UROGENITAL TRAUMA

Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital
Elliott SP, McAninch JW
Department of Urology, University of California School of Medicine, San
Francisco General Hospital, USA
J Urol. 2003; 170: 1213-6

• Purpose: We review our 25-year experience with traumatic ureteral injury, for which the approach to management differs from the far more common iatrogenic injury.
• Materials and Methods: Review of our trauma data base disclosed 36 patients with 38 ureteral injuries (33 penetrating [24 gunshot, 9 stab wounds] and 5 blunt) from 1977 to 2003, a period during which we treated approximately 4,000 traumatic genitourinary injuries.
• Results: The site of injury was the upper ureter in 70%, mid in 8% and distal in 22%. Major intra-abdominal injuries were often associated, but hematuria and hypotension were not consistent findings (75% and 50%, respectively). Excretory urograms performed in 24 patients was diagnostic in only 40%. Computerized tomography and retrograde pyelogram were diagnostic in 4 of 4 and 1 of 1 injuries, respectively (100%). Overall, diagnosis was by radiographic findings in 13 of the 36 injuries (36%) and by laparotomy in 23 (64%). Management was with stenting in 2 patients, primary closure in 12, ureteroureterostomy in 12, ureteroneocystostomy in 5, transureteroureterostomy in 1, Boari flap in 1 and nephrectomy in 1. The complication rate was 18%.
• Conclusions: Although traumatic ureteral injury is rare these patients are often critically ill and delay in diagnosis will increase the risk of complications. Contrast enhanced imaging in patients who are not undergoing laparotomy for associated injury should not be limited to those with hematuria and hypotension since these are not entirely sensitive. Most injuries are short segment loss in the upper ureter and can be repaired with debridement and tension-free anastamosis (sic).]
  
  
• Editorial Comment
  Ureteral injuries from external violence are rare and few large series exist. An update on the treatment of ureteral strictures from San Francisco General Hospital (which first presented some of these patients in 1989) allows a review of salient principles. It is the largest series yet published on the subject.
  There are several relevant points in this paper: 1)- In most series, a significant proportion of the patients have initially missed injuries. In this series only 3/38 had missed injuries (8%). This shows that if the doctors really look, they can decrease the number of missed injuries; 2)- All blunt injury patients need ureteric imaging with computed tomography scan or intraoperative one-shot intravenous pyelogram (IVP) if they have gross hematuria, or microhematuria together with shock, major associated injuries, or deceleration injury; 3)- The authors suggest that if the criteria of flank ecchymosis or flank tenderness is added to the above criteria in cases of blunt trauma, then detection of ureteric injury is improved (although I wonder how much this would increase the number of CT scans performed in the trauma population…); 4)- All penetrating injury patients need ureteric imaging if they have gross hematuria, microhematuria, or a flank wound; 5)- One shot IVP can be helpful in identifying ureteric injury, but intraoperative inspection of the ureter should still be done if the missile path is close to the ureter; 6)- The authors suggest that patients too unstable to tolerate ureteral repair should have the ureter tied off with silk suture and postoperative percutaneous nephrostomy placed. Definitive delayed repair can be completed later. Interestingly, none of the 38 injured ureters required this approach!; 7)- Most upper and mid ureteral injuries can be treated by minimal debridement and uretero-ureterostomy; 8)- Most distal ureteral injuries should be treated by ureteroneocystostomy; 9)- Some patients with delayed presentation may respond to ureteric stenting at the time of retrograde pyelogram. If not, then open repair will be required.

Dr. Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA