FIREARM WOUNDS OF THE LOWER URINARY-TRACT IN MEN - EMERGENCY SURGICAL-MANAGEMENT

The lower urinary tract is injured in less than 1% of all firearm woun ds in men. In war medicine, blast wounds occur in 75% of the cases whi le in civil medicine ballistic injuries are more frequent. When the bl adder and the posterior urethra is involved, the projectile usually fo llows a path through the gluteal muscles and pelvis. A perineal genita l path is usually found for injuries to the anterior urethia. This exp lains the frequency of associated vascular and colorectal lesions in p elvic wounds and genital injuries in perineal wounds. Bone and muscle injuries occur in both situations. A mental reconstruction of the proj ectile path is required for a precise diagnosis of the lesions, togeth er with the clinical examination (urine outlet, miction impossible wit h or without bladder extension, urethral bleeding) and most importantl y standard x-ray of the pelvis in search of bone lesions and the proje ctile. Urethrography should always be performed whenever the urethra i s injured in all civil wounds. However, the final diagnosis of the les ions can only be made at surgery. Urology procedures, usually performe d by polyvalent surgeons, should be simple, rapid and reliable. It is important to preserve urinary and genital functions in these young sub jects usually under 30 years of age. Cystostomy and drainage is the st rict minimum. In addition, depending on the infectious and hemodynamic status, conservative excision of damaged tissue is needed prior to pr imary closure. Wounds involving the bladder can be closed in 95% of th e cases. Closure is simple for wounds involving the superior portion o f the bladder. For deeper wounds involving the trigone endovesical sut ure is used after intubing the ureters. Ureteral drainage is mandatory when the bladder is highly damaged and cannot be closed. Urethro-pros tato-membranous wounds should also be repaired to avoid inevitable fib rosis of fistulization. However, access to the apex of the prostate ca uses major bleeding and there is a risk of injuring the sphincter or e rection nerves, particularly by surgeons inexperienced in urogenital s urgery. When massive bleeding cannot be controlled by clamping the two hypogastrics, symphysiotomy, rather than symphysectomy, is recommende d. In other cases, aligning the urethral extremities may be sufficient . Short wounds to the anterior urethra should be cleaned and the extre mities spatulated and anastomosed on a guide when they can be closed. In other cases, a perineal or penile urethrostomy is created. Associat ed wounds involving the anus and rectum require colostomy, emptying th e excluded rectum and wide pelvic-perineal drainage. An attempt should be made to repair the rectum or the sphincter. Genital lesions requir e early repair : tight suture of the albuginea of the cavernous bodies with or without a patch, preservation of viable testicular parenchyma and adnexal tissues (but orchidectomy is necessary in 50% of the case s).