Battlefield scrotal trauma: how should it be managed in a deployed military hospital?

Management of severe defects of humerus in combat patients injured in Russo-Ukrainian war

INTRODUCTION

Russo-Ukrainian war is associated with application of high-energy weapon, causing severe multifragmental injuries to the bones an associating with severe bone defects. The aim of the study was to evaluate various methods to treat combat patients with severe defects of humerus and to demonstrate the experience of orthopedic war surgeons in managing gunshot injuries to the humerus defects in the ongoing war.

PATIENTS AND METHODS

A 24 patients were active-duty military personnel of Armed Forces of Ukraine. These patients were diagnosed with severe humerus defects due to gunshot injury in battlefield zone in various areas of Ukraine. Data was collected within period between February, 24th 2022 till January, 01st 2023. The following approaches were applied to replace bone defect: preoperative 3D printing with polyetheretherketone (PEEK) as orthobiological material; closed reduction, percutaneous lag screw and Ilizarov external fixation; vascularized fibula grafting.

RESULTS

Data analyses of the segmental defects of humerus showed 5 cm defect in 3 (13 %) patients, from 5 to 10 cm in 4 (17 %) patients, over 10 cm in 17 (71 %) patients. Analyses were performed in these 17 (71 %) patients, showing 5 patients treated with 3D-printed PEEK implants, 6 patients with vascular-pedicle graft of fibula, 6 patients with closed reduction, percutaneous lag screw, Ilizarov external fixation. Osteomyelitis was diagnosed in one case (20 %) after the use of PEEK implants, requiring to remove both PEEK implant and metal implants followed by application of the antibiotic joint spacers and Ex-Fix fragments of the humerus. In our opinion, the osteomyelitis happened due to inadequate debridement of the wound and non-compliance with the conversion criteria (replacement of the fixation method). The mean length of hospital stay was 5.5 months for patients treated with 3D-printed PEEK implants.

CONCLUSIONS

Closed reduction, percutaneous lag screw and Ilizarov external fixation as well as vascularized fibula grafting are associated with good outcomes in management of the patients with severe humerus defect due to gunshot injury. 3D printing and PEEK implants could also be considered for the reconstructions of the humerus multifragmental fractures with a bone defect over 10 cm associated with gunshot injury due to high-energy weapon in the war settings.

Urology during Afghanistan mission: lessons learned and implications for the future

PURPOSE

Battle-related trauma is common in modern warfare and can lead to genitourinary injuries. In Western countries, urogenital injuries are rare in the civilian environment. The main objective of this study was to assess urological workload for surgeons on deployment.

MATERIAL AND METHODS

Data were acquired over a period of five years of deployment in a U.S. facility in Afghanistan.

RESULTS

German urological surgeons treated on average one urologic outpatient per day and performed 314 surgical interventions overall. Surgical interventions were categorized as battle-related interventions (BRIs, n = 169, 53.8%) and nonbattle-related interventions (non-BRIs, n = 145, 46.2%). In the BRI group, interventions were mainly performed on the external genitalia (n = 67, 39.6%), while in the non-BRI group, endourological procedures predominated (n = 109). This is consistent with a higher rate of abdominal or pelvic procedures performed in the BRI group (n = 51, 30.2%). Furthermore, the types of interventions performed on the external genitalia differed significantly. In the BRI group, 58.2% (n = 39) of interventions were scrotal explorations, but none of those procedures were performed in the non-BRI group (p < 0.001). However, 50.0% (n = 13) of scrotal explorations in the non-BRI group were due to suspected torsions of the testes followed by orchidopexy (BRI: n = 1, 1.5%, p < 0.001). Concerning outpatients, the consultation was mainly due to complaints concerning the external genitalia (32.7%, n = 252) or kidney/ureteral stones (23.5%, n = 181).

CONCLUSION

While the treatment of urological outpatients in a deployment setting resembles the treatment of soldiers in Germany, BRIs requires abdominal/retroperitoneal urosurgical skills and basic skills in reconstructive surgery.

Male Genitourinary Injuries in Combat - A Review of United States and British Forces in Afghanistan and Iraq: 2001-2013

As we look to the current conflict in Ukraine, our service members deploy to periphery Northern Atlantic Treaty Organization countries. At the same time, we see an increase in high-kinetic wounding patterns in the United States. We look to the important underrepresented topic of urologic trauma in combat casualties to prepare for the wounds of modern warfare. Genitourinary wounds are increasingly frequent and affect both military and civilian casualties; civilian urologists and deployed surgeons require proficiency in treating these wounds. We present this review of urologic trauma in Afghanistan and Iraq to inform considerations for urologic surgeons and first responders.

Penetrating Scrotal Injuries: A War Time Experience in a Civilian Setup

AIM: To present our experience in managing testicular involvement in penetrating scrotal injuries, trying to highlight a possible role for conservative management of selected cases. METHODS: We reviewed retrospectively all-penetrating scrotal injuries presented to Alyarmook teaching hospital for the period between January 2009 and November 2015, including only those injured victims who reached the hospital alive. Patients’ charts reviewed regarding their demographic data including age, status being civilian or military, and married or single. We documented as well the cause of injury (bullets vs. explosive devices), laterality, associated injured organs, and type of management performed whether operative or non-operative conservative approach. Postoperative complications were recorded while in-patient and after a follow-up period of at least 1 month. RESULTS: Thirty-one penetrating scrotal injuries were identified, resulted in 34 injured testicles. The patients’ mean age was 34.35 years (±12.89standard deviation [SD]) (18–70 years). Most of the victims 24 (77.4%) were civilians. Explosive devices were the cause of injury in 23 patients (74.2%), while bullets were the cause in the remaining 8 patients (25.8%). Orchidectomy needed to be done in 17 (50%) testicles, while 11 (32.4%) injured testes were repaired by suturing. Six cases (17.6%) were treated conservatively without any surgical intervention. The overall testicular salvage rate was (50%). Twenty-one patients (68%) had associated injuries, mostly fractures. Complications occurred in 10 (32.2%) patients, including two mortalities. CONCLUSIONS: Management of genitourinary injuries continues to be a challenging task. In our penetrating testicular injured series, we succeeded to salvage 50% of the injured testes. Non -surgical treatment is feasible in selected patients, an approach that needs further study and longer follow-up.

Changes in Sexual Behavior of Orchidectomized Rats Under Influence of Allotransplantation of Testicular Interstitial Cell Suspension

Transplantation of hormone-producing cells is an experimental endocrine dysfunction treatment. The present study investigated the effects of orchidectomy (OE) and transplantation of interstitial cell suspension (ICS) on rat sexual behavior. Adult experimental animals were divided into two populations. One of these populations had sexual experience before the experiment and the other did not. Each population was divided into three groups: control group and two orchidectomized groups. One of the orchidectomized groups was treated with ICS, and the other was treated with the vehicle. The changes in the sexual behavior were investigated on the following parameters: mount latency (ML), intromission latency (IL), ejaculation latency (EL), mount frequency (MF), intromission frequency (IF), copulatory efficacy (CE), and IF/EL ratio. The investigation of these changes lasted 4 weeks after ICS transplantation. The parameters of sexual behavior reflected a decrease in sexual function after OE at the beginning of the observation, especially for the animals that did not have a sexual experience. However, it was shown that sexual activity increased in the following 4 weeks. We have indicated that the loss of gonads attenuated the capacity to acquire sexual experience; nonetheless, it did not mean that the animals completely lost this capacity. Transplantation of ICS facilitated the maintenance of male sexual behavior after OE, fractionally enlarged the size of regressed seminal vesicles of the animals, and increased the free testosterone (T) level. These findings suggest the ICS can be considered as a temporal source of androgens, which can facilitate a restoration of sexual activity.

Lower genitourinary tract trauma

Lower genitourinary tract trauma comprises a substantial portion of the trauma burden in the USA. Some key trends and findings are described. Mortality is relatively high in patients with bladder trauma due to associated injuries. Urethral injuries should be suspected in patients presenting with the triad of blood at the urethral meatus, suprapubic fullness indicative of a full bladder, and urinary retention. Urethral injury is common in penetrating penile trauma, and stab wounds to the penis are more likely to involve the urethra than gunshot wounds. Penile fracture is largely a clinical diagnosis and suspicion of fracture requires urgent surgical exploration. Zipper injuries are the most common cause of presentation to the emergency department for penile trauma in adults. Toilet seat injuries are the leading cause of penile pediatric trauma presenting to the emergency department. In the setting of testicular trauma, rates of testicular salvage are excellent when exploration is prompt. Trauma in the form of animal or human bites requires treatment with broad-spectrum antibiotics in addition to repair of the injury. Military trauma has seen an increase in explosive injuries to the lower urinary tracts due to evolution of warfare tactics. Increasing awareness of presentation and context of lower genitourinary tract trauma can reduce delay of diagnosis and morbidity associated with such injuries.