Urology during Afghanistan mission: lessons learned and implications for the future

Abstract

Purpose: Battle-related trauma is common in modern warfare and can lead to genitourinary injuries. In Western countries, urogenital injuries are rare in the civilian environment. The main objective of this study was to assess urological workload for surgeons on deployment.

Material and methods: Data were acquired over a period of five years of deployment in a U.S. facility in Afghanistan.

Results: German urological surgeons treated on average one urologic outpatient per day and performed 314 surgical interventions overall. Surgical interventions were categorized as battle-related interventions (BRIs, n = 169, 53.8%) and nonbattle-related interventions (non-BRIs, n = 145, 46.2%). In the BRI group, interventions were mainly performed on the external genitalia (n = 67, 39.6%), while in the non-BRI group, endourological procedures predominated (n = 109). This is consistent with a higher rate of abdominal or pelvic procedures performed in the BRI group (n = 51, 30.2%). Furthermore, the types of interventions performed on the external genitalia differed significantly. In the BRI group, 58.2% (n = 39) of interventions were scrotal explorations, but none of those procedures were performed in the non-BRI group (p < 0.001). However, 50.0% (n = 13) of scrotal explorations in the non-BRI group were due to suspected torsions of the testes followed by orchidopexy (BRI: n = 1, 1.5%, p < 0.001). Concerning outpatients, the consultation was mainly due to complaints concerning the external genitalia (32.7%, n = 252) or kidney/ureteral stones (23.5%, n = 181).

Conclusion: While the treatment of urological outpatients in a deployment setting resembles the treatment of soldiers in Germany, BRIs requires abdominal/retroperitoneal urosurgical skills and basic skills in reconstructive surgery.

Keywords: Battle-related injury; Genitourinary injury; Laparotomy; Reconstructive surgery; Urological surgery.

Fig. 1

Outpatient consultations without reconsultations (n = 733). External genitalia summarizes pain or swelling of the external genitalia due to hydro/varicocele or hernia and meatus stenosis. OR procedures were excluded. Consultations of one patient could contain more than one diagnosis (n = 770)

Fig. 2

Urological surgical interventions (n = 314). Within urological interventions, 53.8% (n = 169) were considered battle related, while 46.2% (n = 145) were considered nonbattle related

Fig. 3

Analysis of surgical urological interventions. In the battle-related intervention group, the prevalence of testis-related interventions prevailed (BRI = 39.6%, n = 67; non-BRI = 17.9%, n = 26, p < 0.001), while in the nonbattle-related intervention group, most interventions were endourological procedures (non-BRI = 75.2%, n = 109; BRI = 24.2%, n = 41, p < 0.001). Furthermore, a significantly higher rate of abdominal interventions was observed in the battle-related intervention group (BRI = 30.2%, n = 51, non-BRI = 2.1%, n = 3, p < 0.001)

Fig. 4

Analysis of scrotal interventions (n = 93). In the battle-related intervention group, most procedures were performed due to scrotal trauma (BRI = 58.2%, n = 39, non-BRI = 0%, p < 0.001), while in the nonbattle-related intervention group, procedures were mainly due to suspected torsion of the testis (non-BRI = 50%, n = 13, BRI = 1.5%, n = 1, p < 0.001) or reduction of hydrocele (non-BRI = 19%, n = 5, BRI = 0%, p < 0.001)