Tsukamoto T, Kumamoto Y, Miyao N, Masumori N, Takahashi A, Yanase M (1992) Interleukin-6 in renal cell carcinoma. J Urol 148:1778 Videtic GM, Ago CT, Winquist EW (1997) Hypercalcemia and carcinoma of the penis. Med Pediatr Oncol 29:576 Walther MM, Johnson B, Culley D et al (1998) Serum interleu- kin-6 levels in metastatic renal cell carcinoma before treat- ment with interleukin-2 correlates with paraneoplastic syn- dromes but not patient survival J Urol 159:718 Watanobe H, Yoshioka M, Takebe K (1988) Ectopic ACTH syn- drome due to Grawitz tumor. Horm Metab Res 20:453 Weinstein EC, Geraa JE, Greene LF (1961) Hypernephroma presenting as fever of obscure origin. Proc Mayo Clinic 36:12 Weissglas M, Schamhart D, Lowik C, Papapoulos S, Vos P, Kurth KH (1995) Hypercalcemia and cosecretion of inter- leukin-6 and parathyroid hormone related peptide by a hu- man renal cell carcinoma implanted into nude mice. J Urol 153:854 Wolchok JD, Herr HW, Kelly WK (1998) Localized squamous cell carcinoma of the bladder causing hypercalcemia and in- hibition of PTH secretion. Urology 51:489 Yalcin S, Erman M, Tekuzman G, Ruacan S (2000) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) as- sociated with prostatic carcinoma. Am J Clin Oncol 23:384 Yamazaki T, Suzuki H, Tobe T et al (2001) Prostate adenocarci- noma producing syndrome of inappropriate secretion of an- tidiuretic hormone. Int J Urol 8:513 Yoshinaga A, Hayashi T, Ishii N, Ohno R, Watanabe T, Yamada T (2005) Successful cure of dermatomyositis after treatment of nonseminomatous testicular cancer. Int J Urol 12:593 182 14 Urologic Paraneoplastic Syndromes 15.1Urologic Trauma: General Considerations S.P. Elliott, J.W. McAninch 15.1.1 Iatrogenic Injury 183 15.1.1.1 Background 183 15.1.1.2 Intraoperative Guidelines 183 15.1.1.3 Postoperative Guidelines 183 15.1.2 External Trauma 184 References 184 15.1.1 Iatrogenic Injury 15.1.1.1 Background Wehaveallbeenoneitherthegivingorreceivingendof ahelpfulintraoperativeconsult.Itisalwaysremarkable how a different point of view, a different incision, or a unique approach to the operative management of a problem can turn a sour occasion into a successful one. When one is the urologist called in to repair an iatro- genic injury to the genitourinary system, it is essential that we bring that fresh perspective to the situation. This is best accomplished via two principles: (1) do your best to duplicate the operative setting with which we are all more familiar – the elective case, and (2) be flexible and change your approach as demanded by the clinical situation at hand. 15.1.1.2 Intraoperative Guidelines When consulted for an intraoperative injury, there is often a sense of urgency to correct an iatrogenic injury immediately. However, in most cases a urologic injury is not life-threatening. One would never perform an elective operation without reviewing the patient’s his- toryandweshouldhavethesamestandardswhencon- sulted for an iatrogenic injury. Depending on the situa- tion, a brief conversation with the surgeon of record, a review of the chart, or a conversation with the patient’s family may be appropriate. Knowledge about preopera- tive renal function or prior pelvic surgery could signifi- cantly alter one’s reconstructive plans. In order to make the surgical experience as familiar and comfortable as possible, one should order special instruments or re- tractors early. Rather than trying to make do with what’s available, optimize the surgical situation. Should bleeding be a problem, packing the wound with lapa- rotomy pads can control the situation while prepara- tion for repair is underway. If the incision is one with which you are not familiar, then take some time to fa- miliarize yourself with the anatomy or extend the inci- sion before making any moves. Since many injuries oc- cur at the limits of a surgeon’s exposure, extending the incision also helps one look for unrecognized concomi- tant injuries. Stage the injury completely. Assess the blood supply of the structure you are repairing. This is especially true in the case of a ureteral injury. If the ure- ter has been devascularized as well as transected it will alter your plan for repair. Additionally,while we recom- mendmakingtheoperativesituationasmuchlikean elective case as possible, this cannot always be done – one may have to modify the operative plan in light of the limitations of the operating room. For instance, whereas one may feel most comfortable staging a ure- teralinjurybyperformingcystoscopyandretrograde pyelograms, patient positioning or the orientation of the operating table may prohibit cystoscopy and/or fluoroscopy. Finally, consider the patients overall con- dition and the limitations of the operative setting. Whileitmightbepossibletoreconstructaninjuryina single setting, it may be more judicious to temporize drainage of the urinary system until a later date if the patient is unstable. 15.1.1.3 Postoperative Guidelines When helping a colleague with an iatrogenic injury, one should be gracious and never accusatory – in the operating room, in the operative dictation, in conversa- tion with the family, and in casual talk with fellow urol- ogists. One should talk with the family immediately af- ter the case, even as a consulting surgeon. Whenever possible it is best to have the surgeon of record along- side you when talking with the family so that a uniform explanation of the circumstances surrounding the inju- ry can be presented. Nothing is gained in the operative dictation by using words such as “error”, “iatrogenic”, 15 Trauma or “mistake.” Rather, one should describe the situation in passive terms, without introducing bias, i.e., “I was called into the room to examine and repair a transected ureter” rather than “Due to the large amount of blood in the field and poor visibility the ureter had been mis- takenly injured. I was asked to repair this iatrogenic in- jury.” The former gives the necessary information without introducing an unsolicited opinion about the factors leading to the event, whereas the latter is fodder for litigation. 15.1.2 External Trauma Two rules should govern the management of urologic trauma. First, in the stable patient all efforts should be made to evaluate and address genitourinary injuries at presentation. Imaging of the urinary tract can be easily incorporated into computerized tomography (CT) of the abdomen by obtaining delayed images during the renal excretion phase. This allows complete staging of renal and ureteral injuries. Assessment of bladder inju- ries should be done with plain film or CT cystogram. Early imaging and expeditious repair of select urologic injuries is essential as delayed management can lead to increased complications (Elliott and McAninch 2003). In fact, even if an injury may eventually heal with con- servative management one should consider an opera- tive repair if the patient is being taken to the operating room for repair of another injury (Gomez et al. 2004; Santucci et al. 2004). The first rule is illustrated by two examples. If a pa- tient is being explored by general surgery and a gun- shot wound injury of the kidney is discovered that is amenable to renorrhaphy, then a renal repair should be done, as this leads to a decreased incidence of delayed urine leak and blood transfusion (Meng et al. 1999). Likewise, if a patient with a blunt trauma is being ob- served for a large extraperitoneal bladder rupture and he is taken to the operating room for fixation of an un- stable pelvic fracture, then the bladder rupture should be repaired, as it will decrease his recovery and cathe- terization time (Gomez et al. 2004). The second rule is that in the unstable patient the urologic injuries must be measured alongside other, of- ten more life-threatening, injuries; urologic injuries can often be managed without reconstruction or tem- porized with a drain (Elliott and McAninch 2003; Go- mez et al. 2004; Santucci et al. 2004). This rule is illustrated by the example of a patient with a gunshot wound injury to the central portion of the kidney who is hemodynamically unstable. In this case, a nephrectomy may be preferable to a complicated reconstruction. Likewise, in a patient with a ureteral injury who is unstable due to concomitant injuries, the ureteral injury may be temporized with ligation of the ureter and placement of a nephrostomy tube rather than reconstruction of the ureter. For these reasons, it is essential that the urologist have excellent communication with the other services involved in trauma care. Our management of the uro- logic injuries will often need to be modified based on the management plan for concomitant injuries. The management of iatrogenic injury and urologic trauma both demand the perfect balance of vigilance and due caution. References Elliott SP, McAninch JW (2003) Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol 170:1213–1216 Gomez RG, Ceballos L, Coburn M et al (2004) Consensus state- ment on bladder injuries. BJU Int 94:27–32 Meng MV, Brandes SB, McAninch JW (1999) Renal trauma: in- dications and techniques for surgical exploration. World J Urol 17:71–77 Santucci RA, Wessells H, Bartsch G et al (2004) Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int 93:937–954 184 15 Trauma 15.2Modern Trauma: New Mechanisms of Injury Due to Terrorist Attacks N.D.Kitrey,A.Nadu,Y.Mor 15.2.1 Introduction 185 15.2.2 Mechanisms of Explosive Injury 186 15.2.2.1 Primary Mechanism (Primary Blast Injury) 186 15.2.2.2 Secondary Mechanism 186 15.2.2.3 Tertiary Mechanism 186 15.2.2.4 Quaternary Mechanism 186 15.2.3 Characteristics of Terrorist-Related Blast Injuries 186 15.2.4 Characteristics of Terrorist-Related Gunshot Injuries 187 15.2.5 Medical Management of Terrorist-Related Injuries 187 15.2.6 Urological Aspects of Terrorist-Related Injuries 188 15.2.7 Summary 190 References 190 15.2.1 Introduction Terrorism has increasingly become an integral part of the reality in many regions of the world. In the past few decades, there has been a surge in the number and in the intensity of terrorist attacks all over the globe, and the treatment of terror-related mass casualty incidents presents a special challenge to the medical teams in- volved. According to the Worldwide Incidents Tracking System (WITS) of the American National Counterter- rorism Center (National Counterterrorism Center 2006), there were 3,204 terrorist incidents worldwide in the year 2004 with 6,110 fatalities and 16,257 wounded. Many of the casualties resulted from suicide bombings in Iraq, Chechnya, Uzbekistan, Israel, and Pakistan. Unfortunately,thenumbersareexpectedtoincrease further and the world has realized that terrorist attacks are no longer confined to certain locations. Consequently, management of terror-related inju- ries has become a global public health challenge and in- creased awareness of medical teams to their unique characteristics is warranted. Furthermore, the medical community should develop adequate preparedness to various nonconventional terrorist scenarios, caused by chemical, biological, and radiological weapons, in or- der to decrease the associated chaos and improve the probability of survival of those injured (Shemer and Shapira 2001). The term “terrorism” itself derives from the Latin word “terrere” (to frighten), and it dates back to 1795 when it was used to describe the actions of the Jacobin Club in their rule of revolutioary France during the Reign of Terror. The modern definition of “terrorism” is emotionally and politically charged (Wikipedia 2006). However, nearly all of its definitions include cer- tain key criteria in termsof the unlawful use of violence with political, religious or ideological motivation, while the target is civilian, and the objective is to de- moralize and to provoke fear. According to a United Nations panel in 2004, acts of terrorism are “intended to cause death or serious bodily harm to civilians or non-combatants with the purpose of intimidating a population or compelling a government or an interna- tional organization to do or to abstain from doing any act” (Wikipedia 2006). Bombs and explosions directed against innocents are the primary instrument of modern terrorist groups. These weapons are easily and inexpensively manufactured, often according to clear instructions that are freely distributed on the internet, and are usu- ally very simple to activate either directly or remotely, automatically or manually, momentarily or at a de- ferred time using various timers (Kluger 2003; Sutphen 2005). Terrorists use explosive devices of various levels of sophistication and power, which can be military, commercial, or homemade. The common mechanism ofallexplosivedevicesistherapidconversionofsolid or liquid material into gas with associated release of en- ergy. The explosion substances are categorized as ei- ther high- or low-order (Sutphen 2005). High-order ex- plosives, like TNT, Semtex, and dynamite generate heat, loud noise, and a supersonic overpressurization shock wave (blast wave) that expands outward and is followed by a returning vacuum wave. Low-order ex- plosives, like gunpowder-based bombs and Molotov cocktails, create an explosion with a relatively slow re- lease of destructive energy without the overpressuriza- tion wave. 15 Trauma Suicide bombing is currently the most effective ter- rorist strategy since it maximizes the effect of mass ca- sualty incidents. Suicide bombers are difficult to identi- fy and their entrance into crowded confined places can cause an urban disaster. They may wear either an ex- plosive belt or vest and can also use cars or trucks heavily loaded with explosives without attracting sus- picion and trigger themselves with perfectly controlled timing (Sutphen 2005). The explosive device is detonat- ed by a simple electric charge activated either remotely or more commonly by the suicide bomber himself (Kluger 2003). Occasionally, terrorists use secondary devices to detonate at a slightly delayed time, in order to harm the emergency response personnel taking care of the victims of the first act. 15.2.2 Mechanisms of Explosive Injury Injuries inflicted by explosion have been known since the invention of gunpowder and detonation devices, al- though they are rarely encountered in civilian hospi- tals. Explosion injuries have a multidimensional pat- tern and complicated clinical course composed of the simultaneous combination of four distinct injury mechanisms (DePalma et al. 2005; Kluger 2003; Singer et al. 2005; Stein and Hirshberg 1999; Sutphen 2005). 15.2.2.1 Primary Mechanism (Primary Blast Injury) The energy produced by the explosion generates a shock wave that has three components: an extremely short high-positive pressure phase, a longer but milder nega- tive-pressure phase, and a “blast wind” – a massive movement of air. Gas-containing organs, such as the middle ear, the respiratory system, and the gastrointesti- nal tract, are injured by this baro-trauma with micro- and macroscopic tears of the gas–fluid interface. The common injuries consist of perforation of the eardrums, “blast lung” (alveolar capillary disruption, broncho- pleural fistulas, and air emboli), andbowel perforations. 15.2.2.2 Secondary Mechanism The secondary mechanism consists of injury caused by the impact of displaced debris and particles of the deto- nation device. Terrorists add nails, screws, steel pellets, and other metallic fragments to the explosive device in order to inflict as much damage as possible. These fly- ing objects cause penetrating and blunt trauma. They have an initial velocity of 2,000 m/s but their irregular shape and unsteady course cause rapid deceleration, hence their effect is maximal at close range. 15.2.2.3 Tertiary Mechanism These injuries occur as a result of people being thrown into fixed objects by the blast wind, especially during the deceleration phase when the body hits a stationary rigidsurface.Inaddition,thetertiarymechanismin- cludes extensive blunt injuries that are caused by struc- tural collapse and fragmentation of buildings or vehi- cles. 15.2.2.4 Quaternary Mechanism Other explosion-related injuries are caused by burns, smoke or toxic gas inhalation, crush injury, and exacer- bation of preexisting illnesses. 15.2.3 Characteristics of Terrorist-Related Blast Injuries The epidemiological and clinical outcomes of an explo- sion depend on several prognostic factors: the magni- tude of explosion, the composition and amount of the explosive material, the surrounding environment, and the distance between the blast and the victim. The blast-induced injuries are considerably influenced by whether the blast occurs in an open or in a confined space.Forexample,inanopen-airterroristbombingin Istanbul, Turkey on November 15, 2005, there were 69 casualties that were treated in the American Hospital in Istanbul. Only four of them (5%) had an Injury Severi- ty Score of 16 or more and none of them had primary blast injury (Rodoplu et al. 2005). On the other hand, blast victims in confined spaces have an increased mor- tality rate (15.8% vs 2.8%), a higher mean Injury Sever- ityScore(ISS)insurvivors(11%vs6.8%),ahigherin- cidenceofprimaryblastinjury,andmoreextensive burn injuries (Kluger 2003; Rodoplu 2005). In ultracon- fined spaces such as buses, the overpressure from the explosion is instantly magnified by reflections from the walls and has devastating consequences with an excep- tionally high fatalities-to-casualties ratio and mortality rate (49%) (Almogy et al. 2004; Kluger et al. 1997; Sha- loner 2005; Sutphen 2005). Moreover, blasts that cause structural collapse are associated with an immediate mortality rate as high as 25% (Arnold et al. 2003, 2004). A terrorist attack can cause a unique form of severe intentional injury and it presents with a unique epide- miology and several distinctive features, differing from conventional trauma injuries. Several studies from Is- rael, based on the Israeli National Trauma Registry, have tried to characterize patients hospitalized as a re- sult of terrorist injuries and to compare them to other 186 15 Trauma trauma casualties (Kluger 2003; Kluger et al. 2004; Pe- leg et al. 2003 ). According to these studies, the majority of terrorist-related victims were relatively young, half of them in their 20s, since crowded public places such as malls, pubs, and buses are frequently crowded by young people (Kluger 2003; Kluger et al. 2004). It is noteworthy that children, especially adolescents, are frequently injured in terrorist attacks and the injury se- verity,aswellasthesubsequentmorbidityandmortali- ty, is exceptionally high among children injured by ex- plosions (Aharonson-Daniel et al. 2003; Amir et al. 2005; DePalma et al. 2005). The terrorist-related injuries were generally more severeand29%ofthemhadanInjurySeverityScore (ISS) above 16, as compared to 10% in all other conven- tional trauma admissions (Kluger 2003; Kluger et al. 2004). The severity of injuries is also manifested by the state of consciousness on admission (as represented by theGlasgowComaScalescores),theincreasedfrequen- cy of hypotension on admission, and the fact that the majority of the victims sustain injuries to multiple bodyregions(Klugeretal.2004).Furthermore,survi- vors of terrorist-related bomb explosions underwent significantly more surgical interventions (53%, espe- cially orthopedic and abdominal surgery), they more frequently required the services of intensive care units (23%), their overall hospital stay was remarkably pro- longed (20% were hospitalized for more than 14 days), and they required more rehabilitation treatment com- pared to casualties of other types of trauma (Kluger 2003; Kluger et al. 2004; Mintz et al. 2002; Sutphen 2005). However, despite all efforts, this group of pa- tients eventually had an increased in-hospital mortality rate of 6.1%, as compared to 3 % in motor vehicle acci- dents and 1.8%in other trauma, probably related to the increased injury complexity (Kluger et al. 2004). Sever- alstudieshavenotedthatthehighspecificmortality rate in explosions is primarily due to abdominal inju- ries (19%) and severe head injuries (20–25%) (Amir et al. 2005). 15.2.4 Characteristics of Terrorist-Related Gunshot Injuries Aside from bombs and explosions, terrorists still wide- lyuseothermeansofviolencesuchasgunshooting, stabbing, and stoning. The outcomes of terrorist-relat- ed gunshot and stab wounds are similar to those seen in criminal and military scenarios. In the Israeli experi- ence, most gunshot wounds were inflicted by sniper shootings at high velocity into passing cars or at pedes- trians, though a few incidents of gunshots from auto- matic weapons into crowds of people were also encoun- tered (Amir et al. 2005). Correspondingly, while explo- sion victims usually arrive at the hospital as a part of a mass casualty event, gunshot victims typically arrive as individuals (Peleg et al. 2004; Singer et al. 2005). Gun- shot victims, compared with explosion victims, had a higher proportion of open wounds (63% vs 53%) and fractures(42%vs31%),morefrequentabdominal,spi- nal, and chest wounds, and overall they presented with a double incidence of moderate-severity injuries (ISS 9–14) (Mintz et al. 2002; Peleg et al. 2004; Singer et al. 2005). Explosion victims, on the other hand, had higher proportions of both minor and critical injuries (related to the distance from the focus of the explosion). The in- patient death rate is not significantly different (7.8% vs 5.3%), perhaps because the available data exclude many patients who die at the scene in an explosive inci- dent or subsequently arrive dead at the hospital; how- ever, a larger proportion of gunshot victims died dur- ing the first day (Peleg et al. 2004). 15.2.5 Medical Management of Terrorist-Related Injuries Terrorist acts frequently generate mass casualty events that overwhelm the regional health care system and cause a temporary imbalance between the sudden ur- gent demand for large-scale resources and expertise at a specific location and the availability of such resources (Shemer and Shapira 2001). The inundation of the medical system with hundreds of victims presents two types of challenge: a medical challenge, i.e., proper medical management with accurate triage, and a logis- tical challenge (Hirshberg 2004; Shemer and Shapira 2001). While the management of the single patient should initially follow the guidelines of Advanced Trau- ma Life Support (ATLS) (Shaloner 2005), the medical team should be aware of the unique multidimensional nature of terrorist-related injuries and take this into consideration during triage, diagnosis, treatment, and hospital organization (Peleg and Aharonson-Daniel 2005). As the individual victim is often treated as part of a mass casualty scenario, prompt triage is crucial in order to utilize the hospital resources effectively, sort- ing the patients into urgent versus nonurgent catego- ries and directing the efforts to a maximal number of salvageable patients (Kluger et al. 2004; Peleg et al. 2004; Stein and Hirshberg 1999; Sutphen 2005). In ac- cordance, Israeli studies have demonstrated that only 20%–23% of the casualties present with critical inju- ries and require urgent care (Almogy et al. 2004; Einav et al. 2004; Frykberg 2004; Peleg et al. 2004); therefore every effort should be made to prevent treatment of un- salvageable patients and victims who do not really re- quire immediate medical care (overtriage) from delay- ing the recognition and treatment of the small number 15.2 Modern Trauma: New Mechanisms of Injury Due to Terrorist Attacks 187 of patients with urgent and salvageable life-threatening injuries (undertriage) (Frykberg 2004; Kluger 2003; Stein and Hirshberg 1999). In these circumstances, pri- oritization of treatment regimens is mandatory and de- finitive therapy should be delayed until the patient is hemodynamically stabilized: damage control princi- ples should be applied. However, identifying those crit- ically injured patients who are candidates for damage control maneuvers, which aims to achieve hemostasis and prevent uncontrolled spillage of bowel contents and urine, is undoubtedly a challenge. Throughout the management of the event, coordination between the primary on-scene teams responsible for the primary triage and evacuation is obligatory, followed by similar close interaction between the in-hospital teams con- ducting the triage, the initial treatment, the surgical in- terventions and the intensive care, as well as between neighboring hospitals, in order to optimize utilization of the hospitals’ personnel and resources (Almogy et al. 2004; Einav et al. 2004; Hirshberg 2004). Special consid- eration should be given to the fact that shrapnel con- taining human remains might transfect hepatitis B vi- rus (HBV) or human immunodeficiency virus (HIV); thus immunization is recommended in appropriate scenarios (Singer et al. 2005; Sutphen 2005). The psy- chological effects on victims and family members shouldnotbeoverlooked,hencetheimmediateroleof specialized psychological teams is critical (Kluger 2003; Rusch et al. 2002). Subsequently, during the long course of rehabilitation, one should not forget the emo- tional and psychological support for the trauma vic- tims who might present posttraumatic stress disorder, depressivedisorder,panicdisorder,phobias,andsub- stance abuse (Rusch et al. 2002). Similarly, the medical personnel involved should not be ignored and special sessions should be scheduled for the teams in order to minimize the individual psychological burden andalle- viate the reactions (Kluger 2003). 15.2.6 Urological Aspects of Terrorist-Related Injuries A review of the literature reveals that there is a paucity of data on terrorist-related urological injuries. Impor- tant data is available from the Israeli Trauma Registry (ITR), which records all hospitalizations for physical trauma at most of the Israeli trauma centers. Unfortu- nately, the accumulated experience of the Israeli medi- cal system with terrorist-related injuries during the last two decades is exceptional in duration and intensity, out-ranging any comparable practice gained elsewhere, as only between September 2000 and December 2003, nearly 20,000 terrorist incidents were reported in Israel (Singer et al. 2005). All the patients recorded in the ITR with terrorist-related trauma to the urogenital system between 1997 and 2003 were studied retrospectively (Kitrey et al. 2005); 2% of all the terrorist attack casual- ties had urological injuries, one-third of them were in- juredbyexplosions,andtheresthadgunshotwounds. Theurologicalinjurieswereuniformlypartofamulti- organ injury. The majority of the victims were young males with severe injuries, 53% of them were treated in intensivecareunits,and46%werehospitalizedfor more than 2 weeks. Urologic injuries during conventional wars and re- gionalconflictswereinvestigatedmuchmoreandseem to be comparable to terrorist-related injuries, especial- ly the data from Northern Ireland in the 1970s and the Balkans in the 1990s. Nowadays, this comparison is in- creasingly accurate in view of the changing patterns of battlefield urological injuries secondary to an in- creased use of explosive weapons and the observation that the vast majority of urologic injuries currently sus- tained in war are caused by fragmentation devices (Hu- dak et al. 2005). This trend is evident on review of the mechanism of injury in different conflicts and wars throughout history. In the Irish conflict, 89.4% of the injuries were caused by gunshots, usually low velocity weapons (Archbold et al. 1981) and similarly in the Vietnam War, 92% of injuries were the result of pene- trating missiles (Hudak et al. 2005). Later on, during the Bosnia-Herzegovina conflict, most of the urologic injuries (52.9%–75%) were inflicted by explosions of bombs, rockets, mines, mortars, and grenades, while only a minority of urologic injuries was caused by fire- arms (Hudolin and Hudolin 2003; Kuvezdic et al. 1996; Tucak et al. 1995; Vuckovic et al. 1995). In accordance, in the Israeli terrorist-related series, 59 % of urological injuries were due to gunshots and 34% were from ex- plosions (Kitrey et al. 2005). Urologic war injuries are relatively infrequent and have constituted a small percentage of battlefield casu- alties during the past century. Review of the literature reveals that the genitourinary system is involved in 0.7%–10% of all war-related trauma cases (Ta- ble 15.2.1). Generally, the urological injuries are severe, even life-threatening, and combined with injuries to other organs in up to 76%–100% of cases (Busch et al. 1967; Hudolin and Hudolin 2003; Kuvezdic et al. 1996; Vuckovicetal.1995).Comparably,intheIsraeliexperi- ence, only 2 % of all terrorist-related trauma patients had urologic injuries, uniformly as a part of a com- bined or a multitrauma injury (Kitrey et al. 2005), simi- larly to the data from the Balkans and Ireland. Since these casualties rarely suffer from injuries that are lim- ited solely to the genitourinary system, a thorough uro- logical evaluation is often impossible at arrival. Conse- quently, the genitourinary injuries are often detected during exploratory laparotomy, as the patients are he- modynamically unstable at presentation and time-con- suming preoperative imaging is impossible (Hudak et 188 15 Trauma Table 15.2.1. Review of urologic injuries in recent wars Rate of uro- logic injuries Proportion of abdominal injury (kidneys and ureters) Proportion of pelvic and ex- ternal genitalia injury World War II a 0.7%–4% 14%–30% 66%–82% Korean War b 1.7% Vietnam War (1960s) c 4.2%–10% 20.8% 75% Northern Ireland (1970s) d 2.25% 50% Balkan War (1990s) e 2.4%–2.6% 45%–53% 47%–55% Gulf War (1990s) f <2% 17% 83% Israel (terrorist-related) g 2% 67% 33% a Busch et al. 1967; Hudak et al. 2005 b Hudak et al. 2005 c Busch et al. 1967; Hudak et al. 2005 d Archbold et al. 1981 e Hudolin and Hudolin 2003; Kuvez- dic et al. 1996; Tucak et al. 1995; Vuckovic et al. 1995 f Hudak et al. 2005; Thompson et al. 1998 g Kitrey et al. 2005 al. 2005); consequently, damage control strategies are usually applied. Blast injury causes injuries to the torso in 38%; only one-third of them are isolated, whereas the others are abdominal injuries combined with head, chest, or ex- tremity injuries (Peleg et al. 2003). Gas-containing or- gans are the most vulnerable to primary blast effect, thoughinjuriestosolidorganssuchasthekidneysare also encountered as a result of acceleration and deceler- ation forces. At exploration, this injury usually takes the form of hemorrhage beneath the visceral peritone- um that extends into the mesentery, possibly associated with perforation of the bowel or rupture, infarction, is- chemia, or hemorrhage of solid organs, including the genitourinary system (Centers for Disease Control 2006; DePalma et al. 2005; Stein and Hirshberg 1999). During warfare, the proportion of the abdominal inju- ry with involvement of the kidneys and ureters is quite varied in different series because of the different char- acteristics of the conflict and the medical management. During World War II, these injuries were relatively in- frequent (Table 15.2.1), perhaps because evacuation was delayed and severely wounded patients with ab- dominal injuries did not reach the hospital alive. Therefore, renal injury was probably underestimated then, because of high mortality rates in the combat area while awaiting evacuation and treatment (Hudak et al. 2005). On the other hand, during the Gulf war, as an ex- ample of a modern war, evacuation time was usually short, but renal and ureteral injuries were infrequent as well.Thismayhaveresultedfromthefactthatmostof the reported wounded were American soldiers using flak jackets protecting their flank and abdomen (Thompson et al. 1998). In the same war, civilians and soldiers from the other side, not wearing flak jackets, had many more renal and ureteral injuries (Abu-Zidan et al. 1999). The urban scenarios of the Balkan and the Irish conflicts seem more comparable to terrorist at- tacks because both the civilian population and most of the armed forces involved did not use body armor and the evacuation was usually rapid. In these series, the kidneys and ureters were involved in half of the urolog- ic injuries (Table 15.2.1). In accordance, in Israel, two- thirds of the terrorist-related victims with some sort of urological involvement had renal and ureteral injuries, whether injury resulted from gunshots or explosions (Kitrey et al. 2005). However, bladder injuries were more common in gunshots victims (17% vs 9%), while traumatotheexternalgenitaliawasmorecommonfol- lowing explosive injuries (26% vs 14%). Altogether,the urological injuries encountered following terrorist as- saults present particularly complex and severe woun- ding patterns that are not typically seen in other forms of trauma, probably because they involve a combina- tion of penetrating and blunt mechanisms (Frykberg 2004). Consequently, surgeons should be prepared to face complex renal contusions and lacerations, a high incidence of ureteral injuries, which are often over- looked, bladder ruptures, and severe injuries to the ex- ternal genitalia, mostly with testicular rupture second- ary to blast injury (Centers for Disease Control 2006). In view of these distinct complex urological insults as- sociated with other multiorgan injuries, urologists should adapt their surgical approach to the situation, improvise, and often apply damage control principles in order to provide temporary stabilizing solutions. Understandably, unusual urological injuries may beget unusual original management approaches. This was previously illustrated by our colleagues (Sofer et al. 2004), by the management of a15-year-old girl who was injured in a terrorist suicide blast. On admission, an open abdominal wound with enteral evisceration was noted and she was urgently operated on to repair a transection of the right iliac vessels. Radiological imag- ing performed on the following day revealed a 6-cm- long nail in the right kidney, passing through the col- lecting system. As the patient was asymptomatic from the urological point of view and the nail was considered to be entrapped and unlikely to migrate, conservative, nonoperative management was chosen. An intravenous urogram (Fig. 15.2.1), taken 1 year after the injury, re- vealed normal excretion with no migration of the nail. Thepatient’sfollow-upwasuneventfulfor5yearsafter the injury. An early review of the published experience with terrorist bombings up to the late 1980s clearly showed that abdominal injury carries the highest specific mor- tality rate (19%) of any single body system injury 15.2 Modern Trauma: New Mechanisms of Injury Due to Terrorist Attacks 189 Fig. 15.2.1. Intravenous urogram showing a metallic nail in the right kidney (Sofer et al. 2001). among the immediate survivors (Frykberg and Tepas 1988). The mortality rate among patients with urologic injuries in the Balkan war was much the same, report- edly 15.6% (Tucak et al. 1995). Similarly, in the Israeli study, 19.1% of the terrorist-related urological patients died during their hospitalization (Kitrey et al. 2005). This high mortality rate may have resulted from several factors, including the short evacuation period, which means that even very severely injured patients arrive at the hospital alive, the high prevalence of severe injuries to other organs, and the unprecedented powerful weap- ons. 15.2.7 Summary Terrorist attacks have become a reality all over the world. Medical facilities and physicians alike should be prepared for terrorist-related mass casualty events with their distinctive features. 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J Trauma 39:733 References 191 [...]... within 1 h after injury, creatinine measurement reflects renal function prior to the injury An increased creatinine usually reflects preexisting renal pathology 15 .4 Renal Trauma Imaging: Criteria for Radiographic Assessment in Adults Decisions about radiographic imaging in cases of suspected renal trauma are based on the clinical findings and the mechanism of injury Since the majority of renal injuries... significant penetrating renal lacerations J Urol 157: 24 Wightman JM, Gladish SL (2001) Explosions and blast injuries Ann Emerg Med 37:6 64 Chapter 15 .4 Renal Trauma 15 .4 E Serafetinides 15 .4. 1 Anatomy 15 .4. 2 Iatrogenic Vascular Injuries 202 15 .4. 3 Renal Transplantation 15 .4. 4 Percutaneous Renal Procedures 201 202 203 15 .4. 5 Renal Injuries 205 15 .4. 5.1 Background 205 15 .4. 5.2 Mode of Injury 205 Injury Classification... Renal reconstruction is feasible in most cases (Fig 15 .4. 14 – 15 .4. 17) Fig 15 .4. 15 Extroperitoneal incision over aorta to expose renal vessels Left renal vein Inferior mesenteric vein Right renal vein Left renal artery Gonadal vein Right renal artery Fig 15 .4. 14 Exploration and reconstruction of injured kidney Midline incision (Fig 15 .4. 14 17 © Hohenfellner 2007) Fig 15 .4. 16 Exposure and placement of... of injuries in survivors of open-air versus confined-space explosions J Trauma 41 :1030 Lynch D, Martinez-Pi˜ eiro L, Plas E et al (2003) European Asn sociation of Urology Guidelines on Urological Trauma Eur Urol 47 :1 McAninch JW (2003) Editorial: New technology in renal trauma J Urol 169: 1368 McAninch JW, Santucci RA (2002) Genitourinary trauma In: Retik AB, Vaughan ED Jr, Wein AJ (eds) Campbell’s urology, ... possible Renal Injuries Coexisting injuries are identified in 14 % – 34 % of blunt trauma and in 50 % – 80 % of penetrating renal trauma cases, mostly involving the liver with right-sided injury and the spleen in the left-sided cases (Krieger et al 19 84; McAninch and Santucci 2002; Peterson 2000) The urologist might therefore be involved with renal trauma as a consultant in a shared abdomen at laparotomy... accurate in finding perirenal hematomas, assessing the viability of renal fragments, and detecting preexisting renal abnormalities, but failed to visualize urinary extravasation on initial examination The authors concluded that MRI could replace CT in patients with iodine allergy and could be used for initial staging if CT was not available (Leppaniemi et al 1997) The use of intravenous gadolinium-based... immediate intervention among the many others with non-life-threatening injuries, for whom treatment can be delayed The generally accepted principles of triage for mass casualty scenarios divide patients into four groups (Frykberg 2002; Jacobs et al 1979) 1 Patients with life-threatening injuries requiring immediate and expeditious intervention in terms of the ABC care principles: airway compromise, breathing... 206 15 .4. 5.3 Diagnosis: Initial Emergency Assessment 207 History and Physical Examination 208 Laboratory Evaluation 208 Imaging: Criteria for Radiographic Assessment in Adults 209 15 .4. 5 .4 Treatment 213 Indications for Renal Exploration 213 Operative Findings and Reconstruction 2 14 Nonoperative Management of Renal Injuries 215 Postoperative Care and Follow-up 216 Complications 216 Renal Injury in the... test in the evaluation of patients with suspected renal trauma Hematuria is the presence of an abnormal quantity of red blood cells in the urine and is usually the first indicator of renal injury Microscopic hematuria in the trauma setting may be defined as greater than 5 red blood cells per high-power field (rbc/hpf), while gross hematuria is the finding in urine that is readily visible as containing... valuable in organ preservation in cases of multiple lacerations (Kluger et al 1999) All penetrating injuries are explored via a transabdominal approach for preserving the kidney if feasible, exploring the contralateral kidney, and controlling other abdominal injuries, since in many cases preoperative evaluation is insufficient (Kuvezdic et al 1996) Patients with hematuria undergoing an exploration following . B, Culley D et al (1998) Serum interleu- kin-6 levels in metastatic renal cell carcinoma before treat- ment with interleukin-2 correlates with paraneoplastic syn- dromes but not patient survival. similar close interaction between the in- hospital teams con- ducting the triage, the initial treatment, the surgical in- terventions and the intensive care, as well as between neighboring hospitals, in. Urologic injuries in the Gulf War. Int Urol Nephrol 31:577 Aharonson-Daniel L, Waisman Y, Dannon YL et al (2003) Epi- demiology of terror-related versus non-terror-related trau- matic injury in children.