MILITARY MEDICINE, 162,5:346, 1997

Urogenital War Injuries

Zvonimir Marekovic, MD PhD Ivan Krhen, MD PhD Daniel Derezic, MD PhD Zeljko Kastelan, MD MS

Out of 1,350 war casualties treated at the University Hospital Results Rebro during the defensive war in Croatia, 60 (4.4%) injuries of the urogenital tract were present. Among these 60 casualties, We found combined injuries of the genitourtnary tract and 51 (85.0%) had multiple injuries, most often abdominal and otherorgansin 51patients(Table I). Most frequently, thesewere urogenital. These patients were accordingly treated by com­ injuriesto the smallintestineand the colon, as well as to the bined urological and surgical teams. Regarding injuries, there liver, spleen, pancreas, and lungs (Table II). Downloaded from https://academic.oup.com/milmed/article/162/5/346/4831527 by guest on 29 September 2021 were 21 injuries, 11 (2 patients had bilateral injuries), 7 , 2 urethral, 15 testicular, and 6 Out of 21 kidney injuries, 18 were penetrating and 3 were penile injuries subjected to surgical treatment. caused by blunt trauma. In 9 wounded patients, 11 ureteral was performed in 6/21 patients with kidney injuries. Orchiec­ injuries were found (bilateral in 2) caused by penetrating ab­ tomy was performed in 40%of patients with testicular injuries. dominal injuries. All 7 urinarybladderlesions were caused by In the remaining patients with urological tract injuries, surgi­ penetrating injuries and were accompanied bybowel damage. A cal reconstruction with organ conservation was performed. penile segment injury in 1 and a prostatic segment injury in another made up the 2 casualties with injured . Both Introduction patients had rectal injuries as well. In 21 injuries of external rogenitalinjuriessustainedduringthewarusuallycome in genitals, 15 testicularand 6 penile injurieswere observed. All U association with abdominal and multiple organ injuries. patients received simultaneously the antibiotics penicillin and Those in World WarIIand the Vietnam Warresultedfrom gun­ aminoglycosides withmetronidazole postoperatively. shot as the most frequent causative factor. Injuries ofexternal Asfaras surgical treatmentwasconcerned, nephrectomy had genitals (intact urinary tract, 33.750/0) and urethral injuries to be performed 6 times, in cases of kidney vascular pedicle (with or without injury to the external genitals, 16.250/0) ac­ damage, excessive hematoma, and kidney tissue destruction. countedforone-half" to two-thirds ofurogenital tnjurtes." Kid­ Fifteen injuries required conservative kidney : partial ney and urinary bladder injuries, usually resulting from gun­ nephrectomy (8injuries) orrupture suturingand the excision of shot and mortar wounds to the abdomen and lower trunk, the squashed devitalized tissue and (7 injuries) appeared in about one-third of urological casualties. Ureteral (Table II!). After surgical conservation ofthe kidney, no compli­ injuriescameas a rare occurrence, but nevertheless accounted cationsor majordeterioration ofthe overall renalfunction were for2.2 to 4.20/0 ofurogenital injuries. 3-7 observed in the postoperative course. In this studywehaveexamined urological injuriessustained Ureteral injuries (11) requiring eightureterocystoneostomies during the defensive war in Croatia over a 3D-month period presented most often with the distal segment damage. In 2 (June 1991-December 1993). Thebattlefield wasmainly around injuries with the resection of the devital­ cities and in inhabited areas, contributing to a promptevacua­ ized ureteral edges and splint insertion were performed. In the tionofcasualtiesto well-equipped regional hospitals withmed­ ical equipment for adequateworkup. Atotal of24,865injured patient with bilateral injuries ofthe median ureteral segment, personstreated on an inpatientbasis were registered through­ renal autotransplantation and ureterocystoneostomy were per­ out Croatia as war casualties during that period. Out of this formed on opposite sides 6 months after the trauma. In this number, 588 patients had 629 injuriesofthe urogenital tract. patient the kidney function was good and there were no stric­ tures or ureteralfistulas postoperatively (Table III). Materials In five urinarybladderinjuries, bladderwall sutures withthe evacuation ofthe hematoma and cystostomy were performed. In During the 3D-month period, 1,350 casualties of war with two casualties withextensively ruptured bladderswithinvolve­ either blunt or penetrating trauma were hospitalized in the ment of the trigonal region, temporary bilateral ureterocuta­ University Hospital Rebro in zagreb. Most casualties reached neostomies were performed frrst. Then in one patient, psoas­ the hospitalwithin 1 to 3 hours after the trauma, coming di­ hitch bladder with ureterocystoneostomies was done. In the rectly from the battlefield, where they had received immediate other,afterthe urinarybladderrestitution, bilateral ureterocy­ care including hemostasis, maintenance of respiration, com­ stoneostomy was performed (Table III). In both patients com­ pensationfor circulating volume, antibiotics, and analgesia. A pleteurinarybladderrestitution wasachieved and kidney func­ smaller number of casualties were transferred from regional tion preserved. hospitalsforadditional surgical and medical care (surgical and There were two urethralinjuries. In the injuryofthe prostatic reconstructive procedures, etc.) segment, cystostomy was performed at the firstsurgery, and, 3 monthslater, endoscopic internalurethrotomy was performed. Department ofUrology, University Hospital Center zagreb, 10000 zagreb, Croatia. This manuscript wasreceived for review in June 1996. The revised manuscript was Continence waspreserved, but the injuryofthe neuromuscular accepted for publication in December 1996. pedicle resulted in impotence. When the penile urethral seg­ Reprint & Copyright ©byAssociation ofMilitary Surgeons ofU.S., 1997. mentwas injured(injuries < 1 em long), devitalized tissue was

Military Medicine, Vol. 162, May 1997 346 Urogenital War Injuries 347

TABLE I UROGENITAL WAR INJURIES

Site of Injury Kidney Ureter Bladder Urethra Testis Penis Total

Number of patientsa 21 (35.0) 9 (15.0) 7 (11.6) 2 (3.3) 15 (25.0) 6 (10.0) 60 Number of Injurtes" 21 (33.8) 11 (17.7) 7 (11.2) 2 (3.2) 15 (24.1) 6 (9.6) 62 Number of patients with associated Injuries" 12 (57.1) 9 (100.0) 7 (100.0) 2 (100.0) 15 (100.0) 6 (100.0) 51 'Values in parentheses are percentages of total patients. byalues in parentheses are percentages of total injuries. 'Values in parentheses are percentages of total patients with a given injured organ.

TABLEll Downloaded from https://academic.oup.com/milmed/article/162/5/346/4831527 by guest on 29 September 2021 ASSOCIATED INJURIES IN PATIENTS WITHUROGENITAL WAR INJURIES

Site of Injury Associated injuries Kidney Ureter Bladder Urethra Testis Penis Total Small bowel 5 4 6 15 Colon 8 7 3 2 20 Lungs 4 4 Liver 2 2 Stomach 3 3 Spleen 2 2 Pancreas 1 1 Inguinal region 2 2 2 15 5 26 Lower extremities 2 13 4 19

TABLEm MANAGEMENT OF RENAL, URETERAL, ANDBLADDERWAR INJURIES

Kidney No. Ureter No. Bladder No. Nephrectomy 6 Ureterocystoneostomy 8 Sutures plus cystostomy 5 Partial nephrectomy 8 Ureteroureterostomy 2 Ureterocutaneostomy (temporary) 2 (X2) Debridement plus control of bleeding 7 Kidney autotransplantation plus 1 ureterocystoneostomy Total 21 11 7 excised, the urethra directly sutured, and a and cys­ Discussion and Conclusion tostomy inserted. Theoutcome was favorable (Table IV). In 6 out of 15testicularinjuries, orchiectomy wasperformed Penetrating kidney injuries were most frequently caused by becauseofmassive testiculartissue damage. In 9 injuries, de­ high-velocity missiles, which caused damage not only to the vitalized tissue excision and the reconstruction of the tunica kidneys but to the neighboring tissues and organs as well." albuginea withscrotaldrainage were done. These combined injuries, mostoften gunshotinjuriestoabdom­ Out ofsix penile injuries, bilateral cavernous body ruptures inalorgans, were the reasonfor the primarily surgical treatment with no urethral lesions were observed in two patients. The in the majority of these casualties. Surgical management of surgery consisted of tunica albuginea reconstruction. In both simultaneous injuriesofabdominal and urogenital organschar­ patientserections were absentfor 6 monthsduetothe injury. In acterized the World War II and Vietnam War approach as 1 4 these patientslocal prostaglandin wassuccessfully temporarily well. - Evacuation circumstances sometimes determined the applied. In four patients, along with the treatment of the cav­ timing ofcomplex surgical procedures. However, being in haste, ernousbody injuries, mortarshellfragments were alsoremoved surgeons did not havetimeto introduce special procedures for (Table IV). diagnosing urogenital system injuries, Therefore, these were

TABLE IV MANAGEMENT OF URETHRAL, TESTICULAR, ANDPENILEWAR INJURIES

Urethra No. Testis No. Penis No. Cystostomy 1 Orchiectomy 6 Debridement plus sutures of tunica albuginea corpora cavernosa penis 6 Sutures plus cystostomy 1 Partial orchiectomy 9 Total 2 15 6

Military Medicine, Vol. 162, May 1997 348 Urogenital War Injuries

usually revealed during the surgery of other injured organs. segment rupture ofthe penile urethra, a resection can be per­ This, it seems, along with massive kidney trauma, made ne­ formed andterminal-terminal anastomosis viaurethralcatheter phrectomy mandatory. The high rate of combined injuries re­ donealong withthe obligatory cystostomy insertion. quiring immediate opensurgerywasthe reasonthat urography, Mer kidney injuries, injuries to the external genitals are the single-shot urography, or computed tomography were not per­ mostfrequent. 16 Our treatment oftesticularinjurieswas max­ formed as a rule.However, ultrasonographic examinations were imally conservative. Still, in spiteofthis, sixorchiectomies had regularly performed at the operating table, when lumbar or tobe performed duetosevere damage (necrosis) ofthe testicular retroperitoneal collection containing hematoma and urine were tissue. In penile injuries the principle was to excise the devital­ present. ized tissue and stopbleeding bysuturing the tunica albuginea. Ureteral injuriespresented oneofthe mostcomplex diagnos­ It should be pointed out that several factors influenced the tic problems, beingas a rule associated withabdominal organ survival and the success of the treatment of war casualties. injuries. 9,10 Since theywere all associated withsevere abdomi­ These were: assurance and maintenance ofrespiration, hemo­ nalinjuries, notinonecasecould ureteralinjurybeimmediately Downloaded from https://academic.oup.com/milmed/article/162/5/346/4831527 by guest on 29 September 2021 recognized. Urine "leakage" afterthe surgerywasthe firstsignal stasis, and volume replacement as well as analgesia and the ofureteralinjury. timethat elapsed from the moment ofinjuring until arrival at a Based on our experience, endoscopic treatmentoftheseinju­ medical institution, sincedeath usuallyoccurred in this inter­ ries (double J stent, nephrostomy) doesnot seemjustified. Even val. During the hospital treatment no deaths occurred. The whenit is possible topass the injurysitewitha stent, a scarand above factors directly influenced the survival, the successrateof consequent strictures are usually formed and the fistula does organpreservation and function, and the possibilities forrecon­ not heal. The choice of surgical procedure defends on the structive surgery and rehabilitation. position ofthe ureteral injuryand on its extent. 1 Ureterocystoneostomy or anastomosis supported by psoas­ References hitchwere possible in mostpatients,sincethe distalthird ofthe ureterwasinjured. Incaseofsmaller defects ofthe ureteralwall 1. Culp 0: War wounds of the genito-urinary tract: early results observed in 160 (2-3 cm), devitalized ureteral tissue was resected and ureter­ patients treated in the European theater of operations. J Uro11947; 57: 1117-28. 2. Busch FM, Chenault OW, Zinner NR, et al: Urological aspects of Vietnam war oureterostomy was performed. In our experience, in case of injuries. J Urol 1967; 97: 763-5. too-short proximal ureteral segments, the method of choice is 3. Kimbrough JC: War wounds of the urogenital tract. J Urol 1946; 55: 179-89. temporary nephrostomy. After the patient'srecovery, the ureter 4. Salvatierra 0 Jr, Rigdon WO, Norris DM, et al: Vietnam experience with 252 shouldbe reconstructed. urological war injuries. J Uro11969; 101: 615-20. All seven casualties with urinary bladder injuries had as­ 5. Georgi BA,Massad M, Obied M: Ballistic trauma to the abdomen: shell fragments versus bullets. J Trauma 1991; 31: 711-6. sociated abdominal injuries. Simple allowed 6. Stuart M, Selikowitz SM: Penetrating high-velocity genitourinary injuries. Part I. quick correct diagnoses. It is surprising that in the two cases Statistics, mechanisms and renal wound. Urology 1977; 8: 371-85. ofmultipleurinary bladder rupture, a complete spontaneous 7. Ivatury RR, Zubowski R, Stahl WM:Penetrating renovascular trauma. J Trauma recovery of the bladder occurred. The treatment consisted of 1989; 29: 1620-3. 8. Presti JC, Carrol PR, McAninch JW: Ureteral and renal pelvic injuries from hematoma evacuation, necrotic bladder tissue removal, and external trauma: diagnosis and management. J Trauma 1989; 29: 370-4. cystostomy after the suturing of bladder remnants and 9. Rober PE, Smith JB, Pierce JM: Gunshot injuries of the ureter. J Trauma 1991; ureterocutaneostomy.P'!" 30: 83-5. Peacetime urethral injuries are frequently accompanied by 10. Guerriero G: Ureteral injury. Urol Clin North Am 1989; 16: 237-48. 11. Guerriero WG: Trauma to the kidneys, , bladder and urethra. Surg Clin strictures,incontinence, and impotence. 15 Inwartime, however, North Am 1982; 62: 1047-74. theselesions are mostoften associated withthe injuriesofother 12. Cass AS: Bladder trauma in the multiple injured patient. J Urol 1976; 115: tissues and organs. Therefore, cystostomy as the firstprocedure 667-9. is quite sufficient, whereas in cases oflargerperineal hemato­ 13. Renvall S, Nurmi M, Aho A: Rupture of the urinary bladder, a potentially serious mas drainage is required as well. condition. Scand J Urol Nephro11989; 23: 185-8. 14. Guerriero WG: Urethral trauma. Urol Clin North Am 1989; 16: 237-48. When the prostateis tom, fixing sutures throughthe urinary 15. Cass AS: Testicular trauma. J Uro11983; 129: 299-300. bladderneck, the prostate, and the perineum are necessary to 16. Nicilaisen GS, Melamud A,Williams RD, et al: Rupture of the corpus cavernosum: manage the bleeding and the urineleakage. Inthe caseofshort- surgical management. J Urol 1983; 130: 917-9.

Military Medicine, Vol. 162, May 1997