A Clinical Guide to Urologic Emergencies

94 94 Reilly, K.J., Shapiro, M.B., and Haskal, Z.J. (1996). Angiographic embolization of a penetrating traumatic renal arteriovenous fistula. J. Trauma 41 (4): 763.

95 95 Tucci, P., Doctor, D., and Diagonale, A. (1979). Embolization of post‐traumatic renal arteriovenous fistula. Urology 13 (2): 192–194.

96 96 Reigle, M.D., Selzman, A.A., Elder, J.S., and Spirnak, J.P. (1998). Use of ureteral stents in the management of major renal trauma with urinary extravasation: is there a role? J. Endourol. 12 (6): 545–549.

97 97 Buckley, J.C. and McAninch, J.W. (2006). Selective management of isolated and nonisolated grade IV renal injuries. J. Urol. 176 (6 Pt 1): 2498–2502; discussion 2502.

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101 101 Keihani, S., Anderson, R.E., Fiander, M. et al. (2018). Incidence of urinary extravasation and rate of urethral stenting after high‐grade renal trauma in adults: a meta‐analysis. Transl. Androl. Urol. 7 (Suppl. 2): S169–S178. https://doi.org/10.21037/tau.2018.04.13.

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Jonathan Wingate

Madigan Army Medical Center, Tacoma, WA, USA

The World Health Organization (WHO) defines traumatic injuries as either intentional (interpersonal violence related, war‐related, or self‐inflicted injuries) or unintentional injuries (motor vehicle collisions, falls, etc.). Traumatic injuries are the leading cause of death in the United States for people aged 1–44 years [1]. Worldwide, traumatic injuries are the ninth leading cause of death and disproportionately affects males and those in low and middle‐ income countries (LMIC) [2]. By 2030, the WHO projects a 28% increase in global deaths due to trauma and injury [3].

In civilian trauma, the kidneys are the most commonly injured genitourinary (GU) organ. The kidneys are injured in 1–5% of trauma patients and comprise up to 24% of traumatic solid abdominal organ injuries [4–6]. Stratifying by mechanism, there is wide geographical variation for penetrating renal injury (PRI) versus blunt renal injury (BRI) and the reported range for PRI is between 10.9 and 43.9% of all renal injuries [7–9].

Historically, in wartime trauma, the kidneys were the predominant GU organ injured during conflicts in the early and mid‐twentieth century. Hugh Hampton Young described the GU injury patterns for Allied Forces in World War I and noted a 7.3% incidence of renal trauma at time of laparotomy with a 50% mortality rate [10]. These were almost all penetrating injuries, with 93.9% of soldiers having a concomitant hollow viscous injury. Surprisingly, the nephrectomy rate was only 18.1% [10]. There has been a paradigm shift in GU injuries due to advancements in technology – specifically the use of Kevlar body armor – resulting in a significant decline of PRIs and an increase in complex lower tract blast injuries, the signature GU injury of the recent conflicts in the Middle East [11–14].

Although penetrating trauma is seen in both civilian and military trauma, mechanistically they vastly differ. Civilian penetrating trauma has an equal distribution between stab and gunshot wounds (GSW) and the majority of GSW are low‐velocity handguns [15]. Military penetrating trauma is usually due to high kinetic weapons such as rifles or due to blast injury (BI). However, due to the global increase of terror attacks and mass shootings, managing patients with injuries from these high kinetic weapons among civilian surgeons is increasing, so understanding how to manage these injuries is paramount.

Low‐velocity weapons, such as knives, lead to local tissue damage and effects along the tract of penetration. High‐velocity projectiles, such as bullets and shrapnel, result in wider tissue injury. This is governed by the formula KE = ½ MV 2, where KE is kinetic energy, M is the bullet mass, and V is the velocity. On average, a rifle (such as the AK‐47 or M‐16A1) has a bullet velocity 2–3 times greater than a standard handgun. This translates into 4–9 times greater kinetic energy (holding mass constant), thus causing greater damage. There are two areas of projectile‐tissue interaction in missile wounds – the permanent and temporary cavity. The permanent cavity is due to local tissue damage and necrosis due to the projectile, whereas the temporary cavity is caused by the transient lateral displacement of tissue [16]. Due to varying bullet characteristics, such as fragmentation, weight, and yaw patterns, bullets can cause variable and significant damage in the temporary cavity that may seem out of proportion to the entry or exit wound.