Medical Science Publication No. 4, Volume 1
THE EARLY MANAGEMENT OF GENITOURINARY WAR WOUNDS*
COLONEL JACK W. SCHWARTZ,MC
Introduction
As in other fields of surgery, morbidity and mortality rates in genitourinarywar wounds during the Korean conflict showed a significant reduction fromthose of World War II. Of prime importance in accomplishing this has beenthe remarkable achievement of teamwork in integrating all echelons of theArmy Medical Service. In this war the Mobile Army Surgical Hospital (MASH)came into its own, and for the first time in the history of warfare thewounded soldier could receive definitive major surgery within minutes ofbeing injured, transportation in a large percentage of cases being effectedby helicopter from as far forward as the battalion aid station.
Other factors which have favorably influenced wound management in Koreaare: the development of a vast array of antibiotic drugs; improvementsin anesthesia, shock control and blood vessel surgery; and the applicationof the artificial kidney and body armor.
Because of the high concentration of the broad-spectrum antibioticsin the urine, these drugs have been of particular benefit in the treatmentof wounds of the urinary tract. Conservative renal surgery can be performedin some cases today in which conservatism would have been unthinkable adecade ago. The development of the highly skilled specialty of anesthesiology,improved anesthetic agents and the endotracheal tube have assisted thesurgeon materially in lowering operative mortality rates by providing greaterrelaxation, shock control and longer safe operating time. The anesthesiologisthas been a boon particularly to the thoracic surgeon, and incidentallyto the urologist because of the frequent concomitance of thoracic and renalwounds. In the control of shock the use of whole blood in Korea largelydisplaced the use of plasma and the plasma extenders. Toward the end ofthe conflict whole blood was being brought by ambulance or helicopter andused as far forward as the battalion aid station. Administration of bloodduring transportation of the casualty was a common practice. However, theearly enthusiasm for intra-
*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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arterial transfusion has largely waned; it is questionable whether ithas any advantage over intravenous administration.
Although the many contributions in blood vessel surgery made in Koreaby the Surgical Research Unit have as yet had little application to traumaticurology, opportunities exist for future treatment of renal vascular injuries.The use of hemodialysis and body armor are mentioned later.
Incidence
Information obtained from the Medical Statistical Division of the Officeof The Surgeon General reveals that "final tabulation of medical statisticaldata for World War II and Korea have not yet been completed and none areavailable in sufficient detail of cross-tabulation to furnish total U.S. Army battle injuries and wounds by detailed anatomical location, inparticular wounds or injuries involving the genitourinary organs."Partial data, however, are available for World War II up until June 1944,and for the Korean conflict from July 1950 through December 1952. On thebasis of these preliminary tabulations, it is determined that genitourinarycasualties represented 0.5 percent of all World War II casualties and 0.65percent of Korean casualties. These figures were further broken down toreveal the following percentages: World War II-kidney, 25 percent; ureter,1 percent; bladder, 15 percent; external genitalia, 56 percent; whereasthe following incidence occurred in Korea-kidney, 22 percent; ureter, 1percent; bladder, 12 percent; external genitalia, 59 percent.
It is known that of 8,000 consecutive casualties admitted to Tokyo ArmyHospital, 1 percent demonstrated urological wounds.
Marshall, reporting on urological casualties in the European Theaterof Operations, stated that battle casualties accounted for 93.3 percent,whereas 6.3 percent were due to motor accidents, falls, blast injuries,etc.
Interesting statistics compiled by the Second Auxiliary Surgical Group,1942-45, and reported by Beebe and DeBakey, reveal the marked rise in mortalityrates when multiple organs are injured. With single organs involved, theyreport the following mortality percentages in urinary tract wounds: kidney,16; bladder, 0; ureter, 0. If complicated by trauma to other viscera, thesepercentages rise to: kidney, 38; bladder, 34; ureter, 42.
General Considerations
War wounds are, in the main, "open" wounds and result fromgunshot missiles or shell fragments. It is this type of wound that is ofprimary concern to the military surgeon at present. Unconventional
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weapons of the future may alter the type of casualty the military surgeonwill be called upon to treat.
Open wounds of the urinary tract are frequently associated with woundsof other organs which are more serious and of greater urgency. Penetratingwounds of the abdomen or chest must of necessity, as a rule, take priorityin treatment. Because of the magnitude of associated wounds, injury tothe urinary tract may be overlooked.
Injury to the kidney, ureter or bladder may be suspected from the courseof the missile. Free fluid in the abdomen should make one suspicious ofurinary extravasation into the peritoneal cavity. The urine of the woundedpatient should always be examined, even if catheterization is requiredto obtain a specimen. The presence of gross hematuria indicates injuryto some level of the urinary tract. The degree of hematuria is no criterionof the extent of injury; for example, in severance of the renal vesselsor ureter, hematuria may be absent.
Urinary extravasation is a serious complication and if it occurs ina closed wound prompt drainage is imperative. Frequently the missile tractprovides a sinus through which adequate drainage occurs and the hazardis lessened. Extravasation into the abdominal cavity may occur from anintraperitoneal rupture of the bladder, or through perforation of the posteriorparietal peritoneum associated with ureteral or renal injury.
The usual diagnostic urological procedures, namely, excretory urography,cystoscopy, cystography and ureteral catheterization, as a rule have noplace in the management of the severely wounded casualty. The decisionto operate must be made on physical signs. While early operative interventionis definitive in that it is lifesaving, it is not necessarily curative,and secondary procedures may be required later at fixed hospitals wherethe whole diagnostic armamentarium may be used to good advantage.
The surgical approach is influenced by involvement of associated organs.The conventional lumbar incision should be used only if is certain thatthe injury is limited to the kidney or ureter. Otherwise, the abdominalor thoraco-abdominal approach is indicated. In the abdominal explorationof any war casualty the surgery is not complete without an inspection ofthe posterior parietal peritoneum.
Proximal urinary diversion is a well established principle in the repairof a wound of the urinary tract. This is accomplished by nephrostomy, pyelostomy,ureterostomy or cystostomy, depending on the site and extent of the lesion.
Renal Injuries
Wounds of the kidney are relatively uncommon in combat. In World WarII only 0.1 percent of combat casualties suffered wounds
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limited to the kidney. Information obtained from the Office of The SurgeonGeneral reveals that in World War II, 10 percent of chest wounds and 6percent of abdominal wounds were complicated by renal injury. For Koreait is estimated that 8 percent of chest wounds and 7 percent of abdominalwounds were similarly complicated. Conversely, in open renal wounds inwarfare approximately 70 percent are complicated by injury to adjacentabdominal or thoracic viscera. Approximately 25 percent of all genitourinarytract injuries involve the kidney.
The extent of renal trauma varies in severity from contusions with subcapsularrupture to extensive lacerations, pulpification and infarction of parenchyma,tears into the renal pelvis and major injury to the renal vessels. Hematuria,pain, tumor and shock are present to a greater or lesser degree in allcases. However, these signs may be masked by the severity of associatedinjuries.
The emergency treatment of open renal wounds is directed toward controllinghemorrhage and providing drainage. The principle of treatment should beconservatism and only irretrievably damaged kidneys should be removed.That this principle of conservatism was practiced in World War II is indicatedby the report of only 54 primary nephrectomies in a total of 205 casesof renal injury (Clarke and Leadbetter). Primary nephrectomy should bereserved for massive or uncontrollable hemorrhage or urinary extravasation,extensive destruction and infarction, severe infection and secondary hemorrhage.
Improvements in anesthesia, blood replacement and antibiotics have permittedgreater conservatism in renal surgery. Bleeding may be controlled by packing,or better still by suture of the parenchyma over fat pads. The chemicalhemostatic agents are not favored because they encourage infection. Inpolar injuries, segmental resection only is indicated, the open marginbeing closed with figure-of-8 or mattress sutures over a fat or musclepad. Nephrostomy drainage should be provided in all severe injuries tothe kidney. All retroperitoneal tubes and drains should be delivered tothe exterior through a stab wound in the flank. Improvement in vascularsurgery developed in the Korean war makes repair of wounds of the renalvascular pedicle feasible; however, there has yet been no report of thesuccessful employment of this procedure in war casualties.
A small percentage of late secondary nephrectomies will be requiredbecause of infection, hydronephrosis, atrophy, stone formation, persistenturinary fistula and hypertension. This late surgery has no place in thecombat zone. In no instance should a kidney be removed without prior determinationof the presence and condition of the opposite organ.
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Ureteral Injuries
Because of the deep and protected position of the ureters, injury tothese structures is uncommon. Kimbrough reported 8 cases of ureteral damagein 235 genitourinary tract injuries in World War II. A total of only 35cases has been collected from all casualties in World War II. LieutenantColonel Carl W. Hughes, MC, collected 7 cases of ureteral injury in 448wounds of the abdominal organs in 291 patients admitted to a MASH in Korea.
Less than 20 percent of wounds of the ureter are recognized at the timeof injury or initial surgery. Urinary leakage in an open wound may be thefirst indication of ureteral injury, the fistula developing days or weeksafter the initial trauma. Damage to the ureter should be suspected if thewound of entrance or exit is in the flank, or if a retroperitoneal hematomais discovered at the time of any abdominal exploration.
Initial repair of the ureteral injury is highly desirable. Delay inrepair frequently results in scar formation with obstruction and hydronephrosisnecessitating a later nephrectomy. Rarely, a minor wound of the ureterwill heal spontaneously. Occasionally, healing will occur merely by insertingan inlying ureteral catheter. As a rule, however, surgical interventionis required. If the ureter has been transected, end-to-end anastomosiswith interrupted catgut sutures incorporating only the adventitia is thetreatment of choice. The ends of the severed ureter should be cut obliquelyto lessen the chance of stricture formation. A splinting tube, preferablypolyethylene, should be left indwelling for 3 weeks. Small rents or lacerationsof the ureter can be treated with ureteral intubation, omitting the sutures,as advocated by D. M. Davis. Recent evidence indicates that an avulsedsmall segment of ureter will bridge an indwelling splinting tube even thoughthe ends cannot be approximated, all layers of the ureter being completelyregenerated in approximately 6 weeks. Except in the mildest trauma, proximalurinary diversion should be provided. The use of a T-tube inserted througha proximal ureterotomy, the lower limb splinting the suture line, offersboth intubation and drainage. In the event that a large segment of ureterhas been avulsed or primary repair is not feasible for other reasons, theproximal segment should be exteriorized and reparative surgery deferred.
Ureteral injury near the bladder is difficult to recognize because ofthe presence of the associated hematoma. If the patient's condition isgood and the distal ureter is suspected of involvement, the bladder maybe opened and the orifice catheterized to determine the integrity of theureter. If severed, a primary ureteroneocystostomy is the operation ofchoice.
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In all cases of ureteral injury or suspected injury the retroperitonealspace should be drained through a small stab wound in the flank. Becauseof the frequency of stricture formation following ureteral injury, theureter should be calibrated a few weeks after surgery. Periodic dilatationsmay be required in rear area hospitals.
Bladder Injuries
In Kimbrough's series, 15 percent of all genitourinary tract woundsinvolved the bladder. In 70 percent of the 315 bladder wounds collectedby Clarke and Leadbetter, there were concomitant wounds of the rectum,large or small bowel. Injury to the bony pelvis was common. Intraperitonealor combined extra- and intraperitoneal perforations occurred in 83 percentof bladder wounds. With the incorporation of the female soldier into ourArmed Forces injuries to the internal female genitalia may add furthercomplications.
Bladder injury should be suspected in all penetrating wounds of thelower abdomen, buttocks and adjacent regions. Leakage of urine throughthe wound is positive evidence of perforation. Hematuria, tenesmus andinability to void are presumptive symptoms. A fluctuant mass may be palpableto the examining finger on rectal examination. Cystoscopy, which adds shockto the already wounded patient, is unnecessary and usually contraindicated.Withdrawal of an injected measured amount of fluid into the bladder througha urethral catheter may be a dangerous procedure and is diagnosticallyfallible.
Immediate exploration is indicated if the diagnosis is in doubt. Ordinarilythis is performed at the evacuation hospital unless associated wound requiretreatment at the Mobile Army Surgical Hospital.
In intraperitoneal rupture the peritoneal cavity should first be evacuatedof blood and urine. The bowel should be examined for injury. The bladderperforation should be repaired from the peritoneal aspect and the peritonealcavity closed without drainage. The bladder is then exposed extraperitoneallyand cystostomy drainage provided, the drainage tube being placed high inthe fundus of the bladder and brought out along an oblique tract to aidsubsequent healing. Prognosis is much poorer in intraperitoneal perforation.
In extraperitoneal perforation, the bladder should be opened and inspected.It should be remembered that both a wound of entrance and a wound of exitmaybe present. If possible, the laceration should be sutured from the outeraspect of the bladder. If this is not easily accomplished intravesicalclosure may be done. If the wounds are small, closure is not essential.Cystostomy drainage, however, should always be provided. The perivesicalspaces should be well drained
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with Penrose drains placed deep into the pelvis on either side of thebladder, as well as into the prevesical space.
In combined rectal and vesical wounds, in addition to repair of thebladder, a colostomy is indicated. Additional drainage must also be providedthrough a perineal incision with insertion of drains into the ischiorectalfossae and the retrorectal space.
Wounds of Urethra and External Genitalia
These comprised 59 percent of all genitourinary tract injuries in thefirst 8,000 Korean war casualties admitted to Tokyo Army Hospital. In WorldWar II, Kimbrough reported 68 percent incidence in 235 genitourinary casualtiesand Culp, 50 percent in 160 cases. Land mines contribute a large part inthe high incidence of this type of casualty.
Urethral bleeding, urinary retention and extravasation are the signsand symptoms of urethral injury. The extravasation occurs within Colle'sfascia if the injury is distal to the triangular ligament and into theperivesical and retroperitoneal spaces if proximal to the triangular ligament.
The principles of treatment in urethral injury consist of: (1) urinarydiversion by cystostomy, and (2) reestablishment of the continuity of theurethra. End-to-end suture of the severed urethra should accomplished overan indwelling catheter where possible. If the urethra is not completelydivided, insertion of a splinting urethral catheter is usually adequate.If difficulty is encountered in passing the catheter or locating the severedends, this can usually be overcome by the use of interlocking sounds, onepassed through the penile urethra and the other downward through the openedbladder. If a segment of urethra has been avulsed, prohibiting the approximationof the severed ends, an indwelling catheter bridging the gap and left inplace 8 weeks will permit regeneration of the urethra over the splint.Every effort should be made to repair the urethra at the initial surgery,as delay results in extensive scar formation and jeopardizes a satisfactoryend result.
Where the emembranous urethra has been torn loose from the triangularligament, as frequently occurs by shearing action in pelvis fractures,a Foley catheter should be introduced into the bladder with the interlockingsounds and traction applied to the catheter to pull the bladder neck down.In the exceptional case, suture of the divided urethra can be accomplishedthrough perineal exposure, but as a rule associated perineal injury prohibitsthis procedure.
As in bladder wounds, wounds of the urethra associated with large bowelinjury must be treated also with a proximal colostomy. Rectourethral fistulaeare fairly common in these wounds and their repair
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is a function of Zone of Interior hospitals. The method of Young andStone of advancement of the rectum in the treatment of recto-urethral fistulaegives good results. Lewis utilized this operation successfully in 13 cases.
Wounds of the external genitalia should be treated with the utmost conservatism.Because of the excellence of the blood supply of these organs, tremendousregeneration can occur. Trauma to the urethra is frequently associatedwith lacerations of the corpora, and results in deformity of the penis.Tears in Buck's fascia should be sutured and the shaft bandaged over anindwelling urethral catheter to control hemorrhage, but being careful toavoid constriction. Van Buskirk reported one case of denudation of thepenis in a Korean casualty treated by burying the organ in a scrotal tunnel.
More than 50 percent of external genital wounds involve the testes.Every attempt should be made to conserve these traumatized organs, unlessthe blood supply is hopelessly lost. Lacerations of the testicle shouldbe treated by débridement and suture of the tunica albuginea toprevent herniation of the spermatogenic tissue. In avulsion of the scrotum,the testes should be placed under the skin of the inner aspects of theproximal thighs.
The Neurogenic Bladder
In World War I, 60 percent of patients who sustained spinal cord injuriesdied of urinary tract infections. With better understanding of bladderphysiology and the urological management of the neurogenic bladder, themortality of spinal cord injuries has been reduced to about 15 percent.
Spinal cord injury, regardless of the level or extent of the lesion,results in a temporary period of "spinal shock" below the levelof the lesion. During this period the detrusor muscle is devoid of sensationand reflex activity but retains its inherent tone. The period of "spinalshock" which may last from a few hours to many months is criticalfrom the standpoint of preserving bladder tone. If permitted to distendand overflow, the bladder eventually decompensates, becomes anoxic, infectedand fibrotic and eventual functional return cannot occur even though thenerve injury may be relatively trivial.
Bladder tone may be preserved by providing drainage as soon as a diagnosisof neurogenic bladder is made. The urethral catheter should be insertedin the most forward medical installation in the chain of evacuation. Asmall catheter, 16F to 18F, preferably Foley type, should be used. A largercaliber is apt to cause infection and trophic ulceration of the urethra.Intolerance to the catheter, manifested by excess purulent urethral discharge,periurethral abscess of
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epididymitis, is indication for suprapubic cystostomy. If the patienttolerates the catheter well it may be left indefinitely, being changedonly as often as is necessary to prevent incrustation and urethritis. Spontaneousoverflow or intermittent catheterization should never be used inthe treatment of the neurogenic bladder. A closed system of drainage shouldbe attached to the indwelling catheter. Irrigation with Subey's "G"or similar solution, by tidal or manual method, incorporated in the drainagesystem, acts to prevent incrustations and bladder stones.
The ultimate functioning pattern of the stabilized neurogenic bladderwill depend on the level and extent of the cord or brain lesion. Rehabilitationof the paraplegic is a function of Zone of Interior medical installations.The Veterans Administration is now charged with this responsibility followinginitial stabilization of the patient in military hospitals.
Artificial Kidney
The Renal Insufficiency Center of the Surgical Research Team, undercommand of Major William H. Meroney, MC, was assigned to Korea for thelast 11/2 years ofthe Korean conflict for the evaluation of hemodialysis in the treatmentof acute renal failure associated with war injury. Approximately 150 patientswere treated by this unit with results which were encouraging and evendefinitely lifesaving in several instances, although the results were difficultto evaluate in most cases because of the severity of associated trauma.Hollingsworth Smith, at a committee meeting of the National Research Councilin Washington, D. C. (18 March 1953), reported that the mortality rateof severely wounded anuric soldiers in Korea was reduced from approximately90 percent to 60 percent when an artificial kidney was employed behindthe front lines. Because of the small numbers involved these figures canhardly be considered statistically significant.
Hemodialysis is not a substitute but an adjunct to the intelligent managementof renal failure. There are few dangers to its use when employed by a skillfulteam. Active bleeding remains the only real contraindication to dialysis.Heparinization in these individuals may result in a fatal hemorrhage.
The artificial kidney promises great usefulness in the treatment ofwar casualties. Because of the relative infrequency for its need and thehighly trained staff required for its employment, it is believed that onlyone artificial kidney per Theater of Operations would be sufficient providedtransportation facilities were adequate.
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Body Armor
All combat troops of the Eighth U. S. Army were eventually suppliedwith body armor. The first trials were begun in June 1951, but more extensivetests were not started until March 1952. The type of body armor generallyissued was the thoraco-abdominal vest made of nylon. Some use was made,on a much more limited scale, of armored shorts.
Evaluation of the protection afforded by body armor has not been completed.Information obtained from the Office of The Surgeon General states: "Althoughdata are not presently available to this division which measure the efficiencyof body armor with respect to particular sites, it is generally believedthat the absolute incidence of wounds of the kidney would be reduced bythe general use of body armor of the nylon vest type." Because morethan half of all genitourinary wounds occur to the external genitalia,the urologist would favor the use of protective armor covering this area.
References
1. Beebe, G. W., and DeBakey, M. E.: Battle Casualties.Charles C Thomas, Springfield, Illinois, 1952.
2. Clarke, B. S., and Leadbetter, W. F.: Management ofWounds and InJuries of the Genito-Urinary Tract; A review of the ReportedExperiences in World War II. J. Urol. 67: 719-739, May 1952.
3. Davis, D. M.: Intubated Ureterotomy: Result After FourYears. J. Urol. 57: 233-237, 1947.
4. Hughes, Carl W.: Personal communication.
5. Kimbrough, J. C.: Urology in the European Theater ofOperations. J. Urol. 57: 1105-1116, 1947.
6. Lewis, L. G.: Repair of Recto-Urethral Fistulas. J.Urol. 57: 1173-1181, 1947.
7. Marshall, D. F.: Urological Wounds in an EvacuationHospital. J. Urol. 55: 119-132, 1946.
8. Meroney, William H.: Personal communication.
9. Office of The Surgeon General, Department of the Army:Personal communication.
10. Bowers, W. F.: Surgery of Trauma. J. B. LippincottCo., Philadelphia, 1953.
11. Prather, G. C.: Urological Aspects of Spinal CordDisease. Charles C Thomas, Springfield, Illinois, 1949.
12. Van Buskirk, Kryder E.: Personal communication.
13. VA Tech. Bull., TB 10-97, Dept. of Med. & Surg.,Washington 25, D. C., 15 February 1954.
