Figure. A, B, Dismounted complex blast injuries seen in the Afghanistan and Iraq wars; images courtesy of ZRM.

A rise in the incidence of survivable genitourinary (GU) trauma has been a phenomenon of advances in prehospital and surgical care juxtaposed with advances in protective equipment such as body armor. These have benefited US and NATO (North Atlantic Treaty Organization) troops but have been absent for most civilians and many partner forces, leading to even more severe injuries. These injuries are important to understand, as they can help inform the long-term rehabilitation of service members (SMs) and provide insight to those actively deploying to ever-changing theaters of operation.

The earlier conflicts of World War II and Vietnam showed higher proportions of urologic injuries to the internal organs (eg, kidneys) with lower survivability compared to contemporary conflicts, affecting approximately 2% to 5% of SMs at that time. Gunshot wounds were the predominant mechanism of injury over explosives. The introduction of mobile army surgical hospitals and forward surgical teams improved SMs’ survival, bringing surgical units closer to the battlefield.¹ After 9/11, improved protective equipment and prehospital and surgical care led to SMs surviving more severe wounds. Body armor shielded vital internal organs, changing the proportions of previously seen wounding patterns. The introduction of dismounted complex blast injuries became a prominent injury in the conflicts of Afghanistan and Iraq; improvised explosive devices, often planted in the ground, would detonate and project their blast upward, often injuring unshielded genitalia and perineum.²

In the modern conflicts limited to Afghanistan and Iraq, adults sustained a GU injury at rates of 5% to 10% (5.3% overall), while collectively, this was 5% to 13% (7.2% overall) for Afghanistan, Iraq, Libya, and Syria.^2,3 Children comprised 8% of all battlefield injuries, with 13% suffering a GU injury and 41% requiring operative intervention (likely due to a lack of protective equipment in this population).

Urologic injuries in combat are most commonly part of a complex polytrauma, not occurring in isolation; concomitant traumatic brain injury was seen in 40.2%, lower extremity amputation in 28.7%, pelvic fracture in 25.0%, and colorectal injuries in 21.7% (Figure). Pelvic and perineal injuries showed higher mortality risks, with thermal injuries worsening the prognosis.⁴ Many are so severely injured they require a massive transfusion protocol, making up 28% of all massive transfusion protocols activated during the initial resuscitation (RR = 5.08). Over half of the injuries were to the external genitalia, with 7% of all GU injuries being renal. Surgeries to the bladder made up the majority, and half of all kidney injuries received operative intervention.²

While many renal injuries can be managed nonoperatively in the civilian system, up to 67% of renal injuries in combat zones received a nephrectomy. Over 50% received an orchiectomy if a testicular injury was sustained, even if it may have been deemed salvageable.⁴ The reasons are multifactorial: urologists are not often available in the combat setting for specialty care, interventional radiology is unavailable, and resource management becomes an issue with blood being limited in austere environments, often having to draw in real-time from walking blood banks on base (other SMs).

SMs acquire injuries that often become lifelong comorbidities requiring management from civilian urologists, as the large majority of veterans do not obtain their care at Veterans Affairs facilities. Many suffer a psychiatric diagnosis in this setting and require complex fertility management considerations, complicating their recovery further. The long-term effects of GU trauma will become more of a concern moving forward for all of us. To provide expert care for our veterans, we must anticipate the challenges and needs of SMs or civilian combat casualties as they transition back to the civilian medical system.