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War injuries
of the kidney
H. KuveZdic, A. Tucak and B. Grahovac Urology Clinic, Clinical Hospital,
Osijek, Croatia
Befween 2 May 2991 avrd 2 l~oz~e~ber 2992, 4425 ~ouvzded people were treated at the Clinical ~5s~~tff~ of Osijek, Cronfia. A hundred atzd fifteen (2.6 per cent) had a urogenital injury, 64 (56 per cent) of whom had penetrating kidney injuries. Sixteen (25 per cent) of this 64 were caused by gunshot wounds and 48 (75 per cent) by ~ras~evzts of mines, mortars or grenades. Tile v~ajorjty of the 64 kidtzey injuries had aiso assocjafed iv@ries qf some ofher vnajur urgarr system, particulffrly in the abdomen, with only three cases of is&fed kjd~zey injury. ln 53 patients (‘82.8 per cent) surgical access uvas by fra~~sabdunzivzfzlirrcision, in nivze (14 per cent) by cxfraperitoneal flank incision and in fwo cases thoracophrenolaparotovny was also performed. Nephrectovny was performed in 16 patients (25 per cent). In 46 (75 per cent) an organ-s~ar~tz~ proce&rre was done: kidney sutures in 28 143.8 per cent), kid?~ey resecfiovz in fiue ('7.8 per red) md e.r~?~uraf~o?z only in 15 (23.‘4 per cent). fvztrahospital deaths occurred in 12 (18 per cent), seuen ivz the operating Nzeatre. An ez~aluafiorz of the 6~v~o?lt~z~o~~o~u up for 90 per cent of the sz~r~~jz~ivz~~vafjevztsis presented. it seems that the frequency of rennl war i@ries was lower than usually reported. Associated abdovninal injuries justij?ed surgical access by transabdovninal incision. The high mortality rate is cxplairzed by a large number of associated ~~jz~ries and by the proximity of the battl~~e~d ~~f~z resulti~l~ rapid transport of pnfienfs (azterage 52 mini, which e.ucbtded the Tossibilify of separating out the moribund pnfievzts. tong-term foll~zu up covz~rnzed fhe ben~~ts of fire ~oils~~~~~l~ surgical izp~roach. Co~!/r~~~z~ 0 1996 ElsezGer Science Ltd.
Injury, Vol.
27, No.
8, 557-559,
1996
gunshot or explosive kidney injuries. The results of treatment and late complications could be evaluated in 34 patients. The examinations were performed 6 months or more after injury.
Patients and methods From 2 May 1991 to 2 November 1992, 4425 wounded patients were treated at the Clinical Hospital, Osijek, 115 (2.6 per cent) of whom had urogenital injuries. Of these 115, 64 (55.7 per cent) had renal injuries. The average age was 32.8 years (range, 12-69 years). Sixteen (25 per cent) were caused by projectiles from light weapons, while 48 (75 per cent) were caused by fragments from explosive devices. In addition to the kidney injury, two patients had an injury of the ureter, four of the urinary bladder and three of the external genitalia. In only three (4.7 per cent) was the kidney the only injured organ; 61 (95.3 per cent) had associated penetrating injuries of other organs (Table I)” A review of the renal injuries and the surgical procedures performed are presented in Taboo Il. In 53 (82.8 per cent) of the wounded, transabdominal access was the primary surgical approach, and in two (3.1 per cent) the access was by thoracophrenolaparotomy; in nine (14.6 per cent), an extraperitoneal flank incision was performed, but in three of these the procedure was concluded by laparotomy. Intrahospital mortality occurred in 11 patients (17.9 per cent). Of these, seven (63.6 per cent) died
Introduction After 30 years of the treatment of kidney injuries in peace time, the aetiology pathophysiology and surgical doctrine of war injuries to this organ opened a new field of experience to physicians at the Urology Clinic in Osijek. After nearly 1 year has elapsed we have evaluated the experience gained and the results of treating these injuries. The aim was to assess the effectiveness of the diagnosis and treatment. In a retrospective review, data were analysed on the cause of the wounds, the clinical status at admission, associated injuries, intra-operative findings, operative procedures, postoperative course and early complications in 64 wounded patients with
Table I. Associated injuries Site
-.
Abdomen Liver large intestine Small intestine Spleen Stomach Gall bladder Pancreas Thorax Head Limbs Large blood vessels* *Abdominal
and thoracic
N
%
54
84.3
26 22
20 9 9 3 2
10 6
15.6 9.4
25
39.1
8 aorta,
common
12.5 iliac artery
and vein.
Injury: International Journal of the Care of the Injured Vol. 27, No. 8,1996
558
Table II. Renal injuries: classification and surgical procedures Surgical Description Contusion Laceration* Rupture? Maceration Renal vessel Total *Laceration
of injury
Exploration
Sutures
15 0 0 0
procedure
Nephrectomy
0 14 14 0
Resection
0 0 z
0 0 : 0 5 (7.8%)
injury 15 (2:4%) = rupture
of the parenchyma
28 (403%) without
injury
to the channel
16 (;5%)
Total 15 14 24 5 6 64
23.4% 21.9% 37.5% 7.8% 9.4% 100%
system.
iRupture = rupture of the capsule, p~renchyma an~c~annel system
during surgical exploration due to haemorrhage from multiple injuries. Two others died on the second day after operation, after not recovering from immediate traumatic shock. One died on the fifth day after operation following relaparotomy because of continuous liver bleeding, and one on the seventh day because of peritonitis. Thirty-four patients were available for assessment 6 or more months after injury. In all of the wounded, the urea and creatinine values were within physiological limits. In 32 of them, intravenous pyelography and ultrasound of the kidney were normal. In two patients there was a ureteric stricture needing surgical correction. In 16 patients dynamic scintigraphy of the kidney was performed with assessment of kidney function. The results of these tests in all patients (including three after partial nephrectomy) were assessed as good or satisfactory, with an average loss of renal function of 12 per cent in comparison with expected values.
Discussion The frequency of kidney injury of 1.5 per cent of the total number of wounded patients treated at the Clinical Hospital Osijek during 18 months of the war in Croatia is lower than that in other conventional wartime conflicts this century”. On the contrary, it is striking that there were more associated injuries of the kidney with penetrating injuries of the abdomen: in 227 abdominal injuries, 64 (28.2 per cent) kidney injuries were found. Kidney injuries as a rule are part of associated injuriese5: only three patients (4.6 per cent) were treated for isolated kidney injuries. The most frequent accompanying injuries were abdominal. A transabdominal approach seems to be essential for (1) a conserving surgical attitude with the aim of kidney preservation; (2) contralateral kidney exploration; (3) control of other abdominal injuries and (4) because insufficient pre-operative diagnostic methods are available under wartime conditioruF. The high mortality rate is, in our opinion, a consequence of the high proportion of multiply injured patients, often arriving in a state of shock, who would be classified as moribund by the usual wartime surgical triage. In our case the hospital was almost on the battlefield; this proximity resulted in a rapid patient transport, which prevented separating out the moribund cases. A high mortality rate can be
also explained by the exceptional destructive power of modern explosives. Seventy-five per cent of the organ-sparing surgical procedures had good results and this justifies such an approach in kidney injuries: preserve the organ, eliminate and drain urohaematomata, remove devitalized tissue and foreign bodies and control bleedi@+. This doctrine needs the parti~pation of a urologist in the team assigned to care for penetrating abdominal war injuries.
Conclusions Kidney injuries form a high proportion of urological war wounds: (56 per cent). Ninety-five per cent of injuries are associated with other injuries especially abdominal injuries. Because the hospital was close to the battlefield, the wounded were transported directly to the operation theatre and investiga~ons were few. The organ-sparing surgical approach is justified by the 75 per cent rate of kidney conse~ation. The high mortality rate (18 per cent) could be explained by (1) the high proportion of multiply injured patients; (2) the proximity of the battlefield which prevented separating out the moribund cases; and (3) the exceptionally destructive power of modern explosive weapons.
References 1 ~ch~ld
JAA, Barros JYSa AAB and Morrison E. Genito-
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Kuveidic
et al.: War injuries of the kidney
7 Ivantury RR, Zubowski R and Stahl WM. Penetrating renovascular trauma. J Trauma 1989; 29: 1620. 8 Carlton CE Jr. Upper urinary tract trauma. In: Glenn JF, eds. Urologic Surgery. Harper & Row: New York, 1975, p. 154. 9 Dixon CM and McAninch JW. Reconstruction of the traumatised Kidney. In: Webster G, Kirby R, King L and
559 Goldwasser B, eds. Reconstructive Urology. Blackwell Scientific Publications: Boston, 1993, p. 273.
Paper accepted 4 May 1996. Correspondence should be addressed to: Professor Antun Tucak MD, Urology Clinic, Clinical Hospital Osijek, 31 Osijek, Huttlerova 4, Croatia.