Urologic Aspects of Damage Control

In events involving mass casualties, the principles of triage and damage control are congruent, as both aim to diminish the mortality rates by allowing a limited number of qualified personnel treat more patients with life-saving minimal maneuvers and delayed preplanned definitive treatment.

The chances for a urologist to be involved as a trauma case manager in a mass casualty event are rather low, as this role is usually held by general surgeons. However, urologists are frequently consulted in problematic cases, as they are often involved as additional surgical specialists in severe multivisceral trauma patients. Understandably, with the expanding role of the damage control approach, the knowledge of its principles and its implications should no longer be held only by general surgeons, and surgeons from various specialties should be equally familiar with those aspects. From the urological point of view, dilemmas such as whether to explore a retroperitoneal hematoma during acute laparotomy in an unstable patient or performing time-consuming urinary reconstruction vs quick diversion for ureteral or bladder injury in the context of a multitrauma patient are to be currently addressed according to principles of the damage control approach. The thorough understanding of damage control principles that allow delayed diagnostic and reconstructive procedures in the unstable patient is thus deemed to improve the urologist's interaction with the trauma team in the emergency room or the operating room and eventually result in improved survival and diminished morbidity. Similar considerations can be applied in mass casualty events, when the number of casualties overwhelms the medical resources and every surgeon, regardless of his specialty, is expected to provide acceptable care for the maximal amount of injured patients.

In 1993, Hirshberg and Mattox (1993), in an article entitled "Damage control in trauma surgery," expressed their hope that "surgeons from all specialties involved in trauma care will adapt to the new strategy by developing appropriate surgical solutions for injuries in their respective fields." Review of the current literature, more than a decade later, reveals that their wishful prophecy is still far from being carried out in most of the surgical subspecialties. Specifically, in urology, perhaps because of the dominating elective nature of our profession, management of urological trauma has been traditionally based on temporary immediate measures and planned deferred definitive surgery, which is fortunately in line with the modern damage control principles. As previously stated, the common denominator of the already developed damage control techniques, in all kind of surgical subspecialties, is primarily increased awareness leading to creative improvisation. In Israel, as surgeons are unfortunately being exposed to urban terrorist bombings and civilian mass casualty events and are routinely trained, even in peace time, for their emergency assignment as field surgeons during war, the principles of damage control have been well implemented in various surgical specialties.

The following discussion addresses the damage control principles of management of urological injuries involving the kidney, ureter, bladder, urethra, and genital organs dictated in scenarios involving mass casualties.

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