Epidemiology of Genitourinary Injuries among Male U.S. Service Members Deployed to Iraq and Afghanistan: Early Findings from the Trauma Outcomes and Urogenital Health (TOUGH) Project

Urologic Trauma Management for Military Providers

INTRODUCTION

Genitourinary (GU) trauma resulting from combat and the treatment of these injuries is an inadequately explored subject. While historically accounting for 2 to 5% of combat-related injuries, GU-related injuries escalated considerably during U.S. involvements in Iraq and Afghanistan due to improvised explosive devices (IEDs). Advanced body armor increased survivability while altering injury patterns, with a shift toward bladder and external genitalia injuries. Forward-deployed surgeons and military medics manage treatment, with Role 2 facilities addressing damage control resuscitation and surgery, including GU-specific procedures. The review aims to provide an overview of GU trauma and enhance medical readiness for battlefield scenarios.

MATERIALS AND METHODS

This review examined urologic trauma management in combat, searching PubMed, Cochrane Central, Scopus, and Web of Science databases with search terms "wounds" OR "injuries" OR "hemorrhage" AND "trauma" AND "penile" OR "genital" AND "combat." Records were then screened for inclusion of combat-related urologic trauma in conflicts after 2001 and which were English-based publications. No limits based on year of publication, study design, or additional patient-specific demographics were implemented in this review.

RESULTS

Ultimately, 33 articles that met the inclusion criteria were included. Included texts were narrowed to focus on the management of renal injuries, ureteral trauma, bladder injuries, penile amputations, urethral injuries, testicular trauma, Central nervous system (CNS) injuries, and female GU injuries.

CONCLUSIONS

In modern conflicts, treatment of GU trauma at the point of injury should be secondary to Advanced Trauma Life Support (ATLS) care in addition to competing non-medical priorities. This review highlights the increasing severity of GU trauma due to explosive use, especially dismounted IEDs. Concealed morbidity and fertility issues underscore the importance of protection measures. Military medics play a crucial role in evaluating and managing GU injuries. Adherence to tactical guidelines and trained personnel is vital for effective management, and GU trauma's integration into broader polytrauma care is essential. Adequate preparation should address challenges for deploying health care providers, prioritizing lifesaving and quality-of-life care for casualties affected by GU injuries.

The State of Urotrauma Education Among Residency Programs in the United States: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

Management of urotrauma is a crucial part of a urologist's knowledge and training. We therefore sought to understand the state of urotrauma education in the United States.

RECENT FINDINGS

Using themes of "Urotrauma" and "Education," we performed a systematic review and meta-analysis by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, BIOSIS, Scopus, and Web of Science through May 2023. The primary outcome was the pooled rate of urology trainee and program director attitudes toward urotrauma education. Secondary outcomes involved a descriptive summary of existing urotrauma curricula and an assessment of factors affecting urotrauma exposure. Of 12,230 unique records, 11 studies met the final eligibility criteria, and we included 2 in the meta-analysis. The majority of trainees and program directors reported having level 1 trauma center rotations (range 88-89%) and considered urotrauma exposure as an important aspect of residency education (83%, 95% CI 76-88%). Despite possible increases in trainee exposure to Society of Genitourinary Reconstructive Surgeons (GURS) faculty over the preceding decade, nearly a third of trainees and program directors currently felt there remained inadequate exposure to urotrauma during training (32%, 95% CI 19-46%). Factors affecting urotrauma education include the limited exposure to GURS-trained faculty and clinical factors such as case infrequency and non-operative trauma management. Urology resident exposure to urotrauma is inadequate in many training programs, underscoring the potential value of developing a standardized curriculum to improve urotrauma education for trainees. Further investigation is needed to characterize this issue and to understand how it impacts trainee practice readiness.

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.

Male Sexual Health Related Complications Among Combat Veterans

INTRODUCTION

With improved armor and combat trauma care, more male service members in the 21st century are surviving devastating injuries to their genitourinary (GU) system. The impact of these injuries can have long lasting effect on their sexual function and fertility status.

OBJECTIVES

To review the current literature on sexual health-related complications and fertility implications among male service members sustaining combat related injuries.

METHODS

We performed a literature search that included male sexual health complications and combat injuries using PubMed and Google Scholar. We reviewed the impact of traumatic injuries to the pelvis and perineum on sexual function and fertility, and we also discuss sexual dysfunction from posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBI).

RESULTS

Injuries sustained during combat are usually polytraumatic, especially in recent conflicts with improvised explosive devices. The majority of GU combat injuries involve the scrotum, testes, and penis resulting in lasting structural dysfunction. PTSD is associated with higher levels of erectile dysfunction, hypoactive sexual desire, and premature ejaculation. Overall, veterans diagnosed with PTSD had a higher risk of developing sexual dysfunction. Veterans with TBI experience sexual health complications, such as decreased libido, difficulties with arousal maintenance, and the ability to achieve orgasm. Combat related injuries can have significant fertility implications on service members as they typically serve in their peak fertility years.

CONCLUSIONS

Traumatic GU injuries, PTSD, TBI, and associated endocrine dysfunction can all contribute to sexual dysfunction among combat veterans. Given the complex nature of sexual dysfunction in this population, these patients are best managed by a multidisciplinary team. Castillo O, Chen IK, Amini E, et al. Male Sexual Health Related Complications Among Combat Veterans. Sex Med Rev 2022;XX:XXX-XXX.

DoD-VA Trauma Infection Research Collaboration

BACKGROUND

In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma.

METHODS

As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined.

RESULTS

Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time.

CONCLUSIONS

Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.

Hidden trauma: shedding light on the relationship between gun violence and infertility

Objective

To study the existing data on the relationship between penetrating abdominopelvic injuries and fertility guidance on managing fertility concerns of these patients using a case report and scoping review.

Design

Case report and scoping review.

Setting

Not applicable.

Patient(s)

People who have experienced abdominopelvic trauma from gun violence or in the course of combat.

Intervention(s)

None.

Main Outcome Measure(s)

We extracted case report data from electronic health records. We performed a scoping review using PubMed and Scopus. Search terms were related to penetrating abdominopelvic trauma, gunshot wounds (GSW), war, and fertility/infertility. We evaluated the study year, age and race, mechanism of injury, fertility outcomes, and how fertility concerns were addressed with patients who experienced penetrating abdominopelvic trauma.

Result(s)

In the case report, the couple had 10 years of infertility. The male partner experienced an abdominopelvic GSW before attempting to conceive. After evaluation, he was diagnosed with retrograde ejaculation. He recalled being advised that his GSW might affect his future fertility. The couple has discontinued care.

For the scoping review, 879 sources were identified and 25 studies were included in the review. Among the studies conducted in the United States, most patients included were African American.

Eighty-eight percent (n = 22) of the sources acknowledged the importance of fertility or used fertility-related outcome measures. One study commented on how to address fertility concerns with victims of abdominopelvic penetrating trauma.

Conclusion(s)

There is a paucity of data on the intersection of penetrating abdominopelvic injuries and fertility or guidance on how to discuss fertility issues with patients.

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.

Living with someone else's penis: The lived experiences of two South African penile allograft recipients: A descriptive phenomenological study

Background

In South Africa, penile loss is a recognised complication of ritual circumcision which has a profoundly negative effect on these men's psyches and their everyday lives. The purpose of this paper was to investigate the experiences of the first two South African penile allograft transplantation recipients in order to assess the psychosocial impact of this surgery.

Materials and methods

A qualitative descriptive phenomenology approach was used. A total of four in-depth interviews were conducted with the two South African penile transplant recipients. The interviews were transcribed verbatim while adding the field and observational notes. Thematic analysis was used to derive meaning from the collected data.

Results

After the penile loss, both participants reported feeling suicidal for the following reasons: their communities shunned them and regarded them as ‘dead,’ they felt severely ashamed of their disfigured bodies, they were unable to develop intimate relationships and could not have children. Transplantation gave them a fully functional penis, which resolved the majority of these issues. The participants were able to build relationships and satisfy their own and their partners' sexual and relationship needs. The transplant led to complete restoration of their self-image and manhood. They were, however, still persecuted by their traditional communities as they had not successfully completed the ritual circumcision ceremony.

Conclusion

This study emphasises the necessity of offering penile transplantation as treatment for penile loss as this is not only life enhancing but lifesaving, especially within the South African context.

•

Recipients fully accepted the transplanted penis as their own.

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Penile function was fully restored including sexual function and therefore the ability to reproduce.

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Penile transplantation had positive impact on recipients' psychological state and self-image.

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Despite need for lifelong immunosuppressants, recipients were satisfied with decision to have penile tansplant.

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The emotional and social transformation which occurred in the recipients were not only life-enhancing, but lifesaving.

Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings

Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).

Fertility Preservation Before Deployment: Oocyte and Sperm Freezing in Members of the Active Duty Military

Active duty military service and deployment has the potential to compromise fertility through combat-related genitourinary injury, gonadotoxic exposures, and physical separation from a partner. Despite a growing interest among the military community as well as promising efficacy and safety data, fertility preservation remains an uncovered benefit for active duty soldiers. In 2016, the Pentagon proposed a program that would cover oocyte and sperm cryopreservation for any member of the active duty military desiring its use. Regrettably, that funding was not secured and predeployment fertility preservation remains an out-of-pocket expense. Today, advocacy groups, non-for-profit organizations, and physicians remain vigilant in their attempts to drive another government initiative through Congress. While activism continues, it is important to stress the value of fertility preservation counseling in soldiers' predeployment preparation and military family planning.

The Baltimore Criteria for an ethical approach to penile transplantation: a clinical guideline

Significant advances and increasing acceptance of vascularized composite allotransplantation (VCA) have contributed to emerging success of penile transplantation. The aims of penile transplantation are fourfold: adequate urinary function, enabling natural erections, restoration of erogenous sensation and appearance of external male genitalia. Successful penile transplantation also requires limiting risks and managing complications of lifelong immunosuppression. Given the limited experience with this procedure, potential recipients must understand that penile transplantation is not currently standard of care and long-term functional outcomes are unknown. Moreover, these transplants are associated with complex ethical issues. Nevertheless, as the efficacy and safety of penile transplantation are being evaluated, clear indications for transplant are needed. Although preliminary recommendations have been proposed, a more comprehensive framework is needed. We performed a literature review for English language publications related to penile transplantation and ethics. Based on the results of the search, a review of prior recommendations, and our experience performing the first whole male genital allotransplantation including penis, scrotum and abdominal wall; screening and identifying potential donors and recipients for the procedure; and addressing the associated ethical issues, we propose guidelines for responsible penile transplantation: The Baltimore Criteria for an Ethical Approach to Penile Transplantation.

Urinary Tract Infections after Combat-Related Genitourinary Trauma

Background: We examined clinical outcomes among combat casualties with genitourinary injuries after blast trauma. Methods: Characteristics, clinical care, urologic complications, and infections for subjects enrolled in the Trauma Infectious Disease Outcomes Study (TIDOS) were collected from Department of Defense (DOD) and Department of Veterans Affairs (VA) sources. Logistic regression identified predictors for urinary tract infections (UTIs) after genitourinary trauma. Results: Among 530 TIDOS enrollees who entered VA care, 89 (17%) sustained genitourinary trauma. The majority of subjects (93%) were injured via a blast and 27% had a dismounted complex blast injury (DCBI). Sexual dysfunction was reported with 36% of subjects, whereas 14% had urinary retention/incontinence and 8% had urethral stricture. Urologic complications were comparable between patients with and without DCBIs. Nineteen (21%) subjects had one or more UTI with a total of 40 unique UTI events (25% during initial hospitalization and 75% during subsequent DOD or VA care). The UTI incidence rate was 0.89 per patient-year during initial hospitalization, 0.05 per patient-year during DOD follow-up, and 0.07 per patient-year during VA healthcare. Subjects with UTIs had a higher proportion of bladder injury (53% vs. 13%; p < 0.001), posterior urethral injury (26% vs. 1%; p = 0.001), pelvic fracture (47% vs. 4%; p < 0.001), soft-tissue infection of the pelvis/hip (37% vs. 4%; p = 0.001), urinary catheterization (47% vs. 11%; p < 0.001), urinary retention or incontinence (42% vs. 6%; p < 0.001), and stricture (26% vs. 3%; p = 0.004) compared with patients with genitourinary trauma and no UTI. Independent UTI risk factors were occurrence of a soft-tissue infection at the pelvis/hip, trauma to the urinary tract, and transtibial amputation. Conclusions: Among combat casualties with genitourinary trauma, UTIs are a common complication, particularly with severe blast injury and urologic sequelae. Episodes of UTIs typically occur early after the initial injury while in DOD care, however, recurrent infections may continue into long-term VA care.

Urethral injury in major trauma

Urethral injury in major trauma is infrequent, with complex problems of diagnosis and treatment. The aims of this study are to determine the incidence and epidemiological factors relating to urethral injury in major trauma, as well as determine if any additional prognostic factors are evident within this cohort of patients. A retrospective review of patients sustaining urethral injury following major trauma was made over a 6-year period, from 2010 to 2015. Quantitative analysis was made using the national trauma registry for England and Wales, the Trauma Audit and Research Network (TARN) database, identifying all patients with injury codes for urethral injury. 165 patients with urethral injuries were identified, over 90% were male, most commonly injured during road traffic accidents and with an associated overall mortality of 12%. Urethral injury in association with pelvic fracture occurred in 136 patients (82%), representing 0.6% of all pelvic fractures, and was associated with double the rate of mortality. Urethral injury was associated with unstable pelvic fractures (LC2, LC3, APC3, VS, CM) but not with a specific pelvic fracture type. This study confirms the rare incidence of this injury in major trauma at 1 per 2 million population per year.

Penile transplantation: the US experience and institutional program set-up

Penile transplantation using vascularized composite allografts is an emerging technique to treat genital loss. In the United States, this procedure has been performed successfully at Massachusetts General Hospital in a patient who had previously undergone treatment for penile cancer. The Johns Hopkins Medical Institutions has developed a research protocol to perform penile transplantation in patients with genital loss secondary to trauma. The process of selecting the appropriate candidate for genitourinary (GU) vascularized composite allograft surgery is rigorous including extensive physical examination, laboratory testing, imaging and psychological evaluations. After transplantation, limiting the potential complications associated with immunosuppression is critical given that the procedure is intended to improve quality of life and is not life-saving. Ultimately, penile transplant is a surgical intervention which may have numerous applications. Optimization of the pre-operative screening process, surgical technique, and immunosuppressive protocol is required to establish this method as the standard treatment for patients with genital loss and limited reconstructive options.

Military genitourinary injuries: past, present, and future

Genitourinary (GU) injuries among military service members are as old as war itself. The frequency and clinical picture of GU injuries sustained in conflicts over the ages have evolved along with the constantly changing nature of combat. In this review, we discuss changing trends in the diagnosis and management of GU injuries over the past century and introduce areas of innovation which could impact the care of casualties who sustain GU trauma in the future.

Attitudes Toward Penile Transplantation Among Urologists and Health Professionals

Introduction

Penile transplantation, in its infancy, has the potential to reestablish functional outcomes for men with penile loss and disfigurement. However, significant bioethical considerations are pertinent, and systematic discussions are necessary to safely progress implementation.

Aim

To determine the attitude of health practitioners toward the penile transplant and identify the key aspects of concern pertinent to the operation and clinical care.

Methods

Health care professionals from the United States responded to either email invitation, web link, or social media post on Facebook to complete a questionnaire investigating perceptions and attitudes toward penile transplantation.

Main Outcome Measures

Respondents' attitude toward penile transplantation, their own perceived important functions of the penis, and concerns about performing a penile transplantation. Respondents' previous exposure to visceral transplants, to penile disfigurement, and information about penile transplants were used as independent factors in analysis.

Results

Among 412 health care professionals who responded to the questionnaire, 95.9% were in favor of visceral organ transplant, but only 64.3% were in favor of penile transplantation. The results showed that 61.3% of respondents first learned about the penile transplant from mass media, whereas only 37.5% had been exposed through a scientific journal, formal lecture, or a professional colleague. Younger health professionals and those exposed through professional forums surrounding penile transplantation were more likely to be in favor of the procedure (P < .001). The most important functions of the penis were identified by respondents as being sexual function (role in sexual activity) and gender identity (being a man) with rates of 86.4% and 85.3%, respectively (P < .001). Barriers identified by respondents included the use of immunosuppression and the potential subsequent effect on healthcare resource utilization. Reading an excerpt about penile trauma in war during the questionnaire improved acceptance of penile transplantation (P = .05).

Conclusion

Penile transplantation is accepted by most health professionals surveyed. Younger respondents and those informed through professional outlets are more favorable toward penile transplantation. Anticipated limitations include the risk of immunosuppression, lack of available donors, and the effect on healthcare utilization.

Najari B, Flannigan R, Hobgood J, et al. Attitudes Toward Penile Transplantation Among Urologists and Health Professionals. Sex Med 2018;6:316–323.

Trauma to the bladder and ureter: a review of diagnosis, management, and prognosis

BACKGROUND

Injuries to the ureter or bladder are relatively rare. Therefore, a high level of clinical suspicion and knowledge of operative anatomy is of utmost importance for their management. Herein, a review of the literature related to the modern diagnosis, management, and prognosis for bladder and ureteral injuries is presented.

METHODS

A literature search was conducted through PubMed. A thorough search of the world's literature published in English was completed. Search terms included "injury, diagnosis, prognosis, and management for ureter and bladder". All years, both genders, as well as penetrating, blunt, and iatrogenic mechanisms were evaluated for inclusion. Following PRISMA guidelines, studies were selected based on relevance and then categorized.

RESULTS

172 potentially relevant studies were identified. Given our focus on modern diagnosis and treatment, we then narrowed the studies in each category to those published within the last 30 years, resulting in a total of 26 studies largely consisting of Level IV retrospective case series. Our review found that bladder ruptures occur from penetrating, blunt, or iatrogenic mechanisms, and most are extraperitoneal (63%). Ureteral injuries are incurred from penetrating mechanisms in 77% of cases. The overall mortality rates for bladder rupture and ureteral injury were 8 and 7%, respectively.

LIMITATIONS

Limitations of this article are similar to all PRISMA-guided review articles: the dependence on previously published research and availability of references.

CONCLUSION

The bladder is injured far more often than the ureter but ureteral injuries have higher injury severity. Both of these organs can be damaged by penetrating, blunt, or iatrogenic mechanisms and surgical intervention is often required for severe ureter or bladder injuries. Since symptoms of these injuries may not always be apparent, a high level of suspicion is required for appropriate diagnosis and treatment.