0022-534 7/78/1202-0455$02. 00/0 THE JOURNAL OF UROLOGY Copyright © 1978 by The Williams & Wilkins Co.
Vol. 120, October Printed in U.S.A.
SIGNIFICANCE OF HEMATURIA AFTER TRAUMA THOMAS C. BRIGHT,* KATHY WHITE
AND
PAUL C. PETERS
From the Division of Urology, The University of Texas Southwestern Medical School at Dallas, Dallas, Texas
ABSTRACT
There were 142 consecutive patients with post-traumatic hematuria evaluated prospectively during a 7-month period. Of these 142 cases 22 involved penetrating in~urie~ and. l~O _were secondary to blunt trauma. There were 19 patients with 24 demonstrable gemtourmary mJunes at Of 15 preoperative n~.--.""''~" ...' urograms 7 were abnormal in these patients with - 8 of the 142 patients required an "'"'·"rein for the urologic injuries. The not correlate with the severity of Liberal use of arteriography and n,s•nr,nc,,,,, to delineate precisely the Traumatic hematuria is a frequent finding in emergency departments because of the number of automobile accidents and violent crimes. We herein 1) attempt to define which patients urologic evaluation and 2) compare the quantity of hematuria with the severity of urologic i11jury. MATERIALS
Between September 1, 1975 and March 31, 1976, 3,594 patients were seen after trauma from motor vehicle accidents (2,575), gunshot wounds (596) and stab wounds (423). Of this number 843 patients (391 motor vehicle accidents, 283 gunshot wounds and 169 stab wounds) were admitted to the hospital. During this period 142 patients presented with hematuria after trauma (table 1). On evaluation in the emergency department 37 patients had gross hematuria and 105 had microscopic hematuria. All patients with gross hematuria and most patients with microscopic hematuria were evaluated with a trauma series (rapid high dose infusion pyelogram and static cystogram) in the emergency department. RESULTS
Three categories of patients evolved (table 2). Group 1 consisted of 49 patients with microscopic hematuria and no other injuries. These patients were followed in the outpatient clinic until the hematuria cleared. Group 2 consisted of 49 patients hospitalized for observation (19 of 49 were hospitalized for urologic reasons). None of these patients required a delayed operation for urologic complications. Group 3 included 44 patients who underwent exploratory laparotomy for various reasons. Of these 44 patients 25 had no demonstrable urologic injury at laparotomy: 20 patients with microscopic and 5 with gross hematuria. Of the 49 patients in group 2, 24 had demonstrable genitourinary injuries (table 3). Of the 19 patients with documented genitourinary injuries 12 had gross hematuria and 7 had microscopic hematuria. In the group with proved genitourinary injuries the preoperative trauma series was abnormal in 7 (6 delayed or non-visualization of the kidney and 1 urinary extravasation on cystogram) and normal in 8. The trauma series was not performed in 4 cases because of the unstable condition of the patients. Associated bone fractures were common in patients with hematuria (table 4). Of the 19 patients with documented genitourinary injury 16 had associated visceral injuries (table 5). Most cases ofhematuria (120) vvere caused by blunt trauma Accepted for publication November 18, 1977. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 27-31, 1977. * Requests for reprints: Division of Urology, University of Texas Medical School, 5323 Harry Hines Blvd., Dallas,
but penetrating trauma accounted for a much higher proportion (10 of 22 versus 9 of 120) of documented injuries (table 6). The incidence of major renal i~juries is higher in the penetrating group (4 of 22) than the blunt trauma group (3 of 120). Of the 142 patients 3 died (2 of multiple injuries and 1 of severe closed head injury). None of the deaths was related to the genitourinary injury. Two urologic complications arose in the 93 hospitalized patients (1 case of cystitis and 1 case of prosta ti tis). DISCUSSION
Hematuria is encountered frequently in emergency departments throughout the country. Recent advances in emergency evaluation of trauma patients make thorough investigation mandatory. The amount of hematuria (gross versus microscopic) does not correlate with the degree of urologic injury. The most dangerous of genitourinary injuries are those of the renal pedicle. Of the 3 patients with pedicle injuries in this series 2 (renal vein laceration and avulsion) had microscopic hematuria, while 1 (renal artery thrombosis) had gross hematuria. Guerriero and associates noted gross hematuria in only 10 of 33 patients with renal pedicle injuries and these 10 patients had associated collecting system violations. 1 There are several reports of renal artery thrombosis with only microscopic hematuria or no hematuria. 2- 1 Any patient with hematuria after trauma should be evaluated completely by radiography. Infusion pyelography and cystography are performed immediately in the emergency department. Arteriography is used liberally when the infusion pyelogram is abnormal. Of special note is the non-visualizing kidney. If total non-visualization exists then immediate selective renal arteriography is mandatory to eliminate the possibility of renal artery thrombosis. In addition to renal artery evaluation arteriography is extremely useful in accessing the precise anatomic renal parenchymal injury. In the patient with segmental non-visualization of urinary extravasation renal angiography will delineate the precise parenchymal defect and contribute to the decision to operate or to follow conservative measures. Renal scanning has been advocated by Koenigsberg and associates,° and Berg. 6 Dynamic flow, and immediate and delayed static scintillation studies are performed. These authors advocate renal scanning in every patient with traumatic hematuria seen in the emergency department. Koenigsberg and associates further state that scanning and angiography are of equal value in detecting the presence of major renal injury and that scanning is more sensitive to the discovery of minor renal trauma. 5 They do better anatomical detail once a
456
B;RIGHT, WHITE AND PETERS TABLE
1. Patients presenting with hematuria
TABLE
4. Associated fractures (54 patients)
No. Cases Blunt trauma: Motor vehicle accident Fall Aggravated assault
No. Cases
110 6 4 120
Total Penetrating trauma: Gunshot wound Stab wound
15 7 22
Total
20 18 13
Ribs Pelvis Femur Humerus Tibia-fibula Clavicle Vertebral Skull Radius and ulna Metacarpal Patella
10
10 10 7 6 4 1 1 100
TABLE TABLE
No. Cases Liver Spleen Small bowel Colon Diaphragm Pancreas Stomach Lumbar arteries and veins Femoral arteries and veins Mesocolon Common bile duct Portal vein
No. Cases Group 1-microscopic hematuria followed as outpatient Group 2-admitted for observation (19 for urologic reasons) Group 3-exploratory laparotomy (19 had proved urologic injury)
TABLE
5. Associated visceral and vascular injuries (16 patients)
2. Categories of patients 49 49 44
3. Proved genitourinary injuries at laparotomy
7 6 3 3 3
2 2 1 1 1 1 1
31
No. Cases Renal or perinea! hematoma Bladder injury Renal polar rupture Renal pedicle injury Completely ruptured kidney
13 TABLE
4 3 3
6. Urologic injuries No. Pts.
1
Blunt trauma Penetrating trauma
24
No. Major Renal Injuries
9
10
3 4
TRAUMA VICTIM (hematuria, history & physical)
/
\
mlroscopic hematuria\
/ g r o s s hematur\
normal !VP
home and outpltient fol lowup
normal !VP
A NORMAL !VP
observation tnd bedrest
delayed visualization ( o n l y ) ~ / ;or exlravasa~non-visualization (total or segmental) ~ major extravasation
I
conservative management
/ARTERIOGRAPH\ intact vasculature
,,,,,,,,,,,] "'"'''"'"' proposed for the immediate evaluation and management of the trauma victim with hematuria (see figure). By immediate, complete evaluation of urologic injury with identification of the anatomical detail, less reliance need be placed on expectant management and patients are categorized promptly as to surgical versus non-surgical injuries. REFERENCES
1. Guerriero, W. G., Carlton, C. E., Scott, R. and Beall, A. C.: Renal pedicle injuries. J. Trauma, 115: 53, 1971. 2. Peters, P. C. and Bright, T. C., III: Management of trauma to
3. 4. 5. 6.
va5culaturel interrupted
"'''''''' "'"'''"'"'
the urinary tract. In: Advances in Surgery. Edited by W. P. Longmire. Chicago: Year Book Medical Publishers, vol. 10, p. 197, 1976. Caponegro, P. J. and Leadbetter, G. W., Jr.: Traumatic renal artery thrombosis. J. Urol., 109: 769, 1973. Richie, J. P., Bennett, C. M. and Brosman, S. A.: Traumatic renal artery thrombosis with acute malignant hypertension and hyperreninemia. Urology, 6: 481, 1975. Koenigsberg, M., Blaufox, M. D. and Freeman, L. M.: Traumatic injuries of the renal vasculature and parenchyma. Semin. Nucl. Med., 4: 117, 1974. Berg, B. C., Jr.: Radionuclide studies after urinary-tract injury. Semin. Nucl. Med., 4: 371, 1974.
Vol. 120, October Printed in U.S.A.
SIGNIFICANCE OF HEMATURIA AFTER TRAUMA THOMAS C. BRIGHT,* KATHY WHITE
AND
PAUL C. PETERS
From the Division of Urology, The University of Texas Southwestern Medical School at Dallas, Dallas, Texas
ABSTRACT
There were 142 consecutive patients with post-traumatic hematuria evaluated prospectively during a 7-month period. Of these 142 cases 22 involved penetrating in~urie~ and. l~O _were secondary to blunt trauma. There were 19 patients with 24 demonstrable gemtourmary mJunes at Of 15 preoperative n~.--.""''~" ...' urograms 7 were abnormal in these patients with - 8 of the 142 patients required an "'"'·"rein for the urologic injuries. The not correlate with the severity of Liberal use of arteriography and n,s•nr,nc,,,,, to delineate precisely the Traumatic hematuria is a frequent finding in emergency departments because of the number of automobile accidents and violent crimes. We herein 1) attempt to define which patients urologic evaluation and 2) compare the quantity of hematuria with the severity of urologic i11jury. MATERIALS
Between September 1, 1975 and March 31, 1976, 3,594 patients were seen after trauma from motor vehicle accidents (2,575), gunshot wounds (596) and stab wounds (423). Of this number 843 patients (391 motor vehicle accidents, 283 gunshot wounds and 169 stab wounds) were admitted to the hospital. During this period 142 patients presented with hematuria after trauma (table 1). On evaluation in the emergency department 37 patients had gross hematuria and 105 had microscopic hematuria. All patients with gross hematuria and most patients with microscopic hematuria were evaluated with a trauma series (rapid high dose infusion pyelogram and static cystogram) in the emergency department. RESULTS
Three categories of patients evolved (table 2). Group 1 consisted of 49 patients with microscopic hematuria and no other injuries. These patients were followed in the outpatient clinic until the hematuria cleared. Group 2 consisted of 49 patients hospitalized for observation (19 of 49 were hospitalized for urologic reasons). None of these patients required a delayed operation for urologic complications. Group 3 included 44 patients who underwent exploratory laparotomy for various reasons. Of these 44 patients 25 had no demonstrable urologic injury at laparotomy: 20 patients with microscopic and 5 with gross hematuria. Of the 49 patients in group 2, 24 had demonstrable genitourinary injuries (table 3). Of the 19 patients with documented genitourinary injuries 12 had gross hematuria and 7 had microscopic hematuria. In the group with proved genitourinary injuries the preoperative trauma series was abnormal in 7 (6 delayed or non-visualization of the kidney and 1 urinary extravasation on cystogram) and normal in 8. The trauma series was not performed in 4 cases because of the unstable condition of the patients. Associated bone fractures were common in patients with hematuria (table 4). Of the 19 patients with documented genitourinary injury 16 had associated visceral injuries (table 5). Most cases ofhematuria (120) vvere caused by blunt trauma Accepted for publication November 18, 1977. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 27-31, 1977. * Requests for reprints: Division of Urology, University of Texas Medical School, 5323 Harry Hines Blvd., Dallas,
but penetrating trauma accounted for a much higher proportion (10 of 22 versus 9 of 120) of documented injuries (table 6). The incidence of major renal i~juries is higher in the penetrating group (4 of 22) than the blunt trauma group (3 of 120). Of the 142 patients 3 died (2 of multiple injuries and 1 of severe closed head injury). None of the deaths was related to the genitourinary injury. Two urologic complications arose in the 93 hospitalized patients (1 case of cystitis and 1 case of prosta ti tis). DISCUSSION
Hematuria is encountered frequently in emergency departments throughout the country. Recent advances in emergency evaluation of trauma patients make thorough investigation mandatory. The amount of hematuria (gross versus microscopic) does not correlate with the degree of urologic injury. The most dangerous of genitourinary injuries are those of the renal pedicle. Of the 3 patients with pedicle injuries in this series 2 (renal vein laceration and avulsion) had microscopic hematuria, while 1 (renal artery thrombosis) had gross hematuria. Guerriero and associates noted gross hematuria in only 10 of 33 patients with renal pedicle injuries and these 10 patients had associated collecting system violations. 1 There are several reports of renal artery thrombosis with only microscopic hematuria or no hematuria. 2- 1 Any patient with hematuria after trauma should be evaluated completely by radiography. Infusion pyelography and cystography are performed immediately in the emergency department. Arteriography is used liberally when the infusion pyelogram is abnormal. Of special note is the non-visualizing kidney. If total non-visualization exists then immediate selective renal arteriography is mandatory to eliminate the possibility of renal artery thrombosis. In addition to renal artery evaluation arteriography is extremely useful in accessing the precise anatomic renal parenchymal injury. In the patient with segmental non-visualization of urinary extravasation renal angiography will delineate the precise parenchymal defect and contribute to the decision to operate or to follow conservative measures. Renal scanning has been advocated by Koenigsberg and associates,° and Berg. 6 Dynamic flow, and immediate and delayed static scintillation studies are performed. These authors advocate renal scanning in every patient with traumatic hematuria seen in the emergency department. Koenigsberg and associates further state that scanning and angiography are of equal value in detecting the presence of major renal injury and that scanning is more sensitive to the discovery of minor renal trauma. 5 They do better anatomical detail once a
456
B;RIGHT, WHITE AND PETERS TABLE
1. Patients presenting with hematuria
TABLE
4. Associated fractures (54 patients)
No. Cases Blunt trauma: Motor vehicle accident Fall Aggravated assault
No. Cases
110 6 4 120
Total Penetrating trauma: Gunshot wound Stab wound
15 7 22
Total
20 18 13
Ribs Pelvis Femur Humerus Tibia-fibula Clavicle Vertebral Skull Radius and ulna Metacarpal Patella
10
10 10 7 6 4 1 1 100
TABLE TABLE
No. Cases Liver Spleen Small bowel Colon Diaphragm Pancreas Stomach Lumbar arteries and veins Femoral arteries and veins Mesocolon Common bile duct Portal vein
No. Cases Group 1-microscopic hematuria followed as outpatient Group 2-admitted for observation (19 for urologic reasons) Group 3-exploratory laparotomy (19 had proved urologic injury)
TABLE
5. Associated visceral and vascular injuries (16 patients)
2. Categories of patients 49 49 44
3. Proved genitourinary injuries at laparotomy
7 6 3 3 3
2 2 1 1 1 1 1
31
No. Cases Renal or perinea! hematoma Bladder injury Renal polar rupture Renal pedicle injury Completely ruptured kidney
13 TABLE
4 3 3
6. Urologic injuries No. Pts.
1
Blunt trauma Penetrating trauma
24
No. Major Renal Injuries
9
10
3 4
TRAUMA VICTIM (hematuria, history & physical)
/
\
mlroscopic hematuria\
/ g r o s s hematur\
normal !VP
home and outpltient fol lowup
normal !VP
A NORMAL !VP
observation tnd bedrest
delayed visualization ( o n l y ) ~ / ;or exlravasa~non-visualization (total or segmental) ~ major extravasation
I
conservative management
/ARTERIOGRAPH\ intact vasculature
,,,,,,,,,,,] "'"'''"'"' proposed for the immediate evaluation and management of the trauma victim with hematuria (see figure). By immediate, complete evaluation of urologic injury with identification of the anatomical detail, less reliance need be placed on expectant management and patients are categorized promptly as to surgical versus non-surgical injuries. REFERENCES
1. Guerriero, W. G., Carlton, C. E., Scott, R. and Beall, A. C.: Renal pedicle injuries. J. Trauma, 115: 53, 1971. 2. Peters, P. C. and Bright, T. C., III: Management of trauma to
3. 4. 5. 6.
va5culaturel interrupted
"'''''''' "'"'''"'"'
the urinary tract. In: Advances in Surgery. Edited by W. P. Longmire. Chicago: Year Book Medical Publishers, vol. 10, p. 197, 1976. Caponegro, P. J. and Leadbetter, G. W., Jr.: Traumatic renal artery thrombosis. J. Urol., 109: 769, 1973. Richie, J. P., Bennett, C. M. and Brosman, S. A.: Traumatic renal artery thrombosis with acute malignant hypertension and hyperreninemia. Urology, 6: 481, 1975. Koenigsberg, M., Blaufox, M. D. and Freeman, L. M.: Traumatic injuries of the renal vasculature and parenchyma. Semin. Nucl. Med., 4: 117, 1974. Berg, B. C., Jr.: Radionuclide studies after urinary-tract injury. Semin. Nucl. Med., 4: 371, 1974.
