A review of the literature reveals that there is a paucity of data on terrorist-related urological injuries. Important data is available from the Israeli Trauma Registry (ITR), which records all hospitalizations for physical trauma at most of the Israeli trauma centers. Unfortunately, the accumulated experience of the Israeli medical 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 casualties had urological injuries, one-third of them were injured by explosions, and the rest had gunshot wounds. The urological injuries were uniformly part of a multiorgan injury. The majority of the victims were young males with severe injuries, 53 % of them were treated in intensive care units, and 46% were hospitalized for more than 2 weeks.
Urologic injuries during conventional wars and regional conflicts were investigated much more and seem to be comparable to terrorist-related injuries, especially the data from Northern Ireland in the 1970s and the Balkans in the 1990s. Nowadays, this comparison is increasingly accurate in view of the changing patterns of battlefield urological injuries secondary to an increased use of explosive weapons and the observation that the vast majority of urologic injuries currently sustained 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 penetrating 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 firearms (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 explosions (Kitrey et al. 2005).
Urologic war injuries are relatively infrequent and have constituted a small percentage of battlefield casualties 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 (Table 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; Vuckovic et al. 1995). Comparably, in the Israeli experience, only 2% of all terrorist-related trauma patients had urologic injuries, uniformly as a part of a combined or a multitrauma injury (Kitrey et al. 2005), similarly to the data from the Balkans and Ireland. Since these casualties rarely suffer from injuries that are limited solely to the genitourinary system, a thorough urological evaluation is often impossible at arrival. Consequently, the genitourinary injuries are often detected during exploratory laparotomy, as the patients are he-modynamically unstable at presentation and time-consuming preoperative imaging is impossible (Hudak et
Rate of uro- Proportion of Proportion of logic injuries abdominal injury pelvic and ex-
(kidneys and ternal genitalia ureters) injury
Table 15.2.1. Review of urologic injuries in recent wars 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
World War IIa Korean Warb Vietnam War (1960s)c Northern Ireland (1970s)d Balkan War (1990s)e Gulf War (1990s)f Israel (terrorist-related)g
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 extremity injuries (Peleg et al. 2003). Gas-containing organs are the most vulnerable to primary blast effect, though injuries to solid organs such as the kidneys are also encountered as a result of acceleration and deceleration forces. At exploration, this injury usually takes the form of hemorrhage beneath the visceral peritoneum that extends into the mesentery, possibly associated with perforation of the bowel or rupture, infarction, ischemia, 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 injury with involvement of the kidneys and ureters is quite varied in different series because of the different characteristics of the conflict and the medical management. During World War II, these injuries were relatively infrequent (Table 15.2.1), perhaps because evacuation was delayed and severely wounded patients with abdominal 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 example of a modern war, evacuation time was usually short, but renal and ureteral injuries were infrequent as well. This may have resulted from the fact that most of 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 attacks 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 urologic 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 trauma to the external genitalia was more common following explosive injuries (26 % vs 14%). Altogether, the urological injuries encountered following terrorist assaults present particularly complex and severe wounding patterns that are not typically seen in other forms of trauma, probably because they involve a combination 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 overlooked, bladder ruptures, and severe injuries to the external genitalia, mostly with testicular rupture secondary to blast injury (Centers for Disease Control 2006). In view of these distinct complex urological insults associated 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 a 15-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 imaging performed on the following day revealed a 6-cm-long nail in the right kidney, passing through the collecting 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, revealed normal excretion with no migration of the nail. The patient's follow-up was uneventful for 5 years after 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 mortality rate (19%) of any single body system injury
among the immediate survivors (Frykberg and Tepas 1988). The mortality rate among patients with urologic injuries in the Balkan war was much the same, reportedly 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 weapons.
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