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Injuries of the Genito-Urinary Tract
INJURIES OF THE GENITO-URINARY TRACT JOHN B. WEAR1
A discussion of trauma cannot follow a fixed pattern of general statements without limitation as to the cause and extent of the injury. Of these two, the most important and most difficult for the surgeon to ascertain is the extent of the injury. In civil life the type of injury is usually determined by how the people in that community either work or play, and associated organs are usually not involved. In military life the same types of injuries may occur. But in addition we have more penetrating wounds from missiles of all sorts as well as extreme degrees of tissue loss which may involve more than one organ. THE KIDNEY
The kidney is not frequently injured in either civil or military life. Due to its location it is well protected from all types of injury, and this same position makes it possible for the kidney to recover without surgery in most cases. The mere fact that blood appears in the urine and a mass appears in the side does not call for an immediate operation. Grave injury may occur without hematuria and without a mass, but pain is usually a predominant symptom in those cases. In establishing the extent of the injury one may utilize the retrograde pyelogram, the exploratory operation or clinical judgment based on observation with the intravenous urogram which may or may not give the desired information. In the past 13 years we have had under our care 23 traumatized kidneys. Only 2 were penetrating from through and through gunshot wounds and both recovered without treatment directed to the kidney after abdominal exploration. A kidney may be lost by an early operation as well as by one done too late. I have selected 5 cases to demonstrate some of the difficulties involved in treatment and to question surgical judgment. Case 1. G. G., a 20 year old white man, fell on his back from a platform in the gymnasium. He had gross hematuria for 4 days and a mass in the right renal area. Seven days after admission an intravenous urogram showed no medium in the right kidney (fig. 1, A). He continued to improve and the mass in his side had disappeared in 2 weeks, at which time a retrograde pyelogram was done (fig. 1, B). Indigo carmine appeared from the right kidney in 11 minutes. Five months later an intravenous urograrn showed only a faint trace of Diodrast in the 20 minute film. Here is a case of apparently mild injury without evidence of loss of the normal contour of the kidney; yet function is markedly reduced. Would the patient have had this loss of function if the kidney had been explored? He has not developed hypertension in 5 months, as one would expect if the loss is due to a constricting mass about the renal parenchyma. Case 2. L. S., aged 19, was kicked in the left side while playing college foot- · 1 Read at annual meeting, North Central Section, American Urological Association, Cleveland, 0., October 23-25, 1947. 280
INJURIES OF THE GENITO-URINARY TRACT
281
ball. He had a very large tender, mass in the left side and gross blood in his urine. Conservative treatment was instituted. Three days later his blood pressure began to rise, and varied from 150/85 to 185/95 for several days. As this mass began to subside his pressure fell to his normal level, 125/70. He was discharged after 2 -weeks and an intravenous urogram (fig. 2) one month after the injury is normal. This is considered an example of a severe injury recovering without surgery. Would he have been as likely to recover without surgery if he had had a retrograde pyelogram? The rising blood pressure caused some concern, and it might have become an indication for surgical intervention.
Fm. 1
Case 3. H. M., an 18 year old sailor, fell when jumping a fence and struck his left side. On admission to the hospital there was a large, tender mass in the left side, and gross blood in the urine. He was treated conservatively and the urine cleared in 5 days, and the mass began to decrease in size. The intravenous urogram showed some extravasation at the lower pole (fig. 3, A). Twelve days after admission he got out of bed during the night and engaged in some play with the other boys. The urine again became bloody and the mass reappeared. Secondary hemorrhage was diagnosed and the kidney was explored. The lower pole -was fragmented and the perirenal area filled with large clots. Packs controlled the hemorrhage and the patient was discharged 20 days after operation. An intravenous urogram (fig. 3, B) showed a kidney with good function but some distortion due to the injury. This case demonstrated the value of bed rest in conservative treatment. Secondary hemorrhage is always a possibility, and -when it does occur it is usually serious and demands immediate surgical intervention.
282
JOHN B. WEAR
Case 4, D. B., an 18 year old boy, fell and struck the right side of his abdomen on a post. When admitted he had generalized abdominal pain with rigidity of
FIG. 2
FIG. 3
the right side. The urine was clear. A laparotomy was performed and a right retroperitoneal mass was found. The area was drained by stab wounds and the patient referred to the urological service. Retrograde pyelograms a few days
INJURIES OF THE GENITO-URINARY TRACT
283
later revealed a large hydronephrosis; 450 cc of urine were aspirated through the catheter (fig. 4). Three weeks after admission a right nephrectomy was done. At the time of the injury the hydronephrotic sac had been ruptured. Recovery was uneventful. Case 5. F. M., a 12 year old boy, was caught betvrnen a boxcar and a loading platform. He was taken to the hospital in severe shock. Treatment was conservative and he never showed any blood in the urine. He was sent home 16 days after admission. Three weeks later a large mass appeared in his left side and he entered the Wisconsin General Hospital. An intravenous urogram showed a normal right kidney but no function on the left side. The left renal area was explored and a large amount of urine was found in the perirenal area. The ureter had been torn from the pelvis and the kidney was embedded in dense adhesions. Nephrectomy was performed and recovery was uneventful.
Frn. 4
Here are 2 cases where the injury did not involve the parenchyma, and no blood was found in the urine. Hydronephrotic kidneys are particularly prone to injury, and early operation is indicated where the pelvis or ureter are injured. Delay may not cost the patient's life, but the kidney is not likely to be saved unless surgery is done early. BLADDER AND URETHRA
Bladder and urethral injuries are considered together as in the cases under discussion, the urethral wound was behind the urogenital diaphragm, thus placing the extravasation in the same area as in vesical trauma. I have chosen 5 cases which demonstrate 5 different types of associated injuries. They were all sailors or marines. The treatment in this type of case is usually clearly indicated. The results are dictated by the extent of the injury, the first treatment given, and the time element of the definitive treatment. Re-
284
JOHN B. WEAR
constructive operations after injury to the bladder and urethra follow a more fixed pattern than does injury to the kidney. The first principle is that of drainage and diversion of the urinary stream. Where associated organs are injured, their repair takes preference over the urinary tract after the first principle is observed. These cases are presented in diagrammatic form drawn by the artist from the x-ray pictures and the finding at the time of operation.
FIG. 5
Case 6. A marine was injured by a machine gun bullet entering his left thigh (fig. 5, A). He was admitted to the hospital 3 weeks later. Purulent urine was draining from the hip wound, his right hip joint was fixed, and he voided only a few drops of urine. X-rays revealed the bullet to be in his right hip joint, and the left ischial bone to be fractured. Attempts at catheterization were unsuccessful. Suprapubic cystotomy was done. Much purulent material was evacuated from the prevesical space, and the bullet had traversed the prostate near the vesical neck. By retrograde dilatation a catheter was passed and a balloon catheter pulled into the bladder. The balloon was inflated and held by light pressure against the internal orifice. Three weeks later he was voiding normally
INJURIES OF THE GENITO-URINARY TRACT
285
and the sinus tract in the left hip was healed. His urethra was dilated with sounds every 10 clays until his discharge. Although this patient recovered from his urinary injury, the right hip joint was destroyed. Case 7. A naval officer was crushed between a splinter shield and a gun mount. He was admitted to the hospital 6 hours later. His shock was treated by blood and plasma administration. Catheterized urine was bloody. Suprapubic cystotomy revealed a 2 inch laceration in the anterior wall of the bladder (fig. 5, B). Extravasated urine was evacuated from the anteromedial aspect of the right thigh. X-rays revealed multiple fractures of the pelvis with wide separations of the pubic bones, and subluxation of the right sacra-iliac joint. He later developed an abscess over the left pubic bone which was drained. This abscess communicated with the urethra anterior to the prostate. Urethral dilatations were carried out, and three months later he was voiding, and six months after injury he returned to duty. But he had a slight impediment in his gait as the symphysis was still widely separated.
Fm. 6
This case is cited as an example of extreme pelvic bone injury with extreme extravasation both above and below the urogenital diaphragm. Case 8. A 17 year old sailor was knocked down and run over by an airplane. He was admitted to the hospital 3 hours later complaining of pain in his abdomen and inability to void. X-rays showed multiple fractures of the pelvic bones (fig. 5, C); and only a few drops of urine were obtained by catheter. Suprapubic cystotomy revealed a laceration on the right side of the bladder. Much blood and urine were evacuated from the perivesical area. As he ,vas being returned to his bed, it was noticed that his right foot was cold and the dorsalis pedis artery could not be palpated. He was transferred to the surgical service, but in the end he lost his leg from the knee down due to arterial occlusion. Undoubtedly the pelvic vessels had been severely traumatized and an arterial embolus from this area caused the occlusion. Dicumerol and heparin or embolectomy might have saved his leg. Case 9. A marine was admitted to the hospital several months after his original injury. He had been shot with a rifle. The bullet entered the lower ab-
286
JOHN B. WEAR
domen over the bladder and the point of exit was the right buttock (fig. 5 D). Urine was draining from this tract. His right leg was paralyzed and he could not walk even with crutches. His immediate treatment had consisted of laparotomy, indwelling catheter, and right nephrectomy, as the bullet had severed the right ureter as it left the bladder. Cystoscopy showed an opening about 1 cm. in diameter in the region where the right ureteral orifice should have been located. A catheter passed into the opening emerged from the buttock wound. Supra pubic cystotomy revealed the right bladder wall to be densely adherent to the pelvic bone. It could not be separated, so the area was resected, the bladder closed, and the adherent tissue then removed with a periosteal elevator. The buttock sinus promptly healed. Sensation and motion gradually returned in his leg and 9 months later he was walking ·with a cane. The sciatic nerve was evidently traumatized by the bullet but not entirely severed. Case 10. A marine was shot in the perineum by a rifle bullet. The point of exit was near the lower portion of the sacrum (fig. 6). Colostomy and suprapubic cystotomy had been done in the for,vard area and we saw him 3 months later. At the time of admission he was emaciated and complained of pain in the bladder area. There was an impassable stricture in the region just anterior to the membranous urethra. The colostomy and supra pubic tube were functioning well. Rectal examination revealed a tender mass on the right side. This abscess was drained by an extraperitoneal incision, and from then on improvement was rapid. One month later the urethra was exposed and found to be completely severed just in front of the urogenital diaphragm. The scar tissue was cut away and the ends anastomosed over a urethral catheter. Recovery was uneventful; 2 weeks later the colostomy was closed, and 1 week later the suprapubic tube was removed. At the time of his discharge he was voiding without difficulty, but he was instructed to have urethral dilatations at regular intervals. This case is a good example of bowel and urethral injury. The abscess which developed is not an unexpected complication. Early repair of the urethra would have saved some morbidity but was not practical under the circumstances. SUMMARY
Even moderate renal trauma may cause loss of function and repeated intravenous urograms several months after the injury are desirable. After severe injury the kidney will frequently recover without surgery, and without evidence of permanent damage, but secondary hemorrhage from too early ambulation requires immediate surgery. Lack of blood in the urine does not necessarily mean that the kidney is intact, and evidence of pelvic injury demands early surgery. Late surgery in kidney wounds usually results in nephrectomy. In bladder wounds immediate drainage is imperative. When associated structures are injured, their care has precedence after bladder drainage. Late urethral repair means morbidity and difficult surgery.
I. S. Pinckney St., Madison, Wis.
A discussion of trauma cannot follow a fixed pattern of general statements without limitation as to the cause and extent of the injury. Of these two, the most important and most difficult for the surgeon to ascertain is the extent of the injury. In civil life the type of injury is usually determined by how the people in that community either work or play, and associated organs are usually not involved. In military life the same types of injuries may occur. But in addition we have more penetrating wounds from missiles of all sorts as well as extreme degrees of tissue loss which may involve more than one organ. THE KIDNEY
The kidney is not frequently injured in either civil or military life. Due to its location it is well protected from all types of injury, and this same position makes it possible for the kidney to recover without surgery in most cases. The mere fact that blood appears in the urine and a mass appears in the side does not call for an immediate operation. Grave injury may occur without hematuria and without a mass, but pain is usually a predominant symptom in those cases. In establishing the extent of the injury one may utilize the retrograde pyelogram, the exploratory operation or clinical judgment based on observation with the intravenous urogram which may or may not give the desired information. In the past 13 years we have had under our care 23 traumatized kidneys. Only 2 were penetrating from through and through gunshot wounds and both recovered without treatment directed to the kidney after abdominal exploration. A kidney may be lost by an early operation as well as by one done too late. I have selected 5 cases to demonstrate some of the difficulties involved in treatment and to question surgical judgment. Case 1. G. G., a 20 year old white man, fell on his back from a platform in the gymnasium. He had gross hematuria for 4 days and a mass in the right renal area. Seven days after admission an intravenous urogram showed no medium in the right kidney (fig. 1, A). He continued to improve and the mass in his side had disappeared in 2 weeks, at which time a retrograde pyelogram was done (fig. 1, B). Indigo carmine appeared from the right kidney in 11 minutes. Five months later an intravenous urograrn showed only a faint trace of Diodrast in the 20 minute film. Here is a case of apparently mild injury without evidence of loss of the normal contour of the kidney; yet function is markedly reduced. Would the patient have had this loss of function if the kidney had been explored? He has not developed hypertension in 5 months, as one would expect if the loss is due to a constricting mass about the renal parenchyma. Case 2. L. S., aged 19, was kicked in the left side while playing college foot- · 1 Read at annual meeting, North Central Section, American Urological Association, Cleveland, 0., October 23-25, 1947. 280
INJURIES OF THE GENITO-URINARY TRACT
281
ball. He had a very large tender, mass in the left side and gross blood in his urine. Conservative treatment was instituted. Three days later his blood pressure began to rise, and varied from 150/85 to 185/95 for several days. As this mass began to subside his pressure fell to his normal level, 125/70. He was discharged after 2 -weeks and an intravenous urogram (fig. 2) one month after the injury is normal. This is considered an example of a severe injury recovering without surgery. Would he have been as likely to recover without surgery if he had had a retrograde pyelogram? The rising blood pressure caused some concern, and it might have become an indication for surgical intervention.
Fm. 1
Case 3. H. M., an 18 year old sailor, fell when jumping a fence and struck his left side. On admission to the hospital there was a large, tender mass in the left side, and gross blood in the urine. He was treated conservatively and the urine cleared in 5 days, and the mass began to decrease in size. The intravenous urogram showed some extravasation at the lower pole (fig. 3, A). Twelve days after admission he got out of bed during the night and engaged in some play with the other boys. The urine again became bloody and the mass reappeared. Secondary hemorrhage was diagnosed and the kidney was explored. The lower pole -was fragmented and the perirenal area filled with large clots. Packs controlled the hemorrhage and the patient was discharged 20 days after operation. An intravenous urogram (fig. 3, B) showed a kidney with good function but some distortion due to the injury. This case demonstrated the value of bed rest in conservative treatment. Secondary hemorrhage is always a possibility, and -when it does occur it is usually serious and demands immediate surgical intervention.
282
JOHN B. WEAR
Case 4, D. B., an 18 year old boy, fell and struck the right side of his abdomen on a post. When admitted he had generalized abdominal pain with rigidity of
FIG. 2
FIG. 3
the right side. The urine was clear. A laparotomy was performed and a right retroperitoneal mass was found. The area was drained by stab wounds and the patient referred to the urological service. Retrograde pyelograms a few days
INJURIES OF THE GENITO-URINARY TRACT
283
later revealed a large hydronephrosis; 450 cc of urine were aspirated through the catheter (fig. 4). Three weeks after admission a right nephrectomy was done. At the time of the injury the hydronephrotic sac had been ruptured. Recovery was uneventful. Case 5. F. M., a 12 year old boy, was caught betvrnen a boxcar and a loading platform. He was taken to the hospital in severe shock. Treatment was conservative and he never showed any blood in the urine. He was sent home 16 days after admission. Three weeks later a large mass appeared in his left side and he entered the Wisconsin General Hospital. An intravenous urogram showed a normal right kidney but no function on the left side. The left renal area was explored and a large amount of urine was found in the perirenal area. The ureter had been torn from the pelvis and the kidney was embedded in dense adhesions. Nephrectomy was performed and recovery was uneventful.
Frn. 4
Here are 2 cases where the injury did not involve the parenchyma, and no blood was found in the urine. Hydronephrotic kidneys are particularly prone to injury, and early operation is indicated where the pelvis or ureter are injured. Delay may not cost the patient's life, but the kidney is not likely to be saved unless surgery is done early. BLADDER AND URETHRA
Bladder and urethral injuries are considered together as in the cases under discussion, the urethral wound was behind the urogenital diaphragm, thus placing the extravasation in the same area as in vesical trauma. I have chosen 5 cases which demonstrate 5 different types of associated injuries. They were all sailors or marines. The treatment in this type of case is usually clearly indicated. The results are dictated by the extent of the injury, the first treatment given, and the time element of the definitive treatment. Re-
284
JOHN B. WEAR
constructive operations after injury to the bladder and urethra follow a more fixed pattern than does injury to the kidney. The first principle is that of drainage and diversion of the urinary stream. Where associated organs are injured, their repair takes preference over the urinary tract after the first principle is observed. These cases are presented in diagrammatic form drawn by the artist from the x-ray pictures and the finding at the time of operation.
FIG. 5
Case 6. A marine was injured by a machine gun bullet entering his left thigh (fig. 5, A). He was admitted to the hospital 3 weeks later. Purulent urine was draining from the hip wound, his right hip joint was fixed, and he voided only a few drops of urine. X-rays revealed the bullet to be in his right hip joint, and the left ischial bone to be fractured. Attempts at catheterization were unsuccessful. Suprapubic cystotomy was done. Much purulent material was evacuated from the prevesical space, and the bullet had traversed the prostate near the vesical neck. By retrograde dilatation a catheter was passed and a balloon catheter pulled into the bladder. The balloon was inflated and held by light pressure against the internal orifice. Three weeks later he was voiding normally
INJURIES OF THE GENITO-URINARY TRACT
285
and the sinus tract in the left hip was healed. His urethra was dilated with sounds every 10 clays until his discharge. Although this patient recovered from his urinary injury, the right hip joint was destroyed. Case 7. A naval officer was crushed between a splinter shield and a gun mount. He was admitted to the hospital 6 hours later. His shock was treated by blood and plasma administration. Catheterized urine was bloody. Suprapubic cystotomy revealed a 2 inch laceration in the anterior wall of the bladder (fig. 5, B). Extravasated urine was evacuated from the anteromedial aspect of the right thigh. X-rays revealed multiple fractures of the pelvis with wide separations of the pubic bones, and subluxation of the right sacra-iliac joint. He later developed an abscess over the left pubic bone which was drained. This abscess communicated with the urethra anterior to the prostate. Urethral dilatations were carried out, and three months later he was voiding, and six months after injury he returned to duty. But he had a slight impediment in his gait as the symphysis was still widely separated.
Fm. 6
This case is cited as an example of extreme pelvic bone injury with extreme extravasation both above and below the urogenital diaphragm. Case 8. A 17 year old sailor was knocked down and run over by an airplane. He was admitted to the hospital 3 hours later complaining of pain in his abdomen and inability to void. X-rays showed multiple fractures of the pelvic bones (fig. 5, C); and only a few drops of urine were obtained by catheter. Suprapubic cystotomy revealed a laceration on the right side of the bladder. Much blood and urine were evacuated from the perivesical area. As he ,vas being returned to his bed, it was noticed that his right foot was cold and the dorsalis pedis artery could not be palpated. He was transferred to the surgical service, but in the end he lost his leg from the knee down due to arterial occlusion. Undoubtedly the pelvic vessels had been severely traumatized and an arterial embolus from this area caused the occlusion. Dicumerol and heparin or embolectomy might have saved his leg. Case 9. A marine was admitted to the hospital several months after his original injury. He had been shot with a rifle. The bullet entered the lower ab-
286
JOHN B. WEAR
domen over the bladder and the point of exit was the right buttock (fig. 5 D). Urine was draining from this tract. His right leg was paralyzed and he could not walk even with crutches. His immediate treatment had consisted of laparotomy, indwelling catheter, and right nephrectomy, as the bullet had severed the right ureter as it left the bladder. Cystoscopy showed an opening about 1 cm. in diameter in the region where the right ureteral orifice should have been located. A catheter passed into the opening emerged from the buttock wound. Supra pubic cystotomy revealed the right bladder wall to be densely adherent to the pelvic bone. It could not be separated, so the area was resected, the bladder closed, and the adherent tissue then removed with a periosteal elevator. The buttock sinus promptly healed. Sensation and motion gradually returned in his leg and 9 months later he was walking ·with a cane. The sciatic nerve was evidently traumatized by the bullet but not entirely severed. Case 10. A marine was shot in the perineum by a rifle bullet. The point of exit was near the lower portion of the sacrum (fig. 6). Colostomy and suprapubic cystotomy had been done in the for,vard area and we saw him 3 months later. At the time of admission he was emaciated and complained of pain in the bladder area. There was an impassable stricture in the region just anterior to the membranous urethra. The colostomy and supra pubic tube were functioning well. Rectal examination revealed a tender mass on the right side. This abscess was drained by an extraperitoneal incision, and from then on improvement was rapid. One month later the urethra was exposed and found to be completely severed just in front of the urogenital diaphragm. The scar tissue was cut away and the ends anastomosed over a urethral catheter. Recovery was uneventful; 2 weeks later the colostomy was closed, and 1 week later the suprapubic tube was removed. At the time of his discharge he was voiding without difficulty, but he was instructed to have urethral dilatations at regular intervals. This case is a good example of bowel and urethral injury. The abscess which developed is not an unexpected complication. Early repair of the urethra would have saved some morbidity but was not practical under the circumstances. SUMMARY
Even moderate renal trauma may cause loss of function and repeated intravenous urograms several months after the injury are desirable. After severe injury the kidney will frequently recover without surgery, and without evidence of permanent damage, but secondary hemorrhage from too early ambulation requires immediate surgery. Lack of blood in the urine does not necessarily mean that the kidney is intact, and evidence of pelvic injury demands early surgery. Late surgery in kidney wounds usually results in nephrectomy. In bladder wounds immediate drainage is imperative. When associated structures are injured, their care has precedence after bladder drainage. Late urethral repair means morbidity and difficult surgery.
I. S. Pinckney St., Madison, Wis.