UROGENITAL TRAUMA

Evaluation and management of gunshot wounds of the penis: 20-year experience at an urban trauma center
Kunkle DA, Lebed BD, Mydlo JH, Pontari MA
Department of Urology, Temple University Hospital, Philadelphia, Pennsylvania, USA
J Trauma. 2008; 64: 1038-42

• Background: Although gunshot injuries to the penis occur relatively infrequently in patients with penetrating trauma, they often present dilemmas of subsequent evaluation and management. We review our extensive experience with gunshot wounds to the penis at a high volume urban trauma center.
• Methods: The urologic trauma database was retrospectively reviewed to extract and compile information from the records of 63 patients treated for gunshot wounds to the penis. Data were accumulated for a 20-year period from 1985 to 2004 with regard to findings on physical examination, diagnostic evaluation, associated injuries, management, and outcome. We detail our technique of penile exploration and artificial erection in the management of these injuries.
• Results: Penile gunshot wounds were associated with additional injuries in 53 of 63 (84%) patients. A total of 48 (76%) patients were taken to the operating room and 44 (70%) penile explorations were performed. Evaluation included retrograde urethrogram in 50 of 63 (79%) patients and was diagnostic for urethral injury in 11 of 12 (92%) cases. Primary urethral repair was performed in 8 of 12 (67%) patients with urethral injury versus 4 of 12 (33%) who underwent urinary diversion by means of suprapubic cystotomy.
• Conclusions: Evaluation and management of gunshot wounds to the penis may potentially be complex. Retrograde urethrogram should be performed in all cases except the most insignificant and superficial wounds. We describe our technique of penile exploration and artificial erection, noting excellent results in patients for whom follow-up is available. Additional studies are needed to prospectively evaluate techniques for management of gunshot urethral injuries.
  
  
• Editorial Comment
  The above two articles are from major trauma centers in the US, from San Francisco and Philadelphia. The San Francisco paper is unique in that the 30 year experience is the cumulative experience of one surgeon (an authority in the field) over the course of his career. This continuity and consistency of care, strengthens the conclusions of this paper.
  Overall, both papers illustrate that penetrating genital injuries occur uncommonly – even in major trauma centers, only 3 or so cases per year. Such rare events, further values the conclusions and cumulative experience of papers over such long study period. Aside from evaluating the injury to the genitals, all patients need to be evaluated according to AAST trauma protocols, including routine radiographs of the chest and abdomen, with entrance and exit wounds marked with radio-opaque markers. General surgical principles for managing penetrating injuries apply well to external genitalia trauma, except for wounds of the corpora cavernosum and spongiosum, which should be treated like vasculature, with limited debridement and good hemostatic closure, except repaired with absorbable suture material. General management consists of meticulous hemostasis, vigorous saline lavage, removal of foreign bodies, hematoma evacuation, conservative debridement of devitalized tissue, repair of associated injuries, and primary wound closure. Infection is rare in properly debrided wounds.
  Penetrating injuries to the penis (deep to Buck’s fascia) demand evaluation for associated urethral injury by either retrograde urethrography or cystoscopy. Surgical exploration should be performed in all cases except with the most insignificant and superficial wound. Blood at the meatus or gross hematuria highly suggests a urethral injury and warrant evaluation. Corporal injuries should be repaired primarily with absorbable sutures. Low velocity penetrating urethral injuries should be repaired primarily – typically by an anastomotic urethroplasty. Primary realignment for such urethral injuries often results in high urethral strictures rates. Staged urethral injury repair is often reserved for extensive injuries – as is often seen in high velocity gunshot wound tissue injuries Patients with injuries to the scrotum deep to Dartos fascia or with scrotal swelling also warrant exploration. Penetrating wounds to the scrotum damage a testis or cord roughly half the time. Once the testis is struck, the chance to salvage the testis after a low velocity GSW is 25 -50%. This contrasts sharply for high velocity injuries of the battlefield, where salvage is rare. Scrotal stab wounds seem to more commonly involve the vascular cord, and thus explaining the reported poor salvage rate.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
E-mail: brandess@wudosis.wustl.edu