SIMULTANEOUS UPPER AND LOWER URINARY TRACT INJURY FROM EXTERNAL TRAUMA A. S. CASS, M.B.B.S. M. LUXENBERG, PH.D. From the Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT--We found simultaneous upper and lower urinary tract injury to be rare, being present in 10 of 2,310 patients (0.4 %). Multiple associated injuries were present in all patients (average 4.4 per patient). In 3 patients both upper and lower urinary tract injuries were minor, and I patient died of associated injuries. In 4 patients one of the urinary injuries was significant and the other minor, and 2 of these patients died. In 3 patients both urinary injuries were significant, and all 3 died of associated injuries. A comprehensive urologic evaluation was required in all 10 patients because of their severe associated multiple injuries.
A recent review reported 17 patients (0.6% of the series) with simultaneous upper and lower urinary tract injuries. Commonly, at least one of the urinary injuries was of minor consequence; and when both upper and lower tract injuries were significant, the patient usually had suffered multisystem trauma incompatible with survival.* We reviewed our 10 patients with simultaneous upper and lower urinary tract injuries with similar results. Material and Methods From 1959 to 1985, 2,310 patients with blunt and penetrating urinary tract injuries were admitted to Hennepin County Medical Center and St. Paul-Ramsey Medical Center. Of these, 10 (0.4%) had simultaneous upper and lower urinary tract injuries. An additional 7 patients with renal contusion plus penile or scrotal contusion or laceration are excluded from this study. The patients were grouped according to the site and nature of the injury. Minor injuries were contusion and superficial laceration. Significant injuries were deep laceration and rupture. The radiologie evaluation consisted of ex-
cretory urography (IVU) and r e t r o g r a d e cystography in almost all patients with further evaluation (arteriography, computed tomogra; phy, surgical exploration) when the IVU f i n d i ings were not normal. Results All 10 patients with simultaneous uppe lower urinary tract injuries had suffered trauma (traffic accidents in 8 and a blow or fali~il in 1 each). Most were thirty years of age of~i~ younger, and only 1 was female (Table I). Miii! had severe associated injuries (average 4.4 pet's:}! patient). Both urinary injuries were minor bladder contusion) in 3 patients. Only patients, an elderly woman, died. "1 was attributable to multiple fraetl urinary injury was minor and the ot[ cant in 4 patients, 2 of whom died of injuries. Both upper and lower tract injurie, nificant in 3 patients, and all of the associated injuries. Comment
*Peterson NE, and Schulze KA: Selective diagnostic uroradiography for trauma, J Urol 137:449 (1987).
226
Peterson and Schulze* reported simultaneous upper and lower tr~
UROLOGY
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SEPTEMBER 1990
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VOLUME XXXVI
TABLE I. Age/ Sex
Sites and types of urinary tract and associated injuries in i0 patients
Urinary Injuries
Both urologic injuries minor 23/M Renal and bladder contusions
30/M 71/F
Renal and bladder contusions Renal and blader contusions
One significant, 1 minor urologic injury 54/M Renal vein laceration; bladder contusion 20/M Renal contusion; bladder rupture 29/M Renal laceration; bladder contusion 22/M
Renal contusion; bladder/ urethral rupture
Both urologic injuries significant 22/M Renal artery and bladder rupture 22/M Renal laceration; bladder/ urethral rupture
57/M
Renal vein, UPJ, and bladder rupture
Associated Injuries
Outcome*
Pelvic and extremity fracture, ruptured spleen and liver, severe head injury Spine, pelvic, and extremity fractures Skull, pelvic, and extremity fractures
S
Ruptured liver and bowel; pelvic, rib, and extremity fractures Spine, pelvic and extremity fractures Ruptured spleen and liver; severe head injury; skull, rib, pelvic and extremity fracture Ruptured bowel; severe head injury; pelvic fracture Ruptured bowel; spine, pelvic, and extremity fractures Severe head injury; femoral vessels transected; pelvic and extremity fracture Ruptured diaphragm, spleen, liver and bowel; transected common iliac artery; rib, spine, pelvic, and extremity fracture
S D S S D D
D D D
*S =survived, D = died.
among 382 urologic injuries (0.5%) and reviewed 17 patients in 2,750 cases from the urologic literature. They found that when both upper and lower tract injuries exist one injury commonly is of minor consequence. When both :injuries are significant, the patient usually has suffered trauma from which recovery is doubtful. Those authors stated that the inffequency of coexisting upper and lower tract injuries in i salvageable patients calls into question the requirement for comprehensive uroradiographic i appraisal, the exception being in massive traumatic injury that mandates a comprehensive evaluation. They endorsed a policy of diagnostic inquiry limited to the site of maximum trauma.1
UROLOGY
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SEPTEMBER 1990
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Our findings confirmed those of Peterson and Schulze that coexisting upper and lower tract injuries are infrequent in salvageable patients. Moreover, none of the survivors sustained two significant urinary injuries. If massive traumarie injury mandates comprehensive evaluation, then all of our patients would have had such an evaluation, as all our patients with upper and lower tract injury had multiple injuries. A diagnostic injury limited to the site of maximum trauma could be applied to patients with urinary tract injury alone, as suggested by Peterson and Schulze, but did not apply in any of our patients. Minneapolis, Minnesota 55415 (DR. CASS)
VOLUME XXXVI, NUMBER 3
227
ABSTRACT--We found simultaneous upper and lower urinary tract injury to be rare, being present in 10 of 2,310 patients (0.4 %). Multiple associated injuries were present in all patients (average 4.4 per patient). In 3 patients both upper and lower urinary tract injuries were minor, and I patient died of associated injuries. In 4 patients one of the urinary injuries was significant and the other minor, and 2 of these patients died. In 3 patients both urinary injuries were significant, and all 3 died of associated injuries. A comprehensive urologic evaluation was required in all 10 patients because of their severe associated multiple injuries.
A recent review reported 17 patients (0.6% of the series) with simultaneous upper and lower urinary tract injuries. Commonly, at least one of the urinary injuries was of minor consequence; and when both upper and lower tract injuries were significant, the patient usually had suffered multisystem trauma incompatible with survival.* We reviewed our 10 patients with simultaneous upper and lower urinary tract injuries with similar results. Material and Methods From 1959 to 1985, 2,310 patients with blunt and penetrating urinary tract injuries were admitted to Hennepin County Medical Center and St. Paul-Ramsey Medical Center. Of these, 10 (0.4%) had simultaneous upper and lower urinary tract injuries. An additional 7 patients with renal contusion plus penile or scrotal contusion or laceration are excluded from this study. The patients were grouped according to the site and nature of the injury. Minor injuries were contusion and superficial laceration. Significant injuries were deep laceration and rupture. The radiologie evaluation consisted of ex-
cretory urography (IVU) and r e t r o g r a d e cystography in almost all patients with further evaluation (arteriography, computed tomogra; phy, surgical exploration) when the IVU f i n d i ings were not normal. Results All 10 patients with simultaneous uppe lower urinary tract injuries had suffered trauma (traffic accidents in 8 and a blow or fali~il in 1 each). Most were thirty years of age of~i~ younger, and only 1 was female (Table I). Miii! had severe associated injuries (average 4.4 pet's:}! patient). Both urinary injuries were minor bladder contusion) in 3 patients. Only patients, an elderly woman, died. "1 was attributable to multiple fraetl urinary injury was minor and the ot[ cant in 4 patients, 2 of whom died of injuries. Both upper and lower tract injurie, nificant in 3 patients, and all of the associated injuries. Comment
*Peterson NE, and Schulze KA: Selective diagnostic uroradiography for trauma, J Urol 137:449 (1987).
226
Peterson and Schulze* reported simultaneous upper and lower tr~
UROLOGY
/
SEPTEMBER 1990
/
VOLUME XXXVI
TABLE I. Age/ Sex
Sites and types of urinary tract and associated injuries in i0 patients
Urinary Injuries
Both urologic injuries minor 23/M Renal and bladder contusions
30/M 71/F
Renal and bladder contusions Renal and blader contusions
One significant, 1 minor urologic injury 54/M Renal vein laceration; bladder contusion 20/M Renal contusion; bladder rupture 29/M Renal laceration; bladder contusion 22/M
Renal contusion; bladder/ urethral rupture
Both urologic injuries significant 22/M Renal artery and bladder rupture 22/M Renal laceration; bladder/ urethral rupture
57/M
Renal vein, UPJ, and bladder rupture
Associated Injuries
Outcome*
Pelvic and extremity fracture, ruptured spleen and liver, severe head injury Spine, pelvic, and extremity fractures Skull, pelvic, and extremity fractures
S
Ruptured liver and bowel; pelvic, rib, and extremity fractures Spine, pelvic and extremity fractures Ruptured spleen and liver; severe head injury; skull, rib, pelvic and extremity fracture Ruptured bowel; severe head injury; pelvic fracture Ruptured bowel; spine, pelvic, and extremity fractures Severe head injury; femoral vessels transected; pelvic and extremity fracture Ruptured diaphragm, spleen, liver and bowel; transected common iliac artery; rib, spine, pelvic, and extremity fracture
S D S S D D
D D D
*S =survived, D = died.
among 382 urologic injuries (0.5%) and reviewed 17 patients in 2,750 cases from the urologic literature. They found that when both upper and lower tract injuries exist one injury commonly is of minor consequence. When both :injuries are significant, the patient usually has suffered trauma from which recovery is doubtful. Those authors stated that the inffequency of coexisting upper and lower tract injuries in i salvageable patients calls into question the requirement for comprehensive uroradiographic i appraisal, the exception being in massive traumatic injury that mandates a comprehensive evaluation. They endorsed a policy of diagnostic inquiry limited to the site of maximum trauma.1
UROLOGY
/
SEPTEMBER 1990
/
Our findings confirmed those of Peterson and Schulze that coexisting upper and lower tract injuries are infrequent in salvageable patients. Moreover, none of the survivors sustained two significant urinary injuries. If massive traumarie injury mandates comprehensive evaluation, then all of our patients would have had such an evaluation, as all our patients with upper and lower tract injury had multiple injuries. A diagnostic injury limited to the site of maximum trauma could be applied to patients with urinary tract injury alone, as suggested by Peterson and Schulze, but did not apply in any of our patients. Minneapolis, Minnesota 55415 (DR. CASS)
VOLUME XXXVI, NUMBER 3
227
