IMMEDIATE RADIOLOGICAL EVALUATION AND EARLY SURGICAL MANAGEMENT OF GENITOURINARY INJURIES FROM EXTERNAL TRAUMA ALEXANDERS. CASS* From the Department of Urology, St. Paul Ramsey Medical Center, St. Paul and the Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT
An immediate diagnostic evaluation of genitourinary trauma is mandatory for an early operation. A method of immediate radiological evaluation is presented and the accuracy rate in the diagnosis of the type and site of injury is detailed. The advantages of early surgical management are compared to the results with expectant management. Diagnosis of the site and type of genitourinary injury is essential for adequate treatment. With expectant management diagnostic evaluation can be delayed. With early surgical management diagnostic evaluation must be immediate. This evaluation has been accomplished with the modification of an operating room table for radiographic evaluation. 1 Herein is discussed a method to manage patients with genitourinary injuries involving immediate radiological evaluation and early operation. MATERIALS AND METHODS
From January 1959 to December 1978, 1,389 patients with genitourinary injuries had been seen at the hospitals. The injuries involved the kidneys in 948 cases, the ureter in 18 cases, the bladder in 303 cases, the urethra in 60 cases and the testicle in 60 cases. Indications for evaluation of the genitourinary trauma were 1) macroscopic or microscopic hematuria of >8 red blood cells per high power field, 2) perirenal hematoma found during a laparotomy for associated intra-abdominal injury, 3) flank or lateral abdominal pain, tenderness or a mass, 4) fractures of the lumbar transverse processes, 5) blood at the external urinary meatus, 6) inability to pass a urethral catheter as part of the immediate aggressive evaluation of acute severe trauma 1• 2 and 7) painful tender swelling in the scrotum after trauma. Radiological evaluation included a cystogram. The bladder was filled with 400 ml. contrast medium in adults (50 ml. diatrizoate meglumine 60 in 350 ml. normal saline) and 5 cc contrast medium per pound body weight or 20 cc per year of age in children and an anteroposterior x-ray was made. The bladder was emptied and washed out with normal saline. A second anteroposterior x-ray was then taken (washout film). After the cystogram an excretory urogram (IVP) was made with 100 ml. diatrizoate m eglumine 76 or an infusion IVP with 300 ml. 30 per cent diatrizoate meglumine injection for adults and 2 cc per pound body weight for children. X-rays were made 5, 10 and 20 minutes after injection. A retrograde urethrogram was done if blood was present at the external urinary meatus or a urethral catheter could not be passed. Ten to 20 cc contrast medium were injected into the external urinary meatus with a watertight adaptor. Subsequent radiological evaluation of renal arteriography was indicated if the initial IVP was abnormal (non-function, extravasation, or distorted or non-filled calices) and the abdomen was not open for associated intra-abdominal injury. If the abdomen was open renal exploration was done instead of arteAccepted for publication March 9, 1979. • Requests for reprints: Department of Urology, St. Paul Ramsey Medical Center, 640 Jackson St., St. Paul, Minnesota 55101. 772
riography. The subsequent radiological evaluation of a retrograde pyelogram was indicated if the initial IVP showed normal calices and renal outline with extravasation around the renal pelvis or the ureter. Since 1968 this initial radiological evaluation was done immediately after the patient was hospitalized. In the severely injured patient this was made possible by the use of a modified operating room table. 1 The cystogram was done before the IVP so that the washout film would not have contrast m edium in the lower ureters, causing confusion with extraperitoneal rupture. Also, the diagnosis of reflux could be important if an upper tract operation was done, for example ureteral or renal pelvic repair, or partial nephrectomy. Also, since 1968 early surgical management of the more severe degrees of renal injury was introduced. RESULTS
Diagnosis made by immediate radiological evaluation. Renal injury: The IVP provided for a definite diagnosis in 87 per cent of the patients. Therefore, in only 13 per cent was there an indeterminate finding, requiring an arteriogram, retrograde pyelogram or renal exploration if the abdomen was open for associated intra-abdominal injury. The average time from injury to diagnosis of renal pedicle injury was 7.4 hours. Ureteral injury: The IVP and retrograde pyelogram allowed for the diagnosis and localization of the site of injury in 100 per cent of the cases. However, the presentation of ureteral rupture can be late owing to delayed necrosis of the ureteral wall some days after a gunshot wound. 3 Bladder injury: The cystogram provided for the diagnosis of intraperitoneal rupture in 100 per cent of the cases and extraperitoneal rupture in 90 per cent of the cases. The 3 falsely negative cystograms with extraperitoneal rupture occurred with 250 ml. contrast medium bladder filling (instead of 400 ml.) and no washout films were taken in 2 of the 3 cases. Urethral injury: A retrograde urethrogram provided for the diagnosis of rupture in 100 per cent of the cases. Early surgical management. Renal injury: Since 1968 only in patients with the more severe degrees of renal injury (laceration, rupture and pedicle injury) h as an early operation been done. These injuries comprised 20 per cent of all renal injuries or 40 p er cent of all renal injuries found in patients with associated intra-abdominal injuries requiring laparotomy. The average time from injury to early surgical treatm ent of renal pedicle injury was 8. 7 hours in 17 patients. Of these 17 patients 6 had vascular repairs and the average time from injury to operation was 4.3 hours. The nephrectomy rate was 5 per cent. Only 2 per cent of the patients had significant sequelae and/or delayed renal opera-
773
EARLY RADIOLOGY AND SURGERY FOR TRAUMA
tions. There was no need for a second operation for the renal injury that required an operation in those patients having an immediate laparotomy for associated intra-abdominal injury. In this study a laparotomy for associated intra-abdominal injury was done in 42 per cent of all patients with renal injuries and in 57 per cent of the patients with renal injuries and an associated injury. Ureteral injury: Urinary extravasation, retroperitoneal infection and urinary fistula formation were prevented with early surgical management of ureteral ruptures. Bladder injury: A large rent of 3 to 5 cm. in the dome of the bladder usually was found with intraperitoneal rupture. Early operative repair of this rent prevented intra-abdominal urinary extravasation and prolapse of a loop of bowel into the bladder. Some extraperitoneal ruptures were found at operation to be small puncture wounds with minimal extravasation and these patients would have been suitable for conservative management with a urethral catheter alone. Urethral injury: Early surgical management consisted of primary realignment of the ruptured urethra by a urethral catheter plus a suprapubic cystostomy in most cases. A stricture rate of 62 per cent was found on followup but only half of these strictures required operative correction. The incidence of incontinence was 10 per cent and of impotence it was 38 per cent. Testicular injury: Evacuation of the hematocele and repair of the ruptured testicle, if present, comprised the early surgical management in patients with testicular injuries. The orchiectomy rate was 9 per cent. Infective complications and the pressure effects of a large hematocele were prevented with this management. DISCUSSION
The advantages of early surgical management in patients with genitourinary trauma should be clear-cut to warrant the effort of immediate radiological evaluation. The main area of controversy between expectant and early surgical management involves renal injury and, in particular, the more severe degrees of renal injury (laceration, rupture and pedicle injury). All patients with renal contusions were managed successfully with expectant treatment and no complications or delayed renal operations occurred in this group. The main issues in this controversy are 1) the results of early surgical treatment are not superior to expectant treatment, 2) the nephrectomy rate is higher with early surgical treatment and 3) the renal salvage rate with surgical management of pedicle injuries is insignificant. The incidence of significant sequelae and/ or a delayed renal
operation in studies of the expectant treatment with the more severe degrees of renal injury (excluding pre-existing renal anomalies) has been reported as 314 and 45 per cent5 in pediatric cases and 15,6 17, 7 18, 8 22, 9 25, 10 30, 11 32 12 and 58 per cent1 3 in over-all cases. With early surgical management of the more severe degrees of renal injury in this study only 2 per cent had significant sequelae and/or a delayed renal operation. 13 The nephrectomy rate with expectant management of renal injuries (excluding pre-existing renal anomalies) has been reported as 3.5, 10• 11 4, 7 6, 6 8,8 8.5, 14 8.9,9 9, 15 12, 16• 17 135 and 21 per cent. 12 The nephrectomy rate was higher when there was a significant percentage of associated injuries, especially intraabdominal injuries. The nephrectomy rate in this study with early surgical management was 5 per cent. The incidence of associated intra-abdominal injury requiring laparotomy was 42 per cent. Clamping the renal vessels before Gerota's fascia was opened was an essential part of the early surgical management, since this procedure prevents reactivation of hemorrhage from release of the perirenal tamponade after Gerota's fascia is opened. With early surgical management of patients with pedicle injuries 6 vascular repairs were done and 11 kidneys were removed. 18 This vascular repair rate of 35 per cent is significant compared to the 100 per cent renal loss rate with expectant treatment. Guerriero and associates reported a 56 per cent vascular repair rate with immediate surgical management of 41 renal artery or vein injuries in 33 patients 19 (see table4 • 5' 14• 16, 20, 21),
The cystogram for diagnosing bladder injury should be done with 400 ml. contrast medium since falsely negative results occurred with 250 ml. in cases of extraperitoneal rupture. 22 While early operative repair should be done for intraperitoneal and large extraperitoneal ruptures a urethral catheter alone can be used for small extraperitoneal ruptures with minimal extravasation. The controversial issue wit urethral injury involves which type of early surgical manage ent provides the best long-term results. An immediate retrogra e urethrogram and some form of early surgical management ar done for urethral ruptures. 23 Expectant management of pat'ents with a testicular injury resulted in 40 per cent inflamma ory complications and a 45 per cent orchiectomy rate. 24 Ther can be long-term atrophy of the testicle after the large hem tocele absorbs. With early surgical management the inflam atory complications and pressure effect of the large hematoc e are prevented. The orchiectomy rate was 9 per cent. The disability of the large painful swollen scrotum for weeks also is avoided by early surgical management.
Percentage comparison of studies of renal injuries in children Expectant Management
No. injuries Etiology: Falls and blows Traffic accidents Penetrating Other Classification: Contusion Laceration Rupture Pedicle injury Associated injuries Pre-existing anomalies Significant sequelae and/or delayed renal operation* Over-all operative treatment:* Rate Nephrectomy Operations preserving renal tissue * Excluding pre-existing renal anomaly.
Early Operative Management
Reid'
Mertz and Associates"
Persky and Forsythe 16
Morse and Associates 14
78
70
65
80
55 42 0 3
70 23 3 4
69 29 2
Not known
68 26 0 6 Not known 5 31
22 9
13
74 14 12
78
30 21.5 45
Not known 25 12
40
33 13 20
12 12 Not known
20 8.5 11.5
Not known
19
3
10
18
Javadpour and Associates20
llO
Cass and Ireland 21 82
36.5 26.5 31 6
27 65 8
26 59 7 8 25
80 15 1 4 67 2 0
10
Not known
25 7 18
16 5 11
774
CASS
REFERENCES
1. Cass, A. S., Ireland, G. W., Bressler, E., Bjornson, R., DeMeules, J. and Perry, J., Jr.: Modification of an operating-room table for immediate radiographic evaluation of the urinary tract in the acute, severe trauma patient. J. Urol., 105: 569, 1971. 2. Del Villar, R. G., Ireland, G. W. and Cass, A. S.: Management of renal injury in conjunction with the immediate surgical treatment of the acute severe traumatic patient. J. Urol., 107: 208, 1972. 3. Cass, A. S.: Ureteral contusion and delayed necrosis from gunshot injury. Urology, 12: 195, 1978. 4. Reid, I. S.: Renal trauma in children: a ten-year review. Aust. New Zeal. J. Surg., 42: 260, 1973. 5. Mertz, J. H. 0., Wishard, W. N., Jr., Nourse, M. H. and Mertz, H. 0.: Injury of the kidney in children. J.A.M.A., 183: 730, 1963. 6. Sargent, J.C. and Marquardt, C.R.: Renal injuries. J. Urol., 63: 1, 1950. 7. Vermillion, C. D., McLaughlin, A. P., III and Pfister, R. C.: Management of blunt renal trauma. J. Urol., 106: 478, 1971. 8. Nation, E. F. and Massey, B. D.: Renal trauma: experience with 258 cases. J. Urol., 89: 775, 1963. 9. Forsythe, W. E. and Persky, L.: Comparison of ureteral and renal injuries. Amer. J. Surg., 97: 558, 1959. 10. Slade, N.: Management of closed renal injuries. Brit. J. Urol., 43: 639, 1971. 11. Glenn, J. F. and Harvard, B. M.: The injured kidney. J.A.M.A., 173: 1189, 1960. 12. Morrow, J. W. and Mendez, R.: Renal trauma. J. Urol., 104: 649, 1970. 13. Cass, A. S.: Renal trauma in the multiple injured patient. J. Urol., 114: 495, 1975. 14. Morse, T. S., Smith, J. P., Howard, W. H. R. and Rowe, M. I.: Kidney injuries in children. J. Urol., 98: 539, 1967. 15. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. 16. Persky, L. and Forsythe, W. E.: Renal trauma in childhood. J.A.M.A., 182: 709, 1962. 17. Lucey, D. T., Smith, M. J. V. and Koontz, W. W., Jr.: Modern trends in the management ofurologic trauma. J. Urol., 107: 641, 1972. 18. Cass, A. S., Susset, J., Khan, A. and Godec, C. J.: Renal pedicle injury in the multiple injured patient. J. Urol., 122: 728, 1979. 19. Guerriero, W. G., Carlton, C. E., Jr., Scott, R., Jr. and Beall, A. C.:
Renal pedicle injuries. J. Trauma, 11: 53, 1971. 20. Javadpour, N., Guinan, P. and Bush, I. M.: Renal trauma in children. Surg., Gynec. & Obst., 136: 237, 1973. 21. Cass, A. S. and Ireland, G. W.: Renal injuries in children. J. Trauma, 14: 710, 1974. 22. Cass, A. S.: Bladder trauma in the multiple injured patient. J. Urol., 115: 667, 1976. 23. Cass, A. S. and Godec, C. J.: Urethral injury due to external trauma. Urology, 11: 607, 1978. 24. 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. J. Urol., 109: 8, 1973. EDITORIAL COMMENT I agree wholeheartedly with the philosophy of early aggressive radiographic evaluation of the patient suspected of having renal parenchymal injury. It should be apparent that intelligent treatment decisions can be made only if based on knowledge of the location and the extent of a renal laceration. In our experience 15 per cent of nonpenetrating renal injuries are of major extent and it is in this small group of patients that 90 per cent of the complications of expectant treatment occur. We agree that the renal salvage rate is increased greatly by early operative management of this group of major lacerations. Regarding posterior urethral injuries we have followed the lead of Morehead in treating these patients with simple suprapubic cystostomy without urethral instrumentation or manipulation. Approximately 20 per cent of the posterior urethral injuries are partial lacerations, which will heal spontaneously without stricture if manipulation and mobilization are avoided initially. The remaining 80 per cent usually will have some degree of urethral stricture disease, which in our experience can be corrected more easily if there has not been previous instrumentation or mobilization of the injured area. Our experience would tend to support that reported by Morehead and MacKinnon of a marked reduction in the incidence of impotence if no attempt is made to repair the injury during the immediate post-injury phase.
C. Eugene Carlton, Jr. Division of Urology Baylor College of Medicine Houston, Texas
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
IMMEDIATE RADIOLOGICAL EVALUATION AND EARLY SURGICAL MANAGEMENT OF GENITOURINARY INJURIES FROM EXTERNAL TRAUMA ALEXANDERS. CASS* From the Department of Urology, St. Paul Ramsey Medical Center, St. Paul and the Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT
An immediate diagnostic evaluation of genitourinary trauma is mandatory for an early operation. A method of immediate radiological evaluation is presented and the accuracy rate in the diagnosis of the type and site of injury is detailed. The advantages of early surgical management are compared to the results with expectant management. Diagnosis of the site and type of genitourinary injury is essential for adequate treatment. With expectant management diagnostic evaluation can be delayed. With early surgical management diagnostic evaluation must be immediate. This evaluation has been accomplished with the modification of an operating room table for radiographic evaluation. 1 Herein is discussed a method to manage patients with genitourinary injuries involving immediate radiological evaluation and early operation. MATERIALS AND METHODS
From January 1959 to December 1978, 1,389 patients with genitourinary injuries had been seen at the hospitals. The injuries involved the kidneys in 948 cases, the ureter in 18 cases, the bladder in 303 cases, the urethra in 60 cases and the testicle in 60 cases. Indications for evaluation of the genitourinary trauma were 1) macroscopic or microscopic hematuria of >8 red blood cells per high power field, 2) perirenal hematoma found during a laparotomy for associated intra-abdominal injury, 3) flank or lateral abdominal pain, tenderness or a mass, 4) fractures of the lumbar transverse processes, 5) blood at the external urinary meatus, 6) inability to pass a urethral catheter as part of the immediate aggressive evaluation of acute severe trauma 1• 2 and 7) painful tender swelling in the scrotum after trauma. Radiological evaluation included a cystogram. The bladder was filled with 400 ml. contrast medium in adults (50 ml. diatrizoate meglumine 60 in 350 ml. normal saline) and 5 cc contrast medium per pound body weight or 20 cc per year of age in children and an anteroposterior x-ray was made. The bladder was emptied and washed out with normal saline. A second anteroposterior x-ray was then taken (washout film). After the cystogram an excretory urogram (IVP) was made with 100 ml. diatrizoate m eglumine 76 or an infusion IVP with 300 ml. 30 per cent diatrizoate meglumine injection for adults and 2 cc per pound body weight for children. X-rays were made 5, 10 and 20 minutes after injection. A retrograde urethrogram was done if blood was present at the external urinary meatus or a urethral catheter could not be passed. Ten to 20 cc contrast medium were injected into the external urinary meatus with a watertight adaptor. Subsequent radiological evaluation of renal arteriography was indicated if the initial IVP was abnormal (non-function, extravasation, or distorted or non-filled calices) and the abdomen was not open for associated intra-abdominal injury. If the abdomen was open renal exploration was done instead of arteAccepted for publication March 9, 1979. • Requests for reprints: Department of Urology, St. Paul Ramsey Medical Center, 640 Jackson St., St. Paul, Minnesota 55101. 772
riography. The subsequent radiological evaluation of a retrograde pyelogram was indicated if the initial IVP showed normal calices and renal outline with extravasation around the renal pelvis or the ureter. Since 1968 this initial radiological evaluation was done immediately after the patient was hospitalized. In the severely injured patient this was made possible by the use of a modified operating room table. 1 The cystogram was done before the IVP so that the washout film would not have contrast m edium in the lower ureters, causing confusion with extraperitoneal rupture. Also, the diagnosis of reflux could be important if an upper tract operation was done, for example ureteral or renal pelvic repair, or partial nephrectomy. Also, since 1968 early surgical management of the more severe degrees of renal injury was introduced. RESULTS
Diagnosis made by immediate radiological evaluation. Renal injury: The IVP provided for a definite diagnosis in 87 per cent of the patients. Therefore, in only 13 per cent was there an indeterminate finding, requiring an arteriogram, retrograde pyelogram or renal exploration if the abdomen was open for associated intra-abdominal injury. The average time from injury to diagnosis of renal pedicle injury was 7.4 hours. Ureteral injury: The IVP and retrograde pyelogram allowed for the diagnosis and localization of the site of injury in 100 per cent of the cases. However, the presentation of ureteral rupture can be late owing to delayed necrosis of the ureteral wall some days after a gunshot wound. 3 Bladder injury: The cystogram provided for the diagnosis of intraperitoneal rupture in 100 per cent of the cases and extraperitoneal rupture in 90 per cent of the cases. The 3 falsely negative cystograms with extraperitoneal rupture occurred with 250 ml. contrast medium bladder filling (instead of 400 ml.) and no washout films were taken in 2 of the 3 cases. Urethral injury: A retrograde urethrogram provided for the diagnosis of rupture in 100 per cent of the cases. Early surgical management. Renal injury: Since 1968 only in patients with the more severe degrees of renal injury (laceration, rupture and pedicle injury) h as an early operation been done. These injuries comprised 20 per cent of all renal injuries or 40 p er cent of all renal injuries found in patients with associated intra-abdominal injuries requiring laparotomy. The average time from injury to early surgical treatm ent of renal pedicle injury was 8. 7 hours in 17 patients. Of these 17 patients 6 had vascular repairs and the average time from injury to operation was 4.3 hours. The nephrectomy rate was 5 per cent. Only 2 per cent of the patients had significant sequelae and/or delayed renal opera-
773
EARLY RADIOLOGY AND SURGERY FOR TRAUMA
tions. There was no need for a second operation for the renal injury that required an operation in those patients having an immediate laparotomy for associated intra-abdominal injury. In this study a laparotomy for associated intra-abdominal injury was done in 42 per cent of all patients with renal injuries and in 57 per cent of the patients with renal injuries and an associated injury. Ureteral injury: Urinary extravasation, retroperitoneal infection and urinary fistula formation were prevented with early surgical management of ureteral ruptures. Bladder injury: A large rent of 3 to 5 cm. in the dome of the bladder usually was found with intraperitoneal rupture. Early operative repair of this rent prevented intra-abdominal urinary extravasation and prolapse of a loop of bowel into the bladder. Some extraperitoneal ruptures were found at operation to be small puncture wounds with minimal extravasation and these patients would have been suitable for conservative management with a urethral catheter alone. Urethral injury: Early surgical management consisted of primary realignment of the ruptured urethra by a urethral catheter plus a suprapubic cystostomy in most cases. A stricture rate of 62 per cent was found on followup but only half of these strictures required operative correction. The incidence of incontinence was 10 per cent and of impotence it was 38 per cent. Testicular injury: Evacuation of the hematocele and repair of the ruptured testicle, if present, comprised the early surgical management in patients with testicular injuries. The orchiectomy rate was 9 per cent. Infective complications and the pressure effects of a large hematocele were prevented with this management. DISCUSSION
The advantages of early surgical management in patients with genitourinary trauma should be clear-cut to warrant the effort of immediate radiological evaluation. The main area of controversy between expectant and early surgical management involves renal injury and, in particular, the more severe degrees of renal injury (laceration, rupture and pedicle injury). All patients with renal contusions were managed successfully with expectant treatment and no complications or delayed renal operations occurred in this group. The main issues in this controversy are 1) the results of early surgical treatment are not superior to expectant treatment, 2) the nephrectomy rate is higher with early surgical treatment and 3) the renal salvage rate with surgical management of pedicle injuries is insignificant. The incidence of significant sequelae and/ or a delayed renal
operation in studies of the expectant treatment with the more severe degrees of renal injury (excluding pre-existing renal anomalies) has been reported as 314 and 45 per cent5 in pediatric cases and 15,6 17, 7 18, 8 22, 9 25, 10 30, 11 32 12 and 58 per cent1 3 in over-all cases. With early surgical management of the more severe degrees of renal injury in this study only 2 per cent had significant sequelae and/or a delayed renal operation. 13 The nephrectomy rate with expectant management of renal injuries (excluding pre-existing renal anomalies) has been reported as 3.5, 10• 11 4, 7 6, 6 8,8 8.5, 14 8.9,9 9, 15 12, 16• 17 135 and 21 per cent. 12 The nephrectomy rate was higher when there was a significant percentage of associated injuries, especially intraabdominal injuries. The nephrectomy rate in this study with early surgical management was 5 per cent. The incidence of associated intra-abdominal injury requiring laparotomy was 42 per cent. Clamping the renal vessels before Gerota's fascia was opened was an essential part of the early surgical management, since this procedure prevents reactivation of hemorrhage from release of the perirenal tamponade after Gerota's fascia is opened. With early surgical management of patients with pedicle injuries 6 vascular repairs were done and 11 kidneys were removed. 18 This vascular repair rate of 35 per cent is significant compared to the 100 per cent renal loss rate with expectant treatment. Guerriero and associates reported a 56 per cent vascular repair rate with immediate surgical management of 41 renal artery or vein injuries in 33 patients 19 (see table4 • 5' 14• 16, 20, 21),
The cystogram for diagnosing bladder injury should be done with 400 ml. contrast medium since falsely negative results occurred with 250 ml. in cases of extraperitoneal rupture. 22 While early operative repair should be done for intraperitoneal and large extraperitoneal ruptures a urethral catheter alone can be used for small extraperitoneal ruptures with minimal extravasation. The controversial issue wit urethral injury involves which type of early surgical manage ent provides the best long-term results. An immediate retrogra e urethrogram and some form of early surgical management ar done for urethral ruptures. 23 Expectant management of pat'ents with a testicular injury resulted in 40 per cent inflamma ory complications and a 45 per cent orchiectomy rate. 24 Ther can be long-term atrophy of the testicle after the large hem tocele absorbs. With early surgical management the inflam atory complications and pressure effect of the large hematoc e are prevented. The orchiectomy rate was 9 per cent. The disability of the large painful swollen scrotum for weeks also is avoided by early surgical management.
Percentage comparison of studies of renal injuries in children Expectant Management
No. injuries Etiology: Falls and blows Traffic accidents Penetrating Other Classification: Contusion Laceration Rupture Pedicle injury Associated injuries Pre-existing anomalies Significant sequelae and/or delayed renal operation* Over-all operative treatment:* Rate Nephrectomy Operations preserving renal tissue * Excluding pre-existing renal anomaly.
Early Operative Management
Reid'
Mertz and Associates"
Persky and Forsythe 16
Morse and Associates 14
78
70
65
80
55 42 0 3
70 23 3 4
69 29 2
Not known
68 26 0 6 Not known 5 31
22 9
13
74 14 12
78
30 21.5 45
Not known 25 12
40
33 13 20
12 12 Not known
20 8.5 11.5
Not known
19
3
10
18
Javadpour and Associates20
llO
Cass and Ireland 21 82
36.5 26.5 31 6
27 65 8
26 59 7 8 25
80 15 1 4 67 2 0
10
Not known
25 7 18
16 5 11
774
CASS
REFERENCES
1. Cass, A. S., Ireland, G. W., Bressler, E., Bjornson, R., DeMeules, J. and Perry, J., Jr.: Modification of an operating-room table for immediate radiographic evaluation of the urinary tract in the acute, severe trauma patient. J. Urol., 105: 569, 1971. 2. Del Villar, R. G., Ireland, G. W. and Cass, A. S.: Management of renal injury in conjunction with the immediate surgical treatment of the acute severe traumatic patient. J. Urol., 107: 208, 1972. 3. Cass, A. S.: Ureteral contusion and delayed necrosis from gunshot injury. Urology, 12: 195, 1978. 4. Reid, I. S.: Renal trauma in children: a ten-year review. Aust. New Zeal. J. Surg., 42: 260, 1973. 5. Mertz, J. H. 0., Wishard, W. N., Jr., Nourse, M. H. and Mertz, H. 0.: Injury of the kidney in children. J.A.M.A., 183: 730, 1963. 6. Sargent, J.C. and Marquardt, C.R.: Renal injuries. J. Urol., 63: 1, 1950. 7. Vermillion, C. D., McLaughlin, A. P., III and Pfister, R. C.: Management of blunt renal trauma. J. Urol., 106: 478, 1971. 8. Nation, E. F. and Massey, B. D.: Renal trauma: experience with 258 cases. J. Urol., 89: 775, 1963. 9. Forsythe, W. E. and Persky, L.: Comparison of ureteral and renal injuries. Amer. J. Surg., 97: 558, 1959. 10. Slade, N.: Management of closed renal injuries. Brit. J. Urol., 43: 639, 1971. 11. Glenn, J. F. and Harvard, B. M.: The injured kidney. J.A.M.A., 173: 1189, 1960. 12. Morrow, J. W. and Mendez, R.: Renal trauma. J. Urol., 104: 649, 1970. 13. Cass, A. S.: Renal trauma in the multiple injured patient. J. Urol., 114: 495, 1975. 14. Morse, T. S., Smith, J. P., Howard, W. H. R. and Rowe, M. I.: Kidney injuries in children. J. Urol., 98: 539, 1967. 15. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. 16. Persky, L. and Forsythe, W. E.: Renal trauma in childhood. J.A.M.A., 182: 709, 1962. 17. Lucey, D. T., Smith, M. J. V. and Koontz, W. W., Jr.: Modern trends in the management ofurologic trauma. J. Urol., 107: 641, 1972. 18. Cass, A. S., Susset, J., Khan, A. and Godec, C. J.: Renal pedicle injury in the multiple injured patient. J. Urol., 122: 728, 1979. 19. Guerriero, W. G., Carlton, C. E., Jr., Scott, R., Jr. and Beall, A. C.:
Renal pedicle injuries. J. Trauma, 11: 53, 1971. 20. Javadpour, N., Guinan, P. and Bush, I. M.: Renal trauma in children. Surg., Gynec. & Obst., 136: 237, 1973. 21. Cass, A. S. and Ireland, G. W.: Renal injuries in children. J. Trauma, 14: 710, 1974. 22. Cass, A. S.: Bladder trauma in the multiple injured patient. J. Urol., 115: 667, 1976. 23. Cass, A. S. and Godec, C. J.: Urethral injury due to external trauma. Urology, 11: 607, 1978. 24. 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. J. Urol., 109: 8, 1973. EDITORIAL COMMENT I agree wholeheartedly with the philosophy of early aggressive radiographic evaluation of the patient suspected of having renal parenchymal injury. It should be apparent that intelligent treatment decisions can be made only if based on knowledge of the location and the extent of a renal laceration. In our experience 15 per cent of nonpenetrating renal injuries are of major extent and it is in this small group of patients that 90 per cent of the complications of expectant treatment occur. We agree that the renal salvage rate is increased greatly by early operative management of this group of major lacerations. Regarding posterior urethral injuries we have followed the lead of Morehead in treating these patients with simple suprapubic cystostomy without urethral instrumentation or manipulation. Approximately 20 per cent of the posterior urethral injuries are partial lacerations, which will heal spontaneously without stricture if manipulation and mobilization are avoided initially. The remaining 80 per cent usually will have some degree of urethral stricture disease, which in our experience can be corrected more easily if there has not been previous instrumentation or mobilization of the injured area. Our experience would tend to support that reported by Morehead and MacKinnon of a marked reduction in the incidence of impotence if no attempt is made to repair the injury during the immediate post-injury phase.
C. Eugene Carlton, Jr. Division of Urology Baylor College of Medicine Houston, Texas
