Genitourinary Trauma Research Articles

Legal and medical aspects of the problem of postmortem donation in reproductive medicine

The reproductive system plays a crucial role in preserving the human race. The health of the reproductive system reflects not only the genetic viability of future generations but also overall health. It is also related to numerous human rights, including the right to life, liberty, personal integrity, health, education, and the principle of equality and non-discrimination. The state, on the other hand, has positive obligations to ensure the observance, protection, and implementation of reproductive rights. Everyone has the right to the highest attainable level of physical and mental health. Any individual or couple has the right to decide how many children to have, when to have them, and at what intervals, even if it involves postmortem reproduction. That is why it is necessary to pay attention to the need to ensure the rights of servicemen to biological paternity (motherhood), which is extremely important, especially in the context of martial law in Ukraine.Despite some controversial aspects arising in the context of postmortem donation in Ukraine, it is the duty of the legislator to adopt laws and create legal provisions that can properly regulate this area. In doing so, the principle of proportionality should be taken into account, which can help to achieve the necessary balance between personal integrity and respect for the body after death, on the one hand, and the right to family, on the other. It should be understood that the experience of states at war has highlighted the urgency of postmortem donation and the position of society on its legal integration along with other areas of social relations that are subject to regulation. Military service, given its daily risks, can certainly compromise fertility, particularly through genitourinary trauma that can be associated with combat, gonadotoxic exposure, and physical separation from a partner.In addition, the issue of disposing of oocytes in case of death or declaration of death of a servicewoman remains unaddressed. Implementation of postmortem donation in the event of the death of a female military service member is possible only through surrogate motherhood. However, the current legislation in this area does not regulate the possibility of in vitro fertilization after the death of one of the spouses and completely “bypasses” any derivative issues related to surrogate motherhood after death.

External validation of the MiGUTS nomogram for the prediction of bleeding control intervention after renal trauma.

The American Association for the Surgery of Trauma (AAST) renal trauma grading leads to a variable management of patients with high-grade renal injuries. For a better prediction of the risk for bleeding interventions, Keihani et al. introduced the multi-institutional genito-urinary trauma study (MiGUTS) renal trauma nomogram in 2019. The aim of this study was to conduct an external validation and generalization for all kidney trauma cases of the nomogram with a European cohort of a Swiss level 1 trauma center. We collected data from the clinical information system of the Kantonsspital Graubünden, Chur, Switzerland. All patients ≥ 18 years of age from 01.01.2008 to 01.12.2020 with a renal trauma who underwent computed tomography imaging of the abdomen were included. The descriptive analysis was performed by a t-test/Wilcoxon signed-rank test and a Chi-square test. The predictions of the nomogram were analysed by the Pearson correlation coefficient. The threshold of prediction of a bleeding intervention was optimized by a ROC analysis. Overall, 166 patients were included. Most patients were male (80.7%) with a median age of 44 years. Using the prediction from the MiGUTS nomogram developed by Keihani et al. we were able to identify a threshold with a sensitivity of 1.00, specificity of 0.87, positive predictive value of 0.44, negative predictive value of 1.00 and accuracy of 0.88. The MiGUTS nomogram by Keihani et al. demonstrated to be reliable in the prediction of an intervention for bleeding control in our validation study in a European cohort.

Urologic Trauma Management for Military Providers.

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. 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. 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. 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.

Legal Outcomes of Litigation After Iatrogenic Genitourinary Trauma

INTRODUCTIONTo evaluate plaintiff and defendant characteristics associated with iatrogenic genitourinary trauma litigation and outcomes of closed claims. METHODSLexisNexis was queried in April 2023 using terms related to genitourinary organs and injury, and manually reviewed for iatrogenic cases. Case details including defendant, organ involvement, and legal outcome were obtained. Multinomial regression analysis was performed to identify factors associated with outcome. RESULTS410 cases involving 611 defendants were identified, with the ureter the most commonly affected organ (202/410, 49.3%). Most cases involved adult plaintiffs (380, 92.7%) and resulted in favor of the defense (227, 55.4%). Injuries resulted most frequently from gynecologic surgeries (179, 43.7%). Defendants were most commonly obstetricians/gynecologists (243/611, 39.8%) and urologists (168, 27.5%). Penile (OR 6.3 [95% CI 2.5-16.1]) and urethral (OR 4.8 [2.0-11.7]) injuries were associated with greater odds of a plaintiff verdict relative to ureter injury. A plaintiff verdict was also more likely when defendants were academic hospitals compared to individual practitioners (OR 4.3 [1.9-9.9]). In cases ruling in favor of the plaintiff, indemnity payments were larger when the defendants were comprised of individual practitioners compared to a hospital or medical group (median $549,613 vs. $250,000, p < 0.001). CONCLUSIONUrologists may be involved in medical malpractice lawsuits for iatrogenic injury even when they are uninvolved in the index procedure. Most cases that reach litigation result in defense verdicts regardless of the genitourinary organ injured. Defendant characteristics associated with plaintiff verdicts are more nuanced, and providers should be aware of potential downstream effects of litigation.

(160) Improving Symptoms in Young Men with Erectile Dysfunction: Testosterone Therapy With or Without PDE5 Inhibitors

Abstract Introduction While erectile dysfunction (ED) in young men has traditionally been viewed as primarily psychogenic in etiology, a growing body of evidence supports a higher prevalence of organic etiology. Objective The aim of this study was to further characterize the etiology and treatment outcomes of ED in men under 40 years at a single institution. Methods A retrospective chart review of men presenting with ED from 2010-2022 was undertaken. Men initially presenting under the age of 40 years were included and analyzed for hypogonadism, ED etiology, and treatment outcomes. Results Of our cohort, a total of 74 men under the age of 40 years presented with complaint of ED (mean age 31.6 years). Twenty-three (31.1%) men were eugonadal without organic etiology of ED. Of these men, 22 (95.7%) were started on phosphodiesterase-5 inhibitors (PDE5i) and one (4.3%) reported symptom resolution without treatment. The remaining 51 (68.9%) men presented with ED of likely organic origin. Forty-two (82.4%) of these men were hypogonadal and were started on testosterone, human chorionic gonadotropin, clomid and/or a PDE5i. Of those who followed up, 32 (91.9%) men reported improvement in symptoms after therapy. The organic etiologies of ED in the nine (17.6%) eugonadal men included history of urologic surgery (4), Peyronie’s disease (2), prior genitourinary trauma (1), spinal cord tumor (1), and prolactinoma (1). Within this group, four (44.4%) progressed to intra-cavernosal injection, two (22.2%) improved with PDE5i, and three (33.3%) were lost to follow-up. Conclusions It appears that the majority of young patients who present with ED are hypogonadal. Treating this population of men with medication to raise natural testosterone with or without the addition of a PDE5i has been shown to improve their symptoms. Young eugonadal men with no discernable organic etiology of ED respond well to oral PDE5i alone but tended to not follow-up, suggesting possible ED resolution without a need for prolonged treatment. In all, clinicians should check serum testosterone levels and conduct a thorough urological history to identify potential organic etiologies of ED in younger men before assuming a psychogenic basis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for AbbVie, Marius, Tolmar, Endo, Petros, Boston Scientific, Coloplast Investor: Sprout.

Proposed revision of the American Association for Surgery of Trauma Renal Organ Injury Scale: Secondary analysis of the Multi-institutional Genitourinary Trauma Study.

This study updates the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. This was a secondary analysis of a multicenter retrospective study including patients with high-grade renal trauma from seven level 1 trauma centers from 2013 to 2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed-effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST OIS. Based on the 2018 OIS grading system, we included 549 patients with AAST grades III to V injuries and computed tomography scans (III, 52% [n = 284]; IV, 45% [n = 249]; and V, 3% [n = 16]). Among these patients, 89% experienced blunt injury (n = 491), and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded, and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from grade IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC, 0.805; revised AUC, 0.883; p = 0.001) and number of units of packed red blood cells transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. Diagnostic Test/Criteria; Level III.

When the Bullet Finds the Only Kidney: A rare happening of a stray bullet embedded in solitary functioning kidney

Genitourinary trauma as a result of penetrating injury by gunshot wound occurs in about ten per cent. A bullet left in a solitary functioning kidney is extraordinarily rare. We report the case of a young patient who suffered a gunshot injury with that very rare situation--a bullet remaining in his only operational kidney for years and inflected calculus which had grown over it. After successful endoscopic percutaneous lithotripsy, the bullet was retrieved from the patient's urinary bladder. Key Words: PCNL, Renal Stone, Fire-arm injury

The endoscopic removal of urethral foreign body (a fragment of an artillery shell): a clinical case

Gunshot wounds of the external genitalia are present in two-thirds of all penetrating genitourinary trauma in the military setting with prevailing shrapnel wounds.The reported clinical case is aimed at providing rational and demonstrating benefits of endoscopic removal of a splinter from the urethral lumen.The clinical case presents the successful removal of a splinter from the urethral lumen. A 22-year-old man suffered gunshot shrapnel wound to the scrotum and urethra 7 months ago, а splinter was located in the urethral lumen and was successfully removed using endoscopic approach. In some cases X-ray diagnosis does not allow detecting the exact location of the splinter. Therefore, it is rational to use endourological diagnostic procedures.

Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma

ContextThe European Association of Urology (EAU) Guidelines Panel for Urological Trauma has produced guidelines in order to assist medical professionals in the management of urological trauma in adults for the past 20 yr. It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients regarding other parameters such as experience and available facilities. Guidelines are not mandates and do not purport to be a legal standard of care. ObjectiveTo present a summary of the 2023 version of the EAU guidelines on the management of urological trauma. Evidence acquisitionA systematic literature search was conducted from 1966 to 2022, and articles with the highest certainty evidence were selected. It is important to note that due to its nature, genitourinary trauma literature still relies heavily on expert opinion and retrospective series. Evidence synthesisDatabases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 1, 2021 and April 29, 2022. A total of 1236 unique records were identified, retrieved, and screened for relevance. ConclusionsThe guidelines provide an evidence-based approach for the management of urological trauma. Patient summaryTrauma is a serious public health problem with significant social and economic costs. Urological trauma is common; traffic accidents, falls, intrapersonal violence, and iatrogenic injuries are the main causes. Developments in technology, continuous training of medical professionals, and improved care of polytrauma patients reduce morbidity and maximise the opportunity for quick recovery.

Re: Grade V Renal Trauma Management: Results from the Multi-institutional Genito-urinary Trauma Study

Re: Grade V Renal Trauma Management: Results from the Multi-institutional Genito-urinary Trauma Study

Pediatric genitourinary injuries: 7-year experience at the largest tertiary referral hospital in Eastern part of Indonesia

The anatomical variations between children and adults render pediatric patients more prone to urogenital trauma. However, it is not known for certain whether children are more prone to genitourinary trauma than adults. The aim of the study is to scrutinize the characteristic of pediatric genitourinary trauma at, the largest tertiary hospital in Eastern part of Indonesia. The design of the study was analytic retrospective gathering medical records of all pediatric patients with urogenital trauma with total sampling. The number of patients, ages, genders, etiology, locations, and management were collected. Data was statistically analyzed using SPSS®, and p<0.05 was considered statistically significant. We found 13.5 (10-15.5) years as the median age in our 60 samples. Boy (75.00%), renal trauma (56.67%), abdominal and pelvic trauma (96.67%), traffic accident (91.67%), suprapubic catheterization (52.17%), and hemodynamically stable (91.67) was among the majority. We also found that non-operative management was in majority. Statistical analysis demonstrated significant differences for management and grade of injury (p<0.05). This is, to the best of our knowledge, the first study of genitourinary injuries in children who were treated at a tertiary hospital in Indonesia during the course of the 7-year research period. The limitations of this study are retrospective character and conducted in single institution. The highest incidence of pediatric urogenital trauma is renal trauma due to traffic accident, which often multitrauma. Future prospective multi-center studies should be done to corroborate the results.

URETHRAL INJURY IN REGIONAL HOSPITAL IN THE BPJS ERA: A CASE REPORT

ABSTRACT&#x0D; Objective: To present a case of urethral injury treated in a male adult. Case(s) Presentation: A 48 year old Asian male patient previously involved in a motor vehicle accident presented to the hospital with a chief complaint of pain and bleeding from the genitalia. On examination, it is revealed bleeding from the urethral meatus, pain in touch, palpable bladder, high riding prostate, and a butterfly-shaped bruising on the perineum. X-ray examination demonstrated soft tissue mass in the right scrotal region. The patient is diagnosed with urethral rupture with urinary retention and then underwent ultrasonography-guided cystostomy and perineal hematoma evacuation. The patient is followed-up 1 month later with a complaint of difficulty in voiding and erectile dysfunction. The patient is then diagnosed with urethral stricture and underwent direct vision urethrotomy. Discussion: Urethral injury is a rare type of injury of genitourinary trauma that may cause long term morbidity such as strictures, incontinence, impotence, and infertility. Urethral injury can be classified into posterior urethral injury which is associated with pelvic fracture and anterior urethral injury which is associated with blunt trauma. The gold standard of radiographic examination in urethral injury is dynamic retrograde urethrography. Prompt diagnosis, staging, and selecting intervention must be done for minimalizing complications. Sequelae may also develop which also affects quality of life. The usage of universal health coverage such as BPJS in In Indonesia can increase the accessibility of medical treatment. Conclusion: Urethral injury is a rare injury that requires prompt and careful management to minimize complications and increase the patient’s quality of life.&#x0D; Keywords: Urethral Injury, urethrotomy, urethral stricture.

Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study.

To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

Omitting Foley Catheter Use in Mastectomy Patients With or Without Immediate Reconstruction.

Foley catheter placement is often advised in surgeries anticipated to exceed 3 hours; however, this time cutoff does not take into account the type of surgery. Complications from Foley catheter placement include urinary tract infections and genitourinary trauma that may be costly to healthcare systems. Our objective was to determine whether mastectomy with or without reconstruction can be done without Foley use, without an increase in urinary retention risk. One hundred eighty-seven patients who underwent unilateral or bilateral mastectomies with or without reconstruction in 2020 and 2021 were reviewed. Chart review included intraoperative fluids given, estimated blood loss, lymph node dissection, and duration of procedure. After excluding patients with case duration under 180 minutes, 145 remained. Ninety-four patients did not have a Foley and 51 patients had an intraoperative Foley. None of the patients without a Foley experienced postoperative urinary retention, including 3 patients who also underwent lymphatic microsurgical preventive healing approach. Eighty-six percent of patients were discharged on the day of surgery. Patients with or without a Foley did not differ significantly in terms of race, rate of axillary lymph node dissection, body mass index, rate of same-day discharge, presence of hypertension or diabetes, estimated blood loss, or age. Patients undergoing unilateral and bilateral mastectomies with or without reconstruction or lymphatic microsurgical preventive healing approach may avoid Foley catheter placement without increased risk of urinary retention, even if the case is anticipated to exceed 3 hours. Advantages include elimination of catheter-associated urinary tract infections and their associated hospital costs, as well as avoiding genitourinary trauma.

PD12-01 THE ROLE OF NON-OPERATIVE MANAGEMENT IN SEVERE RENAL INJURIES: DO ALL GRADE V INJURIES NECESSITATE INTERVENTION?

You have accessJournal of UrologyCME1 Apr 2023PD12-01 THE ROLE OF NON-OPERATIVE MANAGEMENT IN SEVERE RENAL INJURIES: DO ALL GRADE V INJURIES NECESSITATE INTERVENTION? Nizar Hakam, Sorena Keihani, Nathan Shaw, Douglas Rogers, Sherry Wang, Joel Gross, Ryan Joyce, Patrick Selph, Judith Hagedorn, Rachel Moses, Ian Schwartz, Shubham Gupta, Christopher Dodgion, Nima Baradaran, Bradley Erickson, Frank Burks, Richard Santucci, Joshua Broghammer, Jeremy Myers, and Benjamin Breyer Nizar HakamNizar Hakam More articles by this author , Sorena KeihaniSorena Keihani More articles by this author , Nathan ShawNathan Shaw More articles by this author , Douglas RogersDouglas Rogers More articles by this author , Sherry WangSherry Wang More articles by this author , Joel GrossJoel Gross More articles by this author , Ryan JoyceRyan Joyce More articles by this author , Patrick SelphPatrick Selph More articles by this author , Judith HagedornJudith Hagedorn More articles by this author , Rachel MosesRachel Moses More articles by this author , Ian SchwartzIan Schwartz More articles by this author , Shubham GuptaShubham Gupta More articles by this author , Christopher DodgionChristopher Dodgion More articles by this author , Nima BaradaranNima Baradaran More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Frank BurksFrank Burks More articles by this author , Richard SantucciRichard Santucci More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Jeremy MyersJeremy Myers More articles by this author , and Benjamin BreyerBenjamin Breyer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Non-operative management has become standard for most renal trauma. Little data exists regarding conservative management of American Association for the Surgery of Trauma (AAST) grade V injuries. We aim to evaluate management of grade V renal trauma, focusing on feasibility and safety of non-operative management. METHODS: Grade V renal trauma cases submitted with available imaging from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We report management patterns categorized as expectant (observation with no interventions), conservative (performing kidney angioembolization, or stent / nephrostomy tube / perirenal drain placement), or operative (performing kidney related surgical interventions). RESULTS: 21 cases were independently radiologically verified as grade V cases by the 2018 AAST classification and were included in analysis. Most were males (15; 71%) with blunt trauma (20; 95%) and median age was 34 years (IQR 25-29). Most common management approach was operative (8, 38%), followed by conservative (7, 33%) and expectant (6, 29%). All those operatively management had nephrectomy, with 2 having a failed angioembolization attempt before nephrectomy. 4 out of 7 patients in the conservative group had angioembolization and the other 3 had a stent or drainage tube. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size, laceration size and proportion of cases with >50% and >95% devascularization (Table 1). Vascular contrast extravasation tended to be higher in operatively managed patients, but was not statistically significant. CONCLUSIONS: There is a significant role for non-operative management for grade V renal trauma, particularly in those with blunt trauma and are stable enough to undergo imaging. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e400 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nizar Hakam More articles by this author Sorena Keihani More articles by this author Nathan Shaw More articles by this author Douglas Rogers More articles by this author Sherry Wang More articles by this author Joel Gross More articles by this author Ryan Joyce More articles by this author Patrick Selph More articles by this author Judith Hagedorn More articles by this author Rachel Moses More articles by this author Ian Schwartz More articles by this author Shubham Gupta More articles by this author Christopher Dodgion More articles by this author Nima Baradaran More articles by this author Bradley Erickson More articles by this author Frank Burks More articles by this author Richard Santucci More articles by this author Joshua Broghammer More articles by this author Jeremy Myers More articles by this author Benjamin Breyer More articles by this author Expand All Advertisement PDF downloadLoading ...

A Contemporary Analysis of Combat-related Urological Injuries: Data From the Department of Defense Trauma Registry.

There has been little to no literature published on combat-related genitourinary injuries beyond 2013. With the goal of enhancing medical readiness prior to deployment and making recommendations to improve the long-term rehabilitation of service members as they become civilians, we sought to describe the incidence of combat-related genitourinary injuries and interventions from January 1, 2007, to March 17, 2020. We conducted a retrospective analysis of the Department of Defense Trauma Registry, which is a prospectively maintained database, for the time between 2007 and 2020. We used predefined search criteria to primarily identify any casualties that arrived at a military treatment facility with urological-based injuries. The registry contained 25,897 adult casualties, of which 7.2% sustained urological injuries. The median age was 25. Explosive injuries (64%) and firearms (27%) predominated. The median injury severity score was 18 (IQR 10-29). Most patients survived until hospital discharge (94%). The most frequently injured organs were the scrotum (60%), testes (53%), penis (30%), and kidneys (30%). Massive transfusion protocols were activated in 35% of all patients who sustained a urological injury and accounted for 28% of all protocols between 2007 and 2020. The incidence of genitourinary trauma persistently increased for both military and civilian personnel as the U.S. remained actively engaged in major military conflicts during this period. Patients with genitourinary trauma in this data set were often associated with high injury severity scores and required an increased number of immediate and long-term resources for survival and rehabilitation.

Penetrating gunshot wounds to the penis: a case report of combat patient injured in the war in Ukraine

BackgroundThe current war in Ukraine is associated with frequent applications of multiple-launch rocket systems and cruise missiles as well as other various high-energy weapons to cause severe injuries in military personnel including abdomen wounds, vascular injury, and limb amputations as well as genitourinary trauma. The aim of this report is to demonstrate a case of successful penile salvage by restoring its function in a combat patient with gunshot genitourinary trauma in conditions of an interrupted supply of medical equipment.Case presentationWe describe a case of a 48-year-old male patient with a combined shrapnel gunshot wound to the penis with damage to the urethra and combined injury to the soft tissues of the left thigh. Several hours after the injury, the patient underwent primary surgical debridement of the left thigh, ligation of the great saphenous vein of the thigh, primary sutures on the penile urethra and navicular fossa, suturing of the rupture of the head and penis, drainage of the wound, catheterization of the bladder, and epicystostomy. An artificial erection was performed intraoperatively.The urethral catheter was removed 3 weeks after urethral suturing (May 4, 2022). The epicystostomy was removed 5 months after the injury (August 4, 2022) and 2 days after the restoration of spontaneous urination. At the follow-up of 7 months after the injury, the patient has normal urination with minor urinary dribbling, sufficient erection, and ejaculation.ConclusionsWe have shown that in a case of gunshot wounds to the penis and hanging part of the urethra, even in the presence of combined severe purulent lesions of non-urological localizations, it is possible to perform a primary reconstruction of urogenital injuries using a primary urethral suture and applying a negative pressure device. Findings from this case report shed new light on the management of penile gunshot injury in ongoing warfare as well as provide evidence of the possibility to perform adequate management for penile injury in conditions of limited medical resources, violation of international humanitarian law, and under frequent strikes of high-energy weapons.

2224. Aminopenicillins versus Non-aminopenicillins for Treatment of Enterococcal Cystitis

Abstract Background Aminopenicillins achieve urinary concentrations that overcome aminopenicillin resistance in Enterococcus spp. lower urinary tract infections (UTI). With this rationale, our clinical microbiology laboratory discontinued routine identification on Enterococcus urine isolates in 2012 and report “aminopenicillins are predictably reliable for uncomplicated enterococcal UTI”. The study objective was to compare outcomes of patients treated with aminopenicillins (AP) versus non-aminopenicillins (NAP) for enterococcal cystitis. Methods IRB approved, retrospective cohort of adults hospitalized with symptomatic enterococcal cystitis from 2013-2021. Exclusion: definitive E. faecalis, enterococcal UTI in past year, review of systems unavailable/altered mental status, urinary instrumentation except for stent/catheter, systemic infection, fever, genitourinary trauma, renal transplant. Primary endpoint: clinical and microbiologic success at 14 days, defined as resolution of symptoms without new symptoms and no repeat culture growth of index organism. Logistic regression evaluated characteristics associated with 14-day failure. Sample size of 178 calculated for non-inferiority using α=0.025, β=0.8, 15% non-inferiority margin. Results 178 subjects included, 89 AP, 89 NAP . VRE identified: 73 (82%) AP and 76 (85%) NAP (P=0.50). Amoxicillin (36/89, 40%) and ampicillin (36/89, 40%) used most in AP. Linezolid (41, 46%) and fosfomycin (30, 34%) most common agents in NAP. 14-day clinical composite endpoint was no different between AP and NAP groups, respectively (74 [83%] vs. 73 [82%], P=0.84). No variables independently predicted failure (Table 1). Non-inferiority analysis for AP vs. NAP for 14-day composite: mean difference 1.1% (-0.14 to 0.127, 97.5% CI; P=0.42). Definite E. faecium subgroup: 14-day clinical composite success for was no different between AP and NAP groups, respectively (27/34 [79%] vs. 53/66 [80%], P=0.916). Conclusion AP were non-inferior to NAP, supporting their use as first-line therapy for cystitis due to enterococci, including E. faecium. This stewardship strategy has implications to preserve VRE active therapies (e.g. linezolid) for serious infections. Disclosures All Authors: No reported disclosures.

Penetrating trauma to scrotum and penis caused by a gunshot in 17-year old man: A case report

Penetrating trauma to male external genitalia is a rare trauma case. It accounts for 20% of all genitourinary trauma cases, and penile involvements are presented between 10- 16% of all cases. Male genital trauma is considered a urological emergency due to the high risk of infection, sexual dysfunction, and infertility. In this work, a 17-year-old male patient presented with scrotal and penile injuries due to a low-velocity gunshot wound. Genital examination revealed tissue loss in the foreskin, glans, anterior urethra (distal third), cavernous corpora, and total loss of right testis with a scrotal laceration. The patient was treated with partial penectomy, penile reconstruction, and urethral repair with an excellent uneventful postoperative cosmetic and functional outcome. In conclusion, penetrating male external genital injuries are rare with extremely serious consequences due to the functional, psychological, and aesthetic consequences. The best treatment with penile reconstruction and urethral and cavernous corpora repair may be achieved.

Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis

IntroductionBladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes. MethodsWe performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality. ResultsOf the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) ConclusionsIn our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.