Abstract
Arab Journal of Urology (2018) 16, 250–256 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com TRAUMA ORIGINAL ARTICLE War-related penile injuries in Libya: Single-institution experience a,b, a,c a,d Abdalla M. Etabbal , Fathi F. Hussain , Mohamed O. Benkhadoura , a,e Abdalla M. Banni Faculty of Medicine, University of Benghazi, Benghazi, Libya Department of Urology at Benghazi Medical Center, Benghazi, Libya Department of Plastic Surgery at Benghazi Medical Center, Benghazi, Libya Department of General Surgery at Benghazi Medical Center, Benghazi, Libya Department of Anaesthesia at Benghazi Medical Center, Benghazi, Libya Received 30 November 2017, Received in revised form 5 January 2018, Accepted 30 January 2018 Available online 22 March 2018 KEYWORDS Abstract Objective: To report on our initial experience in the management of war- related penile injuries; proper diagnosis and immediate treatment of penile injuries is Gunshot; essential to gain satisfactory results. Besides treating primary wounds and restoring Penis; penile function, the cosmetic result is also an important issue for the surgeon. Corporal bodies; Patients and methods: The study was conducted in the Department of Urology at Urethral injury; Benghazi Medical Center and comprised all patients who presented with a shotgun, War-related penile gunshot or explosive penile injury between February 2011 and August 2017. The injuries patient’s age, cause of injury, site and severity of injuries, management, postopera- tive complications, and hospital stay, were recorded. ABBREVIATIONS Results: In all, 29 males with war-related penile injuries were enrolled in the AAST, American study. The mean (SD) age of these patients was 31.3 (10.5) years. The glans, urethra, Association for the and corporal bodies were involved in four (13.7%), 10 (34.4%), and 20 (68.9%) of Surgery of Trauma; the patients, respectively. According to the American Association for the Surgery of IED, improvised Trauma Penis Injury Scale, Grade III penile injuries were the most common explosive device Corresponding author at: Benghazi Medical Center, Urology Unit, Benghazi, Libya. E-mail address: abdalla.etabbal@uob.edu.ly (A.M. Etabbal). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier https://doi.org/10.1016/j.aju.2018.01.005 2090-598X 2018 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). War-related penile injuries in Libya 251 (11 patients, 37.9%). The most common post-intervention complications were ure- thral stricture with or without proximal urethrocutaneous fistula (eight patients, 27.5%), followed by permanent erectile dysfunction (five patients, 17.2%). Conclusion: In patients who sustain war-related penile injuries the surgeon’s efforts should not only be directed to restoring normal voiding and erectile function but also on the cosmetic appearance of the penis. 2018 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Introduction come, postoperative complications, and hospital stay, were recorded. These data were collected prospectively and analysed retrospectively. Patients who arrived dead The global rise in terrorism, which is linked to easy or died during surgery were not enrolled in the study. access to the firearms and improvised explosive devices Penile injuries were classified according to the cause of (IEDs), has led to an increase in the incidence of the the penile injury, whether gun/shotgun bullets or shrap- external genital injuries, particularly in rebel areas nel of explosive devises/projectiles. The causes of penile [1,2]. However, injuries caused by gunshots to the exter- injuries due to gunshots were sub-classified according to nal genitalia are relatively rare compared with injuries to the velocity of bullets into: low-velocity gunshot injuries the other parts of the body because anatomical shielding (<350 m/s), medium-velocity gunshot injuries (350–500 provides protection against these injuries [3].AsIEDs m/s), and high-velocity gunshot injuries (>600 m/s) [8]. and landmines are planted at ground level, the destruc- Penile injuries due to explosions were classified as: IEDs, tive impact of these explosive devices is mainly on the personal landmine or explosion of a projectile. The lower limbs, pelvis, and external genitalia [1]. To date, proper assessment of penile injuries depends on clinical there is no single appropriate therapeutic strategy or findings and imaging studies results, as well as on oper- surgical technique suitable to treat all types of penile ative findings. Imaging studies, e.g. plain X-ray, are injuries [4]. Thus, the type, severity, and location of required to identify foreign bodies and/or bone frac- penile injuries should be considered in the choice of sur- tures; however, a retrograde urethrogram can only be gical approach and surgical technique(s) [5]. Although done in cases of superficial penile injuries, in which ure- penile injuries are usually not life-threatening, they can thral injuries are not obvious. CT is usually performed have a significant impact on the victims’ quality of life to assess patients who sustain multiple serious injuries. [6]. Despite good management and regular follow-up The management of penile injuries depends on the sever- of external genital gunshot wounds, such wounds are ity of the injury, physical findings and haemodynamic fraught with the possibility of complications such as stability of the patient; however, patients in shock erectile dysfunction, urethral stricture, and infertility underwent immediate laparotomy without any diagnos- [7]. Therefore, the main therapeutic goals of penile inju- tic imaging studies to treat life-threatening injuries. The ries are to maintain or restore potency, fertility and nat- grades of the penile injuries were classified according to ural urination strength, as well as to maintain the American Association for the Surgery of Trauma aesthetic shape of the penis [1,2]. (AAST) Penis Injury Scale [9] (Table 1). The aim of our present study was to report our initial All patients with penile injury underwent initial surgi- experience in the management of war-related penile inju- cal repair by the same team and because the wounds ries; emphasising that we have limited experience in these types of injuries, as there was no single case of shotgun, gunshot or explosive penile injury recorded before 2011; the date of war in Libya. Table 1 AAST Penis Injury Scale. AAST Description of injury Patients and methods Grade I Cutaneous laceration/contusion The study was conducted in the Department of Urology II Buck’s fascia (cavernous) laceration without tissue at Benghazi Medical Center. This descriptive case series loss was carried out in a proactive manner by immediate reg- III Cutaneous avulsion istration of all operated cases sustaining shotgun, gun- Laceration through glans/meatus Cavernosal or urethral defect <2 cm shot or explosive injuries to the penis from February IV Partial penectomy 2011 to August 2017. The patient’s demographic data, V Cavernosal or urethral defect >2 cm cause of injury, site and severity of primary penile inju- Total penectomy ries, surgical management as well as the surgical out- 252 Etabbal et al. were contaminated these patients received parenteral Sciences (SPSS Statistics for Windows, Version 22: prophylactic and postoperative courses of antibiotics. IBM Corp., Armonk, NY, USA). All patients with Grade IV–V penile injuries required suprapubic urinary diversion, whereas, only six cases Results with Grade III penile injuries required a suprapubic cys- tostomy. Patients who presented with Grade I–II penile In all, 29 patients with war-related penile injuries were injuries were usually discharged immediately or within a enrolled in the present study. The mean (SD, range) few days, unless they were associated with other serious age of the patients was 31.3 (10.5, 16–62) years; with injuries that necessitated a longer hospital stay. Isolated most injuries in the 21–40 years age-group. The causes Grade III penile injuries necessitated a hospital stay of penile injuries were gunshots (18 patients, 62%), from 2 to 3 weeks. Severely injured patients were kept explosions (nine, 31%), and shotguns (two, 6.9%) in hospital and then transferred to specialist centres (Fig. 1). abroad 2–3 months after preliminary repair of their According to the AAST Penis Injury Scale, Grade III penile injuries for further management of the penile penile injuries were the most common (11 patients, and/or concomitant serious injuries. Permission for the 7.9%), followed by Grade II penile injuries (eight, study was granted by the Hospital Ethics and Research 27.6%) (Table 2). Committee. The statistical descriptive analysis was car- The war-related penile traumas resulted in glanular ried out using the Statistical Package for the Social laceration (four patients, 13.7%), corporal bodies injury Fig. 1 Grades of penile injuries. (a) Grade III shotgun injury to the penis; (b) Grade III medium-velocity gunshot injury to the penis (arrow); (c) Grade IV explosive injury to the penis; (d) Grade V high-velocity gunshot injury to the penis. War-related penile injuries in Libya 253 Table 2 Penile injury grade and cause of injury. Cause of injury Grade of penile injury, n (%) Total, n (%) I II III IV V Shotgun 1 – 1 – – 2 (6.9) Low-velocity gunshot 1 – 1 – – 2 (6.9) Medium-velocity gunshot – 2 4 – – 6 (20.7) High-velocity gunshot – 3 4 1 2 10 (34.5) IED or personal landmine 1 3 1 1 1 7 (24.1) Explosion of a projectile 1 – – – 1 2 (6.7) Total 4 (13.8) 8 (27.6) 11 (37.9) 2 (6.9) 4 (13.8) 29 (100) (20, 68.9%), and urethral injury (10, 34.5%). In all, 17 (58.6%) patients had associated scrotal (14 patients), testicular (nine testicles in eight patients), abdominal (nine), chest (four), skeletal (four), head (three), and vas- cular (one) injuries. The associated skeletal injuries were amputation of both lower extremities (one), amputation of one leg (two), and fractured femur (one) (Fig. 2a and b). Grade I penile injuries were treated by simple sutur- ing or just dressing of the injured skin (four patients), whereas Grade II injuries were treated by debridement and haemostatic suturing of Buck’s fascia and skin (eight). The treatment of Grade III penile injuries com- prised debridement and haemostatic suturing of the Fig. 3 (a) and (b) shows a Grade V high-velocity gunshot injury tunica albuginea and Buck’s fascia (one), debridement to the penis that underwent immediate repair. and haemostatic suturing of lacerated glans (four) or debridement and reconstruction of injured corporal No obvious post-intervention complications devel- bodies and/or injured urethra in addition to the supra- oped in 18 of the 29 patients (62%) who sustained penile pubic cystostomy (six). Patients with Grade IV penile trauma, of these four had Grade I injuries, eight had injuries underwent partial penectomy with skin grafting Grade II, and six had Grade III penile injuries. How- due to extensive skin loss (two patients), whilst the ever, the other eleven (37.9%) patients developed vari- patients who sustained Grade V penile injuries under- ous complications related to their injuries, of these five went primary and meticulous reconstruction of the cor- had Grade III, two had Grade IV, and four had Grade poral bodies with realignment of fragile urethra over a V penile injuries (Table 3). 18-F silicone catheter with suprapubic urinary diversion In all, 16 (55.1%) patients with Grade I–III penile (four) (Fig. 3). injuries (three, Grade I; seven, Grade II; and six, Grade III) were followed-up for 2–3 months and developed no obvious post-intervention penile injury-related compli- cations. One case of isolated Grade III penile injury developed a urethral stricture after the preliminary repaired urethrocutaneous fistula, which required urethroplasty using a buccal mucosal graft through a perineal approach. Because the number of casualties exceeded the capacity of the only two active hospitals in our city during the period of the war; the other 12 cases of penile injuries (one, Grade I; one, Grade II; four. Grade III; two, Grade IV; and four, Grade V) were sent to advanced centres abroad at the expense of the government for further management of their severe penile and/or concomitant injuries. Stressing that all these patients were kept in the hospital for 1–3 months Fig. 2 (a) Shows a Grade I explosive injury to the penis associated with amputation of a right leg. (b) Shows a surgical and the preliminary results of their penile reconstructive repair of bilateral concomitant testicular injuries in a patient who operations in terms of restoring the shape and contour sustained a Grade I gunshot injury to the penis. of the penis were satisfactory. 254 Etabbal et al. Table 3 Complications after treatment of penile injury. Complication Grade of penile injury, n Total, n (%) I II III IV V No residual complications 4 8 6 – – 18 (62) Mild curvature of penis – – 2 – – 2 (6.8) Severe curvature of penis – – 1 – – 1 (3.4) Temporary erectile dysfunction – – – 1 – 1 (3.4) Permanent erectile dysfunction – – 1 – 4 5 (17.2) Urethral stricture – – 4 – 2 6 (20.6) Urethral stricture with proximal urethrocutaneous fistula – – – – 2 2 (6.8) associated urethral injuries recorded in our present ser- Discussion ies represented 34.4% of all penile injuries. In the pre- sent study, the corporeal bodies were involved in Male reproductive organs are protected by several 68.9% of penile injuries, which correspond with the defence mechanisms, such as size and mobility of these results of other studies reporting that the corporeal bod- organs, as well as their anatomical location that pro- ies were involved in 62% [10] and 81% [15] of penile vides shielding against penetration and blunt trauma wounds. However, we recorded combined corporal bod- [2,10]. Gunshot injuries to the external genital organs; ies and urethral injuries in nine (31%) patients, isolated whether in the military battlefield or during peace time injuries to the corporal bodies in 11 (37.9%), and iso- are relatively uncommon as compared with injuries to lated injury to the urethra in one (3.4%). Previous stud- other parts of the body; however, most of the victims ies have reported that 70–93% of reproductive and are young adults [7]. In the present study, the mean urinary tract injuries are associated with abdominal, (SD, range) patient age was 31.3 (10.5, 16–62) years, chest, and lower limb injuries [17,18]; injury to major with most of the penile injuries recorded in the 21–40 vessels is usually the leading cause of death in these years age-group, representing 62% of the present casualties [11]. In the present study, 51.7% of the penile recorded cases. Al-Azzawi et al. [11] reported that the injuries were associated with abdominal, chest, lower mean (range) age of patients who sustained urethral limb and vascular injuries. In the present study, of nine and penile injuries during civil violence in Iraq was 29 associated testicular injuries (in eight patients), five (14–55) years, with most of the victims in the 20–39 testes were saved and in two previous studies the injured years age-group, representing 78% of all their cases. testes were saved in 44.5% [15], and 74.4% [6] of all Whereas, Dogo et al. [3] reported that the mean (range) cases who sustained genital injuries. Tissue damage in age of victims of missile injuries to the external genitalia cases of gunshot injuries depends on the mass and the in Maiduguri-North Eastern Nigeria was 32.75 (5–70) velocity of the bullets [19]. In the present study, seven years, with most of the victims aged 30–39 years. Indeed, patients had Grade I and II penile injuries that were other authors have reported that most victims are young caused by different weapons with different bullet sizes adults, with a mean age of 30 years [12,13] with predom- and velocities; the similarities of these injuries can be inance in those aged 18–28 years [14]. In Sana’a-Yemen only explained by the differences in shooting distances. and in Maiduguri-North Eastern Nigeria, patients aged For the management of penile gunshot injuries, it is <30 years represented 45% [15] and 38.6% [3] of all important to assess the amount of damage with respect registered cases with war injuries to the external genital- to the shooting distance and bullet calibre, as well as the ia, respectively; whilst in the present study, 55.1% of type of weapon [20]. Superficial or trivial penile lesions penile injuries were recorded in this age group. The high are managed non-operatively in 4.8–10% of cases who rate of genital injuries in this age group reflects the prob- sustain war-related penile injuries [16,21]. We treated lem of disability and productivity losses in afflicted four (13.7%) patients with Grade I penile injuries non- countries. Injuries to the penis and urethra in the Iraq operatively and all of these cases developed no penile- conflict were mainly caused by IEDs (56%) and pistols injury related complications. Early surgical exploration, (44%) [11], whereas in our present study, penile injuries debridement of devitalised tissue, preservation of viable caused by explosions and firearms represented 34.4% tissue, urinary diversion, removal of foreign bodies, and 68.9% of cases, respectively. This discrepancy may securing haemostasis, and repair of injured tissue, are be explained by the fact that most of the victims of the principles for successful treatment of serious genital explosive injuries arrived dead or died during surgery, injuries [18,22]. However, the treatment of genital and consequently they were not enrolled in our present urinary tract injuries can be safely postponed for appro- study. The incidence of urethral injuries has been priate management of any life-threatening concomitant reported to range from 17% to 33% of patients that sus- injuries [1]. Although the surgical approach to penile tain penile gunshot traumas [16], whilst the incidence of War-related penile injuries in Libya 255 injuries depends on the site of injury; a lateral approach impact on the patient due to their postoperative compli- or sub-coronal degloving can provide good exposure for cations; therefore the surgeons’ efforts should be most penile injuries [22]. In the present study, the inlet of focused on restoring the aesthetic shape of the penis, explosive IEDs and shrapnel at the lateral aspect of the erectile function, and normal urethral urination. The scrotal neck provided good exposure to the injury in two present number of cases represents only the ‘tip of the cases of Grade V penile injury. Depending on the degree iceberg’, and does not reflect the magnitude of the disas- of penile and urethral damage, there are varieties of sur- ter in the whole of Libya. gical management; including simple repair, closing the remaining penile stump of a partially amputated penis, Conflict of interest and surgical re-anastomosis or total replacement with phallic reconstruction [23,24]. We performed all types The authors declare that they have no conflict of of reconstructive phallic surgeries including re- interest. anastomosis of nearly amputated penis with intact neu- rovascular bundles in four cases of Grade V injuries to Source of Funding the penis. For surgical repair, adequate exploration and meticulous reconstruction of the corporal bodies The authors declare that this study received no financial is essential to prevent the development of complications, support. such as erectile dysfunction and penile curvature [16].In the cases of urethral lesions, a primary surgical repair is References the option of choice [25], whilst in the cases of extensive urethral defects, the treatment strategy of surgical repair [1] Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: a 30-year single institution experience. J Urol in two stages should be considered [26,27]. 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Journal
Arab Journal of Urology
– Taylor & Francis
Published: Jun 1, 2018
Keywords: AAST; American Association for the Surgery of Trauma; IED; improvised explosive device; Gunshot; Penis; Corporal bodies; Urethral injury; War-related penile injuries
