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Late urologic complication of an abdominal gunshot wound
Late Urologic
Complication
By Eduardo T. Fernandes,
of an Abdominal Gunshot Wound
Earle Wrenn, Memphis,
0 An unusual late complication of an abdominal gunshot wound is presented. It consisted of an acute hydronephrosis of the left kidney by a BB-type bullet that migrated into the ureter of a 1 l-year-old boy 1 month after he was injured in the left flank. causing its complete obstruction. A percutaneous nephrostomy was performed and, with the help of a basket-type catheter, the bullet was removed. To our knowledge this is the first case reported of this rare complication treated by this technique. @ 1990 by W.S. Saunders Company. INDEX WORDS: Abdominal obstruction, traumatic.
gunshot wounds;
urinary tract
A
BDOMINAL gunshot wounds are important cause of morbidity and mortality in all age groups. In general, they cause acute morbidity. An unusual late urologic complication of a BB-type gunshot wound to the abdomen is reported. CASE
REPORT
An 11-year-old boy presented to our emergency room with abdominal pain. He had a 2-day history of an acute onset of a left flank pain, nausea, and vomiting. His mother also observed during the preceding week intermittent hematuria. The past medical history was remarkable for a BB gunshot wound to the left flank 1 month prior to this admission. He had been previously admitted for observation in another hospital, but he was asymptomatic and no treatment was required. The physical examination was normal, except for the presence of tenderness on the left side of the abdomen. The gunshot wound on the flank was well healed. The blood chemistry, the blood count, and the urinalysis were within normal limits. Comparing the plain abdominal radiographic examination obtained during this admission with the one taken when the patient was first injured, we could observe that the bullet was in a more medial and inferior position (Fig 1). Considering the symptoms of an acute hydronephrosis and the findings of the plain abdominal radiographic studies, we suspected a dislodgment and migration of the bullet into the left renal pelvis causing complete obstruction of the ureter. An intravenous urography scan was performed and confirmed the diagnosis. Treatment consisted of the placement of a percutaneous nephrostomy under Auoroswpy, and on the following day, removing the bullet with the help of a basket-type catheter. The patient had an uneventful recovery and was discharged home asymptomatic.
Jr, Gerald Jerkins, and H. Norman
Noe
Tennessee
complete obstruction of the ureter caused by migration of the BB pellet into the renal pelvis and ureter, which was confirmed by the intravenous urography. Laparotomy for the removal of the bullet and decompression of the kidney was one of the options for the management of this patient. Considering that the patient presented with symptoms more than 1 month after the acute injury, surgery was not mandatory at that moment, and other methods of treatment were discussed. The bullet was simulating the symptoms of a patient with an ureteral stone and acute hydronephrosis. We then applied the same treatment techniques that can be used for the management of ureteral calculus. The treatment of ureteral stones changed considerably after the introduction of methods such as the endoscopic and percutaneous manipulation of this disease.’ When feasible, these techniques are preferred over laparotomy, which has a potential to cause more morbidity. For the treatment of lithiasis in the lower third of the ureter, the transurethral manipulation under cystoscopic examination is considered the method of choice.2 This technique cannot be used for calculus of the upper third of the ureter, and severe complications such as avulsion of the ureter requiring nephrectomy and laceration of the iliac vessels have already been reported.’ Percutaneous stone removai methods are the first choice of management for calculus in the upper segment of the ureter in many centers.3 This can be performed under local anesthesia,4 with less morbidity than the other current methods of therapy.3 The most common complication of this method is infection.13334The technique for the percutaneous retrieval of kidney stones varies in different institutions, depending on equipment, ultrasound, and operating room facilities.3 It can be performed in one or many stages.3’4 After the placement of the percutaneous nephrostomy, which was performed in the radiology department under fluoroscopy, we allowed 24 hours for decompression of the kidney and creation of a tract
DISCUSSION
Abdominal gunshot wounds are a common cause of acute morbidity and mortality. Late complications, on the other hand, may be difficult to diagnose. In this patient, when we compared the plain abdominal radiographic examinations obtained 1 month apart from each other, a change on the position of the bullet was noted. Combining the symptoms of an acute hydronephrosis with the radiographic studies, we suspected a Journal
of Pediatric
Surgery,
Vol
25, No
12 (December),
From the Departments of Pediatric Surgery and Pediatric Urology, LeBonheur Children’s Hospital, Memphis. TN. Presented at the National Conference on Pediatric Trauma, Boston, MA, September 1987. Address reprint requests to Earle Wrenn, Jr, MD, Department oj Pediatric Surgery, LeBonheur Children’s Hospital. 848 Adams Ave, DR 300. Memphis, TN 30103. 0 1990 by W.B. Saunders Company. 0022-3468/90/2512-0029$03.00/O
1990: pp 1283-1284
1283
FERNANDES ET AL
1284
Fig 1. (Al Abdominal radiographic examination performed on the day the patient was injured. (61 Radiographic injury showing the bullet in a more medial and inferior position.
that could be dilated in order to facilitate the manipulation of the bullet. On the following day, in the operating room, and with the use of a Dormia catheter, the bullet could be removed. To our knowledge, this is the first reported case of
study 1 month after the
this rare urologic complication treated by percutaneous manipulation of the bullet. The correct diagnosis and the selection of a method of treatment associated with less morbidity contributed to a rapid and prompt recovery of this patient.
REFERENCES 1. Ball TP Jr: Endoscopic and percutaneous manipulation in stone disease. Urol Clin North Am 8:277-298, 1981 2. Drach GW: Transurethral ureteral stone manipulation. Urol Clin North Am 10:709-717, 1983
3. Smith AD, Lee WJ: Percutaneous stone removal procedures including irrigation. Urol Clin North Am l&719-727, 1983 4. Narayan P, Smith AD: Percutaneous nephrostomy as an adjunct in the management of ureteral calculi. Urol Clin North Am 9:137-143, 1982
Complication
By Eduardo T. Fernandes,
of an Abdominal Gunshot Wound
Earle Wrenn, Memphis,
0 An unusual late complication of an abdominal gunshot wound is presented. It consisted of an acute hydronephrosis of the left kidney by a BB-type bullet that migrated into the ureter of a 1 l-year-old boy 1 month after he was injured in the left flank. causing its complete obstruction. A percutaneous nephrostomy was performed and, with the help of a basket-type catheter, the bullet was removed. To our knowledge this is the first case reported of this rare complication treated by this technique. @ 1990 by W.S. Saunders Company. INDEX WORDS: Abdominal obstruction, traumatic.
gunshot wounds;
urinary tract
A
BDOMINAL gunshot wounds are important cause of morbidity and mortality in all age groups. In general, they cause acute morbidity. An unusual late urologic complication of a BB-type gunshot wound to the abdomen is reported. CASE
REPORT
An 11-year-old boy presented to our emergency room with abdominal pain. He had a 2-day history of an acute onset of a left flank pain, nausea, and vomiting. His mother also observed during the preceding week intermittent hematuria. The past medical history was remarkable for a BB gunshot wound to the left flank 1 month prior to this admission. He had been previously admitted for observation in another hospital, but he was asymptomatic and no treatment was required. The physical examination was normal, except for the presence of tenderness on the left side of the abdomen. The gunshot wound on the flank was well healed. The blood chemistry, the blood count, and the urinalysis were within normal limits. Comparing the plain abdominal radiographic examination obtained during this admission with the one taken when the patient was first injured, we could observe that the bullet was in a more medial and inferior position (Fig 1). Considering the symptoms of an acute hydronephrosis and the findings of the plain abdominal radiographic studies, we suspected a dislodgment and migration of the bullet into the left renal pelvis causing complete obstruction of the ureter. An intravenous urography scan was performed and confirmed the diagnosis. Treatment consisted of the placement of a percutaneous nephrostomy under Auoroswpy, and on the following day, removing the bullet with the help of a basket-type catheter. The patient had an uneventful recovery and was discharged home asymptomatic.
Jr, Gerald Jerkins, and H. Norman
Noe
Tennessee
complete obstruction of the ureter caused by migration of the BB pellet into the renal pelvis and ureter, which was confirmed by the intravenous urography. Laparotomy for the removal of the bullet and decompression of the kidney was one of the options for the management of this patient. Considering that the patient presented with symptoms more than 1 month after the acute injury, surgery was not mandatory at that moment, and other methods of treatment were discussed. The bullet was simulating the symptoms of a patient with an ureteral stone and acute hydronephrosis. We then applied the same treatment techniques that can be used for the management of ureteral calculus. The treatment of ureteral stones changed considerably after the introduction of methods such as the endoscopic and percutaneous manipulation of this disease.’ When feasible, these techniques are preferred over laparotomy, which has a potential to cause more morbidity. For the treatment of lithiasis in the lower third of the ureter, the transurethral manipulation under cystoscopic examination is considered the method of choice.2 This technique cannot be used for calculus of the upper third of the ureter, and severe complications such as avulsion of the ureter requiring nephrectomy and laceration of the iliac vessels have already been reported.’ Percutaneous stone removai methods are the first choice of management for calculus in the upper segment of the ureter in many centers.3 This can be performed under local anesthesia,4 with less morbidity than the other current methods of therapy.3 The most common complication of this method is infection.13334The technique for the percutaneous retrieval of kidney stones varies in different institutions, depending on equipment, ultrasound, and operating room facilities.3 It can be performed in one or many stages.3’4 After the placement of the percutaneous nephrostomy, which was performed in the radiology department under fluoroscopy, we allowed 24 hours for decompression of the kidney and creation of a tract
DISCUSSION
Abdominal gunshot wounds are a common cause of acute morbidity and mortality. Late complications, on the other hand, may be difficult to diagnose. In this patient, when we compared the plain abdominal radiographic examinations obtained 1 month apart from each other, a change on the position of the bullet was noted. Combining the symptoms of an acute hydronephrosis with the radiographic studies, we suspected a Journal
of Pediatric
Surgery,
Vol
25, No
12 (December),
From the Departments of Pediatric Surgery and Pediatric Urology, LeBonheur Children’s Hospital, Memphis. TN. Presented at the National Conference on Pediatric Trauma, Boston, MA, September 1987. Address reprint requests to Earle Wrenn, Jr, MD, Department oj Pediatric Surgery, LeBonheur Children’s Hospital. 848 Adams Ave, DR 300. Memphis, TN 30103. 0 1990 by W.B. Saunders Company. 0022-3468/90/2512-0029$03.00/O
1990: pp 1283-1284
1283
FERNANDES ET AL
1284
Fig 1. (Al Abdominal radiographic examination performed on the day the patient was injured. (61 Radiographic injury showing the bullet in a more medial and inferior position.
that could be dilated in order to facilitate the manipulation of the bullet. On the following day, in the operating room, and with the use of a Dormia catheter, the bullet could be removed. To our knowledge, this is the first reported case of
study 1 month after the
this rare urologic complication treated by percutaneous manipulation of the bullet. The correct diagnosis and the selection of a method of treatment associated with less morbidity contributed to a rapid and prompt recovery of this patient.
REFERENCES 1. Ball TP Jr: Endoscopic and percutaneous manipulation in stone disease. Urol Clin North Am 8:277-298, 1981 2. Drach GW: Transurethral ureteral stone manipulation. Urol Clin North Am 10:709-717, 1983
3. Smith AD, Lee WJ: Percutaneous stone removal procedures including irrigation. Urol Clin North Am l&719-727, 1983 4. Narayan P, Smith AD: Percutaneous nephrostomy as an adjunct in the management of ureteral calculi. Urol Clin North Am 9:137-143, 1982