UROGENITAL TRAUMA

Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale
Best CD, Petrone P, Buscarini M, Demiray S, Kuncir E, Kimbrell B, Asensio JA
Department of Urology and Division of Trauma and Critical Care, Los Angeles County and University of Southern California, Los Angeles, California, USA
J Urol. 2005; 173: 1202-5

• Purpose: Ureteral injuries are uncommon and challenging. In this study we report our institutional experience with ureteral injuries. We evaluated the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for ureteral injuries as a predictor of outcomes for complexity of repair, morbidity, mortality and associated injuries.
• Materials and Methods: We performed a retrospective, 120-month study (January 1992 to December 2002) at an urban, level I trauma center.
• Results: In the 57 patients mean hospital Admission blood pressure +/- SD was 115 +/- 25 mm Hg, mean Revised Trauma Score was 7.38 +/- 0.84 and mean Injury Severity Score was 15 +/- 1.15. The mechanism of injury was penetrating in 55 cases (96.5%), including gunshot wound in 52 (54.5%) and stab wound in 2 (5.5%), and in blunt 2 of motor vehicle accidents (3.5%). The anatomical location was the left side in 33 cases (58%), right side in 23 (40%) and bilateral in 1 (2%). The distribution of injuries was proximal in 15 cases (26%), mid in 21 (37%) and distal in 21 (37%). Associated injuries were present in 56 patients (98%). An intraoperative diagnosis was made in 44 cases (77%). Of the patients 50 (88%) required complex repairs or an adjunct procedure, including a double pigtail stent in 33 (58%), ureteroureterostomy in 20 (35%), ureteroneocystostomy with a psoas hitch in 10 (18%), external diversion in 9 (16%), suprapubic cystostomy in 8 (14%), nephrostomy in 2 (3.5%), nephrectomy in 2 (3.5%) and ligation in 2 (3.5%). Injury grade was I to V in 5 (8%), 8 (13%), 13 (22.8%), 18 (31.6%) and 13 (22.8%) cases, respectively. Overall 51 patients (89%) survived. No deaths were related to ureteral injury. Renal salvage was achieved in 49 of the 51 surviving patients (96%).
• Conclusions: Ureteral injuries are uncommon. The complexity of repair and number of associated injuries increase with AAST-OIS injury grade. Mortality increases with AAST-OIS injury grade but it is not related to the ureteral injury. Excellent results can be achieved with complex techniques of primary repair, leading to renal salvage.
  
  
• Editorial Comment
  The American Association for the Surgery of Trauma developed an organ injury scale for each of the Urologic organs, as published in the Journal of Trauma in 1989 and 1992 (1,2). The great value in such scales is that they enable a uniform method of defining urologic injuries and so facilitate the development of comparative studies and research. These injury scales were based on the consensus of experts in urologic trauma, and not by evidence based medicine. The above retrospective review is another in a long line of papers seeking to validate that the complexity of repair and outcomes correlate to the AAST scale of degree of injury.
  Other lessons learned from this study are that ureteral injuries are rare events. The majority of ureteral injuries are due to penetrating trauma. The location of penetrating ureteral injuries is roughly evenly distributed among each one-third of ureter. Penetrating injuries have a very high associated organ injury rate, and it is the associated injuries that primarily cause the morbidity and potential mortality. The most reliable method to diagnosing a ureteral injury is intraoperative direct exploration. Ureteral injuries from blunt trauma are typically due to deceleration and at the ureteropelvic junction.

References
1. Moore EE, Cogbill TH, Jurkovich GJ, McAninch JW, Champion HR, Gennarelli TA, Malangoni MA, Shackford SR, Trafton PG: Organ injury scaling. III: Chest wall, abdominal vascular, ureter, bladder, and urethra. J Trauma. 1992; 33: 337-9.
2. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, Flint LM, Gennarelli TA, Malangoni MA, Ramenofsky ML, et al.: Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989; 29: 1664-6.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA