Mark Edney, MD, FACS
Chairman Benishek, Ranking Member Brownley, members of the Committee, honored guests, fellow service members; I thank the Committee on Veterans Affairs, Subcommittee on Heath for inviting me to testify regarding HR 984, a bipartisan bill introduced by Representative Guthrie to direct the Secretary of Defense to establish a task force on urotrauma.
I am a urologist, a surgical specialist who treats genitourinary disease and injury, in private practice in Salisbury, MD. I am also an Army Reservist of 11 years. I have been called to active duty 3 times: first to Walter Reed Army Medical Center in 2004, one tour with the 399th Combat Support Hospital in Mosul, Iraq in the winter of 2006, and finally a tour at Tripler Army Medical Center in 2009. I have treated genitourinary trauma, or urotrauma, in the theater of operations and have participated in its chronic management at our largest military medical centers stateside.
It’s an honor to represent the American Urological Association (AUA), the world’s premier professional association of urologists, and our urotrauma coalition in support of HR 984 on behalf of this unique class of injured service members. Our urotrauma coalition includes a diverse group of medical societies, veterans’ services organizations and industry partners who all support the policy initiatives with respect to genitourinary injury or urotrauma contained in HR 984. Our coalition partners who have pledged their organizational support to our urotrauma initiative include the: American College of Surgeons, American Congress of Obstetrics and Gynecology, American Association of Clinical Urologists, Large Urology Group Practice Association, American Fertility Association, American Society of Andrology, Society for the Study of Male Reproduction, Society of Male Reproduction and Urology, Society for Women’s Health Research, Veterans of Foreign Wars (VFW), Disabled American Veterans (DAV), AMVETS, Paralyzed Veterans of America, Blinded Veterans Association, Men’s Health Network, Zero- The Project to End Prostate Cancer, RESOLVE: The National Infertility Association, Blue Ribbon Advocacy Alliance, Johnson and Johnson, Astellas, and Endo Pharmaceuticals.
There have been approximately 50,000 soldiers wounded in action since 2003 in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Of those, approximately 16,000 injuries are catalogued in the Joint Theater Trauma Registry (JTTR), the inter-service in-theater trauma database that has been in operation since 2003. Recent studies have indicated that 5-10% of battlefield injuries involve injury of the genitourinary (GU) organs for a total of around 1000 GU injuries. Of those, approximately 60% involve the external organs (scrotum, testicles, penis and urethra), and 40% involve other organs including kidneys, bladder, ureters, uterus, fallopian tubes, and ovaries. The DoD’s Dismounted Complex Blast Injury Task Force studied and reported on this pattern of injury at the direction of the Army Surgeon General in June, 2011. Because improvised explosive devices (IED) are the enemy’s weapon of choice and because soldiers are increasingly required to patrol on foot or “dismounted” in Afghanistan (as compared to Iraq), the incidence of complex blast injury is up 350% in OEF. Dismounted complex blast injury describes the constellation of catastrophic extremity injury with often bilateral lower limb loss, sometimes together with upper limb loss, traumatic brain injury, and in many cases injury to the genitourinary organs.
Although GU-injured veterans may exhibit no outward signs of their injury, they suffer life-changing loss of proper sexual, bowel, and urinary function and fertility. These deficits have significant social effects on marriages and other relationships and enormous effects on quality of life. The cumulative physical and psychological impact of urotrauma on these soldiers is no less profound than for those recovering from extremity loss and neurocognitive injury. As a complex injury, urotruama has not received the same policy attention and care coordination that has been afforded the more common injury patterns such as extremity loss, traumatic brain injury and eye injury -- each with its own DoD center of excellence. Genitourinary injury is increasingly a critical military women’s health issue with women now able to serve in direct combat roles. We must do better with the study and care coordination of urotrauma.
In 2009, the AUA convened a working group comprised of AUA members within the Department of Defense (DoD) together with civilian trauma and GU reconstruction experts to formulate policy, craft legislation, and develop a comprehensive legislative strategy. The broad goals of the working group were to: improve the prevention of, improve and educate regarding the initial management of, and better coordinate the chronic care of urotrauma and to enhance urotrauma’s research infrastructure to facilitate outcomes research and longitudinal follow-up of urotrauma cases.
As a result of those discussions in 2009, key knowledge gaps were identified, necessitating a broader discussion with respect to the treatment of urotrauma. HR 984 ensures that broader discussions occur by directing the Secretary of Defense to establish a task force on urotrauma. The task force is required to conduct a study of urotrauma among members of the Armed Forces and veterans including: an analysis of the incidence, duration, morbidity rate, and mortality rate of urotrauma; an analysis of the social and economic costs and effects of urotrauma; with respect to the Department of Defense and Department of Veterans Affairs (VA), an evaluation of the facilities, access to private facilities, resources, personnel, and research activities that are related to the diagnosis, prevention, and treatment of urotrauma; an evaluation of the programs (including such biological, behavioral, environmental, and social programs) that improve the prevention or treatment of urotrauma; a long-term plan for the use and organization of the resources of the Federal Government to improve the prevention and treatment of urotrauma; an analysis of the shortfalls in research, expertise, and health care infrastructure for female victims of urotrauma; an analysis of the technical, administrative, and budgetary mechanisms to allow for enhanced reproductive services for members who have been affected by urotruama or who are at high risk of urotrauma; an assessment of opportunities to enhance the coordination of Federal resources used to research, prevent, and continuously improve the management of urotrauma; and inter-agency efforts regarding the chronic physical, behavioral, and emotional care of victims of urotrauma.
With respect to research, I am aware of at least two DoD databases that prospectively collect data on urotrauma injuries for the purpose of longitudinal follow-up and outcomes research: the Walter Reed Army Medical Center (WRAMC)/National Naval Medical Center (NNMC)/ Walter Reed National Military Medical Center (WRNMMC) surgical database that has been in use for 6 years and the Expeditionary Medical Encounter Database (EMED), in operation at the Naval Health Research Center, Medical Modeling, Simulation and Mission Support Division in San Diego, CA. The JTTR, as I mentioned earlier, has catalogued more than 16,000 battlefield traumas since 2003, but lacks specificity for details of urotrauma that would enable longitudinal follow-up and outcomes research. The VA also has a robust repository of patient-level data in its electronic medical record, Vista. The appropriate department should be tasked with coordinating these databases as well as any other similar databases, to ensure that they are collecting appropriate urotrauma measures so that they may facilitate the longitudinal follow-up and outcomes research of urotrauma.
The seamless transition from the DoD to the VA, of the soldier suffering urotrauma with his or her complex care needs, represents an opportunity for improvement. DoD Instruction 1300.24 directs the Assistant Secretary of Defense for Health Affairs under the authority, direction, and control of the Under Secretary of Defense for Personnel and Readiness to “coordinate with the VA to develop and implement administrative processes, procedures, and standards for transitioning RSMs [recovering service members] from DoD care and treatment to VA care, treatment, and rehabilitation that are consistent with [language stipulated in the instruction].” A critical element of the transition is that of the transfer of a complete medical and surgical record to accepting providers in the VA. The AUA’s working group has heard from a variety of urologists in both the DoD and VA that the record transfer is not happening in many cases.
DoD currently provides a high level of expertise and care coordination for soldiers with urotrauma. However, the difficulty arises when RSMs are transferred to the VA. While the VA has polytrauma centers of excellence with many highly trained surgeons, there are regions of reduced access to the technology and surgical expertise required to care for these complex cases. Therefore, there are opportunities to improve and standardize communication between DoD and VA physicians. There are also opportunities to optimize the placement of GU-injured soldiers in proximity to the expertise and technology that they need and to employ telemedicine and other new information technologies to deliver needed services reducing the impact of geography on access.
Finally, although each of the functional challenges that result from damage to the genitourinary organs is life-altering, perhaps one of the most profound is the loss of fertility. The brave young Americans who are voluntarily putting themselves in harm’s way in defense of our country are often doing so prior to their reproductive years. Some are suffering injuries that severely impair or eliminate their natural reproductive capability shattering a dream of many -- to begin a family of their own. HR 984 seeks “an analysis of technical, administrative, and budgetary mechanisms to allow for enhanced reproductive services for members who have been affected by urotrauma or who are at high risk of urotrauma”. The AUA recognizes that there’s much to be done in this area from pre-deployment sperm banking, to cryopreservation of sperm at the initial point of care when testicular loss is inevitable, to providing advanced reproductive services to all military urotrauma victims who are infertile and receiving care in the DoD and VA. We are currently short of that goal and the AUA working group also supports legislation to enhance these policies.
In summary, the rate of genitourinary injury suffered by American soldiers is up 350% in the Afghanistan theater compared to the Iraqi theater as a result of the increased necessity of dismounted patrol. Genitourinary injures are an increasingly common, complex constellation of wounds with devastating long term implications for urinary, bowel, and sexual function and fertility. These sequelae in turn have profound impact on soldiers’ mental health, marriages, other social relationships and overall quality of life. HR 984 prescribes the comprehensive study required to address the variety of opportunities for improving the prevention, initial management, care coordination and research of this devastating and increasingly prevalent pattern of injury. We owe these finest of Americans no less for the sacrifices they have made for our great nation. On behalf of the American Urological Association and the urotrauma coalition partners, I urge you to support HR 984 and favorably report it out of the committee.
Again, I want to thank the Veteran’s Affairs Committee for their invitation to testify before you and I am available to answer any questions.