Management of retained bullet fragments from posterior urethra after gunshot wound: a case report

Introduction

Genitourinary (GU) trauma following gunshot wound (GSW) is rare, accounting for approximately 10% of injuries in nearly 2.8 million trauma patients admitted to US hospitals annually.1 Retained or migrated bullet fragments within the GU tract are even more uncommon, with only a few cases reported in the literature. A recent comprehensive review by Phan et al. highlights the variability in presentation and management of retained bullets in the urinary tract, including cases of delayed migration, encrustation, and associated stone formation, sometimes occurring decades after the initial injury.2 Friedman et al. reported a case of a retained bullet within the bladder post GSW with failed retrieval of the bullet using resectoscope, loop, cystoscope, and stone crusher, leading to ultimate transurethral removal using a Perc NCircle grasper.3 Marantidis and Biggs reported a case of a bullet fragment that had migrated into the bladder one year after injury, necessitating open cystolithotomy after failed lithotripsy to disrupt the stone encrusting the bullet fragment.4 The consensus is that retained bullet fragments should be removed to prevent complications such as urinary retention, stone formation, or recurrent infections.5

Here, we present a unique case of a patient with a prostatic urethral injury from a pelvic GSW. An initial bullet fragment was successfully removed endoscopically at the time of initial presentation, but a second fragment later migrated into the prostatic urethra. The second fragment was first identified on follow-up voiding cystourethrogram (VCUG). Endoscopic retrieval was attempted but was unsuccessful. Eventually, this fragment was removed with open cystotomy. While endoscopic management of retained bullet fragments has been reported in the literature, this case is unique in that it involves initial successful endoscopic removal of one fragment, followed by delayed migration of a second fragment requiring open surgical extraction, both of which occurred in the same patient.

Case Report

Patient information and diagnostic assessment

A 44-year-old male with no pertinent past medical history and no previous urologic history presented to the trauma bay after sustaining a GSW to the buttock. He was hemodynamically stable, and a single penetrating injury was noted to the superior intergluteal cleft on examination. The digital rectal exam was unremarkable. Computed tomography (CT) Abdomen/Pelvis with Contrast and delayed washout revealed injuries including: a bullet tract through the left gluteus/sacrum violating several extraperitoneal structures, a low rectal injury with intraperitoneal free air and blood, and a laceration to the majority of the left prostate. Bullet fragments in the area of the prostate were also seen (Figure 1). The washout phase showed an intact bladder and ureters bilaterally. A Foley was placed in the trauma bay with frank blood return, but no urine, prompting a urology consultation. The patient was taken to the operating room (OR) for proctoscopy and exploratory laparotomy with general surgery. Urology assisted due to high concern for lower urinary tract injury.

FIGURE 1. Initial pelvic imaging after gunshot wound (GSW). (A) Computed tomography (CT) of the pelvis showing a bullet located in the area of the prostate in axial view, with an asterix to the immediate left of the bullet. (B) Sagittal view CT of the abdomen and pelvis showing a bullet located in the area of the prostate with asterix to the immediate left of the bullet. (C) X-ray of the pelvis showing a bullet located in the area of the prostatic urethra with asterix to the immediate left of the bullet

Therapeutic intervention

Flexible cystoscopy revealed a large anterior prostatic urethra. During the procedure, the true lumen of the prostatic urethra was not able to be identified due to the degree of trauma to the area, and the scope was not able to be passed into the bladder. A bullet fragment was noted in to be in the posterior prostatic urethra and removed using a zero-tip basket. The decision was made to then attempt antegrade flexible cystoscopy via a cystotomy. The true lumen was not able to be identified via antegrade cystoscopy as well. Finally, the flexible cystoscope was advanced retrograde per the urethra into the anterior prostatic defect, and a council tip catheter was advanced antegrade from the open bladder into the defect. A wire was passed through the council tip catheter and then through the flexible cystoscope. Then both the scope and the catheter were offloaded. This left us with a wire running from the patient’s meatus through the defect, into the bladder, and out the cystotomy that was previously made for antegrade urethroscopy. A catheter was then placed retrograde through the urethra and into the bladder. The anterior prostate tissue was closed overtop this catheter, and an open suprapubic tube (SPT) was placed. The bladder was closed. It was felt that having a catheter in place would potentially mitigate the need for future urethral reconstructive surgery in this patient. Both the catheter and SPT were left to gravity. The trauma surgery team performed debridement of the rectal injury and a diverting colostomy. They left a drain in the pelvis per the request of the urology team.

Jackson Pratt (JP) creatinine on postoperative day 2 was 1.1, consistent with serum, indicating no urine leak. His urethral catheter and SPT continued to drain without issue. He was discharged a week later with oxybutynin for bladder spasms.

He was seen in the office one month later, and a plan was made for VCUG to evaluate for persistent urethral injury. Unfortunately, the patient’s urethral catheter was inadvertently removed a week after his clinic visit; however, his SPT was still in place. He was not able to void spontaneously per urethra. VCUG obtained one day later showed migration of a large retained bullet fragment into the prostatic urethra and persistent leak from the middle third of the prostatic urethra (Figure 2). No fistula was seen, and there was no evidence of bladder injury. Options were discussed, and we recommended that the patient undergo cystoscopy as soon as possible to remove the migrated bullet fragment as well as replace the urethral catheter for another several weeks. The patient was agreeable.

FIGURE 2. (A) Voiding cystourethrogram (VCUG) one month after initial operative management with migration of a bullet fragment into the prostatic urethra, with persistent leak in the prostatic urethra. (B) A second view of the persistent leak. Asterixs are at the location of a persistent leak

The patient underwent rigid cystoscopy per urethra, where the bullet fragment was encountered in the prostatic urethra. However, the fragment was too large to be basketed and removed via the anterior urethra. Flexible cystoscopy was then attempted via his SPT tract, but visualization was poor, and the bladder neck could not be identified. Repeat attempts with rigid cystoscopy from below were unsuccessful. The decision was made to dilate the SPT tract so that rigid cystoscopy could be performed in an antegrade fashion. The SPT tract was dilated over a wire with blue fascial dilators to 24 Fr, but upon reentry with the cystoscope, a false passage was noted, and there was concern for leakage of irrigant into the extraperitoneal space. Both the urethral catheter and SPT were replaced. Placement was confirmed with an on-table cystogram, and the rest of the procedure was aborted. The plan was to reattempt endoscopic removal via the SPT tract approximately 4 weeks.

The subsequent attempt at endoscopic removal began by dilating the patient’s SPT tract to 30 Fr using a nephromax balloon dilator. A sheath typically used for percutaneous nephrolithotomy was then placed. This allowed a flexible cystoscope to be driven easily into the prostatic urethra, where the bullet fragment was encountered. An N Circle basket was used to pull the fragment back into the bladder. A Kelly clamp, ring forceps, and a basket were all used to attempt to remove the fragment from the bladder, but all methods were unsuccessful as the bullet fragment was too large to come through the sheath (Figure 3). Finally, open removal was considered, but the situation was not optimal for an open procedure, as this was being done on a fluoroscopy table in a cystoscopy suite rather than a true operating room. Both catheters were again replaced with the urethral catheter capped and the SPT to gravity. His urethral catheter was later removed in the clinic due to patient intolerance.

FIGURE 3. Attempted endoscopic removal of bullet fragment. Using flexible cystoscope with (A,B) an N Circle basket, (C) Kelly clamp, and (D) percutaneous nephrolithotomy sheath

Follow-up and outcomes

The patient finally underwent exploratory laparotomy, cystotomy, and open removal of the bullet fragment from his bladder on 12/23/2024, nearly 4 months after his initial gunshot wound. During this procedure, a large, nearly 2 cm irregular bullet fragment was extracted through a 4 cm lower midline incision (Figure 4). Flexible cystoscopy showed a patent urethra without any obvious or large defects. His SPT was replaced.

FIGURE 4. Gross images of the removed bullet fragment. (A) Top-down view demonstrating the overall size and shape of the fragment, which measured approximately 2 cm in length. (B) Lateral view showing the irregular, jagged surface of the fragment

Two weeks postoperatively a fluoroscopic cystogram showed no leak, and he was able to void per urethra. His SPT was removed in clinic, and he has since been voiding adequately per urethra. While lower urinary tract symptoms (LUTS) were not explicitly documented at that visit, no complaints were noted by the patient, and no further urologic evaluation was deemed necessary at the time. The patient has not returned for additional follow-up since that appointment.

Discussion

There are a few reports of bullet fragments retained in the GU tract. Our case follows a patient for several months after his initial GSW that resulted in a large prostatic urethral injury as well as a retained bullet fragment in the GU tract requiring removal. There are several noteworthy learning points from our case.

It is well established that suspicion of urethral injury must be high with blood at the meatus following penetrating trauma, and this should prompt urologic evaluation. In our case, the patient went directly to the OR earlier on presentation, and his urethra was evaluated by flexible cystoscopy. This enabled us to immediately identify a bullet fragment in the posterior prostatic urethra that was able to be removed endoscopically at the time of the initial injury. Evaluating the injury in the OR also enabled us to place both a urethral catheter and an suprapubic catheter via an open combined endoscopic approach. We feel that the placement of his initial urethral catheter was imperative to promote urethral healing through primary realignment. It is likely that this patient would have required complex reconstruction if a urethral catheter had not been able to be placed at the time of his initial injury.

Additionally, the patient’s urethral catheter fell out several times, and due to the second bullet fragment migrating into and obstructing the urethra, he was unable to void per urethra. Having an SPC in place prevented acute urinary retention in this patient and offered us safe access to the bladder throughout his entire course. The SPT also allowed an antegrade endoscopic approach to the bladder for further attempts at removing this second bullet fragment. Having suprapubic access was essential for both preventing urinary retention and facilitating endoscopic retrieval of the bullet fragment when it was relocated from the urethra to the bladder. Open removal of a retained urethral fragment would have been significantly more difficult.

American Urological Society urethral trauma guidelines state that prolonged attempts at primary realignment via endoscopy should not be attempted in cases of pelvic fracture-associated urethral injury.5 However, our patient did not have a pelvic fracture. These same guidelines also state that “surgeons should perform prompt surgical repair in patients with uncomplicated penetrating trauma of the anterior urethra”,6 for which, in the absence of a pelvic fracture, our patient meets the criteria, and this was accomplished in our case. Several studies have shown lower rates of urethral stricture in patients with prostatic urethral injuries who undergo primary realignment instead of delayed urethroplasty.7–9 We feel that for our patient, our efforts at primary realignment ultimately allowed us to remove both his initial and subsequent bullet fragments from the urinary tract. This allowed us to protect his continence and voiding function. It also likely allowed him to be catheter-free at a much earlier date. We hope this unique case will provide insight for other clinicians who may encounter prostatic urethral injuries due to penetrating trauma with retained foreign bodies in the future.

In cases of penetrating trauma with retained bullet fragments, especially when multiple fragments are identified on imaging, providers should maintain a high index of suspicion for delayed migration and potential obstruction. Follow-up imaging, such as VCUG or CT, can be essential to detect fragment movement or new complications. When multiple or large fragments are present, especially if endoscopic removal is unsuccessful or limited by anatomical disruption, exploratory laparotomy should be considered early. While endoscopic approaches are less invasive and often preferred, they may not be feasible in all situations, including when fragment size, location, or poor visualization prevent safe removal.

Conclusions

Retained bullet fragments within the urinary tract can pose significant diagnostic and therapeutic challenges, and multiple approaches may be necessary to achieve successful removal. This case highlights the importance of individualized, stepwise treatment strategies, including both endoscopic and open surgical techniques. Maintaining access to the bladder with a suprapubic tube was essential, not only for urinary drainage but also as an access point for endoscopic access and ongoing management. Clinicians should consider early suprapubic access in similar cases, particularly when initial endoscopic efforts are unsuccessful or when reintervention is anticipated.

Acknowledgement

Not applicable.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Contributions

Sarah M. Kodres-O’Brien served as the lead author and was responsible for manuscript drafting, literature review, and figure preparation. Mackenzie Koellermeier contributed to literature review, manuscript editing, and case documentation. Nayan Shah provided clinical insight and critical revisions. Peter Langenstroer supervised the case management and contributed to the final manuscript review. All authors reviewed the results and approved the final version of the manuscript.

Availability of Data and Materials

All relevant data supporting the findings of this case report are included within the manuscript. Additional information may be made available upon reasonable request to the corresponding author.

Ethics Approval

This case report was conducted in accordance with institutional guidelines and ethics approval has been waived by the institution in accordance with local laws and regulations. The Medical College of Wisconsin Ethics Committee does not require Institutional Review Board approval for de-identified case reports.

Informed Consent

Written informed consent was obtained from the patient for publication of this case and any accompanying images.

Conflicts of Interest

The authors declare no conflicts of interest related to this publication.

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