Management of combat-related urological trauma in the modern era

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.

Proteomic profiling of regenerated urinary bladder tissue in a non-human primate augmentation model

Urinary bladder dysfunction can be caused by environmental, genetic, and developmental insults. Depending upon insult severity, the bladder may lose its ability to maintain volumetric capacity and intravesical pressure resulting in renal deterioration. Bladder augmentation enterocystoplasty (BAE) is utilized to increase bladder capacity to preserve renal function using autologous bowel tissue as a "patch." To avoid the clinical complications associated with this procedure, we have engineered composite grafts comprised of autologous bone marrow mesenchymal stem cells (MSCs) co-seeded with CD34+ hematopoietic stem/progenitor cells (HSPCs) onto a pliable synthetic scaffold [poly(1,8-octamethylene-citrate-co-octanol)(POCO)] or a biological scaffold (SIS; small intestinal submucosa) to regenerate bladder tissue in our baboon bladder augmentation model. We set out to determine the global protein expression profile of bladder tissue that has undergone regeneration with the aforementioned stem cell seeded scaffolds along with baboons that underwent BAE. Data demonstrate that POCO and SIS grafted animals share high protein homogeneity between native and regenerated tissues while BAE animals displayed heterogeneous protein expression between the tissues following long-term engraftment. We posit that stem cell-seeded scaffolds can recapitulate tissue that is nearly indistinguishable from native tissue at the protein level and may be used in lieu of procedures such as BAE.

Pain mechanisms in the transgender individual: a review

Specific Aim

Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research.

Methods

A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research.

Results

While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain.

Conclusions

While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.

Proteomic profiling of regenerated urinary bladder tissue with stem cell seeded scaffold composites in a non-human primate bladder augmentation model

Urinary bladder insult can be caused by environmental, genetic, and developmental factors. Depending upon insult severity, the bladder may lose its ability to maintain capacity and intravesical pressures resulting in renal deterioration. Bladder augmentation enterocystoplasty (BAE) is employed to increase bladder capacity to preserve renal function using autologous bowel tissue as a "patch." To avoid the clinical complications associated with this procedure, we have engineered composite grafts comprised of autologous bone marrow mesenchymal stem cells (MSCs) with CD34+ hematopoietic stem/progenitor cells (HSPCs) co-seeded onto a pliable synthetic scaffold [POCO; poly(1,8-octamethylene-citrate-co-octanol)] or a biological scaffold (SIS; small intestinal submucosa) to regenerate bladder tissue in a baboon bladder augmentation model. We set out to determine the protein expression profile of bladder tissue that has undergone regeneration with the aforementioned stem cell seeded scaffolds along with baboons that underwent BAE. Data demonstrate that POCO and SIS grafted animals share high protein homogeneity between native and regenerated tissues while BAE animals displayed heterogenous protein expression between the tissues following long-term engraftment. We posit that stem cell seeded scaffolds can recapitulate tissue that is almost indistinguishable from native tissue at the protein level and may be used in lieu of procedures such as BAE.

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.

Penile reconstruction: An up-to-date review of the literature

Objective

: To review the literature on adult penile reconstruction due to Peyronie’s disease, trauma and cosmesis, while emphasising specific surgical techniques and procedures such as phalloplasty, radial forearm free flap reconstruction, and penile transplant.

Methods

: A comprehensive review of the literature for the years 1992–2020 of the PubMed and SpringerLink databases was performed to identify articles on penile reconstruction. Search terms included ‘penile reconstruction’, ‘penile trauma’, ‘phalloplasty’, ‘penile transplant’, and ‘treatment of Peyronie’s’. Relevant articles were selected. All included studies were performed on adults and written in English.

Results

: We were able to identify 46 papers from PubMed and SpringerLink that included the research terms. From these, we included technical details of procedures and gleaned photographs of their works. Additionally, we included photographs from our institution’s own plication surgery cases.

Conclusions

: The field of adult penile reconstruction is performed for a plethora of reasons. From cosmetic to urgent and from routine to complex, it is most certainly a growing subset of Urology that plays a vital role for the men who need it. To our knowledge, this is the most up-to-date review of adult penile reconstruction.

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).

Towards clinical application of tissue engineering for erectile penile regeneration

Penile wounds after traumatic and surgical amputation require reconstruction in the form of autologous tissue transfers. However, currently used techniques are associated with high infection rates, implant erosion and donor site morbidity. The use of tissue-engineered neocorpora provides an alternative treatment option. Contemporary tissue-engineering strategies enable the seeding of a biomaterial scaffold and subsequent implantation to construct a neocorpus. Tissue engineering of penile tissue should focus on two main strategies: first, correcting the volume deficit for structural integrity in order to enable urinary voiding in the standing position and second, achieving erectile function for sexual activity. The functional outcomes of the neocorpus can be addressed by optimizing the use of stem cells and scaffolds, or alternatively, the use of gene therapy. Current research in penile tissue engineering is largely restricted to rodent and rabbit models, but the use of larger animal models should be considered as a better representation of the anatomical and physiological function in humans. The development of a cell-seeded scaffold to achieve and maintain erection continues to be a considerable challenge in humans. However, advances in penile tissue engineering show great promise and, in combination with gene therapy and surgical techniques, have the potential to substantially improve patient outcomes.

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.

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.

Protein-mediated anti-adhesion surface against oral bacteria

Biomedical materials, such as orthopedic biomaterials, have a great impact on improving life quality and self-esteem of human beings. However, the usage of fixed appliances during dental treatment often increases the difficulty of oral cleaning and enlarges the adhesion opportunity of oral bacteria. Furthermore, the existing anti-adhesion coatings, such as polyethylene glycol derivatives and zwitterionic polymers, have not been universally accepted in the oral environment due to their intrinsic problems. Herein, inspired by the anti-adhesion capability of bovine serum albumin, we report a facile protein-based anti-bacterial surface, showing excellent anti-adhesion performance toward oral bacteria. This protein-mediated anti-adhesion strategy may provide a promising clue for developing new anti-bacterial biomaterials, such as dental fixed appliances, restorative materials and medical mouthwashes.

Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up

INTRODUCTION

Ritual circumcision complicated by gangrene is a leading cause of penile loss in young men in South Africa. This deeply rooted cultural tradition is unlikely to be abolished. Conventional reconstructive techniques using free vascularised tissue flaps with penile implants are undesirable in this often socioeconomically challenged group because donor site morbidity can hinder manual labour and vigorous sexual activity might lead to penile implant extrusion. The psychosociological effects of penile loss in a young man are devastating and replacing it with the same organ is likely to produce the maximum benefit.

METHODS

We first performed a cadaver-to-cadaver penile transplantation as preparation. After approval from the Human Research Ethics Committee was obtained, we recruited potential recipients. We screened the potential participants for both physical and psychological characteristics, including penile stump length, and emotional suitability for the procedure. A suitable donor became available and the penis was harvested. We surgically prepared the penile stump of the recipient and attached the penile graft. Immunosuppression treatment with antithymyocyte globulin, methylprednisolone, tacrolimus, mycophenolate mofetil, and prednisone were commenced. Tadalafil at 5 mg once per day was commenced after 1 week as penile rehabilitation and was continued for 3 months. We collected on quality-of-life scores (Short Form 36 version 2 [SF-36v2] questionnaires) before surgery and during follow-up and measured erectile function (International Index for Erectile Function [IIEF] score) and urine flow rates at 24 months post transplant.

FINDINGS

The warm ischaemia time for the graft after removal was 4 min and the cold ischaemia time was 16 h. The surgery lasted 9 h. An arterial thrombus required urgent revision 8 h after the operation. On post operative day 6, an infected haematoma and an area of proximal skin necrosis were surgically treated. The recipient was discharged after 1 month and first reported satisfactory sexual intercourse 1 week later (despite advice to the contrary). The recipient reported regular sexual intercourse from 3 months after the operation. An episode of acute kidney injury at 7 months was reversed by reducing the tacrolimus dose to 14 mg twice per day. At 8 months after surgery, the patient had a skin infection with phaeohyphomycosis due to Alternaria alternata, which we treated with topical antifungal medication. Quality-of-life scores improved substantially after the operation (SF-36v2 mental health scores improved from 25 preoperatively, to 57 at 6 months and 46 at 24 months post transplant; physical health scores improved from 37 at baseline to 60 at 6 months and 59 at 24 months post-transplant). At 24 months, measured maximum urine flow rate (16·3 mL/s from a volume voided of 109 mL) and IIEF score (overall satisfaction score of 8 from a maximum of 10) were normal, showing normal voiding and erectile function, respectively.

INTERPRETATION

Penile transplantation restored normal physiological functions in this transplant recipient without major complications in the first 24 months.

FUNDING

Department of Health, Western Cape Government.

Urologic Diseases in Korean Military Population: a 6-year Epidemiological Review of Medical Records

We sought to describe the incidence rate of the urologic disease in the Korean military by reviewing diagnoses made in active duty soldiers from 2008 to 2013. A total of 72,248 first visits were generated in the Defense Medical Statistics Information System (DMSIS) with its gradually increasing trend over 6 years. A sharp increase of first visit was observed after implementation of the regular health check-up for all conscripted soldiers since 2013. Urolithiasis, prostatitis, epididymoorchitis, urethritis, and varicocele were prevalent. Prostatitis was the highest diagnosis made in the outpatient service, while varicocele was ranked the highest in the inpatient service. The incidence rates of urologic disease varied from 12.3 to 34.2 cases per 1,000 person-years. The urologic disease in conscripted men showed different distribution when we separated the population into conscripted and professional soldiers. Epididymoorchitis was the highest disease followed by urolithiasis, dysuresia, and balanoposthitis in 2013. This study underscores that the urologic disease has spent significant amount of health care resources in the Korean military. This calls for further study to find any significant difference and contributing factors of the urologic disease in the military and the civilian population.

Improvised explosive device-related lower genitourinary trauma in current overseas combat operations

BACKGROUND

The use of improvised explosive devices (IEDs) has had a profound effect on battlefield trauma in the 21st century. Historically, wounds to the genitourinary (GU) structures have been less common than extremity and penetrating abdominal trauma in combat operations. GU injury incidence, severity, and associated injuries secondary to the use of this weapon in Operations Iraqi and Enduring Freedom has not been described.

METHODS

Data from the Department of Defense Trauma Registry was reviewed for combat-related GU injuries in Operations Iraqi and Enduring Freedom from 2001 to 2011. All wounded US armed service members are included in this database. Subjects were selected by a query of current procedural terminology and DRG International Classification of Diseases-9th Rev. codes related to traumatic injury of the penis, scrotum, testicles, and urethra. A retrospective chart review was performed for each patient to identify the date of injury, the mechanism of injury, and the associated traumatic wounds. Subjects' follow-up records were reviewed until present time or separation from active duty.

RESULTS

A total of 501 soldiers sustained lower GU trauma, with a total of 729 injuries. Of these casualties, 448 (89%) were wounded by IEDs. Dismounted injuries (87%) made up more of the cohort than did vehicular. Specific trauma sites include 149 (20%) penile, 260 (36%) testicular, 284 (39%) scrotal, and 36 (5%) urethral injuries. The 180 limb amputations (36%) and 86 fractures (17%) were the most encountered concomitant skeletal wounds among service members with GU injuries.

CONCLUSION

This is the first review of all lower GU trauma sustained by all US armed service members in current overseas combat operations. Combat-related lower GU trauma is primarily caused by IEDs in the spectrum of complex dismounted blast injuries. The mechanism primarily results in multisystem injury, with isolated GU involvement being uncommon. Continued evaluation of long-term sequelae, including sexual, urinary, and reproductive dysfunction, is needed.

LEVEL OF EVIDENCE

Epidemiologic study, level V.

Penile Amputation: Cosmetic and Functional Results

INTRODUCTION

Penile amputation is a rare type of external genital trauma. It may arise from accidental trauma, assault or self-inflicted mutilation. As with all trauma, initial management focuses on assessment and resuscitation of the patient. When available, hypothermic preservation of the detached penis should be undertaken.

AIM

This review serves to compile the current available information on etiology and management of penile amputation injuries, with focus on functional and cosmetic results.

MAIN OUTCOME MEASURES

Main outcome measures were penile cosmetics, viability, and sensation; urethral patency and graft survival, functionality.

METHODS

A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1980-2013.

RESULTS

Due to the rarity of penile amputation injuries, no randomized trials exist. Likewise, available published series on management of this condition are comprised of a small number of patients.

CONCLUSIONS

Penile amputation is rare but challenging. Current microreplantation procedures have a uniformly good result with a minimum number of post-operative complications. When microreplantation cannot be performed, older corporal reattachment techniques may be offered. When phallic reconstruction is required, a microsurgical free forearm flap phalloplasty may be performed to restore the patient with an acceptable cosmetic and functional phallus. Virasoro R, Tonkin JB, McCammon KA, and Jordan GH. Penile amputation: Cosmetic and functional results. Sex Med Rev 2015;3:214-222.

Influence of the severity and location of bodily injuries on post-concussive and combat stress symptom reporting after military-related concurrent mild traumatic brain injuries and polytrauma

Traumatic brain injuries (TBI) sustained in combat frequently co-occur with significant bodily injuries. Intuitively, more extensive bodily injuries might be associated with increased symptom reporting. In 2012, however, French et al. demonstrated an inverse relation between bodily injury severity and symptom reporting. This study expands on that work by examining the influence of location and severity of bodily injuries on symptom reporting after mild TBI. Participants were 579 US military service members who sustained an uncomplicated mild TBI with concurrent bodily injuries and who were evaluated at two military medical centers. Bodily injury severity was quantified using a modified Injury Severity Score (ISSmod). Participants completed the Neurobehavioral Symptom Inventory (NSI) and the Posttraumatic Stress Disorder Checklist (PCL-C), on average, 2.5 months post-injury. There was a significant negative association between ISSmod scores and NSI (r=-0.267, p<0.001) and PCL-C (r=-0.273, p<0.001) total scores. Using linear regression to examine the relation between symptom reporting and injury severity across the six ISS body regions, three body regions were significant predictors of the NSI total score (face; p<0.001; abdomen; p=0.003; extremities; p<0.001) and accounted for 9.3% of the variance (p<0.001). For the PCL-C, two body regions were significant predictors of the PCL-C total score (face; p<0.001; extremities; p<0.001) and accounted for 10.5% of the variance. There was an inverse relation between bodily injury severity and symptom reporting in this sample. Hypothesized explanations include underreporting of symptoms, increased peer support, disruption of fear conditioning because of acute morphine use, or delayed expression of symptoms.