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Injuries of the Kidney1
IN.JURIES OF THE KIDNEY1 Cmurn ..JA:\IES C. SARGEKT (MCi, USNR
Fundamentally, injuries of the kidney are the same in war as in peace. The immediate field care of battle casualties is something quite distinctive, and the multiple, massive injuries that come with the flying stone and steel of bursting shell are quite unlike anything seen in civilian urology. Still, once the sailor or ooldier with an injured kidney reaches the point where he meets modern urologic equipment and personnel, he is much the same patient that most of LlS have met many times in the receiving wards of our large civilian emergency hospitals. The mine run of urinary tract injuries is quite symptomless and obscure on admission. Indeed, so obvious and commanding are the symptoms of the other injuries, and so silent those of the kidney or bladder that important hours can be lost unless and until the tell-tale sign of hematuria attracts attention. Examination can never be called adequate until a specimen of urine has been obtained and examined. ·without such a routine, the patient with a fractured pelvis may extravasate urine for hours before bladder rupture is even suspected; or the man unconscious from head injury may bleed to death from a macerated kidney. Once injury of the kidney is suspected, it becomes imperative that its extent and severity be known. From a practical clinical standpoint there are two types of sufferers from renal injury: the vast majority who do far better if put to bed and let alone; the occasional and very important patient who is likely to bleed to death if his kidney injury is not recognized and promptly operated upon (fig. 1). This simple and somewhat arbitrary grouping finds justification in two well-known clinical facts. (1) operation upon an injured, bleeding kidney is a very formidable undertaking, especially so because of the frequent presence of substantial shock and the quite common association of seriom; injury elsewhere; (2) the bruised and broken kidney has an astounding power of repair. Logically, one would expect that if kidney tissues were tom and broken the consequences would be terrible. Fractures through renal parenchyma do involve sizable vessels and sharp bleeding does ensue, but physiologic hemostasis within torn renal tissue is such that serious hemorrhage is hardly likely to occur unless the kidney be horribly broken and the renal pedicle itself badly torn . Neither is urinary extravasation the hazard that might be supposed. The amount of urine actually present within the kidney cavity at the moment of injury is negligible. Once injury to the kidney has occurred, that kidney -at least for a considerable time--is content to stop secreting and let its uninjured mate carry the load. This is observed over and over again in excretory urograms made soon after renal injury. Intelligent judgment and efficient treatment arc based on a clear understanding of the exact extent and severity of the kidney injury. Severe shock-past, 1 Head at 21st annual meeting, Western Section of the American Urological AssociaJion, San Francisco, June 2, 1944.
::is1
382
JAMES C. SARGENT
present, or probable-may put surgery completely out of the question. Signs of progressive bleeding occasionally dictate the treatment. Injuries elsewhere sometimes dominate the whole procedure. Two cases are chosen to illustrate this point. Case 1. A middle aged man, bowled off his feet by an automobile 2 hours previously, entered the hospital in moderate shock. Catheterized urine was bloody. Rapidly increasing pain and rigidity suggested left kidney injury, and careful urologic studies ,,·ere carried out. A retrograde pyelogram revealed
FIG. 1. Diagrammatic drawings of common types of kidney rupture. In three instances injury is of a type permitting good healing; in the fourth, kidney is broken beyond hope of repair.
frank fracture of the left kidney and the fact that the kidney with its true pelvis were sufficiently intact to promise good healing (fig. 2). This patient was released from the hospital after 8 days' bed rest. Urologic studies made in connection \Yith litigation the following year demonstrated this kidney to be functionally and anatomically indistinguishable from its uninjured mate. Case 2. A grown girl, too drunk the night before to remember any details of her injury, entered the hospital frightened over bloody urine. No scratch or bruise on her body hinted the presence of injury. A gro,Ying dull ache over the left kidney suggested this organ as a possible source of bleeding. Cystoscopy shmYed blood rolling from the left ureteral orifice. A retrograde pyelogram
INJURIES OF KIDNEY
383
(fig. 3) disclosed complete loss of continuity of the renal pelvis and indicated the kidney to be injured beyond possible repair. Her general condition remained quite good, and operation seemed both safe and wise. Upon exposure, the kidney was found broken completely in two, with an upper and lower half dangling loosely in a quart of clotting blood, one pole anchored by a few viable shreds of pelvic mucosa and the other by the skinned renal artery and vein. Most excretory urograms made just following serious accidents are, in our experience, quite valueless and sometimes gravely misleading. A kidney usually stops secreting promptly upon receipt of injury; this may give a thoroughly false impression of renal damage. Blood clots may fill the pelvis or peripelvic hema-
FIG. 2. Retrograde pyelogram showing contour of renal pelvis quite well preserved despite substantial tearing of renal cortex. Treatment was conservative. Studies one year later proved kidney to be functionally and anatomically indistinguishable from its uninjured mate. FIG. 3. Retrograde pyelogram showing contour of pelvis completely lost. Operation proved kidney to be broken beyond repair.
toma compress it, displacing whatever media may have been excreted. Ileus of varying degree is quite common, and adds to the difficulty of obtaining clear-cut outlines of pelvis and calices. In support of this contention I submit a 20minute excretory urogram and the left retrograde pyelogram (fig. 4), made soon after admission. The type of violence and severity of symptoms suggested the likelihood of serious left kidney injury. The right kidney is well visualized; in the left kidney region nothing but a faint streaking of dye can be seen. Had the excretory urogram been taken at face value, one would have expected to find the left kidney badly damaged. However, the retrograde pyelogram proved it to be completely intact except for an insignificant medullary tear, and several days of bed rest saw the patient well and home again. Retrogr:ade pyelography, done on a proper x-ray table, and with a Bucky
384
JAMES C. SARGENT
diaphragm, must come to be routine in all accident cases in which injury to the kidney is suspected. Using the newer drugs and sterile technique, no serious risk attaches to retrograde pyelography-certainly nothing to equal the danger of case management without it. A good retrograde pyelogram will prove be~ yond reasonable doubt whether or not renal injury has occurred, and will usually visualize the extent of damage to parenchyma and pelvis. With the contour of the renal pelvis comparatively well preserved, even though frank rupture of the parenchyma may be quite evident, one does not expect serious consequences, and a masterful indifference on the surgeon's part is quite likely to see the patient and his kidney both well again. Conversely, if the pyelogram shows the continuity of the pelvic cavity blasted beyond recognition, the sooner nephrectomy can be done the better. Two cases have been chosen to illustrate the truth of these observations.
Frn. 4. Excretory urogram taken soon after injury showing good elimination by right kidney and none by left. Retrograde pyelography proved left kidney undamaged except for inconsequential parenchymal tear at base of lower major calyx. Suppression of secretion by an injured kidney can be badly misleading.
Case 1. A young man who had fallen through 6 floors of scaffolding entered the hospital in profound shock, unconscious from severe brain concussion. In addition to lesser injuries, he suffered 9 more or less serious bone fractures. After several hours of supportive treatment, catheterized urine was thick with blood. Severe pain and board-like rigidity soon settled over the entire right side and back. Cystoscopy showed blood running from the right ureteral orifice. A retrograde pyelogram (fig. 5) gave eloquent proof of the presence and relative inconsequence of his renal injury. Particularly to be noted are the unbroken contour of the entire pelvis and its 3 main branches, and the fog of pyelographic solution floating between upper and middle calix demonstrating the limited extent of parenchymal fracture. This patient spent months in the hospital; but except for his bone injuries he might well have been out and at work within a couple of weeks.
INJURIES OF KIDNEY
385
Case 2. A young girl had been shot in the back; the bullet entered at the left of the upper lumbar spine and emerged high in the left axilla. On admission, her clothes were heavily blood-stained, but there was no indication of alarming hemorrhage. She was neither in shock nor material pain; however, her pulse
FIG. 5. Retrograde pyelogram showing fracture of renal cortex spreading between upper and middle calyces. Main outline of renal pelvis remains quite intact and indicates-prob-ability of good spontaneous repair.
Fm. 6. In this case of gunshot injury, retrograde pyelography proved of uncanny curacy in predicting that kidney would be found completely shattered.
ftC-
became increasingly rapid. All signs seemed to point to abdominal injury except the heavy, bloody discoloration of her urine. A retrograde pyelogram (fig. 6) revealed all but the extreme upper pole of the left kidney to have been shot completely away. Operation disclosed an intact upper pole with the rest of the
386
JAMES C. SARGENT
organ pulverized beyond recognition. The kidney remnant was removed and 2 small wounds in the large bowel closed. The patient later expired. Through all our error and confusion, however, the retrograde pyelogram never left us in the slightest doubt concerning the condition of the injured kidney and what had to be done about it. SUMMARY
Every patient who has received serious body injury should be made to void or be catheterized as one of the very first steps in his examination. Until this procedure becomes routine, recognition of urinary tract injuries will continue to be delayed fateful hours or even days, and mortality will continue to be appalling. Gross hematuria in accident cases demands prompt investigation. Many times it proves to be of no special consequence, but often it bespeaks injury of the first magnitude. Excretory urography can be quite useful as a preliminary procedure in suspected kidney injuries. Retrograde pyelography, however, gives consistent, dependable help in determining the true extent of injury. Most kidney injuries should be left alone. With the renal pelvis reasonably intact, even though substantial fracture of the parenchyma has occurred, one does not expect to meet alarming hemorrhage, and persistent indifference on the surgeon's part is quite likely to see the patient soon recovered. If, on the other hand, the contour of the pelvis is blasted beyond recognition, there can be no hope whatever for that kidney and but little for the patient, unless a propitious time for nephrectomy can be found.
Fundamentally, injuries of the kidney are the same in war as in peace. The immediate field care of battle casualties is something quite distinctive, and the multiple, massive injuries that come with the flying stone and steel of bursting shell are quite unlike anything seen in civilian urology. Still, once the sailor or ooldier with an injured kidney reaches the point where he meets modern urologic equipment and personnel, he is much the same patient that most of LlS have met many times in the receiving wards of our large civilian emergency hospitals. The mine run of urinary tract injuries is quite symptomless and obscure on admission. Indeed, so obvious and commanding are the symptoms of the other injuries, and so silent those of the kidney or bladder that important hours can be lost unless and until the tell-tale sign of hematuria attracts attention. Examination can never be called adequate until a specimen of urine has been obtained and examined. ·without such a routine, the patient with a fractured pelvis may extravasate urine for hours before bladder rupture is even suspected; or the man unconscious from head injury may bleed to death from a macerated kidney. Once injury of the kidney is suspected, it becomes imperative that its extent and severity be known. From a practical clinical standpoint there are two types of sufferers from renal injury: the vast majority who do far better if put to bed and let alone; the occasional and very important patient who is likely to bleed to death if his kidney injury is not recognized and promptly operated upon (fig. 1). This simple and somewhat arbitrary grouping finds justification in two well-known clinical facts. (1) operation upon an injured, bleeding kidney is a very formidable undertaking, especially so because of the frequent presence of substantial shock and the quite common association of seriom; injury elsewhere; (2) the bruised and broken kidney has an astounding power of repair. Logically, one would expect that if kidney tissues were tom and broken the consequences would be terrible. Fractures through renal parenchyma do involve sizable vessels and sharp bleeding does ensue, but physiologic hemostasis within torn renal tissue is such that serious hemorrhage is hardly likely to occur unless the kidney be horribly broken and the renal pedicle itself badly torn . Neither is urinary extravasation the hazard that might be supposed. The amount of urine actually present within the kidney cavity at the moment of injury is negligible. Once injury to the kidney has occurred, that kidney -at least for a considerable time--is content to stop secreting and let its uninjured mate carry the load. This is observed over and over again in excretory urograms made soon after renal injury. Intelligent judgment and efficient treatment arc based on a clear understanding of the exact extent and severity of the kidney injury. Severe shock-past, 1 Head at 21st annual meeting, Western Section of the American Urological AssociaJion, San Francisco, June 2, 1944.
::is1
382
JAMES C. SARGENT
present, or probable-may put surgery completely out of the question. Signs of progressive bleeding occasionally dictate the treatment. Injuries elsewhere sometimes dominate the whole procedure. Two cases are chosen to illustrate this point. Case 1. A middle aged man, bowled off his feet by an automobile 2 hours previously, entered the hospital in moderate shock. Catheterized urine was bloody. Rapidly increasing pain and rigidity suggested left kidney injury, and careful urologic studies ,,·ere carried out. A retrograde pyelogram revealed
FIG. 1. Diagrammatic drawings of common types of kidney rupture. In three instances injury is of a type permitting good healing; in the fourth, kidney is broken beyond hope of repair.
frank fracture of the left kidney and the fact that the kidney with its true pelvis were sufficiently intact to promise good healing (fig. 2). This patient was released from the hospital after 8 days' bed rest. Urologic studies made in connection \Yith litigation the following year demonstrated this kidney to be functionally and anatomically indistinguishable from its uninjured mate. Case 2. A grown girl, too drunk the night before to remember any details of her injury, entered the hospital frightened over bloody urine. No scratch or bruise on her body hinted the presence of injury. A gro,Ying dull ache over the left kidney suggested this organ as a possible source of bleeding. Cystoscopy shmYed blood rolling from the left ureteral orifice. A retrograde pyelogram
INJURIES OF KIDNEY
383
(fig. 3) disclosed complete loss of continuity of the renal pelvis and indicated the kidney to be injured beyond possible repair. Her general condition remained quite good, and operation seemed both safe and wise. Upon exposure, the kidney was found broken completely in two, with an upper and lower half dangling loosely in a quart of clotting blood, one pole anchored by a few viable shreds of pelvic mucosa and the other by the skinned renal artery and vein. Most excretory urograms made just following serious accidents are, in our experience, quite valueless and sometimes gravely misleading. A kidney usually stops secreting promptly upon receipt of injury; this may give a thoroughly false impression of renal damage. Blood clots may fill the pelvis or peripelvic hema-
FIG. 2. Retrograde pyelogram showing contour of renal pelvis quite well preserved despite substantial tearing of renal cortex. Treatment was conservative. Studies one year later proved kidney to be functionally and anatomically indistinguishable from its uninjured mate. FIG. 3. Retrograde pyelogram showing contour of pelvis completely lost. Operation proved kidney to be broken beyond repair.
toma compress it, displacing whatever media may have been excreted. Ileus of varying degree is quite common, and adds to the difficulty of obtaining clear-cut outlines of pelvis and calices. In support of this contention I submit a 20minute excretory urogram and the left retrograde pyelogram (fig. 4), made soon after admission. The type of violence and severity of symptoms suggested the likelihood of serious left kidney injury. The right kidney is well visualized; in the left kidney region nothing but a faint streaking of dye can be seen. Had the excretory urogram been taken at face value, one would have expected to find the left kidney badly damaged. However, the retrograde pyelogram proved it to be completely intact except for an insignificant medullary tear, and several days of bed rest saw the patient well and home again. Retrogr:ade pyelography, done on a proper x-ray table, and with a Bucky
384
JAMES C. SARGENT
diaphragm, must come to be routine in all accident cases in which injury to the kidney is suspected. Using the newer drugs and sterile technique, no serious risk attaches to retrograde pyelography-certainly nothing to equal the danger of case management without it. A good retrograde pyelogram will prove be~ yond reasonable doubt whether or not renal injury has occurred, and will usually visualize the extent of damage to parenchyma and pelvis. With the contour of the renal pelvis comparatively well preserved, even though frank rupture of the parenchyma may be quite evident, one does not expect serious consequences, and a masterful indifference on the surgeon's part is quite likely to see the patient and his kidney both well again. Conversely, if the pyelogram shows the continuity of the pelvic cavity blasted beyond recognition, the sooner nephrectomy can be done the better. Two cases have been chosen to illustrate the truth of these observations.
Frn. 4. Excretory urogram taken soon after injury showing good elimination by right kidney and none by left. Retrograde pyelography proved left kidney undamaged except for inconsequential parenchymal tear at base of lower major calyx. Suppression of secretion by an injured kidney can be badly misleading.
Case 1. A young man who had fallen through 6 floors of scaffolding entered the hospital in profound shock, unconscious from severe brain concussion. In addition to lesser injuries, he suffered 9 more or less serious bone fractures. After several hours of supportive treatment, catheterized urine was thick with blood. Severe pain and board-like rigidity soon settled over the entire right side and back. Cystoscopy showed blood running from the right ureteral orifice. A retrograde pyelogram (fig. 5) gave eloquent proof of the presence and relative inconsequence of his renal injury. Particularly to be noted are the unbroken contour of the entire pelvis and its 3 main branches, and the fog of pyelographic solution floating between upper and middle calix demonstrating the limited extent of parenchymal fracture. This patient spent months in the hospital; but except for his bone injuries he might well have been out and at work within a couple of weeks.
INJURIES OF KIDNEY
385
Case 2. A young girl had been shot in the back; the bullet entered at the left of the upper lumbar spine and emerged high in the left axilla. On admission, her clothes were heavily blood-stained, but there was no indication of alarming hemorrhage. She was neither in shock nor material pain; however, her pulse
FIG. 5. Retrograde pyelogram showing fracture of renal cortex spreading between upper and middle calyces. Main outline of renal pelvis remains quite intact and indicates-prob-ability of good spontaneous repair.
Fm. 6. In this case of gunshot injury, retrograde pyelography proved of uncanny curacy in predicting that kidney would be found completely shattered.
ftC-
became increasingly rapid. All signs seemed to point to abdominal injury except the heavy, bloody discoloration of her urine. A retrograde pyelogram (fig. 6) revealed all but the extreme upper pole of the left kidney to have been shot completely away. Operation disclosed an intact upper pole with the rest of the
386
JAMES C. SARGENT
organ pulverized beyond recognition. The kidney remnant was removed and 2 small wounds in the large bowel closed. The patient later expired. Through all our error and confusion, however, the retrograde pyelogram never left us in the slightest doubt concerning the condition of the injured kidney and what had to be done about it. SUMMARY
Every patient who has received serious body injury should be made to void or be catheterized as one of the very first steps in his examination. Until this procedure becomes routine, recognition of urinary tract injuries will continue to be delayed fateful hours or even days, and mortality will continue to be appalling. Gross hematuria in accident cases demands prompt investigation. Many times it proves to be of no special consequence, but often it bespeaks injury of the first magnitude. Excretory urography can be quite useful as a preliminary procedure in suspected kidney injuries. Retrograde pyelography, however, gives consistent, dependable help in determining the true extent of injury. Most kidney injuries should be left alone. With the renal pelvis reasonably intact, even though substantial fracture of the parenchyma has occurred, one does not expect to meet alarming hemorrhage, and persistent indifference on the surgeon's part is quite likely to see the patient soon recovered. If, on the other hand, the contour of the pelvis is blasted beyond recognition, there can be no hope whatever for that kidney and but little for the patient, unless a propitious time for nephrectomy can be found.