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The Early Management of Genitourinary War Wounds

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 genitourinary war wounds during the Korean conflict showed a significant reduction from those of World War II. Of prime importance in accomplishing this has been the remarkable achievement of teamwork in integrating all echelons of the Army 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 the wounded soldier could receive definitive major surgery within minutes of being injured, transportation in a large percentage of cases being effected by helicopter from as far forward as the battalion aid station.

Other factors which have favorably influenced wound management in Korea are: the development of a vast array of antibiotic drugs; improvements in anesthesia, shock control and blood vessel surgery; and the application of the artificial kidney and body armor.

Because of the high concentration of the broad-spectrum antibiotics in the urine, these drugs have been of particular benefit in the treatment of wounds of the urinary tract. Conservative renal surgery can be performed in some cases today in which conservatism would have been unthinkable a decade ago. The development of the highly skilled specialty of anesthesiology, improved anesthetic agents and the endotracheal tube have assisted the surgeon materially in lowering operative mortality rates by providing greater relaxation, shock control and longer safe operating time. The anesthesiologist has been a boon particularly to the thoracic surgeon, and incidentally to the urologist because of the frequent concomitance of thoracic and renal wounds. In the control of shock the use of whole blood in Korea largely displaced the use of plasma and the plasma extenders. Toward the end of the conflict whole blood was being brought by ambulance or helicopter and used as far forward as the battalion aid station. Administration of blood during transportation of the casualty was a common practice. However, the early 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 it has any advantage over intravenous administration.

Although the many contributions in blood vessel surgery made in Korea by the Surgical Research Unit have as yet had little application to traumatic urology, 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 Office of The Surgeon General reveals that "final tabulation of medical statistical data for World War II and Korea have not yet been completed and none are available in sufficient detail of cross-tabulation to furnish total U. S. Army battle injuries and wounds by detailed anatomical location, in particular 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 the basis of these preliminary tabulations, it is determined that genitourinary casualties represented 0.5 percent of all World War II casualties and 0.65 percent of Korean casualties. These figures were further broken down to reveal the following percentages: World War II-kidney, 25 percent; ureter, 1 percent; bladder, 15 percent; external genitalia, 56 percent; whereas the following incidence occurred in Korea-kidney, 22 percent; ureter, 1 percent; bladder, 12 percent; external genitalia, 59 percent.

It is known that of 8,000 consecutive casualties admitted to Tokyo Army Hospital, 1 percent demonstrated urological wounds.

Marshall, reporting on urological casualties in the European Theater of 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 mortality rates when multiple organs are injured. With single organs involved, they report the following mortality percentages in urinary tract wounds: kidney, 16; bladder, 0; ureter, 0. If complicated by trauma to other viscera, these percentages rise to: kidney, 38; bladder, 34; ureter, 42.

General Considerations

War wounds are, in the main, "open" wounds and result from gunshot missiles or shell fragments. It is this type of wound that is of primary concern to the military surgeon at present. Unconventional


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weapons of the future may alter the type of casualty the military surgeon will be called upon to treat.

Open wounds of the urinary tract are frequently associated with wounds of other organs which are more serious and of greater urgency. Penetrating wounds of the abdomen or chest must of necessity, as a rule, take priority in treatment. Because of the magnitude of associated wounds, injury to the urinary tract may be overlooked.

Injury to the kidney, ureter or bladder may be suspected from the course of the missile. Free fluid in the abdomen should make one suspicious of urinary extravasation into the peritoneal cavity. The urine of the wounded patient should always be examined, even if catheterization is required to obtain a specimen. The presence of gross hematuria indicates injury to some level of the urinary tract. The degree of hematuria is no criterion of the extent of injury; for example, in severance of the renal vessels or ureter, hematuria may be absent.

Urinary extravasation is a serious complication and if it occurs in a closed wound prompt drainage is imperative. Frequently the missile tract provides a sinus through which adequate drainage occurs and the hazard is lessened. Extravasation into the abdominal cavity may occur from an intraperitoneal rupture of the bladder, or through perforation of the posterior parietal peritoneum associated with ureteral or renal injury.

The usual diagnostic urological procedures, namely, excretory urography, cystoscopy, cystography and ureteral catheterization, as a rule have no place in the management of the severely wounded casualty. The decision to operate must be made on physical signs. While early operative intervention is definitive in that it is lifesaving, it is not necessarily curative, and secondary procedures may be required later at fixed hospitals where the 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 that the injury is limited to the kidney or ureter. Otherwise, the abdominal or thoraco-abdominal approach is indicated. In the abdominal exploration of any war casualty the surgery is not complete without an inspection of the posterior parietal peritoneum.

Proximal urinary diversion is a well established principle in the repair of 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 War II only 0.1 percent of combat casualties suffered wounds


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limited to the kidney. Information obtained from the Office of The Surgeon General reveals that in World War II, 10 percent of chest wounds and 6 percent of abdominal wounds were complicated by renal injury. For Korea it is estimated that 8 percent of chest wounds and 7 percent of abdominal wounds were similarly complicated. Conversely, in open renal wounds in warfare approximately 70 percent are complicated by injury to adjacent abdominal or thoracic viscera. Approximately 25 percent of all genitourinary tract injuries involve the kidney.

The extent of renal trauma varies in severity from contusions with subcapsular rupture 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 all cases. However, these signs may be masked by the severity of associated injuries.

The emergency treatment of open renal wounds is directed toward controlling hemorrhage and providing drainage. The principle of treatment should be conservatism and only irretrievably damaged kidneys should be removed. That this principle of conservatism was practiced in World War II is indicated by the report of only 54 primary nephrectomies in a total of 205 cases of renal injury (Clarke and Leadbetter). Primary nephrectomy should be reserved 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 permitted greater conservatism in renal surgery. Bleeding may be controlled by packing, or better still by suture of the parenchyma over fat pads. The chemical hemostatic agents are not favored because they encourage infection. In polar injuries, segmental resection only is indicated, the open margin being closed with figure-of-8 or mattress sutures over a fat or muscle pad. Nephrostomy drainage should be provided in all severe injuries to the kidney. All retroperitoneal tubes and drains should be delivered to the exterior through a stab wound in the flank. Improvement in vascular surgery developed in the Korean war makes repair of wounds of the renal vascular pedicle feasible; however, there has yet been no report of the successful employment of this procedure in war casualties.

A small percentage of late secondary nephrectomies will be required because of infection, hydronephrosis, atrophy, stone formation, persistent urinary fistula and hypertension. This late surgery has no place in the combat zone. In no instance should a kidney be removed without prior determination of 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 to these structures is uncommon. Kimbrough reported 8 cases of ureteral damage in 235 genitourinary tract injuries in World War II. A total of only 35 cases has been collected from all casualties in World War II. Lieutenant Colonel Carl W. Hughes, MC, collected 7 cases of ureteral injury in 448 wounds 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 time of injury or initial surgery. Urinary leakage in an open wound may be the first indication of ureteral injury, the fistula developing days or weeks after the initial trauma. Damage to the ureter should be suspected if the wound of entrance or exit is in the flank, or if a retroperitoneal hematoma is discovered at the time of any abdominal exploration.

Initial repair of the ureteral injury is highly desirable. Delay in repair frequently results in scar formation with obstruction and hydronephrosis necessitating a later nephrectomy. Rarely, a minor wound of the ureter will heal spontaneously. Occasionally, healing will occur merely by inserting an inlying ureteral catheter. As a rule, however, surgical intervention is required. If the ureter has been transected, end-to-end anastomosis with interrupted catgut sutures incorporating only the adventitia is the treatment of choice. The ends of the severed ureter should be cut obliquely to lessen the chance of stricture formation. A splinting tube, preferably polyethylene, should be left indwelling for 3 weeks. Small rents or lacerations of the ureter can be treated with ureteral intubation, omitting the sutures, as advocated by D. M. Davis. Recent evidence indicates that an avulsed small segment of ureter will bridge an indwelling splinting tube even though the ends cannot be approximated, all layers of the ureter being completely regenerated in approximately 6 weeks. Except in the mildest trauma, proximal urinary diversion should be provided. The use of a T-tube inserted through a proximal ureterotomy, the lower limb splinting the suture line, offers both intubation and drainage. In the event that a large segment of ureter has been avulsed or primary repair is not feasible for other reasons, the proximal segment should be exteriorized and reparative surgery deferred.

Ureteral injury near the bladder is difficult to recognize because of the presence of the associated hematoma. If the patient's condition is good and the distal ureter is suspected of involvement, the bladder may be opened and the orifice catheterized to determine the integrity of the ureter. If severed, a primary ureteroneocystostomy is the operation of choice.


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In all cases of ureteral injury or suspected injury the retroperitoneal space should be drained through a small stab wound in the flank. Because of the frequency of stricture formation following ureteral injury, the ureter should be calibrated a few weeks after surgery. Periodic dilatations may be required in rear area hospitals.

Bladder Injuries

In Kimbrough's series, 15 percent of all genitourinary tract wounds involved the bladder. In 70 percent of the 315 bladder wounds collected by Clarke and Leadbetter, there were concomitant wounds of the rectum, large or small bowel. Injury to the bony pelvis was common. Intraperitoneal or combined extra- and intraperitoneal perforations occurred in 83 percent of bladder wounds. With the incorporation of the female soldier into our Armed Forces injuries to the internal female genitalia may add further complications.

Bladder injury should be suspected in all penetrating wounds of the lower abdomen, buttocks and adjacent regions. Leakage of urine through the wound is positive evidence of perforation. Hematuria, tenesmus and inability to void are presumptive symptoms. A fluctuant mass may be palpable to the examining finger on rectal examination. Cystoscopy, which adds shock to the already wounded patient, is unnecessary and usually contraindicated. Withdrawal of an injected measured amount of fluid into the bladder through a urethral catheter may be a dangerous procedure and is diagnostically fallible.

Immediate exploration is indicated if the diagnosis is in doubt. Ordinarily this is performed at the evacuation hospital unless associated wound require treatment at the Mobile Army Surgical Hospital.

In intraperitoneal rupture the peritoneal cavity should first be evacuated of blood and urine. The bowel should be examined for injury. The bladder perforation should be repaired from the peritoneal aspect and the peritoneal cavity closed without drainage. The bladder is then exposed extraperitoneally and cystostomy drainage provided, the drainage tube being placed high in the fundus of the bladder and brought out along an oblique tract to aid subsequent 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 exit maybe present. If possible, the laceration should be sutured from the outer aspect of the bladder. If this is not easily accomplished intravesical closure may be done. If the wounds are small, closure is not essential. Cystostomy drainage, however, should always be provided. The perivesical spaces should be well drained


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with Penrose drains placed deep into the pelvis on either side of the bladder, as well as into the prevesical space.

In combined rectal and vesical wounds, in addition to repair of the bladder, a colostomy is indicated. Additional drainage must also be provided through a perineal incision with insertion of drains into the ischiorectal fossae and the retrorectal space.

Wounds of Urethra and External Genitalia

These comprised 59 percent of all genitourinary tract injuries in the first 8,000 Korean war casualties admitted to Tokyo Army Hospital. In World War II, Kimbrough reported 68 percent incidence in 235 genitourinary casualties and Culp, 50 percent in 160 cases. Land mines contribute a large part in the high incidence of this type of casualty.

Urethral bleeding, urinary retention and extravasation are the signs and symptoms of urethral injury. The extravasation occurs within Colle's fascia if the injury is distal to the triangular ligament and into the perivesical and retroperitoneal spaces if proximal to the triangular ligament.

The principles of treatment in urethral injury consist of: (1) urinary diversion by cystostomy, and (2) reestablishment of the continuity of the urethra. End-to-end suture of the severed urethra should accomplished over an indwelling catheter where possible. If the urethra is not completely divided, insertion of a splinting urethral catheter is usually adequate. If difficulty is encountered in passing the catheter or locating the severed ends, this can usually be overcome by the use of interlocking sounds, one passed through the penile urethra and the other downward through the opened bladder. If a segment of urethra has been avulsed, prohibiting the approximation of the severed ends, an indwelling catheter bridging the gap and left in place 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 satisfactory end result.

Where the emembranous urethra has been torn loose from the triangular ligament, as frequently occurs by shearing action in pelvis fractures, a Foley catheter should be introduced into the bladder with the interlocking sounds and traction applied to the catheter to pull the bladder neck down. In the exceptional case, suture of the divided urethra can be accomplished through perineal exposure, but as a rule associated perineal injury prohibits this procedure.

As in bladder wounds, wounds of the urethra associated with large bowel injury must be treated also with a proximal colostomy. Rectourethral fistulae are fairly common in these wounds and their repair


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is a function of Zone of Interior hospitals. The method of Young and Stone of advancement of the rectum in the treatment of recto-urethral fistulae gives 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, tremendous regeneration can occur. Trauma to the urethra is frequently associated with lacerations of the corpora, and results in deformity of the penis. Tears in Buck's fascia should be sutured and the shaft bandaged over an indwelling urethral catheter to control hemorrhage, but being careful to avoid constriction. Van Buskirk reported one case of denudation of the penis 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, unless the blood supply is hopelessly lost. Lacerations of the testicle should be treated by débridement and suture of the tunica albuginea to prevent herniation of the spermatogenic tissue. In avulsion of the scrotum, the testes should be placed under the skin of the inner aspects of the proximal thighs.

The Neurogenic Bladder

In World War I, 60 percent of patients who sustained spinal cord injuries died of urinary tract infections. With better understanding of bladder physiology and the urological management of the neurogenic bladder, the mortality 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 level of the lesion. During this period the detrusor muscle is devoid of sensation and reflex activity but retains its inherent tone. The period of "spinal shock" which may last from a few hours to many months is critical from the standpoint of preserving bladder tone. If permitted to distend and overflow, the bladder eventually decompensates, becomes anoxic, infected and fibrotic and eventual functional return cannot occur even though the nerve injury may be relatively trivial.

Bladder tone may be preserved by providing drainage as soon as a diagnosis of neurogenic bladder is made. The urethral catheter should be inserted in the most forward medical installation in the chain of evacuation. A small catheter, 16F to 18F, preferably Foley type, should be used. A larger caliber 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 patient tolerates the catheter well it may be left indefinitely, being changed only as often as is necessary to prevent incrustation and urethritis. Spontaneous overflow or intermittent catheterization should never be used in the treatment of the neurogenic bladder. A closed system of drainage should be attached to the indwelling catheter. Irrigation with Subey's "G" or similar solution, by tidal or manual method, incorporated in the drainage system, acts to prevent incrustations and bladder stones.

The ultimate functioning pattern of the stabilized neurogenic bladder will depend on the level and extent of the cord or brain lesion. Rehabilitation of the paraplegic is a function of Zone of Interior medical installations. The Veterans Administration is now charged with this responsibility following initial stabilization of the patient in military hospitals.

Artificial Kidney

The Renal Insufficiency Center of the Surgical Research Team, under command of Major William H. Meroney, MC, was assigned to Korea for the last 11/2 years of the Korean conflict for the evaluation of hemodialysis in the treatment of acute renal failure associated with war injury. Approximately 150 patients were treated by this unit with results which were encouraging and even definitely lifesaving in several instances, although the results were difficult to evaluate in most cases because of the severity of associated trauma. Hollingsworth Smith, at a committee meeting of the National Research Council in Washington, D. C. (18 March 1953), reported that the mortality rate of severely wounded anuric soldiers in Korea was reduced from approximately 90 percent to 60 percent when an artificial kidney was employed behind the front lines. Because of the small numbers involved these figures can hardly be considered statistically significant.

Hemodialysis is not a substitute but an adjunct to the intelligent management of renal failure. There are few dangers to its use when employed by a skillful team. 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 of war casualties. Because of the relative infrequency for its need and the highly trained staff required for its employment, it is believed that only one artificial kidney per Theater of Operations would be sufficient provided transportation facilities were adequate.


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Body Armor

All combat troops of the Eighth U. S. Army were eventually supplied with body armor. The first trials were begun in June 1951, but more extensive tests were not started until March 1952. The type of body armor generally issued 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: "Although data are not presently available to this division which measure the efficiency of body armor with respect to particular sites, it is generally believed that the absolute incidence of wounds of the kidney would be reduced by the general use of body armor of the nylon vest type." Because more than 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 of Wounds and InJuries of the Genito-Urinary Tract; A review of the Reported Experiences in World War II. J. Urol. 67: 719-739, May 1952.

3. Davis, D. M.: Intubated Ureterotomy: Result After Four Years. J. Urol. 57: 233-237, 1947.

4. Hughes, Carl W.: Personal communication.

5. Kimbrough, J. C.: Urology in the European Theater of Operations. 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 Evacuation Hospital. 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. Lippincott Co., Philadelphia, 1953.

11. Prather, G. C.: Urological Aspects of Spinal Cord Disease. 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.