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Surgical Management of Urogenital Injuries at A War Hospital in Bosnia-herzegovina, 1992 to 1995
0022-5347/03/1694-1357/0 THE JOURNAL OF UROLOGY® Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 169, 1357–1359, April 2003 Printed in U.S.A.
DOI: 10.1097/01.ju.0000051220.77880.64
SURGICAL MANAGEMENT OF UROGENITAL INJURIES AT A WAR HOSPITAL IN BOSNIA-HERZEGOVINA, 1992 TO 1995 TVRTKO HUDOLIN
AND
IVAN HUDOLIN
From the Department of Urology, Zagreb University Hospital Center, Zagreb, Croatia, and Department of Surgery, Brcˇko District Hospital, Brcˇko, Bosnia-Herzegovina
ABSTRACT
Purpose: Our experience with urogenital surgery during the Bosnia-Herzegovina conflict of 1992 to 1995 is compared with data from previous wars and peacetime practice. Materials and Methods: A total of 5,370 wounded patients, including 136 (2.5%) with 1 or more urogenital injuries, were treated at a war hospital in northern Bosnia-Herzegovina during 37 months. The hospital was based at a village school and was poorly equipped but it was only 10 to 16 km. from the front line and average transportation time was 30 minutes. Results: Of the 136 patients 72 (52.9%) were injured by explosive weapons, while the other 64 (47.1%) had bullet wounds. The 169 urogenital injuries were to the kidney in 65 cases (38.5%), scrotum in 44 (26%), bladder in 23 (13.6%), penis in 16 (9.5%), urethra in 9 (5.3%), ureter in 6 (3.6%) and other in 6. There was associated damage to organs other than the urogenital system in 116 patients (85.3%). Preference was given to organ sparing operations when possible, but 33.8% of renal injuries required nephrectomy and orchidectomy was performed for 58.3% of testicular injuries. Conclusions: In war settings when injuries are often severe and multiple, and the hospital may lack staff, instruments and other medical supplies, the surgeon frequently must improvise. Even so, the results achieved need not fall far below those of peacetime surgery provided that, as in this hospital in Bosnia-Herzegovina, wounded patients present to the surgeon rapidly, they are young and the surgeons are experienced with the management of war injury. KEY WORDS: urogenital system, wounds and injuries, war, traumatology
Injury to urogenital organs accounts for between 1% and 10% of all war injuries1⫺5 and most are associated with multiple lesions, especially abdominal. In these patients it may be difficult to decide which surgical procedure has priority and the identification of urogenital or other organ damage can be delayed.6 Although the war hospital at which we worked in Bosnia-Herzegovina was close to the front line and, thus, well sited to offer effective treatment,7 it was set up in a village school and was not well equipped. However, our surgical team was skilled with experience in abdominal surgery and traumatology, and in surgery during the 1991 to 1995 war in Croatia. Because war was raging throughout Bosnia-Herzegovina, making prompt transportation of patients to specialized units impossible,8 treatment provided at war hospitals such as ours attempted to avoid the need for secondary surgical procedures. After treatment most wounded individuals left the combat zone and moved to areas free of war or went abroad and followup was usually impossible. We describe our experience with first line surgical management of urogenital injuries during the 37 months of the 1992 to 1995 BosniaHerzegovina conflict and compare it with reports from previous wars and of urogenital injuries treated in peacetime. MATERIALS AND METHODS
A total of 5,370 wounded patients were treated at the war hospital in Maocˇa near Brcˇko, northern Bosnia-Herzegovina, including 136 (2.5%) with 1 or more urogenital injuries. Transportation to specialized medical units farther from the conflict was impossible. The hospital in the village school had no radio-diagnostic equipment or tap water and a field generator was the only source of electricity. The hospital was the Accepted for publication November 1, 2002.
only medical institution providing health care for a population of about 50,000. It was only 10 to 16 km. from the front line and average transportation time was 30 minutes. We examined the records for patient age and sex, the cause of injury (categorized as explosive weapons such as mortar shell fragments, bombs and rockets or bullets), the site of urogenital injury or injuries, the site of any injuries to organs outside of the urogenital system and the surgical procedures done. RESULTS
Median patient age was 31 years (range 12 to 55) and all except 4 were male. Of the patients 72 (52.9%) were injured by explosive weapons, while the other 64 (47.1%) had bullet wounds. A total of 169 urogenital injuries were recorded since 26 patients (19.1%) had 2 or more such lesions, and 116 (85.3%) had an injury to another organ system. Table 1 lists urogenital injuries and their causes, and table 2 shows associated lesions. There were 65 kidney lesions, of which 2 were bilateral and about half were inflicted by explosive weapons. Penetrating wounds accounted for 58 lesions and the other 7 were due to blunt trauma. Associated lesions in other abdominal organs most commonly involved the large intestine, liver or diaphragm. The procedures included 22 nephrectomies, 3 partial nephrectomies, 37 devitalized tissue resections with arrest of bleeding by suture and 3 intraoperative explorations. The 6 ureteral lesions, which were detected during abdominal surgery for associated injuries, consisted of 4 partial and 2 complete transsections. Nephrectomy and ureterocystoneostomy were performed in 1 patient each. In the other 4 cases complete resection of the traumatized area was followed by spatulation and elliptical end-to-end anastomosis
1357
1358
SURGICAL MANAGEMENT OF WAR UROGENITAL INJURIES
TABLE 1. Urogenital war injuries and their causes in 136 patients treated at the war hospital in Bosnia-Herzegovina from May 1, 1992 to May 31, 1995 Injury Site
No. Injury Cause (%)*
No. Injuries (%)
Bullets
Explosive Weapons
65 (38.5) 6 (3.6) 23 (13.6) 9 (5.3) 16 (9.5) 44 (26.0) 6 (3.6)
31 (47.7) 5 (83.3) 14 (60.9) 3 (33.3) 4 (25.0) 15 (34.1) 3 (50.0)
34 (52.3) 1 (16.7) 9 (39.1) 6 (66.7) 12 (75.0) 29 (65.9) 3 (50.0)
75
94
Kidney Ureter Bladder Urethra Penis Scrotum Other
Totals 169 (100) * Incidence at specified sites.
without tension.1, 9 In 2 cases nephropexy was done to lengthen the ureter and achieve tension-free anastomosis.10 Ureteral prostheses were not available. Three patients were followed and all were free of stricture. Of the 23 ruptured bladders 12 were intraperitoneal and 14 were caused by bullets. The rectum, colon and small intestine were the most commonly involved associated abdominal organs. After removing devitalized tissue bladder suture and cystostomy were performed, followed by Retzius space drainage. There were 9 urethral injuries, including 3 posterior and 6 anterior. All posterior urethral injuries caused total disruption, and so reapproximation by realignment over a stenting catheter was done. In 4 of the 6 anterior urethral injuries a short segment rupture required resection and anastomosis via a urethral catheter. When the anterior urethra was severely disrupted, we planned that urethroplasty would be done later. Cystostomy was done in all cases. Three patients were followed, including 1 with stricture and impotence, 1 with impotence and incontinence, and 1 who was free of complications. The 16 penile injuries included 1 amputation and 15 lacerations. After removing devitalized tissue the tunica albuginea was sutured. Followup in 5 patients revealed impotence in 2 and penis angulation in 1. The other 2 patients were free of complications. Most of the 44 scrotal injuries were caused by explosive weapons. There were 48 testicular injuries, including 10 bilateral, and 6 scrotal skin lacerations. A total of 28 testes were removed and tunica albuginea sutures were placed for the remaining 20 injuries. The remaining urogenital injuries were 2 lesions of the left spermatic cord in the inguinal canal and 1 case each of lesions in the left adrenal, left spermatic artery and vein, left deferent duct and prostate.
TABLE 2. Associated injuries in 136 patients with urogenital war injuries treated at the war hospital in Bosnia-Herzegovina from May 1, 1992 to May 31, 1995 Associated Injuries
No. Kidney
No. Ureter
No. Bladder
No. Urethra
No. Penis
No. Scrotum
Chest Diaphragm Liver Duodenum Stomach Spleen Colon Small intestine Pancreas Fractures Vena cava Femoral region Gluteal region Perineal region
25 14 17 5 8 8 21 8 2 21 2 5 6 –
1 1 2 2 2 – 4 2 – 5 1 – 1 –
1 – – – – – 12 8 – 12 – 5 12 3
1 1 1 1 1 – 3 – – 5 – 4 1 2
3 1 1 1 1 – 2 2 – 8 – 7 – 1
3 – 1 1 – – 3 4 – 18 – 21 2 3
DISCUSSION
All internal urogenital injuries in this series were identified during exploratory procedures for penetrating injuries to the thorax, abdomen, lumbar and gluteal regions because preoperative urological investigation was precluded by the urgency of the obvious injuries or by a lack of equipment and personnel. However, abdominal and urogenital repairs were done at the same time, when possible. Urogenital injuries were present in 2.5% of our patients. In other published series of war injuries this rate was 1% to 10%.1⫺5 Differences reflect the type of warfare, the theater of war actions and the way records are maintained.2 In 1 Vietnam series 58% of patients with urogenital injuries were wounded by bullets,5 whereas in the war in Croatia, only 30% of such injuries were caused by bullets.3 In our series the incidence was 47.1%. In Bosnia-Herzegovina the front lines hardly moved and usually lay in or near residential areas. There was close contact between the opposing sides with abundant use of automatic small arms and snipers. The prevalence of explosive weapon injuries to the urethra, penis and scrotum is explained by the use of antipersonnel mines. An important factor in saving the lives of wounded combatants is the time of evacuation from the frontline.11 In World War II average time was 6 hours, while the use of helicopters in Vietnam decreased this time to 60 minutes.1, 5 In Croatia average transportation time was 52 minutes3 or 1 to 3 hours.4 For our hospital the average was only 30 minutes because we were close to the front line and had staff who were experienced with evacuation of the wounded. In Vietnam 93% of wounded individuals with urogenital injuries had associated injuries of other major organ systems, particularly the abdomen and chest.1 In Croatia reports of associated injuries show a rate of 70% to 85% of the wounded.3, 4 In our hospital multiple lesions were recorded in 85.3% of patients, mostly involving the abdomen, thorax and fractures. In our population of patients with urogenital war injuries kidney lesions were most common, achieving a prevalence of 38.5%, whereas in the literature this rate is 14% to 45%.1⫺4 Anatomically the kidney is a well protected organ, which is why renal injuries are usually associated with lesions of adjacent structures. The most common intra-abdominal lesions associated with injuries to the kidneys, ureter and bladder were in the large and small intestine, stomach and duodenum. In addition to their anatomical localization, the high rate of visceral organ involvement could be explained by temporary cavitation in the abdomen caused by high velocity missile injury, which may lead to bowel rupture through sudden enlargement of the intra-abdominal cavity and expansion of bowel gases.2 Nephrectomy rates in case series of penetrating injury vary. The relatively high rates recorded by Salvatierra et al1 and Selikowitz2 of 50% and 84%, respectively, were explained by the severity of the damage that high velocity missiles cause. On the other hand, Ochsner et al, who reported from Vietnam, described a nephrectomy rate of only 30%,5 which is close to the rates in the BosniaHerzegovina (33.8%) and Croatian (25%3 and 29%4) conflicts, and to the nephrectomy rates of 28%12 and 27%13 reported for penetrating injuries to the kidney in civilians. The ureter, which is a narrow tube surrounded by fat and muscle, is rarely injured by external trauma during peacetime.14 However, the use of weapons with high kinetic power increases the incidence of ureteral injury to between 2% and 15% of total urogenital injuries.1⫺4 The proportion was 3.6% in our series. In all of our cases of ureteral injury extensive resection of devitalized tissue was done to prevent high velocity blast effect on the ureter,15, 16 followed by primary ureterourethral reconstruction without a stent. The reported contribution of damage to the bladder to urogenital injuries in war is 8% to 20%1⫺4 and our rate of
SURGICAL MANAGEMENT OF WAR UROGENITAL INJURIES
13.6% lies in this range. In peacetime bladder injuries extraperitoneal rupture is more common than intraperitoneal rupture17 but in our series of war injuries the rates of intraperitoneal and extraperitoneal rupture were almost the same. We avoided urinary catheter placement and used cystostomy drainage, in part because of the risk of catheter associated epididymitis and epididymo-orchitis.17 The frequency of urethral injury in our series (5.3%) was again typical of that in other series of urogenital war injuries (3% to 15%1⫺4). In peacetime the surgeon can choose suprapubic cystostomy followed by later reconstruction or immediate urethral realignment18 but for the military surgeon immediate realignment may be the only option, as in most of our cases. CONCLUSIONS
In war surgery the surgeon frequently must improvise and adjust to working in a hospital with inadequate medical supplies, equipment and personnel. This scenario is true for urogenital injuries, which are often severe and associated with damage to other organs. There must be a compromise, in which the timing and type of surgical intervention are determined by the scale of the urogenital injury, injuries to adjacent structures, and the experience and skill of the surgeon. However, the results of war surgery need not fall far below those of peacetime surgery provided that wounded patients present to the surgeon rapidly, the patients are young and the surgeons are experienced with war injury. In this hospital series in northern Bosnia-Herzegovina all 3 criteria were met. Drs. Ana Marusˇ ic´ and Matko Marusˇ ic´ critically reviewed the article and assisted with its preparation. David Sharp revised the manuscript. REFERENCES
1. Salvatierra, O., Jr., Rigdon, W. O., Norris, D. M. and Brady, T. W.: Vietnam experience with 252 urological war injuries. J Urol, 101: 615, 1969
1359
2. Selikowitz, S. M.: Penetrating high-velocity genitourinary injuries. Part I. Statistics mechanisms, and renal wounds. Urology, 9: 371, 1977 3. Tucak, A., Lukac˘ evic´ , T., Kuveždic´, H., Petek, Zˇ . and Novak, R.: Urogenital wounds during the war in Croatia in 1991/1992. J Urol, 153: 121, 1995 4. Marekovic, Z., Derezic, D., Krhen, I. and Kastelan Z.: Urogenital war injuries. Mil Med, 162: 346, 1997 5. Ochsner, T. G., Busch, F. M. and Clarke, B. G.: Urogenital wounds in Vietnam. J Urol, 101: 224, 1969 6. McAninch, J. W. and Carroll, P. R.: Renal exploration after trauma. Indications and reconstructive techniques. Urol Clin North Am, 16: 203, 1989 7. Husar, J. and Eltz, J.: Mobile surgical teams in Croatian special forces units (1990 –1993). Croat Med J, 34: 276, 1993 ˇ elina, P.: 8. Radosˇ , D., Knezˇ evic´, A., Ezgeta, I., Vlahusˇ ic´, A. and C Health care in the Zˇ epc˘ e region during the war (1992–1995) in Bosnia and Herzegovina. Croat Med J, 36: 212, 1995 9. Carlton, C. E.: Injuries to the ureter. Urol Clin North Am, 4: 33, 1977 10. Liroff, S. A., Pontes, J. E. S. and Pierce, J. M., Jr.: Gunshot wounds of the ureter: 5 years of experience. J Urol, 118: 551, 1977 11. Haacker, L. P.: Time and its effects on casualties in World War II and Vietnam. Arch Surg, 98: 39, 1969 12. Sagalowsky, A. I., McConnell, J. D. and Peters, P. C.: Renal trauma requiring surgery: an analysis of 185 cases. J Trauma, 23: 128, 1983 13. Scott, R., Jr., Carlton, C. E., Jr. and Goldman, M.: Penetrating injuries of the kidney: an analysis of 181 patients. J Urol, 101: 247, 1969 14. Rober, P. E., Smith, J. B. and Pierce, J. M., Jr.: Gunshot injuries of the ureter. J Trauma, 30: 83, 1990 15. Cass, A. S.: Ureteral contusion with gunshot wounds. J Trauma, 24: 59, 1984 16. Stutzman, R. E.: Ballistics and the management of ureteral injuries from high velocity missiles. J Urol, 118: 947, 1977 17. Peters, P. C.: Intraperitoneal rupture of the bladder. Urol Clin North Am, 16: 279, 1989 18. Morehouse, D. D. and MacKinnon, K. J.: Management of prostatomembranous urethral disruption: 13-year experience. J Urol, 123: 173, 1980
Vol. 169, 1357–1359, April 2003 Printed in U.S.A.
DOI: 10.1097/01.ju.0000051220.77880.64
SURGICAL MANAGEMENT OF UROGENITAL INJURIES AT A WAR HOSPITAL IN BOSNIA-HERZEGOVINA, 1992 TO 1995 TVRTKO HUDOLIN
AND
IVAN HUDOLIN
From the Department of Urology, Zagreb University Hospital Center, Zagreb, Croatia, and Department of Surgery, Brcˇko District Hospital, Brcˇko, Bosnia-Herzegovina
ABSTRACT
Purpose: Our experience with urogenital surgery during the Bosnia-Herzegovina conflict of 1992 to 1995 is compared with data from previous wars and peacetime practice. Materials and Methods: A total of 5,370 wounded patients, including 136 (2.5%) with 1 or more urogenital injuries, were treated at a war hospital in northern Bosnia-Herzegovina during 37 months. The hospital was based at a village school and was poorly equipped but it was only 10 to 16 km. from the front line and average transportation time was 30 minutes. Results: Of the 136 patients 72 (52.9%) were injured by explosive weapons, while the other 64 (47.1%) had bullet wounds. The 169 urogenital injuries were to the kidney in 65 cases (38.5%), scrotum in 44 (26%), bladder in 23 (13.6%), penis in 16 (9.5%), urethra in 9 (5.3%), ureter in 6 (3.6%) and other in 6. There was associated damage to organs other than the urogenital system in 116 patients (85.3%). Preference was given to organ sparing operations when possible, but 33.8% of renal injuries required nephrectomy and orchidectomy was performed for 58.3% of testicular injuries. Conclusions: In war settings when injuries are often severe and multiple, and the hospital may lack staff, instruments and other medical supplies, the surgeon frequently must improvise. Even so, the results achieved need not fall far below those of peacetime surgery provided that, as in this hospital in Bosnia-Herzegovina, wounded patients present to the surgeon rapidly, they are young and the surgeons are experienced with the management of war injury. KEY WORDS: urogenital system, wounds and injuries, war, traumatology
Injury to urogenital organs accounts for between 1% and 10% of all war injuries1⫺5 and most are associated with multiple lesions, especially abdominal. In these patients it may be difficult to decide which surgical procedure has priority and the identification of urogenital or other organ damage can be delayed.6 Although the war hospital at which we worked in Bosnia-Herzegovina was close to the front line and, thus, well sited to offer effective treatment,7 it was set up in a village school and was not well equipped. However, our surgical team was skilled with experience in abdominal surgery and traumatology, and in surgery during the 1991 to 1995 war in Croatia. Because war was raging throughout Bosnia-Herzegovina, making prompt transportation of patients to specialized units impossible,8 treatment provided at war hospitals such as ours attempted to avoid the need for secondary surgical procedures. After treatment most wounded individuals left the combat zone and moved to areas free of war or went abroad and followup was usually impossible. We describe our experience with first line surgical management of urogenital injuries during the 37 months of the 1992 to 1995 BosniaHerzegovina conflict and compare it with reports from previous wars and of urogenital injuries treated in peacetime. MATERIALS AND METHODS
A total of 5,370 wounded patients were treated at the war hospital in Maocˇa near Brcˇko, northern Bosnia-Herzegovina, including 136 (2.5%) with 1 or more urogenital injuries. Transportation to specialized medical units farther from the conflict was impossible. The hospital in the village school had no radio-diagnostic equipment or tap water and a field generator was the only source of electricity. The hospital was the Accepted for publication November 1, 2002.
only medical institution providing health care for a population of about 50,000. It was only 10 to 16 km. from the front line and average transportation time was 30 minutes. We examined the records for patient age and sex, the cause of injury (categorized as explosive weapons such as mortar shell fragments, bombs and rockets or bullets), the site of urogenital injury or injuries, the site of any injuries to organs outside of the urogenital system and the surgical procedures done. RESULTS
Median patient age was 31 years (range 12 to 55) and all except 4 were male. Of the patients 72 (52.9%) were injured by explosive weapons, while the other 64 (47.1%) had bullet wounds. A total of 169 urogenital injuries were recorded since 26 patients (19.1%) had 2 or more such lesions, and 116 (85.3%) had an injury to another organ system. Table 1 lists urogenital injuries and their causes, and table 2 shows associated lesions. There were 65 kidney lesions, of which 2 were bilateral and about half were inflicted by explosive weapons. Penetrating wounds accounted for 58 lesions and the other 7 were due to blunt trauma. Associated lesions in other abdominal organs most commonly involved the large intestine, liver or diaphragm. The procedures included 22 nephrectomies, 3 partial nephrectomies, 37 devitalized tissue resections with arrest of bleeding by suture and 3 intraoperative explorations. The 6 ureteral lesions, which were detected during abdominal surgery for associated injuries, consisted of 4 partial and 2 complete transsections. Nephrectomy and ureterocystoneostomy were performed in 1 patient each. In the other 4 cases complete resection of the traumatized area was followed by spatulation and elliptical end-to-end anastomosis
1357
1358
SURGICAL MANAGEMENT OF WAR UROGENITAL INJURIES
TABLE 1. Urogenital war injuries and their causes in 136 patients treated at the war hospital in Bosnia-Herzegovina from May 1, 1992 to May 31, 1995 Injury Site
No. Injury Cause (%)*
No. Injuries (%)
Bullets
Explosive Weapons
65 (38.5) 6 (3.6) 23 (13.6) 9 (5.3) 16 (9.5) 44 (26.0) 6 (3.6)
31 (47.7) 5 (83.3) 14 (60.9) 3 (33.3) 4 (25.0) 15 (34.1) 3 (50.0)
34 (52.3) 1 (16.7) 9 (39.1) 6 (66.7) 12 (75.0) 29 (65.9) 3 (50.0)
75
94
Kidney Ureter Bladder Urethra Penis Scrotum Other
Totals 169 (100) * Incidence at specified sites.
without tension.1, 9 In 2 cases nephropexy was done to lengthen the ureter and achieve tension-free anastomosis.10 Ureteral prostheses were not available. Three patients were followed and all were free of stricture. Of the 23 ruptured bladders 12 were intraperitoneal and 14 were caused by bullets. The rectum, colon and small intestine were the most commonly involved associated abdominal organs. After removing devitalized tissue bladder suture and cystostomy were performed, followed by Retzius space drainage. There were 9 urethral injuries, including 3 posterior and 6 anterior. All posterior urethral injuries caused total disruption, and so reapproximation by realignment over a stenting catheter was done. In 4 of the 6 anterior urethral injuries a short segment rupture required resection and anastomosis via a urethral catheter. When the anterior urethra was severely disrupted, we planned that urethroplasty would be done later. Cystostomy was done in all cases. Three patients were followed, including 1 with stricture and impotence, 1 with impotence and incontinence, and 1 who was free of complications. The 16 penile injuries included 1 amputation and 15 lacerations. After removing devitalized tissue the tunica albuginea was sutured. Followup in 5 patients revealed impotence in 2 and penis angulation in 1. The other 2 patients were free of complications. Most of the 44 scrotal injuries were caused by explosive weapons. There were 48 testicular injuries, including 10 bilateral, and 6 scrotal skin lacerations. A total of 28 testes were removed and tunica albuginea sutures were placed for the remaining 20 injuries. The remaining urogenital injuries were 2 lesions of the left spermatic cord in the inguinal canal and 1 case each of lesions in the left adrenal, left spermatic artery and vein, left deferent duct and prostate.
TABLE 2. Associated injuries in 136 patients with urogenital war injuries treated at the war hospital in Bosnia-Herzegovina from May 1, 1992 to May 31, 1995 Associated Injuries
No. Kidney
No. Ureter
No. Bladder
No. Urethra
No. Penis
No. Scrotum
Chest Diaphragm Liver Duodenum Stomach Spleen Colon Small intestine Pancreas Fractures Vena cava Femoral region Gluteal region Perineal region
25 14 17 5 8 8 21 8 2 21 2 5 6 –
1 1 2 2 2 – 4 2 – 5 1 – 1 –
1 – – – – – 12 8 – 12 – 5 12 3
1 1 1 1 1 – 3 – – 5 – 4 1 2
3 1 1 1 1 – 2 2 – 8 – 7 – 1
3 – 1 1 – – 3 4 – 18 – 21 2 3
DISCUSSION
All internal urogenital injuries in this series were identified during exploratory procedures for penetrating injuries to the thorax, abdomen, lumbar and gluteal regions because preoperative urological investigation was precluded by the urgency of the obvious injuries or by a lack of equipment and personnel. However, abdominal and urogenital repairs were done at the same time, when possible. Urogenital injuries were present in 2.5% of our patients. In other published series of war injuries this rate was 1% to 10%.1⫺5 Differences reflect the type of warfare, the theater of war actions and the way records are maintained.2 In 1 Vietnam series 58% of patients with urogenital injuries were wounded by bullets,5 whereas in the war in Croatia, only 30% of such injuries were caused by bullets.3 In our series the incidence was 47.1%. In Bosnia-Herzegovina the front lines hardly moved and usually lay in or near residential areas. There was close contact between the opposing sides with abundant use of automatic small arms and snipers. The prevalence of explosive weapon injuries to the urethra, penis and scrotum is explained by the use of antipersonnel mines. An important factor in saving the lives of wounded combatants is the time of evacuation from the frontline.11 In World War II average time was 6 hours, while the use of helicopters in Vietnam decreased this time to 60 minutes.1, 5 In Croatia average transportation time was 52 minutes3 or 1 to 3 hours.4 For our hospital the average was only 30 minutes because we were close to the front line and had staff who were experienced with evacuation of the wounded. In Vietnam 93% of wounded individuals with urogenital injuries had associated injuries of other major organ systems, particularly the abdomen and chest.1 In Croatia reports of associated injuries show a rate of 70% to 85% of the wounded.3, 4 In our hospital multiple lesions were recorded in 85.3% of patients, mostly involving the abdomen, thorax and fractures. In our population of patients with urogenital war injuries kidney lesions were most common, achieving a prevalence of 38.5%, whereas in the literature this rate is 14% to 45%.1⫺4 Anatomically the kidney is a well protected organ, which is why renal injuries are usually associated with lesions of adjacent structures. The most common intra-abdominal lesions associated with injuries to the kidneys, ureter and bladder were in the large and small intestine, stomach and duodenum. In addition to their anatomical localization, the high rate of visceral organ involvement could be explained by temporary cavitation in the abdomen caused by high velocity missile injury, which may lead to bowel rupture through sudden enlargement of the intra-abdominal cavity and expansion of bowel gases.2 Nephrectomy rates in case series of penetrating injury vary. The relatively high rates recorded by Salvatierra et al1 and Selikowitz2 of 50% and 84%, respectively, were explained by the severity of the damage that high velocity missiles cause. On the other hand, Ochsner et al, who reported from Vietnam, described a nephrectomy rate of only 30%,5 which is close to the rates in the BosniaHerzegovina (33.8%) and Croatian (25%3 and 29%4) conflicts, and to the nephrectomy rates of 28%12 and 27%13 reported for penetrating injuries to the kidney in civilians. The ureter, which is a narrow tube surrounded by fat and muscle, is rarely injured by external trauma during peacetime.14 However, the use of weapons with high kinetic power increases the incidence of ureteral injury to between 2% and 15% of total urogenital injuries.1⫺4 The proportion was 3.6% in our series. In all of our cases of ureteral injury extensive resection of devitalized tissue was done to prevent high velocity blast effect on the ureter,15, 16 followed by primary ureterourethral reconstruction without a stent. The reported contribution of damage to the bladder to urogenital injuries in war is 8% to 20%1⫺4 and our rate of
SURGICAL MANAGEMENT OF WAR UROGENITAL INJURIES
13.6% lies in this range. In peacetime bladder injuries extraperitoneal rupture is more common than intraperitoneal rupture17 but in our series of war injuries the rates of intraperitoneal and extraperitoneal rupture were almost the same. We avoided urinary catheter placement and used cystostomy drainage, in part because of the risk of catheter associated epididymitis and epididymo-orchitis.17 The frequency of urethral injury in our series (5.3%) was again typical of that in other series of urogenital war injuries (3% to 15%1⫺4). In peacetime the surgeon can choose suprapubic cystostomy followed by later reconstruction or immediate urethral realignment18 but for the military surgeon immediate realignment may be the only option, as in most of our cases. CONCLUSIONS
In war surgery the surgeon frequently must improvise and adjust to working in a hospital with inadequate medical supplies, equipment and personnel. This scenario is true for urogenital injuries, which are often severe and associated with damage to other organs. There must be a compromise, in which the timing and type of surgical intervention are determined by the scale of the urogenital injury, injuries to adjacent structures, and the experience and skill of the surgeon. However, the results of war surgery need not fall far below those of peacetime surgery provided that wounded patients present to the surgeon rapidly, the patients are young and the surgeons are experienced with war injury. In this hospital series in northern Bosnia-Herzegovina all 3 criteria were met. Drs. Ana Marusˇ ic´ and Matko Marusˇ ic´ critically reviewed the article and assisted with its preparation. David Sharp revised the manuscript. REFERENCES
1. Salvatierra, O., Jr., Rigdon, W. O., Norris, D. M. and Brady, T. W.: Vietnam experience with 252 urological war injuries. J Urol, 101: 615, 1969
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