Wehrmedizinische Monatsschrift 8/2017

Renal Gunshot Wounds: Case Report of a Combat Injury

From the Urology Department (Medical Director: Colonel (MC) W. Wagner, MD) of the Bundeswehr Hospital Hamburg (Hospital Commander: Brigadier (MC) J. Hoitz, MD)

Nojan Sanatgar, Dirk Liebchen, Cord Matthies, Walter Wagner

Summary

Renal injuries can be treated either conservatively or with interventional/surgical approaches. Conservative management should always be preferred if patients are haemodynamically stable and renal structures remain intact. Unstable patients as well as patients with injuries to the renal hilum or completely shattered kidneys (AAST V) require surgical treatment.

The following case report shows that in reality the choice between those two different approaches to treatment is not always clear and simple.

Keywords: renal trauma, case report, conservative therapy, interventional therapy, gunshot wound

Introduction

Emergency surgery to treat renal gunshot and fragmentation wounds is not a challenge that surgeons in role 2 or role 3 units are very often faced with on deployment [26]. Every such case requires a decision on whether surgical intervention (often including nephrectomy) is necessary or whether the organ can be preserved with conservative treatment.

This case report of a young soldier who sustained a gunshot wound in Afghanistan serves to illustrate – with a focus on military medical aspects – the diagnosis and treatment of (penetrating) renal injuries and discuss current recommendations for the treatment of renal trauma.

Renal Injuries

Epidemiology

Of all injuries of the genitourinary system, renal injuries are the most common. The main causes are traffic, sports- and work-related accidents, and in some regions violent crime, too [2, 23, 26].

On the whole, however, renal trauma is a rare occurrence thanks to the protected position of the kidneys in the retroperitoneal space. Only 1.4% to 3.25% of all trauma patients also sustain renal injuries. Renal trauma is also often associated with injuries of other organ systems [23].

Among deployment-related injuries, the incidence of renal injuries has drastically decreased since World War II. This is primarily due to the use of body armour. During World War II, the kidney was affected in almost 50% of all urogenital trauma cases [10]. Today, according to the Joint Theater Trauma Registry (JTTR) of the US Armed Forces, only 22.9% of all urogenital injuries sustained during military operations involve the kidneys [25]. The injury patterns clearly show the impact of body armour on the frequency of renal injuries. During the Gulf War (Operation Desert Shield, 2 August 1990 until 28 February 1991), Kuwaiti soldiers, who did not have body armour at their disposal, sustained renal trauma in 33% of cases of urogenital injury, compared with only 17% of US armed forces [13, 27].

Classification of Renal Injuries

The Organ Injury Severity Scale for kidneys of the American Association for the Surgery of Trauma (AAST) is the established grading system for renal trauma and is subdivided into five grades [18]:

Grade I:

Renal contusion with haematuria or subcapsular haematoma, no laceration, no retroperitoneal haematoma 

Grade II:

Parenchymal laceration <1 cm, laceration of renal capsule with retroperitoneal haematoma; no urinary extravasation

Grade III:

Parenchymal laceration >1 cm, laceration of renal capsule with retroperitoneal haematoma; no urinary extravasation

Grade IV:

Parenchymal laceration extends to renal pelvis, urinary extravasation. Main renal artery or vein injury with contained haemorrhage (and segmental loss of function)

Grade V:

Completely shattered kidney, avulsion of renal hilum, hilar injury, complete devascularisation of the kidney

Diagnosis:

Renal Gunshot Wounds: Case Report of a Combat Injury

Image 1: Classification of renal injuries (Source: Campbell-Walsh UROLOGY, 9th edition, Saunders Elsevier, 2007, Vol. 2, p. 1276, Fig. 39 - 1 – Classification of renal injuries by grade)

The haemodynamic status of a trauma patient determines the choice and timing of diagnostic measures. An instable patient should undergo surgery without delay [1].

During the initial physical examination of the patient, a particular focus should be on external signs of renal injury, such as flank pain, haematoma or entry/exit wounds in the abdominal or lumbar region. Renal injury must be considered a possibility in any polytrauma patient.

Sonography

In the trauma room, sonography is often the first diagnostic measure after physical examination [12]. The FAST scan (Focused Assessment with Sonography for Trauma) can provide valuable information to help diagnose renal injuries. The examiner should always consider evidence of urinary stasis or free fluid in the retroperitoneum a sign of possible renal injury [8]. Doppler ultrasound can be used to diagnose devascularisation of the kidney caused by partial avulsion of the renal pedicle with arterial dissection.

Sonography further plays an important role in monitoring free fluid as part of conservative management of renal injury [29].

Diagnostic Urine Tests

Renal injuries are often (80–94%) accompanied by haematuria [11]. There is no proven correlation, however, between the presence or absence of haematuria and the severity of a renal injury [4]. Haematuria in a patient in the trauma room suggests possible injuries to the urinary tract, especially renal injuries. Up to 20% of all patients with grade IV/V injuries, however, do not have haematuria [6].

Diagnostic Radiology

CT examination with intravenous application of contrast agents is considered the gold standard in diagnosing renal injury in stable patients [3]. It allows for correct classification of renal injuries and diagnosis of associated injuries.

In order to correctly assess the severity of renal injuries and to detect injuries of the pelvicalyceal system with contrast media extravasation, the CT scan should always contain an arterial phase and, if possible, a pyelographic phase, approx. 10–20 minutes after contrast application [22].

Since the widespread introduction of CT (including in countries of deployment), excretion urography has become largely irrelevant.

In case of suspected injuries of the collecting system, retrograde pyelography is a safe and highly reliable way of visualising injuries of the ureter and/or renal pelvis [29].

Renal Gunshot Wounds: Case Report of a Combat Injury

Image 2: Entrance to field hospital in Bagram, named after US Army Staff Sergeant Heathe N. Craig, who was killed on 21 June 2006 during a helicopter rescue flight

Therapie

In recent years, there has been a clear trend in the treatment of renal injuries towards conservative management [24]. Patients with renal gunshot wounds should receive prophylactic antibiotic treatment since foreign bodies, such as clothing fibres or other foreign material, can almost always be assumed to have contaminated the wound [7].

Conservative Management of Renal Injuries

Grade I–III injuries (no urinary extravasation) are usually conservatively managed if circulation can be stabilised. Bed rest is important until the urine clears up and vital signs must be closely monitored and regular blood counts performed. Falling haemoglobin levels, flank pain and fever are indications for further sonographic imaging or, if necessary, a CT scan [13]. Patients with AAST category IV renal injuries with stable circulation can be treated with conservative management, which should, however, be accompanied by clinical and CT radiological examinations at close intervals [30].

Ureteral Stenting

Urinomas developed as a result of renal injury resorb spontaneously in 80–90% of cases and require no treatment [14]. Infected urinomas, perinephric abscesses and gunshot injuries with a potential risk of infection/abscess formation, however, may require ureteral stenting [11, 13].

 

Surgical Treatment of Renal Injuries

Absolute indications for surgery (laparotomy) in cases of renal injury include:

  • renal haemorrhage while circulation cannot be stabilised [9];
  • traumatic ureteral avulsion from the renal pelvis [16];
  • urinary extravasation and more than 25% of renal tissue devitalised [17];
  • concomitant intra-abdominal injuries and gunshot wounds [16, 21];
  • grade V renal injuries [5].

Surgical treatment of renal injuries should always be carefully considered. If one or more of the above indications apply, surgery should be performed immediately (usually even before repatriation).

 

Renal Injuries Discovered during Laparotomy

Concomitant renal injuries in patients with blunt trauma may be treated as conservatively as possible. The Gerota's fascia should not be opened as it can sufficiently encapsulate a haematoma. If the fascia is already ruptured (e.g. as a result of penetrating injuries), the kidney, vessels and the ureter near the kidney may be examined. Ureteral closure, renorrhaphy and partial nephrectomy are established treatment options if damage control surgery is not required.

Selective Embolisation

Selective embolisation of renal vessels is a highly effective, minimally invasive method of treating bleeding renal injuries [20]. This procedure, however, requires specialised radiologic resources that are not always available – especially not on deployment. Bleeding can be stopped in 70–80% of all cases, however, up to 90% of all successfully treated cases eventually require a second or third treatment [28].

Renal Gunshot Wounds: Case Report of a Combat Injury

Image 3: Treatment stations in the casualty department of Craig Joint Theater Hospital in Bagram

Case Report

On 23 February 2016, soldiers of the Afghan National Army exchanged fire with anti-coalition forces, resulting in a number of casualties. Five wounded soldiers were treated in the emergency room at the US-operated Heathe N. Craig Joint Theater Hospital in Bagram (north-eastern Afghanistan, role 3 field hospital).

Renal Gunshot Wounds: Case Report of a Combat Injury

Image 4: Abdominal CT showing injury near upper pole of right kidney (arrows = free fluid)

One of the wounded soldiers was a 20-year-old member of the Afghan National Army. Upon admission, the patient was awake, responsive and in stable cardiopulmonary condition. Physical examination showed a projectile entry wound to the right flank. No further injuries were apparent. The soldier had not been wearing any form of body armour.

After inconclusive initial sonography in the trauma room, contrast-enhanced CT was performed. A renal trauma on the right-hand side with a haematoma and a urinoma in the area of the right kidney was diagnosed. Intraperitoneal injuries could not be ruled out. The projectile remained in the patient's body (Image 4).

The clinical director decided that the next step should be to conduct an exploratory laparotomy with nephrectomy. The urologist's recommendation of a prior CT scan with a pyelographic phase was not followed. The patient was immediately taken to the operating theatre.

Renal Gunshot Wounds: Case Report of a Combat Injury

Image 5: Preoperative retrograde pyelography of right kidney: contrast medium extravasation (red arrow) near the upper calyceal group, blue arrow points to projectile

Since his cardiopulmonary condition remained stable, retrograde pyelography was performed on the urologist's urging after administration of a third-generation cephalosporin as antibiotic prophylaxis. The pyelogram revealed an injury in the area of the upper calyceal group of the right kidney with contrast media extravasation (Image 5). A double J stent was placed in the ureter.

The subsequent laparotomy showed no intraperitoneal injuries and only a small retroperitoneal haematoma. The retroperitoneum was not accessed. During surgery, the urologist decided against a nephrectomy. The projectile, which according to the CT scan was situated in the retroperitoneum, was left in situ as removing it would have required opening the retroperitoneum, which entails a high risk of bleeding.

After emergency treatment, the patient's case was presented to colleagues in Germany who are experienced in the treatment of urotrauma. The case and any next steps were discussed almost daily.

Renal Gunshot Wounds: Case Report of a Combat Injury

Image 6: Follow-up CT of abdomen on 6th postoperative day (arrow: no free fluid detectable)

The patient's postoperative clinical and laboratory results were normal. Antibiotic treatment was continued over a total of 10 days. Daily ultrasound follow-ups showed no signs of active bleeding. The urinoma, initially containing 50 ml, shrank gradually. After 6 days, a follow-up CT scan was performed. The scan showed no signs of abscess formation and no increase in the retroperitoneal haematoma and urinoma (Image 6).

On day 13 after surgery, another contrast-enhanced CT scan with a pyelographic phase was performed. This scan showed neither signs of contrast media extravasation from the collecting system nor of abscess formation. The urinoma was no longer detectable and the retroperitoneal haematoma was much smaller (Image 7).

Renal Gunshot Wounds: Case Report of a Combat Injury

Image 7: Follow-up CT of abdomen on 13th postoperative day with pyelographic phase (arrow: contrast medium in the collecting system)

The double J stent was removed and a retrograde pyelography performed on the 21st day after the patient's initial wounding (Image 8). There was no sign of contrast media extravasation from the collecting system. The patient was monitored for two more days. Since the patient's overall condition and his laboratory findings, especially his inflammatory markers and kidney function parameters, were still normal, he was released from hospital after 23 days.

 

Conclusion

This case report demonstrates that even for severe perforating injuries to the kidney, conservative management should be prioritised over surgery to prevent organ loss, especially as there are no differences when it comes to long-term complications [13]. If possible, a urologist experienced in trauma management should always be consulted on deployment-related injuries to the genitourinary tract, via telemedical consultation if necessary. Any unnecessary loss of a kidney must be prevented.

 

Renal Gunshot Wounds: Case Report of a Combat Injury

Image 8: Left side: Pyelography 21 days post injury, right side: late picture of same examination. No extravasation of contrast medium at the upper calycael group(green arrow); the projectile is still in situ (blue arrow).

Key statements

  • If possible, conservative management should be prioritised over surgery in the treatment of renal trauma as there are no differences in terms of long-term complications and renal salvage is more likely.
  • Even though contrast-enhanced CT is considered the gold standard, pyelography can provide valuable information, e. g. if CT cannot be performed.
  • Unless a nephrectomy is necessary to avert immediate danger to the life and health of a patient, a urological consultation should first be sought, via telemedical links if necessary.
  • Injuries to the collecting system do not necessarily require draining of the renal pelvis. The collecting system should, however, be drained in patients with gunshot wounds with a potential risk of infection or abscess formation.
  • Selective embolisation of renal vessels is a highly effective, minimally invasive method of treating bleeding renal injuries which, however, is not always available on deployment.

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Image sources:

Images 2 and 3: Antonia Steves, Bundeswehr Central Hospital Koblenz

Images 4, 6 and 7: Craig Joint Theater Hospital Bagram/Afghanistan, Radiology

Images 5 and 8: Nojan Sanatgar, Bundeswehr Hospital Hamburg

 

Manuscript data:

Submitted: 18 April 2017

Revised version approved: 26 June 2017

 

Citation:

Sanatgar N, Liebchen D, Matthies C, Wagner W: Renal Gunshot Wounds: Case Report of a Combat Injury. Wehrmedizinische Monatsschrift 2017; 61(8): XXX-YYY

 

Corresponding author:

Oberstabsarzt Nojan Sanatgar
Bundeswehrkrankenhaus Hamburg – Abteilung Urologie
Lesserstr. 180, 22049 Hamburg
E-Mail: nojansanatgar@bundeswehr.org

 

Eine Deutsche Version dieses Artikels finden Sie hier
A german version of this article you will find here

 

Autoren: Cord Matthies, Dirk Liebchen, Nojan Sanatgar, Walter Wagner

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