Warfare Injuries: A Case Series of Retained Foreign Bodies in the Genitourinary Tract

By Liaqat Ali¹, Shehzad Faiz¹, Fareeha Afridi², Faiza Hayat¹, Sara Kalsoom¹

Affiliations

1. Department of Urology, Institute of Kidney Diseases, Hayatabad Medical Complex, Peshawar, Pakistan
2. Department of General Surgery, Khyber Teaching Hospital, Peshawar, Pakistan

doi: 10.29271/jcpsp.2025.12.1622

ABSTRACT
Objective: To present the management of retained foreign bodies in the genitourinary system resulting from warfare, bomb blasts, and firearm-related injuries.
Study Design: Descriptive case series.
Place and Duration of the Study: Department of Urology, Institute of Kidney Diseases, Hayatabad Medical Complex, Peshawar, Pakistan, from June 2017 to December 2023.
Methodology: Patients with retained foreign bodies in the genitourinary tract, resulting from previous exposure to bomb blasts, mines, and firearm-related injuries, were included in this study. All patients underwent surgical management. Descriptive statistics were determined for location, duration of retention, type of foreign body, outcome, length of hospital stay, and postoperative complications.
Results: All 14 patients included in the study were male, with a mean age of 30.85 ± 13.38 years. The average indwelling time of these foreign bodies was 33.50 ± 16.34 months, ranging from 10 to 61 months. These foreign bodies were retained in the kidney (n = 5), urinary bladder (n = 4), and testes and ureter (n = 2; each); penis was involved in one case. The extracted foreign bodies were metal pellets (n = 12) and bullets (n = 2). The successful removal of pellets and bullets from kidneys and bladder was achieved endoscopically in nine cases. The mean length of hospital stays for open and endourological procedures was 4.0 ± 1.41 days and 3.5 ± 2.13 days, respectively (p = 0.630). Postoperative complications were reported in one case only, which required a blood transfusion; it was labelled as Clavien-Dindo Grade II.
Conclusion: Retained foreign bodies in the genitourinary tract in warfare injuries are uncommon and can be managed effectively with endourological as well as open surgery.

Key Words: Retained foreign bodies, Genitourinary tract, Bomb blasts, Warfare.

INTRODUCTION

Pakistan has been facing the menace of terrorism for the last four decades in the form of bomb blasts and firearm-related injuries. The province of Khyber Pakhtunkhwa has been the site of war against terrorism. There have been multiple cases of retained foreign bodies, particularly in the head region, including shotgun pellets, wooden materials, and other metallic foreign bodies.^1,2 Improvised explosive devices can cause anterior urethral and genitalia injuries, whereas gunshots most commonly cause posterior urethral and urinary bladder injuries.^3,4 Retained foreign bodies, such as pellets or bullets in warfare or firearm-related injuries, have been rarely reported.^5,6

Delayed presentations of these retained objects can present as urinary stones, obstruction, lower urinary tract symptoms, or chordee, causing impotence. This study aimed to present the largest case series worldwide on the management of retained foreign bodies in the genitourinary system resulting from warfare, bomb blasts, and firearm-related injuries.

METHODOLOGY

This case series was conducted at the Department of Urology, Institute of Kidney Diseases, Hayatabad Medical Complex, Peshawar, Pakistan, from June 2017 to December 2023. A total of 14 patients with suspected foreign bodies in the genitourinary tract, with any clinical manifestation and a history of exposure to bomb blasts, land mines, or firearm-related injuries, were included. Patients with foreign bodies that were symptomatic or not causing any complications, as well as those with concomitant non-urological injuries or pellets, were excluded from the study. After obtaining ethical approval from the Institutional Research and Ethics Board (IREB), all patients who had consented and satisfied with the inclusion criteria were included in the study. Data from clinical history, examination, radiological studies, and treatment charts were collected in a specially designed proforma and entered into SPSS for analysis. Data analysis was performed using IBM SPSS Statistics 20.0. Continuous variables were presented as mean, standard deviation, and range. Categorical variables were presented as frequencies and percentages. The normality of data was ascertained by the Shapiro-Wilk test. Continuous variables were analysed using a t-test, with a statistically  significance  level  set  at  0.05.

RESULTS

All 14 patients included in the study were male. The average age of these patients was 30.85 ± 13.38 years. The average indwelling time of these foreign bodies was 33.50 ± 16.34 months, ranging from 10 to 61 months. The anatomic distribution and procedure of management of pellets are shown in Table I. The extracted foreign bodies were metal pellets (n = 12) and bullets (n = 2). The circumstances of injury were bomb blasts (71.4%), land mines or improvised explosive devices (14.3%), and firearm discharges (14.3%). Depending on their location, these retained foreign bodies were retrieved either by open procedures—including ureteric reimplantation with a Boari flap (n = 2), surgical exploration (n = 3), and nephrolithotomy (n = 1)—or by endourological procedures, including percutaneous nephrolithotomy and cystoscopy (n = 4, each). The mean duration of surgery for open procedures was 119.16 ± 27.82 minutes (p = 0.007), which was longer than the mean duration of endourological procedures (1.87 ± 26.04 minutes). The mean length of hospital stays for open and endourological procedures was 4.0 ± 1.41 days and 3.5 ± 2.13 days, respectively (p = 0.630). Postoperative complications were reported only in one case, which required a blood transfusion (Clavien-Dindo  Grade II).

The pictorial representations of bomb blast pellets in the kidney and urinary bladder, a bullet in the kidney, and a bomb blast pellet in penis are shown in Figure 1 and 2, respectively.

Table I: Showing the location and procedures for retrieving foreign bodies.

Organs Involved	Frequencies	Procedures	Frequencies
Kidney	5	Percutaneous nephrolithotomy (PCNL)	5
Ureter	2	Ureteric reimplantation and Boari flap	2
Urinary bladder	4	Cystoscopic procedure and the removal of pellets	4
Testes	2	Surgical exploration	2
Penis	1	Surgical exploration	1

DISCUSSION

Warfare injuries predominantly affect males, as they are more frequently exposed to warfare, a pattern also observed in the present study. Patients commonly presented with pain, lower urinary tract symptoms, haematuria, and fever. Similar clinical presentations have been reported by Aliabadi et al. and Khan et al.^4,5 Most of the foreign bodies in this study were in the kidney and bladder, a finding also reported by Eisenberg et al.⁶

Figure 1: Radiological images of bomb blast pellets. (A) Bomb blast pellets in the kidney. (B) CT scan showing a bullet in the kidney. (C) Bomb blast pellet in the urinary bladder. (D) Bullet with stone.

Figure 2: Removal of pellets and a bullet from the genitourinary tract. (A) Bullet and stones. (B) Removal of bomb blast pellets from the kidney. (C) Bomb blast pellet in penis. (D) Removal of bomb blast pellets from the urinary bladder.

As this study focused on injuries caused by bomb blasts and firearm-related aetiology, metallic pellets and bullets were the most commonly encountered foreign bodies. The present study reports the longest indwelling time of up to 61 months, observed in a 38-year male patient with a metallic pellet in the kidney, which was retrieved via percutaneous nephrolithotomy. In comparison, a study by Eisenberg et al. demonstrated a case in which a foreign body was retained in the urinary tract for ten years.⁶

Historically, bomb blast pellets and retained bomb blast pellets have been treated conservatively or by nephrectomy. How-ever, the literature has repeatedly emphasised the paucity of information on the timings and options of management in case of delayed presentation of warfare injuries, especially in asymptomatic patients. However, in the present study all patients were symptomatic, presenting with overlaying stone formation in the kidneys and bladder, chordee, or scrotal pain. Percutaneous, retrograde endoscopic, and a combination of antegrade and retrograde endoscopic interventions have been used for the retrieval of retained renal foreign bodies. In the present study, retained foreign bodies in the kidney were managed using a percutaneous approach, except in one patient who required surgical exploration. Open cystotomy, percutaneous cystolitholopaxy, cystoscopy, transurethral cystolitholopaxy, Holmium laser, and laparoscopy successfully removed foreign bodies from the urinary bladder.^7-10 In this study, nearly all foreign bodies in the renal and urinary bladder were managed endoscopically. Only the ureteric and genital pellets required open surgery.

The mean surgery time in this study for endourological procedures was significantly less than that for open procedures. However, there was no significant difference in the length of hospital stay. There is limited relevant literature available on the duration of surgery and the length of hospital stay.⁶ The postoperative complications in the management of retained foreign bodies have been highlighted by several studies.^10,11 Grade II Clavien-Dindo complications were observed in one patient (P12) who required a blood transfusion after undergoing percutaneous nephrolithotomy for a metallic pellet in the kidney. Bansal et al. also reported multiple postoperative complications according to the Clavien-Dindo classification.³

This study highlights the existing, long-term consequences and management of retained foreign bodies in the genitourinary tract resulting from bomb blasts, mines, and firearm-related injuries. It may be relevant to healthcare providers who have been working in terrorism-inflicted and conflict-affected areas. This study does not provide answers to the actual burden of all-cause retained foreign bodies in the genitourinary tract.

The present study focuses explicitly on retained foreign bodies in the genitourinary tract and provides new insights into the long-term physical effects of such injuries, leading to bizarre presentations such as stones and lower urinary tract symptoms. The strength of this study lies in reporting the largest series in which bomb blast pellets and bullets were removed endoscopically in the majority of cases from the kidneys and urinary bladder. Limitations of the study include the reliance on the surgical expertise of a single principal author; hence, the results cannot be generalised. However, the urologists can take inferences from this study across the globe.

CONCLUSION

Symptomatic retained bomb blast pellets and bullets can be successfully removed endoscopically in experienced hands.

ETHICAL  APPROVAL:
Ethical approval was obtained from the Institutional Research and Ethics Board of the Institute of Kidney Disease, Hayatabad, Peshawar, Pakistan (Ref. No. 525/Chairman/R&E/Committee/IKD).

PATIENTS’  CONSENT:
Informed  consent  was  obtained  from  all  the  patients.

COMPETING  INTEREST:
The  authors  declared  no  conflict  of  interest.

AUTHORS’  CONTRIBUTION:
LA: Conception and design of the study.
SF: Acquisition, analysis, interpretation, drafting, and critical revision of the study.
FA: Drafting and critical revision of the study.
FH, SK: Drafting.
All authors approved the final version of the manuscript to be published.

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