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Management of shotgun injuries to the pelvis and lower genitourinary system
ADULT UROLOGY
MANAGEMENT OF SHOTGUN INJURIES TO THE PELVIS AND LOWER GENITOURINARY SYSTEM RABI TIGUERT, JOHN F. HARB, PATRICK M. HURLEY, J. GOMES DE OLIVEIRA, RENE J. CASTILLO-FRONTERA, JEFFREY A. TRIEST, AND EDWARD L. GHEILER
ABSTRACT Objectives. Shotgun injuries are rare, with the extent of injury best determined at time of surgical exploration. There are no defined workup or management guidelines for patients with shotgun injuries to the genitourinary system. Injuries are usually treated on an individual basis. This study was conducted to determine the management and extent of genitourinary tract injuries in 10 patients with shotgun injuries to the pelvis during a 6-year interval. Methods. Between September 1990 and December 1996, 140 patients were treated for firearm injuries to the lower genitourinary tract, of which 10 were secondary to shotgun blasts. We performed a retrospective hospital and clinic chart review and telephone interview to assess organs injured, initial treatment, follow-up surgeries, mortality, and erectile function. Results. Mean patient age was 20 years at the time of the injury. The mean follow-up was 4 years (range 1 to 7). Two patients died, both with major vascular injuries, one in the operating room and the other 1 week later from sepsis. Eight patients underwent radiographic examinations (1 intravenous urogram and 7 urethrocystograms). The bladder was injured in 5 patients, 2 with concomitant complete posterior urethral transection. Of the 5 patients without bladder injury, one had an incomplete penile urethral injury and one had a complete bulbar urethral transection. The initial management consisted of repairing nongenitourinary injuries in 8 cases (80%), most commonly involving injuries to the rectum and small bowel. All patients were treated operatively, including 8 who required laparotomy and 4 who required suprapubic cystotomy. A total of four urethral injuries were noted. Subsequent reconstructive surgeries included two urethroplasties and one permanent supravesical diversion for 3 patients with extensive urethral loss. Erectile dysfunction was present in 3 of 6 patients available for telephone interview. Conclusions. Shotgun injuries involving the lower genitourinary tract are associated with significant soft tissue injury and morbidity. Death usually results from major associated vascular injuries. All hemodynamically stable patients should undergo retrograde urethrograms and cystograms to evaluate possible urethral and bladder injuries. Open primary repair should be attempted for distal urethral, testicular, and corporal injuries. Delayed repair with staged urethral reconstruction should be reserved for patients with extensive loss of urethral tissue. Impotence is common in patients with extensive perineal injuries. UROLOGY 55: 193–197, 2000. © 2000, Elsevier Science Inc.
S
hotgun injuries are rare in the general population; furthermore, involvement of the lower genitourinary system is infrequent and not always reported. Shotgun injuries are considered separate From the Department of Urology, Detroit Receiving Hospital, Wayne State University School of Medicine, Detroit, Michigan, and the Department of Urology, Osceola Regional Medical Center, Osceola, Florida Reprint requests: Jeffrey A. Triest, M.D., Department of Urology, Harper Professional Building, 4160 John R., Suite 1017, Detroit, MI 48201 Submitted: June 16, 1999, accepted (with revisions): August 5, 1999 © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
from those caused by other penetrating projectile weapons such as handguns and rifles, because of their unique wounding effects.1–7 Victims who sustain gunshot injuries are exposed to high-velocity missile forces with larger areas of destruction creating multiple organ injuries. There are no specific guidelines for management of lower genitourinary wounds, with only a few cases having been reported in the literature. We retrospectively evaluated patients treated for shotgun injuries to the lower genitourinary system at our institution during a 6-year period to determine initial and subsequent management of these patients, treatment 0090-4295/00/$20.00 PII S0090-4295(99)00384-2 193
No Info* Yes Yes No Info* NA Yes No No No NA
Erectile Function
complications, erectile function, and overall prognosis.
194
corpora/STGS graft
corpora
Good Good Good Good Died Good End-end urethroplasty Mitrofanoff Island flap urethroplasty Died glans corpora
Between September 1990 and December 1996, 140 patients sustained firearm injuries to the lower genitourinary tract, and were treated at Detroit Receiving Hospital, Wayne State University School of Medicine. Of the 140 patients, 10 sustained shotgun injuries to the pelvis and are the subject of this report. We retrospectively reviewed the patients’ medical records for age, sex, organs involved, radiologic investigations, initial treatment, and follow-up surgeries. A telephone interview was conducted to assess the erectile function and urinary continence in this group of patients.
RESULTS Ten patients (9 male and 1 female), with a mean age of 20 years (range 17 to 29) at the time of the injury, were followed for a mean period of 4 years (range 1 to 7). Two patients died secondary to major vascular injuries, one in the operating room and the other 1 week later from sepsis. Patient demographics and genitourinary injuries are summarized in Table I. NONGENITOURINARY INJURIES Nongenitourinary injuries occurred in 8 of 10 (80%) patients, involving most commonly (in order of decreasing frequency) major soft tissue injury (60%), rectum (50%), small bowel (40%), colon (30%), and vascular structures (20%) (Table II).
KEY: NA ⫽ not applicable; Info ⫽ information; STGS graft ⫽ split-thickness skin graft to penis. * Telephone follow-up not available regarding erectile function.
Orchiectomy Repair No No No No No No No No 23 19 23 17 26 22 19 28 29 20 1 2 3 4 5 6 7 8 9 10
No No Yes No Yes No No Yes Yes Yes
Testicular Testicular No No No No No No No Ovarian
Glandular Corporal No Corporal No Corporal Corporal Corporal Corporal NA
No Penile/partial No No No No Bulbar/complete Posterior/complete Posterior/complete No
No Yes Yes No NA No Yes Yes Yes Yes
Repair Repair No Repair No Repair No No No NA
Outcome/Additional Surgeries Penile Injury Repair Gonadal Repair Suprapublic Tube Placed Urethral Injury Penile Injury Gonadal Injury Bladder Injury Age (yr) Patient No.
TABLE I. Long-term outcome treatment of genitourinary injuries in patients with shotgun injuries to the pelvis
MATERIAL AND METHODS
GENITOURINARY INJURIES The bladder was injured in 5 (50%) patients, 2 of whom had complete posterior urethral transection. Gonadal injuries, including 2 testicular and 1 ovarian, occurred in 3 (30%) patients. The penis was injured in 7 patients, with involvement of the corporal body in 6 and the glans penis in 1 patient. Four patients (40%) had urethral injuries including three complete urethral transections. Six patients had more than one genitourinary organ injured. All 5 patients with bladder injury had associated abdominal and/or vascular injuries. Eight patients (80%) were hemodynamically stable in the emergency room and 2 (20%) patients were hemodynamically unstable, with 1 patient dying in the emergency room because of massive bleeding. Patients were evaluated clinically and imaging studies were obtained according to the trajectory of the blast and the structures suspected to have been injured. One patient had an arteriogram for a shotgun wound to his thigh, ruling out a suspected femoral vessel injury. One patient had an intravenous urogram for a suspected ureteral injury; the visualized ureteral segment revealed a normal ureter. A total of 7 patients had retrograde UROLOGY 55 (2), 2000
TABLE II. Nonurologic injuries in patients with shotgun injuries to the perineum Patient No. 1 2 3 4 5 6 7 8 9 10
Small Bowel Injury No No Multiple Multiple No No No No Multiple Multiple
Rectal Injury
Colon Injury
Major Vascular Injury
No No No No Yes No Yes Yes Yes Yes
No No Yes No No No No No Yes Yes
No No No No Yes No No No No Yes
urethrograms; in 4 patients no urethral disruption was identified. In 1 patient with a readily apparent anterior urethral injury, open repair was performed with flexible urethroscopy performed to rule out additional sites of urethral injury. All patients underwent urgent surgical treatment, 2 patients with major pelvic vascular injuries died, 1 in the operating room and the other 1 week later due to multiorgan failure and sepsis. Penile skin injury required debridement and removal of pellets in 3 patients, repair of a glanular laceration in 1 patient, and debridement and closure of corporal disruption in 3 patients. Scrotal exploration was done in 2 patients (1 requiring orchiectomy and 1 requiring closure of a disrupted tunica). Open bladder repair was done in 5 patients and a suprapubic catheter was placed in 4 patients. In 2 patients suprapubic catheters were removed after 3 weeks; in the other 3 patients with more severe urethral injuries the suprapubic catheter remained until delayed urethral reconstruction was performed (Table I). Four patients required subsequent reconstructive surgery. The first patient with an extensive urethral injury was managed with a chronic indwelling suprapubic catheter. He developed a vesicocutaneous perineal fistula, osteophytic growth of the pubic bone into the prostatomembranous urethra, and bladder calculi (Fig. 1). Open vesicolithotomy and a 7-cm transverse island tubularized patch urethroplasty were performed. Postoperative complications included a persistent vesicocutaneous fistula and additional bladder calculi. The neourethra, 2 years after reconstruction, remained patent without signs of stricture. The second patient had extensive urethral injury (8.5-cm defect) and underwent placement of an appendicovesicostomy (Mitrofanoff). He currently is continent with no complications. The third patient with a 4-cm bulbar urethral defect underwent end-to-end perineal urethroplasty. Six months after a tensionfree repair, a uroflow demonstrated excellent flow. UROLOGY 55 (2), 2000
Major Soft Tissue Injury Yes No No Yes No Yes Yes Yes Yes No
(thigh)
(thigh) (thigh) (perineum) (perineum) (perineum)
FIGURE 1. Photograph showing the nonvisualization of the posterior urethra in a patient treated with a suprapubic tube after shotgun blast to the pelvis with prostatomembranous urethral disruption.
The last patient developed a wound dehiscence postoperatively after debridement and closure of an extensive penile injury. He underwent successful placement of a 3 ⫻ 2-cm split-thickness skin graft. Six patients were successfully contacted for a telephone interview regarding erectile function. Three patients reported impotence more than 1 year after injury. Three patients reported no change in erectile function after their shotgun injuries. Of the patients with erectile dysfunction, one had a distal urethral injury, one had a rectal and bladder injury, and one had a corporal body 195
injury. The corporal injury was repaired primarily. All patients reported potency before injury. COMMENT Lower genitourinary injuries secondary to shotgun blasts are rare. The injuries sustained by these firearms have been variable. Attempts have been made to classify shotgun wounds based on range and tissue damage.1–3 In general, a close-range wound consists of a single wound with a large amount of tissue destruction, whereas at moderate distances there are multiple small wounds due to individual pellets. At greater distances, a scattered or peppered effect occurs with little injury. Ballistics are divided into several phases, including internal (missile motion within the weapon), external (flight of missile from gun to victim), and terminal or wound (missile activity within the victim).4 Wound ballistics are determined by a multitude of factors, including weight (mass), shape, and velocity of the missile. The kinetic energy of the missile at impact is transferred to the target and is proportional to its mass and the square of its velocity. Thus, despite shotguns being essentially low velocity firearms, doubling the mass of the projectile results in doubling the resultant kinetic energy. Moreover, doubling the velocity results in a quadrupling of the kinetic energy. Thus, at close range, shotguns can deliver amounts of energy similar to or greater than that from some military weapons because the pellets are compact and act as a single projectile of high mass. The bladder and external genitalia were the most frequently injured structures in our series. Radiologic evaluation was infrequently used because surgical exploration was deemed necessary for all penetrating abdominal trauma and worthy for most penetrating injuries to the external genitalia. Gomez et al.5 reported on 23 patients with genital gunshot wounds. Three patients had urethral rupture, only one with extensive urethral loss after a shotgun blast. This group relied on serial clinical evaluation and aggressive imaging. Their recommendations for early surgical exploration with conservative debridement and primary repair of corporal, testicular, and urethral injuries are echoed in our series. We agree with the need for retrograde urethrograms or flexible urethroscopy to identify unsuspected proximal urethral injuries. Another reason for careful staging of urethral and bladder injuries is that all patients with bladder injuries had associated bowel injuries. In the face of a bladder injury, it becomes imperative to relentlessly search for a concomitant bowel injury. Life-threatening hemorrhage is most likely to come from sources other than the genitalia, as evident in 2 of our patients.6,7 Genital hemostasis 196
should, however, be achieved at the corpora cavernosa or corpus spongiosum. Careful repair of the tunica albuginea is necessary. Exploration and repair of the corporal bodies was done routinely; however, some investigators believe it may not be necessary for minor injuries.8 Normal erection should return after this repair. Only 1 patient with a corporal injury and repair reported erectile dysfunction. It is possible that erectile dysfunction in this group of patients is neurogenic rather than vasculogenic in origin. Further investigation in this area is needed. Massive tissue destruction after high-energy, close-range shotgun wounds as noted in 3 of our patients required staged reconstructive surgery. Early surgical repair of anterior urethral injuries resulted in no urethral stricture, as confirmed by obtaining uroflows at 1-year follow-up. End-toend anastomosis of a urethral defect is appropriate if a tension-free reconstruction is possible. Delayed repair with staged reconstruction should be reserved for extensive urethral loss. Staged urethral reconstruction was performed in 1 patient with good short-term results including a patent neourethra at 2-year follow-up; however, he later developed recurrence of the chronic urinary-cutaneous fistula. One patient’s extensive urethral loss precluded a urethral reconstruction and he underwent construction of a Mitrofanoff conduit. As highlighted by our series, it is important to manage life-threatening injuries initially in patients with shotgun blasts to the pelvis. Proper staging of genitourinary injuries requires a retrograde urethrogram and cystogram in all cases. The flexible cystoscope can be utilized to stage injuries, as well as to identify additional urethral injuries. A complete multidisciplinary approach is needed when treating these patients, as many have multiorgan injury including nonurologic injuries. CONCLUSIONS Shotgun blasts involving the lower genitourinary system are associated with significant injuries and morbidity. Retrograde urethrogram and cystogram should be performed in all cases. Primary repair should be attempted for distal urethral, testicular, and corporal injuries. Delayed repair with staged urethral reconstruction should be reserved for patients with extensive loss of urethral tissue. Major tissue loss may result in impotence. Successful initial management is essential to ensure a lower complication rate in the future. REFERENCES 1. Fackler ML: Wound ballistics: a review of common misconceptions. JAMA 259: 2730 –2736, 1988. UROLOGY 55 (2), 2000
2. Selikowitz SM: Penetrating high velocity genitourinary injuries. Part I. Urology 9: 371–376, 1977. 3. Selikowitz SM: Penetrating high velocity genitourinary injuries. Part II. Urology 9: 493– 499, 1977. 4. Barach E, Tomlanovich M, and Nowak R: Ballistics: a pathophysiologic examination of the wounding mechanisms of firearms. Part II. J Trauma 26: 374 –383, 1986. 5. Gomez RG, Castanheira AC, and McAninich JW: Gun-
UROLOGY 55 (2), 2000
shot wounds to the male external genitalia. J Urol 150: 1147– 1149, 1993. 6. Glezer JA, Minard G, Croce MA, et al: Shotgun wounds to the abdomen. Am Surg 59: 129 –132, 1993. 7. Miles BJ, Poffenberger RJ, Farah RN, et al: Management of penile gunshot wounds. Urology 36: 318 –321, 1990. 8. Webster GD: Perineal repair of membranous urethral stricture. Urol Clin North Am 16: 303–312, 1989.
197
MANAGEMENT OF SHOTGUN INJURIES TO THE PELVIS AND LOWER GENITOURINARY SYSTEM RABI TIGUERT, JOHN F. HARB, PATRICK M. HURLEY, J. GOMES DE OLIVEIRA, RENE J. CASTILLO-FRONTERA, JEFFREY A. TRIEST, AND EDWARD L. GHEILER
ABSTRACT Objectives. Shotgun injuries are rare, with the extent of injury best determined at time of surgical exploration. There are no defined workup or management guidelines for patients with shotgun injuries to the genitourinary system. Injuries are usually treated on an individual basis. This study was conducted to determine the management and extent of genitourinary tract injuries in 10 patients with shotgun injuries to the pelvis during a 6-year interval. Methods. Between September 1990 and December 1996, 140 patients were treated for firearm injuries to the lower genitourinary tract, of which 10 were secondary to shotgun blasts. We performed a retrospective hospital and clinic chart review and telephone interview to assess organs injured, initial treatment, follow-up surgeries, mortality, and erectile function. Results. Mean patient age was 20 years at the time of the injury. The mean follow-up was 4 years (range 1 to 7). Two patients died, both with major vascular injuries, one in the operating room and the other 1 week later from sepsis. Eight patients underwent radiographic examinations (1 intravenous urogram and 7 urethrocystograms). The bladder was injured in 5 patients, 2 with concomitant complete posterior urethral transection. Of the 5 patients without bladder injury, one had an incomplete penile urethral injury and one had a complete bulbar urethral transection. The initial management consisted of repairing nongenitourinary injuries in 8 cases (80%), most commonly involving injuries to the rectum and small bowel. All patients were treated operatively, including 8 who required laparotomy and 4 who required suprapubic cystotomy. A total of four urethral injuries were noted. Subsequent reconstructive surgeries included two urethroplasties and one permanent supravesical diversion for 3 patients with extensive urethral loss. Erectile dysfunction was present in 3 of 6 patients available for telephone interview. Conclusions. Shotgun injuries involving the lower genitourinary tract are associated with significant soft tissue injury and morbidity. Death usually results from major associated vascular injuries. All hemodynamically stable patients should undergo retrograde urethrograms and cystograms to evaluate possible urethral and bladder injuries. Open primary repair should be attempted for distal urethral, testicular, and corporal injuries. Delayed repair with staged urethral reconstruction should be reserved for patients with extensive loss of urethral tissue. Impotence is common in patients with extensive perineal injuries. UROLOGY 55: 193–197, 2000. © 2000, Elsevier Science Inc.
S
hotgun injuries are rare in the general population; furthermore, involvement of the lower genitourinary system is infrequent and not always reported. Shotgun injuries are considered separate From the Department of Urology, Detroit Receiving Hospital, Wayne State University School of Medicine, Detroit, Michigan, and the Department of Urology, Osceola Regional Medical Center, Osceola, Florida Reprint requests: Jeffrey A. Triest, M.D., Department of Urology, Harper Professional Building, 4160 John R., Suite 1017, Detroit, MI 48201 Submitted: June 16, 1999, accepted (with revisions): August 5, 1999 © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
from those caused by other penetrating projectile weapons such as handguns and rifles, because of their unique wounding effects.1–7 Victims who sustain gunshot injuries are exposed to high-velocity missile forces with larger areas of destruction creating multiple organ injuries. There are no specific guidelines for management of lower genitourinary wounds, with only a few cases having been reported in the literature. We retrospectively evaluated patients treated for shotgun injuries to the lower genitourinary system at our institution during a 6-year period to determine initial and subsequent management of these patients, treatment 0090-4295/00/$20.00 PII S0090-4295(99)00384-2 193
No Info* Yes Yes No Info* NA Yes No No No NA
Erectile Function
complications, erectile function, and overall prognosis.
194
corpora/STGS graft
corpora
Good Good Good Good Died Good End-end urethroplasty Mitrofanoff Island flap urethroplasty Died glans corpora
Between September 1990 and December 1996, 140 patients sustained firearm injuries to the lower genitourinary tract, and were treated at Detroit Receiving Hospital, Wayne State University School of Medicine. Of the 140 patients, 10 sustained shotgun injuries to the pelvis and are the subject of this report. We retrospectively reviewed the patients’ medical records for age, sex, organs involved, radiologic investigations, initial treatment, and follow-up surgeries. A telephone interview was conducted to assess the erectile function and urinary continence in this group of patients.
RESULTS Ten patients (9 male and 1 female), with a mean age of 20 years (range 17 to 29) at the time of the injury, were followed for a mean period of 4 years (range 1 to 7). Two patients died secondary to major vascular injuries, one in the operating room and the other 1 week later from sepsis. Patient demographics and genitourinary injuries are summarized in Table I. NONGENITOURINARY INJURIES Nongenitourinary injuries occurred in 8 of 10 (80%) patients, involving most commonly (in order of decreasing frequency) major soft tissue injury (60%), rectum (50%), small bowel (40%), colon (30%), and vascular structures (20%) (Table II).
KEY: NA ⫽ not applicable; Info ⫽ information; STGS graft ⫽ split-thickness skin graft to penis. * Telephone follow-up not available regarding erectile function.
Orchiectomy Repair No No No No No No No No 23 19 23 17 26 22 19 28 29 20 1 2 3 4 5 6 7 8 9 10
No No Yes No Yes No No Yes Yes Yes
Testicular Testicular No No No No No No No Ovarian
Glandular Corporal No Corporal No Corporal Corporal Corporal Corporal NA
No Penile/partial No No No No Bulbar/complete Posterior/complete Posterior/complete No
No Yes Yes No NA No Yes Yes Yes Yes
Repair Repair No Repair No Repair No No No NA
Outcome/Additional Surgeries Penile Injury Repair Gonadal Repair Suprapublic Tube Placed Urethral Injury Penile Injury Gonadal Injury Bladder Injury Age (yr) Patient No.
TABLE I. Long-term outcome treatment of genitourinary injuries in patients with shotgun injuries to the pelvis
MATERIAL AND METHODS
GENITOURINARY INJURIES The bladder was injured in 5 (50%) patients, 2 of whom had complete posterior urethral transection. Gonadal injuries, including 2 testicular and 1 ovarian, occurred in 3 (30%) patients. The penis was injured in 7 patients, with involvement of the corporal body in 6 and the glans penis in 1 patient. Four patients (40%) had urethral injuries including three complete urethral transections. Six patients had more than one genitourinary organ injured. All 5 patients with bladder injury had associated abdominal and/or vascular injuries. Eight patients (80%) were hemodynamically stable in the emergency room and 2 (20%) patients were hemodynamically unstable, with 1 patient dying in the emergency room because of massive bleeding. Patients were evaluated clinically and imaging studies were obtained according to the trajectory of the blast and the structures suspected to have been injured. One patient had an arteriogram for a shotgun wound to his thigh, ruling out a suspected femoral vessel injury. One patient had an intravenous urogram for a suspected ureteral injury; the visualized ureteral segment revealed a normal ureter. A total of 7 patients had retrograde UROLOGY 55 (2), 2000
TABLE II. Nonurologic injuries in patients with shotgun injuries to the perineum Patient No. 1 2 3 4 5 6 7 8 9 10
Small Bowel Injury No No Multiple Multiple No No No No Multiple Multiple
Rectal Injury
Colon Injury
Major Vascular Injury
No No No No Yes No Yes Yes Yes Yes
No No Yes No No No No No Yes Yes
No No No No Yes No No No No Yes
urethrograms; in 4 patients no urethral disruption was identified. In 1 patient with a readily apparent anterior urethral injury, open repair was performed with flexible urethroscopy performed to rule out additional sites of urethral injury. All patients underwent urgent surgical treatment, 2 patients with major pelvic vascular injuries died, 1 in the operating room and the other 1 week later due to multiorgan failure and sepsis. Penile skin injury required debridement and removal of pellets in 3 patients, repair of a glanular laceration in 1 patient, and debridement and closure of corporal disruption in 3 patients. Scrotal exploration was done in 2 patients (1 requiring orchiectomy and 1 requiring closure of a disrupted tunica). Open bladder repair was done in 5 patients and a suprapubic catheter was placed in 4 patients. In 2 patients suprapubic catheters were removed after 3 weeks; in the other 3 patients with more severe urethral injuries the suprapubic catheter remained until delayed urethral reconstruction was performed (Table I). Four patients required subsequent reconstructive surgery. The first patient with an extensive urethral injury was managed with a chronic indwelling suprapubic catheter. He developed a vesicocutaneous perineal fistula, osteophytic growth of the pubic bone into the prostatomembranous urethra, and bladder calculi (Fig. 1). Open vesicolithotomy and a 7-cm transverse island tubularized patch urethroplasty were performed. Postoperative complications included a persistent vesicocutaneous fistula and additional bladder calculi. The neourethra, 2 years after reconstruction, remained patent without signs of stricture. The second patient had extensive urethral injury (8.5-cm defect) and underwent placement of an appendicovesicostomy (Mitrofanoff). He currently is continent with no complications. The third patient with a 4-cm bulbar urethral defect underwent end-to-end perineal urethroplasty. Six months after a tensionfree repair, a uroflow demonstrated excellent flow. UROLOGY 55 (2), 2000
Major Soft Tissue Injury Yes No No Yes No Yes Yes Yes Yes No
(thigh)
(thigh) (thigh) (perineum) (perineum) (perineum)
FIGURE 1. Photograph showing the nonvisualization of the posterior urethra in a patient treated with a suprapubic tube after shotgun blast to the pelvis with prostatomembranous urethral disruption.
The last patient developed a wound dehiscence postoperatively after debridement and closure of an extensive penile injury. He underwent successful placement of a 3 ⫻ 2-cm split-thickness skin graft. Six patients were successfully contacted for a telephone interview regarding erectile function. Three patients reported impotence more than 1 year after injury. Three patients reported no change in erectile function after their shotgun injuries. Of the patients with erectile dysfunction, one had a distal urethral injury, one had a rectal and bladder injury, and one had a corporal body 195
injury. The corporal injury was repaired primarily. All patients reported potency before injury. COMMENT Lower genitourinary injuries secondary to shotgun blasts are rare. The injuries sustained by these firearms have been variable. Attempts have been made to classify shotgun wounds based on range and tissue damage.1–3 In general, a close-range wound consists of a single wound with a large amount of tissue destruction, whereas at moderate distances there are multiple small wounds due to individual pellets. At greater distances, a scattered or peppered effect occurs with little injury. Ballistics are divided into several phases, including internal (missile motion within the weapon), external (flight of missile from gun to victim), and terminal or wound (missile activity within the victim).4 Wound ballistics are determined by a multitude of factors, including weight (mass), shape, and velocity of the missile. The kinetic energy of the missile at impact is transferred to the target and is proportional to its mass and the square of its velocity. Thus, despite shotguns being essentially low velocity firearms, doubling the mass of the projectile results in doubling the resultant kinetic energy. Moreover, doubling the velocity results in a quadrupling of the kinetic energy. Thus, at close range, shotguns can deliver amounts of energy similar to or greater than that from some military weapons because the pellets are compact and act as a single projectile of high mass. The bladder and external genitalia were the most frequently injured structures in our series. Radiologic evaluation was infrequently used because surgical exploration was deemed necessary for all penetrating abdominal trauma and worthy for most penetrating injuries to the external genitalia. Gomez et al.5 reported on 23 patients with genital gunshot wounds. Three patients had urethral rupture, only one with extensive urethral loss after a shotgun blast. This group relied on serial clinical evaluation and aggressive imaging. Their recommendations for early surgical exploration with conservative debridement and primary repair of corporal, testicular, and urethral injuries are echoed in our series. We agree with the need for retrograde urethrograms or flexible urethroscopy to identify unsuspected proximal urethral injuries. Another reason for careful staging of urethral and bladder injuries is that all patients with bladder injuries had associated bowel injuries. In the face of a bladder injury, it becomes imperative to relentlessly search for a concomitant bowel injury. Life-threatening hemorrhage is most likely to come from sources other than the genitalia, as evident in 2 of our patients.6,7 Genital hemostasis 196
should, however, be achieved at the corpora cavernosa or corpus spongiosum. Careful repair of the tunica albuginea is necessary. Exploration and repair of the corporal bodies was done routinely; however, some investigators believe it may not be necessary for minor injuries.8 Normal erection should return after this repair. Only 1 patient with a corporal injury and repair reported erectile dysfunction. It is possible that erectile dysfunction in this group of patients is neurogenic rather than vasculogenic in origin. Further investigation in this area is needed. Massive tissue destruction after high-energy, close-range shotgun wounds as noted in 3 of our patients required staged reconstructive surgery. Early surgical repair of anterior urethral injuries resulted in no urethral stricture, as confirmed by obtaining uroflows at 1-year follow-up. End-toend anastomosis of a urethral defect is appropriate if a tension-free reconstruction is possible. Delayed repair with staged reconstruction should be reserved for extensive urethral loss. Staged urethral reconstruction was performed in 1 patient with good short-term results including a patent neourethra at 2-year follow-up; however, he later developed recurrence of the chronic urinary-cutaneous fistula. One patient’s extensive urethral loss precluded a urethral reconstruction and he underwent construction of a Mitrofanoff conduit. As highlighted by our series, it is important to manage life-threatening injuries initially in patients with shotgun blasts to the pelvis. Proper staging of genitourinary injuries requires a retrograde urethrogram and cystogram in all cases. The flexible cystoscope can be utilized to stage injuries, as well as to identify additional urethral injuries. A complete multidisciplinary approach is needed when treating these patients, as many have multiorgan injury including nonurologic injuries. CONCLUSIONS Shotgun blasts involving the lower genitourinary system are associated with significant injuries and morbidity. Retrograde urethrogram and cystogram should be performed in all cases. Primary repair should be attempted for distal urethral, testicular, and corporal injuries. Delayed repair with staged urethral reconstruction should be reserved for patients with extensive loss of urethral tissue. Major tissue loss may result in impotence. Successful initial management is essential to ensure a lower complication rate in the future. REFERENCES 1. Fackler ML: Wound ballistics: a review of common misconceptions. JAMA 259: 2730 –2736, 1988. UROLOGY 55 (2), 2000
2. Selikowitz SM: Penetrating high velocity genitourinary injuries. Part I. Urology 9: 371–376, 1977. 3. Selikowitz SM: Penetrating high velocity genitourinary injuries. Part II. Urology 9: 493– 499, 1977. 4. Barach E, Tomlanovich M, and Nowak R: Ballistics: a pathophysiologic examination of the wounding mechanisms of firearms. Part II. J Trauma 26: 374 –383, 1986. 5. Gomez RG, Castanheira AC, and McAninich JW: Gun-
UROLOGY 55 (2), 2000
shot wounds to the male external genitalia. J Urol 150: 1147– 1149, 1993. 6. Glezer JA, Minard G, Croce MA, et al: Shotgun wounds to the abdomen. Am Surg 59: 129 –132, 1993. 7. Miles BJ, Poffenberger RJ, Farah RN, et al: Management of penile gunshot wounds. Urology 36: 318 –321, 1990. 8. Webster GD: Perineal repair of membranous urethral stricture. Urol Clin North Am 16: 303–312, 1989.
197