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UROGENITAL
TRAUMA
Delayed
Diagnosis of Traumatic Ureteral Injuries
Kunkle DA, Kansas BT, Pathak A, Goldberg AJ, Mydlo JH
Departments of Urology and Surgery, Temple University Hospital, Philadelphia,
PA, USA
J Urol. 2006 Dec; 176(6 Pt 1): 2503-7
- Purpose:
We review our experience with traumatic ureteral injuries missed at
exploration. We also conduct meta-analysis to define factors contributing
to missed injury, comparing outcomes of early vs late diagnosis.
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Materials and Methods:
Our genitourinary trauma database was retrospectively reviewed from
1995 through 2004. A total of 40 ureteral injuries were identified including
5 with delayed diagnosis. Previously published series of ureteral trauma
were then analyzed for injuries with delayed diagnosis, with data extracted
and collated for meta-analysis.
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Results:
A total of 40 patients with traumatic ureteral injuries was identified,
all of whom underwent laparotomy. Five (12.5%) injuries were discovered
at a mean of 6.0 +/- 3.0 days after laparotomy. The number of associated
injuries for early and delayed diagnosis was 3.2 and 2.6 (p = 0.25),
respectively. Mean hospital stay was 19.2 vs 36.6 days (p = 0.18) for
those with immediate vs delayed diagnosis, respectively. Only 2 of 5
(40%) patients achieved satisfactory results during initial hospitalization.
Literature review revealed 48 missed ureteral injuries, representing
11.1% of all patients with ureteral injuries who underwent laparotomy.
Rates of nephrectomy for early and late diagnosis were 2.4% and 18.4%
(p = 0.0001). Mortality related to traumatic injuries occurred in 6.1%
with early diagnosis and 13.2% with missed injuries (p = 0.089).
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Conclusions:
Despite preoperative studies and intraoperative inspection, ureteral
injury may remain undiagnosed until after laparotomy. We report intraoperative
exploration to have a sensitivity of 88.9% across multiple series for
traumatic ureteral injuries. Delayed diagnosis of ureteral injuries
produces an association with prolonged hospital stay, and meta-analysis
reveals a statistically significant increase in the rate of nephrectomy
when ureteral injury is missed at exploration.
- Editorial
Comment
Kunkle et al. report on their experience with missed ureteral injuries
at a busy inner city trauma center. This is a well written and comprehensive
paper on delayed diagnosis. Tables 3 and 4 are nice metanalyses demonstrating
that roughly 11% of ureteral injuries are missed at laparotomy, resulting
in an overall nephrectomy rate of 18% and death at 13%. Even in the
busiest of trauma centers, external ureteral injuries are rare, typically
with fewer then 10 injuries seen per year. In the literature, there
are only a few series with a sizable experience, and they are all retrospective,
cover long study periods (10-40 years), and are mostly treated by heterogeneous
groups of physicians. Most external ureteral injuries occur from gunshot
wounds. Missile path even in proximity to the ureter can cause significant
delayed tissue destruction. Such injuries can be difficult to identify
initially and often present in a delayed fashion. Penetrating ureteral
injuries are almost always associated with multiple intra-abdominal
organ injuries (such as, small bowel, colon, liver and iliac vessels.
Associated injuries are often more obvious and overshadow the ureteral
injury. Ureteral injuries from blunt trauma are equally rare. They usually
occur in children during rapid deceleration, causing excessive hyperextension
and disruption at the ureteropelvic junction. Such patients are usually
poly-traumatized and have associated multiple organ injuries (mostly
liver, spleen and skeletal system).
In the acute trauma setting, therefore, the diagnosis of ureteral injury
can be difficult. When the ureteral injury is missed and not diagnosed
till late or the primary repair fails, the complication rate increases
considerably, including renal loss and even death.
Dr.
Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA |