IMPACT OF BODY ARMOR ON GENITOURINARY TRAUMA 2199

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EDITORIAL COMMENT

This study of GU injuries and prevention in wartime is asignificant contribution to the trauma literature despite thesmall number of genitourinary injuries identified in thedatabase. Rapid analysis of data during an ongoing militaryconflict is innovative and points toward a future when we

use injury analysis to modify risks in real time. The rate of

renal injury in this military conflict (29 of 2,712 or 1.1%) issimilar to population based rates in the United States. Thefinding that body armor did not prevent severe kidney injurywas notable. As in civilian practice nephrectomy is the mostcommonly performed operative intervention for renal trauma.1

The most important finding of the study is the reduced rateof GU injuries in soldiers equipped with body armor. How-ever, several important limitations require further analysisbefore we can attribute a protective effect to body armor.

The author needs to adjust for important confounders thatcould affect the rate of GU trauma overall and renal injury inparticular. Without adjustment for age, mechanism of injury,injury severity score, associated injuries, diagnostic studiesand accuracy of staging the conclusions are subject to signifi-cant bias. For example, it is possible that those with bodyarmor had more blunt injuries and, thus, a lower rate of renaltrauma. It is also possible that those without armor had moresevere associated injuries resulting in more diagnostic testingand/or operative interventions that led to a higher discoveryrate for GU injuries. Furthermore, it was not documented inthe database whether the groin protector piece was worn at thetime of injury. If the men without such protection were not atlower risk for injury, the biological plausibility of the associa-tion would be further weakened. If the finding of a reduced rateof genitourinary injury in soldiers wearing body armor can bevalidated in a larger, better characterized cohort, further re-search and expenditures to protect our military personnel willbe indicated.

Hunter WessellsDepartment of Urology

Harborview Medical CenterSeattle, Washington

1. Wessells H, Suh D, Porter JR, Rivara F, MacKenzie EJ, JurkovichGJ et al: Renal injury and operative management in theUnited States: results of a population-based study. J Trauma2003; 54: 423.

REPLY BY AUTHOR

Unfortunately the relatively small cohort prevented us fromdoing multiple subset analysis, which might have teased outsome of the effects of confounders. The majority of casualtieswere of adult age and so adjustment for age would be of nobenefit. Injury severity score was not included because itwas not available for everyone in the JTTR. As discussed,the lack of renal injury staging was due to inadequate accessto radiological studies and complete operation reports in thisaustere environment. I agree that an analysis of renal sal-vage based on injury stage would be useful.

We were actually surprised that overall GU injuries weresignificantly less in casualties wearing body armor comparedto those not wearing body armor. The original intention was toexamine the effect of body armor on renal injuries only. Theceramic plates are specifically designed to protect against tho-racic and upper abdominal trauma. The lack of documentationof the groin protector is a clear weakness of the database,especially when dealing with GU trauma. Continued analysisof the trauma database and the protective armor worn by our

soldiers in ongoing and necessary.