Management of shotgun injuries to the pelvis and lower genitourinary system

Objectives. Shotgun injuries are rare, with the extent of injury best deter mined at time of surgical exploration. There are no defined workup or manag ement guidelines for patients with shotgun injuries to the genitourinary sy stem. Injuries are usually treated on an individual basis. This study was c onducted to determine the management and extent of genitourinary tract inju ries in 10 patients with shotgun injuries to the pelvis during a 6-year int erval. Methods, Between September 1990 and December 1996, 140 patients were treate d for firearm injuries to the lower genitourinary tract, of which 10 were s econdary to shotgun blasts. We performed a retrospective hospital and clini c chart review and telephone interview to assess organs injured, initial tr eatment, follow-up surgeries, mortality, and erectile function. Results. Mean patient age was 20 years at the time of the injury. The mean follow-up was 4 years (range I to 7). Two patients died, both with major va scular injuries, one in the operating room and the other I week later from sepsis. Eight patients underwent radiographic examinations (1 intravenous u rogram and 7 urethrocystograms). The bladder was injured in 5 patients, 2 w ith concomitant complete posterior urethral transection. Of the 5 patients without bladder injury, one had an incomplete penile urethral injury and on e had a complete bulbar urethral transection. The initial management consis ted of repairing nongenitourinary injuries in 8 cases (80%), most commonly involving injuries to the rectum and small bowel. All patients were treated operatively, including 8 who required laparotomy and 4 who required suprap ubic cystotomy. A total of four urethral injuries were noted. Subsequent re constructive surgeries included two urethroplasties and one permanent supra vesical diversion for 3 patients with extensive urethral loss. Erectile dys function was present in 3 of 6 patients available for telephone interview. Conclusions. Shotgun injuries involving the lower genitourinary tract are a ssociated with significant soft tissue injury and morbidity. Death usually results from major associated vascular injuries. All hemodynamically stable patients should undergo retrograde urethrograms and cystograms to evaluate possible urethral and bladder injuries. Open primary repair should be atte mpted for distal urethral, testicular, and corporal injuries. Delayed repai r with staged urethral reconstruction should be reserved for patients with extensive loss of urethral tissue. Impotence is common in patients with ext ensive perineal injuries. (C) 2000, Elsevier Science Inc.