EXECUTIVE SUMMARY

Between 2001 and 2013, U.S. Service Members (SMs) sustained 1,631 amputations and 1,462 genitourinary (GU) injuries; excluding female GU injuries and those who died from their wounds, there were 1,367 patients who made up 5.3% of all injuries sustained in Afghanistan and Iraq.1 The trend of GU injuries continued to rise, mostly secondary to an increased incidence of complex blast injuries (dismounted improvised explosive device injuries), to an annual incidence of over 13% before the Iraq drawdown in 2011, with an overall incidence of 7.2% between 2007 and 2020.2 The injury patterns varied, with 73% involving the external genitalia; injuries included scrotal (56%), testicular (31%), penile (21%), and renal (9.1%).1,3 GU injuries are often a component of more severe polytrauma, primarily caused by explosive mechanisms and require a high amount of resources. Comorbid injuries included traumatic brain injuries (40%), lower extremity amputations (29%), pelvic fractures (25%) and colorectal injuries (22%).1

Patients who sustained these injury patterns most often survived their injuries (94%), requiring numerous resources for short-term survival and long-term rehabilitation. The median injury severity scores for this population were 18 (IQR 10-29), with high associated injury severity scores to the abdomen/pelvis (2; 0-3) and extremities (3; 0-3).2 Massive transfusion protocols (MTP), defined as 10 or more units of blood given within 24 hours, were activated 4.4 times more in patients with complex blast injuries that included GU wounds (RR=5.08) from 2007 to 2020. Overall, 35% of all injuries with GU involvement required MTP. Of all MTPs during these 13 years, GU injuries made up 28%.2

Genitourinary surgery constitutes approximately 1.15% of procedures performed for combat injuries. During forward deployment, surgeons usually deploy without urology support.1 Mirroring the above injury patterns, the most common procedures involve testis (21%), bladder (19%), scrotum (18%), and kidneys (14%). The most common individual procedures performed were unilateral orchiectomy (394, 9.9%), suture of laceration of scrotum and tunica vaginalis (373, 9.4%), nephroureterectomy (360, 9.1%), and suprapubic cystostomy (268, 6.8%). Orchiectomies occurred 48% of the time for any testicular surgery, and nephroureterectomies occurred 67% of the time for any surgery to the kidneys.1,3,4 Surgery on the male genitalia, bladder, and kidney comprised the most commonly required genitourinary operative procedures at deployed facilities.1 All deploying surgeons may be required to evaluate, stage, and surgically manage genitourinary and gynecologic conditions. Therefore, all surgeons should be familiar with the appropriate treatment of these injuries.

These guidelines provide direction for the identification of life-threatening GU injuries, control of hemorrhage, the establishment of urinary drainage, and the preservation of GU function when possible.