The timeline of history is punctuated by war and with conflict comes casualty. Over time, wartime casualties have evolved, reflecting the increasing power and lethality of the weapons of war.

But whether the war is major or minor, one thing is the same: the need for medical personnel to administer care and learn how to best prevent, stabilize and treat the wounds of war. As weaponry has evolved from arrows to bullets and from cannons to rockets and explosive devices, the improved prevention and management of these injuries has followed.

This year’s AUA history exhibit “Battlefield Urology” explores the lessons learned from wartime urological injury and disease over the ages and appreciates the urologists, trauma surgeons, and allied health professionals who have contributed to the current state-of-the-art care, not just for military urological injury and disease, but for civilian trauma and urologic patients everywhere.

Since the beginning of the two major campaigns of the 21st century, Operations Iraqi Freedom and Enduring Freedom (OIF/OEF), the enemy’s weapon of choice has been the improvised explosive device (IED). Injuries from IEDs are dependent on a soldier’s proximity to the blast. Most IED-induced urethral injuries are in soldiers who are within feet of the blast. The pressure wave and shrapnel from IED explosions can cause significant pendulous penile and anterior urethral injury (Goldman type 5).

Initial management of major blast injury to the penis and scrotum include minimalist debridement, knowing additional debridement is often required as devitalized tissue declares itself in the days that follow. Lessons learned from prior approaches to battlefield penile and scrotal injury include the notion that overly aggressive debridement at the time of initial stabilization sometimes foreclosed future reconstructive options. To the extent possible, injured urethra is reconstructed over a Foley catheter, and suprapubic catheter drainage is established when possible.

The first report of cryopreservation of human sperm comes from Lazzaro Spallanzani in 1776, an Italian physiologist; 90 years later in 1886, Paolo Mantegazza, an Italian neurologist, physiologist and anthropologist, reported that human sperm survived cooling to -17°C for more than four days. Mantegazza is credited with envisioning the first sperm bank, dreaming that “a man dying on a battlefield may beget a legal heir with his semen frozen and stored at home.”

In 1949, Drs. Parkes, Polge, and Smith discovered the protective effects of glycerol during cryopreservation of sperm. In 1953, Drs. Jerome K. Sherman and urologist Raymond Bunge further refined the process of cryopreservation by adding slow cooling and refrigeration with solid CO2. These advancements contributed to the first thawed sperm fertilization of an egg and the first successful human pregnancy using frozen sperm.

This monumental achievement sparked medical ethics debates as the non-scientific community expressed concern. In 1953, the Cook County Supreme Court in Chicago ruled Donor Insemination as “contrary to public policy and good morals, and considered adultery on the mother’s part.”

The modern era of cryopreservation in soldiers is defined by an increased numbers of blast injuries in recent wars in Iraq and Afghanistan, advances in sperm retrieval techniques, and continued ethical discussion about posthumous reproduction. Nevertheless, cryopreservation of sperm remains a viable and effective way to aid civilians and service members in protecting and in building families.

Confronted with smallpox and typhus epidemics, military surgeons gave priority to limb injuries, considering other wounds as inevitably fatal. War reports described different operations of the genito-urinary tract (kidney, ureter, prostate, bladder, genitals) on both German and French soldiers. More operations were performed on the genitalia (12) than on abdominal wounds related to the kidney or bladder (3). Most of the wounds were gunshot wounds. German physicians applied Lister’s principle with great benefit, whereas their French counterparts completely neglected this recent finding.

Ernst von Bergmann (1836–1907, German surgeon and war correspondent) championed Lister’s protocol:

Bergmann’s letters reveal rigorous hand-washing practices between patients, how he sprayed phenol on wounds, and his thoughts on organizing the treatment chain from the battlefield to the hospital.

The German army set up a series of quarantine centers (lazarettos), regularly spaced according to troop advancement and established 21 medical trains, each with 200 beds. James Israel of Berlin, pioneer in modern urologic and renal surgery, was in charge of a lazaret train in 1914-1915. In contrast, the French had no such specialized transport.

During WWI, the prognosis of the wounded in urology was improved by newly introduced X-ray analysis and a paradigm shift to earlier wound management, wound drainage and refined anesthesia. New techniques in kidney and prostatic surgery helped improve the outcome of the wounded. Seventy percent of all injuries and deaths, not only in urologic cases, were due to mortar shells, which also caused new pathologies and types of grossly contaminated wounds. Neurologic disorders due to gunshot wounds to the spinal cord now appeared.

During World War II, reports of GU injuries came from the hospital where injured patients received their definitive care. Bladder injuries were predominately intraperitoneal and were closed primarily when possible.

As military jets broke the sound barrier, engineers at the Dornier aviation company noted that supersonic flight through a rainstorm led to pitting on the outer structure of the jets. Though the erosion caused by the rain drops at the point of impact could be explained, it was also found that shockwaves transmitted through the water droplets also caused damage at other locations throughout the interior of the plane. Physicists at Dornier carried out further research to explain this and to design planes resistant to shockwave damage.

The impact of shockwaves on living tissue was of equal interest to the military. At the end of the 1960s, research conducted at Dornier - in collaboration with the Institute of Applied Physics and Electrical Engineering of the University Saarbrücken - revealed that shockwaves caused no visible injury when passing through muscle tissue, fat tissue or fascia – with some exceptions. This project sparked the idea that kidney stones could be destroyed inside the body using shockwaves.

In 1971, at the symposium of the German Physical Society, Häusler and Kiefer reported the first results showing that shockwaves were able to destroy kidney stones. In 1974, numerous experimental and theoretical studies conducted by an interdisciplinary workgroup of urologists and engineers began. Seven years of experimental work and development went into the creation of the Dornier HM1 (Human Model 1), the first clinical lithotripter, and culminated in the treatment of the first patient with Extracorporeal Shockwave Lithotripsy (ESWL) on February 7, 1980. In 1982, FDA investigational sites for shockwave lithotripsy in the United States were chosen and included Indianapolis (Drs. Newman and Lingeman), Houston (Dr. Griffith), Gainesville (Dr. Finlayson), Boston (Dr. Dretler) and Charlottesville (Dr. Gillenwater). After evaluation of the clinical data, shockwave lithotripsy was approved in the United States by the FDA in 1984.