Experience with renal gunshot injuries in a rural setting

doi:10.1016/S0090-4295(99)00313-1

Urology

Volume 54, Issue 6, December 1999, Pages 972-975

https://doi.org/10.1016/S0090-4295(99)00313-1 Get rights and content

Abstract

Objectives. To investigate the high nephrectomy rate in patients with gunshot injury at Dicle University Medical School Research Hospital and to determine the factors that affect our nephrectomy decision.

Methods. During a 4-year period, 71 patients were hospitalized for renal injuries at our hospital. Renal gunshot injuries (RGIs) were noted in 45 kidneys of 42 patients (59.1%). Twenty-five patients underwent nephrectomy (55.5%). Twenty kidneys were reconstructed (44.4%). The hospital records were reviewed retrospectively. In these two groups of patients, the following clinical data were entered into a computer data base and compared: presence and type of hematuria, type and degree of renal injury, hemodynamic status, results of imaging studies, surgical technique, type of weapon, reason for nephrectomy, associated organ injury, injury severity score, complications, and mortality.

Results. The patients who underwent renal repair and those who underwent nephrectomy had a mean injury severity score of 33.6 ± 7.5 and 42.0 ± 9.9, respectively (P <0.001). The main grade of injury was 4.4 ± 0.8 in nephrectomy patients and 2.8 ± 0.9 in the patients for whom renal salvage was possible (P <0.05). Patients who required nephrectomy, as a group, appeared to have a higher rate of high-velocity bullet injury (HVBI) (76%) (P <0.05) and higher numbers of associated abdominal injury (P <0.05).

Conclusions. HVBI makes extensive tissue debridement imperative and reconstruction difficult. We believe that in RGIs caused by a high-velocity bullet, nephrectomy is more likely to be required. Hemodynamic instability was the major reason for our intraoperative nephrectomy decision. HVBI should be accepted as a subcategory of RGI.

Section snippets

Material and methods

Between 1990 and 1994, 71 patients were hospitalized at our Departments of Urology and General Surgery with renal trauma. RGIs were noted in 42 patients (59.1%), and these patients made up the main group of this study. All patients underwent surgical exploration. The criteria establishing the presence of renal injury were the same as described previously by McAninch et al.2 A total of 45 kidneys (39 unilateral, 3 bilateral) were injured by gunshots during this period. Twenty-five patients

Results

The study group consisted of 37 males (88%) and 5 females (12%) between 15 and 68 years old (mean age 28 ± 2.4 and 27 ± 3.7 for male and female patients, respectively). Twenty-four of the patients (61.9%) had high-velocity bullet injury (HVBI), 12 patients had low-velocity bullet injury, and the other 6 patients had been wounded with shrapnel. Microscopic hematuria was present in 14 (33.3%) and macroscopic hematuria in 27 (64.2%). One patient with vascular injury had neither macroscopic nor

Comment

Our hospital serves people who live in 13 cities throughout the southeast and eastern regions of Turkey. Most trauma patients are transferred to this center for their final diagnosis and treatment. In rural areas, every residence has a gun for protection against enemies or for hunting. Additionally, the sociopolitical conditions of our region also increase the incidence of RGIs compared with other studies.1, 4, 7 Gunshot wounds may have a profound influence on surrounding tissues because of the

Conclusions

HVBI has a special nature. In rural areas, the type of weapon and condition of the patient during transfer to a trauma center can change the rate of, and reason for, nephrectomy. HVBI should be accepted as a subcategory of RGI.

References (14)

P Nash et al.
Nephrectomy for traumatic injuries
J Urol
(1995)
J.A Eastham et al.
Urologic evaluation and management of renal proximity stab wounds
J Urol
(1993)
H Kuveždic et al.
War injuries of the kidney
Injury
(1996)
M.L Fackler
Physics of missile injuries
J.W McAninch et al.
Renal gunshot woundsmethods of salvage and reconstruction
J Trauma
(1993)
A.I Sagalovski et al.
Renal trauma requiring surgeryan analysis of 185 cases
J Trauma
(1983)
J.W McAninch
Injuries to the genitourinary tract

There are more references available in the full text version of this article.

Cited by (29)

Renal Trauma Increases Risk of Future Hypertension
2018, Urology
To determine if traumatic renal injuries or computed tomography (CT) findings are predictive of hypertension (HTN) development following injury.
A retrospective review of a renal trauma database was performed from 1995 to 2015. Renal injuries were graded by the American Association for the Surgery of Trauma system, with high-grade defined as IV or V. Nonrenal genitourinary trauma (ie bladder, penile, urethral, and testicular) patients were selected as controls. Patients with a diagnosis of HTN before their trauma or those lacking follow-up were excluded. Risk factors associated with HTN following trauma were identified using multivariable regression with propensity scoring.
In total, 163 patients had a renal injury and 60 had nonrenal, genitourinary injuries. The median age was 31 years (interquartile range 23-43) with median follow-up of 4.7 years (interquartile range 1.9-8.5). Twenty-three (14%) patients with renal trauma were newly diagnosed with HTN on follow-up, compared with 2 (3%) in the control groups. (P = .02) After propensity quartile adjustment, patients with high-grade trauma had higher odds of developing HTN compared with low-grade renal trauma patients and controls (adjusted odds ratio 3.5, 95% confidence interval 1.3-9.3, P = .01). Patients with a midpole medial laceration and medial blood on CT had higher odds of developing HTN compared with patients without these characteristics (odds ratio 5.36, 95% confidence interval 1.3-22.6, P = .02).
Increasing renal trauma grade is a risk factor for future development of HTN. CT findings at trauma presentation may be useful in stratifying patients who are at increased risk.
Surgical Management of Solid Organ Injuries
2017, Surgical Clinics of North America
Citation Excerpt :
This is largely due to the particular vulnerability of the kidney to deceleration injuries following high-velocity impact trauma, as it is essentially tethered in place by just the vascular pedicle and renal pelvis.170,171 However, in more urban areas with higher rates of gun and knife violence, or regions with high levels of civil unrest, rates of penetrating renal trauma are much higher.163,172–174 Renal injuries occur along a spectrum, with most injuries being on the milder side of this range.164
Current epidemiology of genitourinary trauma
2013, Urologic Clinics of North America
Experience of open renal trauma in a urology service
2012, Actas Urologicas Espanolas
El traumatismo renal abierto alcanza en zonas urbanas entre un 15-20% del total de traumatismos renales. Es producido principalmente por armas blancas o de fuego; estas últimas son de alta energía y se asocian a lesiones en otros órganos. Se presenta nuestra experiencia en traumatismo renal abierto en los últimos 24 meses.
Estudio retrospectivo. Se evaluaron los pacientes con traumatismo torácico, abdominal y toracoabdominal ingresados entre julio de 2009 y junio de 2011. Se identificaron 14 pacientes con diagnóstico de traumatismo renal abierto con confirmación diagnóstica por imágenes o durante el intraoperatorio.
Las edades oscilan entre 16 y 37 años, con un promedio de 24,5; 13 casos de 14 fueron hombres. El mecanismo del traumatismo es en un 71% (10/14) por arma de fuego y en un 29% (4/14) por arma blanca. Se clasificó el traumatismo renal según la American Association for the Surgery of Trauma, encontrándose que 3/14 (21%) corresponden a grado II, 4/14 (29%) a grado III, 4/14 (29%) a grado IV y 3/14 (21%) a grado V. El descenso de hematocrito varió entre el 1 y 27%, con un promedio de 13,9%. Se decidió un manejo conservador en 6/14 pacientes, considerándose como tal las cirugías efectuadas por lesión de órgano no urológico. Un total de 6 pacientes (42%) requirió nefrectomía. Hubo lesiones toracoabdominales asociadas en el 79%.
A pesar de la baja incidencia de traumatismo renal abierto, se observa un gran número de pacientes considerando otras series nacionales. Lo anterior probablemente sea debido a las características socioculturales del centro hospitalario.
Opened renal trauma in urban areas reaches 15 to 20% of all renal traumas. It is mainly caused by gunshot wounds or knifes. Gunshot wounds are classified as high energy trauma and are usually associated to other organ injuries. We present our experience in opened renal trauma in the last 24 months.
Retrospective study: patients with thoracic, abdominal and thoraco-abdominal trauma admitted to the emergency room between July 2009 and June 2011 were studied. Fourteen patients were identified with opened renal trauma, with diagnostic confirmation by imaging study or during surgery.
Ages ranged from 16 to 37 years, with a mean age of 24.5 years. Thirteen patients were males. The mechanism of injury was produced by gunshot in 71% (10/14) and by knife in 29% (4/14). The opened renal traumas were classified according to the American Association for the Surgery of Trauma. Of these, 3/14 (21%) belonged to grade II, 4/14 (29%) to grade III, 4/14 (29%) to grade IV and 3/14 to grade V (21%). Fall in hematocrit ranged from 1% to 27%, with an average of 13.9%. Expectant management was done in six patients, however, this management did not take into account those surgeries performed due to non-urologic organ injuries. Six patients (42%) required nephrectomy. Thoraco-abdominal injuries were associated in 11 patients (79%).
Despite the low incidence of opened renal trauma, many patients are observed when other national reports are considered, probably due to the socio-cultural characteristics of this hospital.
Multidetector Computed Tomography of Penetrating Abdominal Trauma
2012, Seminars in Roentgenology
Citation Excerpt :
CT findings suggestive of a diaphragmatic injury also include a wound track outlined by air, hemorrhage, or bullet fragments caused by the missile or knife extending to the diaphragm, focal thickening of the diaphragm, and a defect in the continuity of the normal diaphragm, even in the absence of associated hematoma or bleeding. Penetrating injuries to solid organs are almost always caused by gunshot or stab wounds, except for the few iatrogenic injuries resulting from percutaneous biopsy or other medical procedures.21-23 The mechanism consists of direct damage to the parenchyma itself, renal excretory system or biliary system, and vascular structures.
Evaluation and treatment of kidney penetrating wounds
2006, Annales d'Urologie
Le traumatisme pénétrant du rein est moins fréquent que le traumatisme fermé. Toutefois, son incidence a augmenté au cours des dernières décennies en raison de l'accroissement de la violence urbaine. Les principales causes de traumatisme pénétrant sont les plaies par arme blanche et par arme à feu, avec une proportion de lésions rénales plus importante dans le deuxième cas. Le traitement du traumatisme rénal a évolué au cours de ces dernières années. Auparavant, l'exploration chirurgicale était d'emblée indiquée dans la plupart des cas, ce qui était associé à un taux élevé de néphrectomies. Actuellement, le développement des nouvelles techniques de diagnostic par imagerie disponibles dans les services d'urgence permet, dans certains cas, l'abstention thérapeutique, avec une surveillance stricte des patients, afin de préserver le rein. Le principal examen diagnostique est la tomodensitométrie (TDM) avec injection de produit de contraste, qui permet de classer correctement les lésions rénales et de choisir à tout moment la meilleure stratégie de prise en charge initiale. Devant un traumatisme pénétrant, le premier pas consiste à évaluer l'état hémodynamique du patient. En cas d'instabilité hémodynamique, il faut réaliser une exploration chirurgicale immédiate. Si, en revanche, l'état du patient est stable, il faut réaliser une TDM avec des images tardives. Les lésions rénales des grades I et II justifient l'abstention thérapeutique. Les lésions des grades III et IV associées à d'autres lésions intrapéritonéales nécessitant la réalisation d'une laparotomie d'urgence s'explorent chirurgicalement et relèvent de la reconstruction ou de la néphrectomie. La plupart des lésions de grade IV avec atteinte du hile rénal et des lésions de grade V relèvent également du traitement chirurgical. Les lésions rénales mineures justifient l'abstention thérapeutique avec une surveillance du patient qui comporte des déterminations successives du taux d'hémoglobine et de l'hématocrite, ainsi que des examens TDM ou échographiques pour suivre l'évolution de la lésion et détecter d'éventuels urinomes ou saignements prolongés. La diminution progressive de l'hématocrite et les fistules artérioveineuses doivent être traitées initialement par embolisation. Les fistules urinaires persistantes en cas d'abstention thérapeutique seront traitées, si nécessaire, par cathétérisme urétéral et drainage percutané de l'urinome.
Penetrating lesions of the kidney are less frequent than closed wounds. However, their incidence has increased these past decades, in relation with the augmentation of urban violence. The main causes of penetrating wounds are knives and firearms, with a related rate of renal lesions more important in the second case. The treatment of renal traumas has evolved these past years. Previously, surgical investigations were systematically indicated in most cases, which was associated with an elevated number of nephrectomies. Today, the development of new diagnostic imaging techniques available in most emergency units allows in certain cases the replacement of therapy by a strict follow-up of the patient, the objective being to preserve the kidney. The principal diagnostic investigation is CT scanning with injection of a contrast product, which is useful to adequately classify renal lesions and to make decision regarding the best first-line therapeutic management. In case of penetrating lesion, the first step is the evaluation of the haemodynamic condition of the patient. In case of haemodynamic instability, immediate surgical investigation is necessary. Conversely, if the patient is stable, CT with delayed imaging must be carried out. For grade I and II renal lesions, therapeutic abstention is recommended. Grade III and IV lesions associated with other intraperitoneal lesions that require emergency laparotomy must be surgically investigated and in these cases, reconstructive surgery or nephrectomy must be considered. Most grade IV lesions associated with a lesion of the renal hilus and grade V lesions must be referred to surgery. Minor renal lesions may not be treated; such cases necessitate a follow-up of the patient that should include successive assessments of the haemoglobin and the haematocrite, together with CT and ultrasonographic investigations aimed at the follow-up of lesion evolution and detection of potential urinomas or prolonged bleedings. The progressive decrease of the haematocrite and arteriovenous fistulae must be treated first by an embolization. Untreated patients with persistent urinary fistulae will undergo, if necessary, ureteral catheterization and percutaneous drainage of the urinoma.

View all citing articles on Scopus

View full text

Adult UrologyExperience with renal gunshot injuries in a rural setting

Abstract

Section snippets

Material and methods

Results

Comment

Conclusions

J Urol

J Urol

Injury

Physics of missile injuries

Renal gunshot woundsmethods of salvage and reconstruction

J Trauma

Renal trauma requiring surgeryan analysis of 185 cases

J Trauma

Injuries to the genitourinary tract

Adult Urology
Experience with renal gunshot injuries in a rural setting