OBJECTIVE To assess the efficacy and safety of circumferential cremasteric lysis in the treatment of adult symptomatic retractile testicles.MATERIALS AND METHODS This is a retrospective chart review of all patients who had undergone circumferential cremasteric lysis at a single institution performed by a single surgeon between January 2010 and December 2011. We evaluated the etiology, pre-and postoperative pain intensity, postoperative pain alleviation, and any surgical complications. We used the Wilcoxon signed-rank test to compare pain levels before and at last follow-up after surgery.RESULTS Eight patients (mean age, 31.5 +/- 10.60; range, 22-51 years) underwent circumferential cremasteric lysis. The procedure resulted in a clinically meaningful and statistically significant difference in postoperative pain intensity. The mean pain levels decreased from 5.6 (preoperatively) to 1.5 (at last follow-up) (5.6 vs 1.5, P <.01, Wilcoxon signed-rank test). The mean follow-up was 21.63 +/- 13.70 months (range, 9-50 months). Four patients (50%) reported complete resolution and four (50%) reported partial resolution of their testicular pain at last follow-up.CONCLUSION In this limited retrospective study, we demonstrated that circumferential lysis of the cremasteric muscle through a small subinguinal incision is a safe and effective minimally invasive procedure for physical activity-precipitated painful retractile testicular pain. UROLOGY 100: 246-248, 2017.

INTRODUCTION:Penetrating injuries to the pelvis and perineum can result in fistulas between the rectum and lower urinary tract. These injuries are often complicated, which creates challenges for successful repair. Operative strategies may include initial fecal and/or urinary diversion combined with an eventual trans-perineal, trans-anal, or posterior/transrectal approach, but the selected approach should be guided by precise anatomic localization of the injury. We aim to discuss different possible repair strategies as well as the relevant data surrounding gastrointestinal-genitourinary (GI-GU) fistula management.MATERIALS AND METHODS:We present this series of three post-traumatic rectovesical and rectourethral fistulas to illustrate the surgical options for treatment of these conditions. In this series, we have retrospectively reviewed our experience at Walter Reed National Military Medical Center in caring for three Wounded Warriors who had suffered these types of injuries. The study was exempt from institutional review board approval because of the size of the series.RESULTS:Our three patients all were managed with initial urinary and fecal diversion before an eventual trans-perineal, trans-anal, or posterior/transrectal approach. All three patients ultimately underwent reversal of diverting ostomies with good functional results and successful resolution of their GI-GU fistulas.CONCLUSIONS:This series demonstrates the complexity of traumatic GI-GU fistulas. Successful management depended on early diversion of both urine and feces, localization of the fistula, and an interdisciplinary surgical approach specifically tailored to each patient. All three patients had favorable overall functional outcomes despite their devastating injuries. This review should help to illustrate some of the possible repair strategies for these difficult surgical problems.

One of the most challenging injury patterns to emerge from the recent military conflicts in Iraq and Afghanistan is the dismounted complex blast injury (DCBI), with multiple proximal amputations, pelvic fractures, and extensive perineal wounds (Fig. 1).(1-5) Lessons learned from managing patients with this pattern of injury must be captured to minimize the morbidity and mortality of those suffering similar injuries in the future. These lessons also apply to civilian patients suffering open pelvic fractures and crush injuries to the pelvis. 6 The aim of this review was to detail the diagnostic work-up and initial multidisciplinary management of DCBI patients, to describe some of the most common complications after DCBI, and to discuss future research efforts to improve the survivability and outcomes of DCBI.

PURPOSE:We examined the long-term natural history of testosterone recovery in patients with complex battle injuries.MATERIALS AND METHODS:We retrospectively reviewed the charts of patients who participated in Operation Enduring Freedom and Operation Iraqi Freedom, and underwent urological surgical consultation at Walter Reed Army Medical Center, Washington, D.C. or the National Naval Medical Center, Bethesda, Maryland, from 2001 to August 2011. Of the 192 patient charts reviewed 138 (72%) had testosterone values available. The study inclusion criterion of at least 2 testosterone measurements, including 1 made within 40 days of injury, was met by 84 patients (61%) with testosterone data available. Those treated with bilateral orchiectomy were not required to meet this criterion.RESULTS:Initial patient testosterone after injury in the testosterone recovery group was inversely proportional to the degree of scrotal injury. In patients in whom testosterone recovered to at least 250 ng/dl the recovery occurred a mean of 4.5 months after injury. Patients who required testosterone replacement had lower initial testosterone (p = 0.0063) and lower testosterone velocity (p <0.0001).CONCLUSIONS:Monitoring the velocity of testosterone recovery is a viable approach in male patients who receive significant genitourinary trauma. In patients in whom testosterone recovered the recovery occurred within a mean of 5 months after injury. It is reasonable to observe patients with scrotal injuries since testosterone may recover in many of them without intervention.

Complex genitourinary injuries--associated with lower-extremity amputation as well as pelvic and abdominal wounding--have emerged as common occurrences in current military combat operations. The nature of combat injuries of the genitourinary tract is varied, as are the strategies used in their management. For example, 5% of all combat injuries include wounds of the urinary system or genitalia. For injuries that are predominantly penetrating in nature, immediate care requires the judicious preservation of viable tissue. Once the patient is stable, urethral, corporal and testicular lacerations are closed primarily, whereas soft tissue injuries are re-approximated in a delayed fashion. Negative-pressure dressings have been a useful aid in wound management; wound coverage is most commonly completed with split-thickness skin grafts and local flaps. Complex penile and urethral reconstructions are often delayed so orthopaedic injuries can heal and the patient can manage activities of daily living. Final reconstruction requires a urologist with a full understanding of reconstructive techniques.

INTRODUCTIONThe U.S. Army 28th Combat Support Hospital (CSH), an echelon III facility, deployed to Iraq at the start of military operations in 2003. Shortly after arrival, it was designated as the hospital primarily responsible for burn care for the U.S. military in Iraq. This report reviews the experience of the CSH with burn care during combat operations.METHODSAn after-action review was conducted during a 2-day period after the hospital's redeployment.RESULTSBetween April 11, 2003, and August 21, 2003, the 28th CSH treated a total of 7,920 patients, of whom 103 (1.3%) had burns. Patients included U.S. and allied service members, U.S. contractors, and Iraqi prisoners of war and civilians. Although a CSH is designed to care for patients until they can be stabilized and evacuated, usually within 1 to 3 days, the length of stay for some Iraqi patients was as long as 53 days. Definitive care, including excision and grafting of the burn wound, was thus required for some Iraqi patients. The largest graft completed comprised 40% of the total body surface area. The largest burn survived involved approximately 65% of the total body surface area. Eighteen (17%) of 103 patients returned to duty after treatment at the 28th CSH. The mortality rate for burn patients at the 28th CSH was 8%. Shortages of burn-experienced personnel and burn-specific supplies were identified during the after-action review.CONCLUSIONSThe CSH provided complex definitive care to burn patients in an austere environment. Predeployment identification of military field hospitals for such specialized missions, with early assignment of experienced personnel and materiel to these units, may improve future wartime burn care.

Excision with spatulated primary anastomosis (EPA) is an excellent reconstructive option for short bulbar urethral strictures with success rates between 90 and 95% in appropriately selected patients. Patient selection requires a careful history, physical examination, and radiographic staging. Failure with this reliable method is caused by inadequate excision of urethral stricture and incomplete mobilization of the urethra with excessive anastomotic tension. Complications that include wound and urinary tract infections, chordee, and erectile dysfunction, are uncommon. EPA warrants strong consideration as a first line treatment due to its excellent and durable long-term results.

In the field of trauma and reconstruction, some aspects have changed significantly, whereas others continue to refine concepts that have developed over recent years. In urethral reconstruction, procedures are becoming more complex. The morbidity of the lithotomy position has been recognized for years. Recent literature has clarified the argument over the ‘best stirrup’, and time in lithotomy has been identified as a significant contributor to morbidity. Implantation of the AMS-800 sphincter has been examined in irradiated patients. The complication and revision rate is higher but not so high as to preclude consideration of its use. A number of articles have examined the use of cystoscopy in all cases of complicated pelvic surgery and in specific urethral suspension procedures. This has been recognized by urologists for years; it is a new concept in the gynecology literature. Cystoscopy continues to be routinely used, as many ‘routine cases’ when examined with cystoscopy are found to be associated with complications to the genitourinary tract. The non-operative management of renal trauma is expanded to select blunt grade 5 renal injuries. A series examined the use of computed tomography scan for bladder injuries and found it to be both sensitive and specific.

Penile amputation is an uncommon injury resulting from self-mutilation, felonious assault, or accidental trauma. Management requires resuscitation and stabilization of the patient with particular attention to underlying psychiatric illness. Amputated tissue can be preserved under hypothermic conditions in preparation for surgical replantation. Current replantation techniques rely on microsurgical approximation of the dorsal structures and cavernosal arteries with uniformly good results. Phallic replacement may be necessary when the amputated segment is lost. Microsurgical free forearm flap phalloplasty is the current mainstay of penile replacement surgery. Although urethral complications remain problematic, the results continue to be acceptable with regard to appearance and function. A unique subset of patients sustaining amputation injury is children. Both replantation and phallic construction have been successful in children and represent an alternative to gender reassignment.