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War Injuries to the Genito-urinary Tract1
WAR INJURIES TO THE GENITO-URINARY TRACT1 A BRIEF REVIEW OF THE TYPE OF INJURIES OBSERVED IN ONE
u. s. NAVAL BASE
HOSPITAL IN THE PACIFIC
CAPT. LLOYD R . REYNOLDS (MC), USNR
A summary of injuries to the genito-urinary tract in World War I revealed such a high mortality that comparatively few patients lived to reach a base hospital. Final statistics following World War II will probably show a very high mortality following urogenital injuries in areas where there is extensive land fighting, because of the difficulty in evacuating patients from the firing line to stations where adequate hospital facilities are available. In most of the engagements in the mid-Pacific theater, excellent medical aid is readily available, either ashore or aboard ship, and most of the seriously wounded are given first aid and transported by air with so little loss of time that they are . admitted to the base hospital in fair condition. At one time, following invasion of a mid-Pacific island, we admitted patients suffering from wounds representing injuries to each of the major urologic structures. Some kidney injuries were caused by bullets or shell fragments, but the majority resulted from blows in the flank by objects, or from impact against obstructions. Most of these cases had minor fracture of the renal parenchyma without serious hemorrhage, and required nothing more than bed rest and urinary antiseptics by mouth to make a complete recovery. All were checked by intravenous pyelograms upon admission, and again before being discharged to duty. Two cases with fractures of the lower pole of the kidney as demonstrated by urograms continued to have microscopic hematuria for as long as 16 days. We followed the plan of watchful waiting, and did not resort to surgery unless hemorrhage was severe enough to endanger life. Our conservative· attitude was justified by the final results. In cases requiring surgery for arrest of hemorrhage nephrectomy was necessary to assure complete hemostasis in the presence of partial shock. Only 1 patient sustained injury to the ureter; damage was so severe that nephrectomy was imperative. Bladder injuries were more frequent and more adaptable to surgical repair. Unfortunately, I am unable to show the cystograms of this interesting group of patients, but under the circumstances they are not available. I have selected the cases I think represent the problems with which we were confronted, and will describe the manner in which we tried to solve them. One of the most interesting of the group demonstrates what is being accomplished by the combination of early first aid, rapid transporation and base hospital facilities. CASE REPORTS
Case. A 20-year old marine was wounded by a high powered, large caliber bullet, which entered the right thigh about 2 inches below the right trochanter, 1 Read at the 21st annual meeting, Western Section of the American Urological Association, San Francisco, Calif., June 3, 1944. 419
420
LLOYD R. REYNOLDS
coursed slightly upward through the prostate and bladder neck and emerged at the lower edge of the left trochanter. There was extensive extravasation of urine and blood in the suprapubic area, and immediate suprapubic cystotomy was performed by the surgeon at the advanced station, who used the rubber tubing from his stethoscope as a suprapubic drain. In order to control bleeding he packed the prostatic capsule, the bladder and the perivesical space to the left of the bladder neck. The patient was given 2 units of plasma and placed aboard a seaplane which delivered him to the base hospital 4 hours later. There he received a transfusion of 1000 cc. of whole blood. Three days later the wound was opened, the packing removed and the damage estimated. The larger part of the prostate had been torn away, and the left side of the bladder had been severed from the bladder neck from 6 to 12 o'clock. This defect was repaired with interrupted No. 2 chromic catgut sutures, and a Foley catheter was passed through the urethra and adjusted. At the end of 3 weeks the patient was well so far as his urogenital tract was concerned. He had some damage to the left sciatic nerve, and was transferred to the neurosurgical service for further observation. As would be expected, injuries to the posterior urethra were more numerous than any other type in the urologic field. The majority were in conjunction with fracture of the bony pelvis. Often it was impossible to pass an instrument to the bladder via the urethra, and suprapubic drainage became imperative. We made it a practice to instruct medical officers and some of the advanced corpsmen in the simple method of introducing a No. 22 F . caliber trocar suprapubically and of passing a No. 16 F. catheter through the trocar. The procedure requires a minimum of equipment and can be done under local anesthesia at any dressing station. Unless there is extensive bladder hemorrhage, this established adequate drainage, keeps the patient dry and comfortable and can be regulated by himself. Case. A 20-year old seaman, acting as assistant communications officer on the control bridge of one of our large airplane carriers, was struck by shell fragments and thrown to the flight deck 12 feet below. He managed to pull himself back up the ladder to his station and carried on his duties until ordered to abandon ship. He then went over the side to a raft, from which he was rescued by a destroyer. It was then found that he had suffered a fracture of the left femur, both pubic rami on the left, separation of the symphysis, rupture of the membranous urethra, and that about 2 inches of the midpenile urethra had been torn away by shell fragments. The officer aboard the destroyer performed suprapubic drainage of the bladder, using the trocar method. On admission to the hospital 2 days lat er, he was in good condition. When his fractures had healed sufficiently, the urethral defects were corrected by external urethrotomy and plastic repair. He recovered completely and is again on active duty aboard one of our carriers. Patients with extensive loss of skin from the scrotum or penis, or both, were also drained suprapubically by means of trocar puncture. Plastic operations were much more successful following such drainage than after inlying catheterization or normal voiding. We have also found this the procedure of choice in caring for paralyzed bladders following spinal cord injuries. Attempts at establishing automatic bladders and the use of tidal drainage were unsuccessful. Five cases
WAR INJURIES TO GENITO-URINARY TRACT
421
with broken necks were drained in this manner and none developed symptoms of pyelitis or urinary supression. Three were examined at post mortem four weeks or more after the suprapubic catheter had been introduced, and in no instance was there evidence of renal damage. CONCLUSIONS
Injuries to the urogenital tract in war present the same problems as those in civilian life. Injuries to the kidney require surgical interference only when hemorrhage is extensive enough to demand control. In such cases nephrectomy usually has to be done to assure hemostasis. Suprapubic puncture of the bladder to establish drainage is the procedure of choice in most cases suffering from ruptured urethra or bladder paralysis due to central nerve injury. Our present means of controlling shock, and the efficiency of the urinary antiseptics at our disposal, enable us to save more patients with severe injuries to the urogenital tract than was formerly possible.
U.S. Naval Hospital, Shoemaker, Calif.
u. s. NAVAL BASE
HOSPITAL IN THE PACIFIC
CAPT. LLOYD R . REYNOLDS (MC), USNR
A summary of injuries to the genito-urinary tract in World War I revealed such a high mortality that comparatively few patients lived to reach a base hospital. Final statistics following World War II will probably show a very high mortality following urogenital injuries in areas where there is extensive land fighting, because of the difficulty in evacuating patients from the firing line to stations where adequate hospital facilities are available. In most of the engagements in the mid-Pacific theater, excellent medical aid is readily available, either ashore or aboard ship, and most of the seriously wounded are given first aid and transported by air with so little loss of time that they are . admitted to the base hospital in fair condition. At one time, following invasion of a mid-Pacific island, we admitted patients suffering from wounds representing injuries to each of the major urologic structures. Some kidney injuries were caused by bullets or shell fragments, but the majority resulted from blows in the flank by objects, or from impact against obstructions. Most of these cases had minor fracture of the renal parenchyma without serious hemorrhage, and required nothing more than bed rest and urinary antiseptics by mouth to make a complete recovery. All were checked by intravenous pyelograms upon admission, and again before being discharged to duty. Two cases with fractures of the lower pole of the kidney as demonstrated by urograms continued to have microscopic hematuria for as long as 16 days. We followed the plan of watchful waiting, and did not resort to surgery unless hemorrhage was severe enough to endanger life. Our conservative· attitude was justified by the final results. In cases requiring surgery for arrest of hemorrhage nephrectomy was necessary to assure complete hemostasis in the presence of partial shock. Only 1 patient sustained injury to the ureter; damage was so severe that nephrectomy was imperative. Bladder injuries were more frequent and more adaptable to surgical repair. Unfortunately, I am unable to show the cystograms of this interesting group of patients, but under the circumstances they are not available. I have selected the cases I think represent the problems with which we were confronted, and will describe the manner in which we tried to solve them. One of the most interesting of the group demonstrates what is being accomplished by the combination of early first aid, rapid transporation and base hospital facilities. CASE REPORTS
Case. A 20-year old marine was wounded by a high powered, large caliber bullet, which entered the right thigh about 2 inches below the right trochanter, 1 Read at the 21st annual meeting, Western Section of the American Urological Association, San Francisco, Calif., June 3, 1944. 419
420
LLOYD R. REYNOLDS
coursed slightly upward through the prostate and bladder neck and emerged at the lower edge of the left trochanter. There was extensive extravasation of urine and blood in the suprapubic area, and immediate suprapubic cystotomy was performed by the surgeon at the advanced station, who used the rubber tubing from his stethoscope as a suprapubic drain. In order to control bleeding he packed the prostatic capsule, the bladder and the perivesical space to the left of the bladder neck. The patient was given 2 units of plasma and placed aboard a seaplane which delivered him to the base hospital 4 hours later. There he received a transfusion of 1000 cc. of whole blood. Three days later the wound was opened, the packing removed and the damage estimated. The larger part of the prostate had been torn away, and the left side of the bladder had been severed from the bladder neck from 6 to 12 o'clock. This defect was repaired with interrupted No. 2 chromic catgut sutures, and a Foley catheter was passed through the urethra and adjusted. At the end of 3 weeks the patient was well so far as his urogenital tract was concerned. He had some damage to the left sciatic nerve, and was transferred to the neurosurgical service for further observation. As would be expected, injuries to the posterior urethra were more numerous than any other type in the urologic field. The majority were in conjunction with fracture of the bony pelvis. Often it was impossible to pass an instrument to the bladder via the urethra, and suprapubic drainage became imperative. We made it a practice to instruct medical officers and some of the advanced corpsmen in the simple method of introducing a No. 22 F . caliber trocar suprapubically and of passing a No. 16 F. catheter through the trocar. The procedure requires a minimum of equipment and can be done under local anesthesia at any dressing station. Unless there is extensive bladder hemorrhage, this established adequate drainage, keeps the patient dry and comfortable and can be regulated by himself. Case. A 20-year old seaman, acting as assistant communications officer on the control bridge of one of our large airplane carriers, was struck by shell fragments and thrown to the flight deck 12 feet below. He managed to pull himself back up the ladder to his station and carried on his duties until ordered to abandon ship. He then went over the side to a raft, from which he was rescued by a destroyer. It was then found that he had suffered a fracture of the left femur, both pubic rami on the left, separation of the symphysis, rupture of the membranous urethra, and that about 2 inches of the midpenile urethra had been torn away by shell fragments. The officer aboard the destroyer performed suprapubic drainage of the bladder, using the trocar method. On admission to the hospital 2 days lat er, he was in good condition. When his fractures had healed sufficiently, the urethral defects were corrected by external urethrotomy and plastic repair. He recovered completely and is again on active duty aboard one of our carriers. Patients with extensive loss of skin from the scrotum or penis, or both, were also drained suprapubically by means of trocar puncture. Plastic operations were much more successful following such drainage than after inlying catheterization or normal voiding. We have also found this the procedure of choice in caring for paralyzed bladders following spinal cord injuries. Attempts at establishing automatic bladders and the use of tidal drainage were unsuccessful. Five cases
WAR INJURIES TO GENITO-URINARY TRACT
421
with broken necks were drained in this manner and none developed symptoms of pyelitis or urinary supression. Three were examined at post mortem four weeks or more after the suprapubic catheter had been introduced, and in no instance was there evidence of renal damage. CONCLUSIONS
Injuries to the urogenital tract in war present the same problems as those in civilian life. Injuries to the kidney require surgical interference only when hemorrhage is extensive enough to demand control. In such cases nephrectomy usually has to be done to assure hemostasis. Suprapubic puncture of the bladder to establish drainage is the procedure of choice in most cases suffering from ruptured urethra or bladder paralysis due to central nerve injury. Our present means of controlling shock, and the efficiency of the urinary antiseptics at our disposal, enable us to save more patients with severe injuries to the urogenital tract than was formerly possible.
U.S. Naval Hospital, Shoemaker, Calif.