Vol. 114, December
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1975 by The Williams & Wilkins Co.
BLUNT URETERAL TRAUMA WITH PERINEAL URINE FISTULIZATION: REVIEW OF THE LITERATURE E. WALLIJN,* W. DE SY
AND
E. FONTEYNE
From the Department of Urology, University Hospital, De Pintelaan 135, Ghent, Belgium
ABSTRACT
The first case of blunt ureteral disruption with external urine fistulization is presented. Reanastomosis with temporary urine diversion by a nephrostomy tube was successful. A review of the literature since 1950 revealed only 49 cases that proved this pathology should be considered in the differential diagnosis of post-traumatic hematuria or the development of mass in the flank. Nephrectomy is no longer used since a thorough attempt at reconstructive surgery will provide good functional results. cerclage of the pubis was performed and the muscles and skin were sutured after adequate external drainage had been assured. Immediately postoperatively central fat embolism caused coma and finally apnea. Artificial respiration was necessary for 4 days. Urine leakage in the perineal wound was noted 9 days postoperatively. A cystogram was normal and the patient was watched carefully. The daily perineal urine fistulization gradually CASE REPORT increased to 400 cc. The patient became pyrexial An 8-year-old boy was admitted to the hospital 12 days postoperatively and his temperature on May 31, 1973, following an automobile accident remained at 39C for the next 3 days. A firm in which he was hurled throu~h the windshield. swelling the size of a child's head became evident Admission blood pressure was 80/40 mm. Hg, pulse in the right hypochondrium and loin. An excretory urogram (IVP) showed moderate 140 per minute and there were no symptoms of shock. The level of consciousness was slightly pyelocaliectasis on the right side, some upward disturbed as a result of a commotio cerebri. X-rays displacement of the kidney and extravasation of revealed a normal abdomen, a closed fracture contrast medium (fig. 1, A). Because of the precarious condition of the through the diaphyseal portion of the femur and a patient we performed only a simple incision and fracture of the right ilium immediately lateral to the sacro-iliac joint with a severe diastasis of the drainage of the mass. After 1 1. of infected but non-hemorrhagic urine gushed out, the fever and pubis. The most important injury was a deep perineal perineal urine fistulization rapidly disappeared. In the following weeks there was improvement in wound extending from the left groin to the anus. With the patient under general anesthesia the general condition and neurological state of the exploration showed that the tear extended into the patient. However, an IVP demonstrated a definite anus and rectum and that there was a complete worsening of the right hydronephrosis (fig. 1, B) disruption of the left crus penis, the left and an exploratory operation was done. A right ischiocavernosus muscle, the urogenital lumbotomy was performed 21 days later. The diaphragm, and the external and internal anal ureter was completely severed at the level of the sphincter. In the depth of the wound the perineal ureteropelvic junction with a 4 cm. diastasis of the urethra could be seen but the bulbous and distal avulsed ends. Dissection and debridement were portion of the corpus spongiosum could not be difficult. Every effort was made to prevent injury identified. A rupture of the levator ani enabled us to the ureteral blood vessels. The necrotic ends of pelvis and ureter were carefully freshened and the to see a small part of a slightly distended bladder. A balloon catheter was inserted without ureter was spatulated. Downward displacement of difficulty and 300 cc clear urine was passed. A the kidney was performed after its complete mobilization. A splinting ureteral catheter was Accepted for publication April 25, 1975. introduced into the ureter and brought out * Requests for reprints: Department of Urology, alongside a nephrostomy tube. Reanastomosis was Akademisch Ziekenhuis, De Pintelaan 135, 9000 Ghent, Belgium. accomplished using interrupted sutures of 4-zero Rupture of the ureter resulting from penetrative injuries to the abdomen, such as gunshot and war injuries, or from extensive pelvic and retroperitoneal operations is not uncommon. There have been few reports on ureteral avulsion caused by blunt abdominal trauma because this condition is rare. Herein we report a case of closed ureteral rupture, namely urine fistulization in a deep perineal wound.
942
BLUNT URETERAL TRAUMA WITH PERINEAL URINE FISTULIZATION
943
FIG. 1. A, IVP shows right hydronephrosis and extravasation of contrast medium. B, IVP shows worsening of hydronephrosis.
catgut and the area of anastomosis was surrounded by live fat to prevent adhesions. The external drainage was provided by a periureteral redon drain. Convalescence was uneventful. The nephrostomy tube and ureteral catheter were removed 16 days postoperatively. An IVP on June 5, 1974 showed a normal right kidney (fig. 2). DISCUSSION
In a review of the literature from 1868, when the first case was reported by Poland, 1 to 1950 Wilenius found only 30 cases of subcutaneous rupture of the ureter. 2 Frequently, it was an accidental post mortem finding and in the other cases the first symptom was urinoma in the loin. Treatment was exclusively nephrectomy. The number of case reports on this pathology has been increasing lately. In a survey of the literature since Wilenius, we were able to list another 49 cases of proved blunt ureteral avulsion. This clearly shows that the condition, although rare, is of clinical as well as academic importance. Sixteen publications were not included in our review because description of the lesion, treatment and/or followup was not complete. Of the 33 remaining cases traffic accidents were responsible for all but 2. The victims are generally young (66 per cent are less than 14 years old) and most of them have sustained other serious visceral or bony traumas. The mechanism of this type of injury was already understood by Kusher in 1896. 3 He stated that ureteral rupture was caused by torsion and stretching of the ureter over the transverse processes on violent lateral flexion of the lumbar spine. However, according to the experimental
FIG. 2. IVP 1 year after accident shows normal right kidney.
944
W ALLIJN, DE SY AND FONTEYNE
studies of Wilenius in 1950, rupture of the ureter and renal pelvis could be produced by compressing them against the 12th rib or the upper transverse processes. Reznichek and associates explained avulsion by a rapid succession of 2 separate events: a tensing of the ureter by its stretching like a bowstring and a snap or lash against the vertebral column with disruption of the ureter.• Children are predominantly inflicted by this type of injury because they have a greater elasticity and mobility of the truncal structures, and because there is a sparsity of retroperitoneal supporting fat. It may also be expected that the rupture commonly occurs at or near the pelvioureteral junction, where the surrounding supporting structures are loosely composed. Indeed, in our review only 4 avulsions were localized in the middle third of the ureter and only 2 in the inferior third. Ureteral trauma always leads to urinary extravasation, aseptic inflammation, lipolysis and fibrosis. In cases of incomplete rupture the urinary leakage quickly ceases and healing of the ureter occurs with more or less serious scarring. However, complete avulsion gives a persistent retroperitoneal urine efflux with pocketing of urine in the retroperitoneal tissues. In this way disruptions of the middle and inferior third may create paraureteral urinary pseudocysts, whereas avulsions of the upper third and the pelvioureteral junction give rise to the better known pararenal pseudocysts. • These encysted urine collections are surrounded by a thick fibrotic wall and an intact periureteral or renal fascia. If those fasciae are also torn by the injury, extensive retroperitoneal urinary phlegmons may arise. 6 In our case the urine extravasation had expanded gradually until the urine tracked into the pelvic cellular tissues and finally reached the perineal wound. In 1960 Sturdy and Magell described an analogous case of pre-sacral edema caused by urine extravasation along the foramen ischiadicum majus as the first symptom of a ureteropelvic junction disruption. 7 When the dorsal peritoneum is also torn, urinary ascites may arise. However, this is rare since only 1 case of ascites in relation to blunt ureteral avulsion has been published. 8 Our review stresses the difficulty of early diagnosis. The pathology was recognized after an average of 28 days in 33 cases and the diagnosis was made within 14 days in only 11. In the initial period urologic symptoms and urinary findings are sometimes negative. Hematuria is the most consistent finding"· 10 and, because it is often transient, early and frequent urine examinations for blood are important. We found only 14 cases of gross hematuria. The development of a soft tissue mass in the loin, usually within a few days or weeks, is a more reliable finding and has been described 16 times. In 7 cases high fever suggested that retroperitoneal urine collections are frequently infected.
The vague urologic symptoms are often overshadowed by more important and vital associated traumatology, thus delaying urologic investigation. An IVP should be done in any polytraumatized patient. In cases of a heavy abdominal or flank trauma this investigation is obligatory, even in the absence ofhematuria. Early urography usually shows dye extravasation but because the seriousness and accurate localization of the rupture are often difficult to judge, immediate cystoscopy with retrograde pyelography should be done. When an accurate diagnosis is made, the catheter is brought up as high as possible in the ureter and left in place, thus making detection of the ureter easier during the operation. Formerly, nephrectomy was the only therapeutic outcome. However, since 1958 when Seright 11 performed the first successful reanastomosis of a ruptured ureter, reconstructive surgery has been applied 24 times with fair results. In view of those successes, every attempt at repair of the ureter has to be commended. The operative technique depends on the localization of the rupture. For an avulsion in the neighborhood of the pyeloureteral junction a dismembered Anderson-Hynes pyeloplasty is suitable. On a lower level an end-to-end reanastomosis should be performed with interrupted 4-zero catgut sutures after freshening and spatulating the severed ureteral ends. To reduce tension on the reanastomosis the kidney frequently has to be mobilized to allow maximal descent. Disruptions near the bladder can be treated by performing a ureteroneocystostomy. Sometimes retraction and necrosis of the ureteral ends are so important that reapproximation is impossible. When this occurs we can choose among ureterocalicostomy, 12 transureteroureterostomy, ureteroil eocystostomy, Boari-plasty or even autotransplantation of the kidney. In many of these techniques, temporary diversion of urine by a nephrostomy tube or a splinting ureteral catheter is desirable. REFERENCES
1. Poland, A.: Cited by Slater, R. B. and Kirkpatrick, J. R.: A case of closed injury of the upper ureter. Brit. ,J. Ural., 43: 591, 1971. 2. Wilenius, R.: Subcutaneous rupture of the ureter. Ann. Chir. et Gynaec. Fenniae, 39: 1, 1950. 3. Kiisher: cited by Seright. 11 4. Reznichek, R. C., Brosman, S. A. and Rhodes, D. B.: Ureteral avulsion from blunt trauma. J. Ural., 109: 812, 1973. 5. Crabtree, G. E.: Pararenal pseudo-hydronephrosis with report of three cases. Trans. Amer. Ass. Genito- Urin. Surg., 28: 9, 1935. 6. Bartley, 0., Ekdahl, P. H. and Wahlqvist, L.: Rupture of the ureter with pseudocyst formation. Acta Chir. Scand., 132: 390, 1966. 7. Sturdy, D. E. and Magell, J.: Traumatic perinephric cysts ('pseudohydronephrosis'). Brit. J. Surg., 48: 315, 1960. 8. Carabalona, P., Delmas, M. and Bonnel, F.: Rupture
BLUNT URETERAL TRAUMA WITH PERINEAL URINE FISTULIZATION
9. 10. 11. 12. I
de l'uretere lumbaire par contusion abdominale. Ureterorraphie. Resultat a 4 ans. Chirurgie, 98: 421, 1972. Ainsworth, T., Weems, W. L. and Merrell, W. H., Jr.: Bilateral ureteral injury due to non-penetrating external trauma. J. Urol., 96: 439, 1966. Fruchtman, B. and Newman, H.: Upper ureteral avulsion secondary to non-penetrating injury. J. Urol., 93: 452, 1965. Seright, W.: Traumatic closed rupture of the upper ureter. Brit. J. Surg., 46: 511, 1959. Moloney, G. E.: Avulsion of the renal pelvis treated by ureterocalycostomy. Brit. J. Urol., 42: 519, 1970.
I.
COMMENT These authors call our attention to the problem of avulsion injuries of the ureter at the level of the ureteropelvic junction, which in our experience is being seen with in-
945
creasing frequency. This injury and intimal thrombosis of the renal artery are seen primarily in severe cases of trauma to the trunk, which occur with automobile-pedestrian accidents, when a person is thrown from an automobile as in the case reported or in sudden deceleration injuries. When a patient is seen after any of these circumstances, it is wise to obtain an IVP, which will suggest intimal thrombosis of the renal artery by failure to visualize the involved kidney or suggest ureteral avulsion by the presence of extravasation. We favor early surgical debridement and watertight repair of avulsion injuries of the ureter and do not use urinary diversion or stenting catheters if the anastomosis can be achieved with healthy tissue in a watertight fashion in the absence of tension or gross contamination.
C. Eugene Carlton, Jr. Baylor College of Medicine Houston, Texas
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1975 by The Williams & Wilkins Co.
BLUNT URETERAL TRAUMA WITH PERINEAL URINE FISTULIZATION: REVIEW OF THE LITERATURE E. WALLIJN,* W. DE SY
AND
E. FONTEYNE
From the Department of Urology, University Hospital, De Pintelaan 135, Ghent, Belgium
ABSTRACT
The first case of blunt ureteral disruption with external urine fistulization is presented. Reanastomosis with temporary urine diversion by a nephrostomy tube was successful. A review of the literature since 1950 revealed only 49 cases that proved this pathology should be considered in the differential diagnosis of post-traumatic hematuria or the development of mass in the flank. Nephrectomy is no longer used since a thorough attempt at reconstructive surgery will provide good functional results. cerclage of the pubis was performed and the muscles and skin were sutured after adequate external drainage had been assured. Immediately postoperatively central fat embolism caused coma and finally apnea. Artificial respiration was necessary for 4 days. Urine leakage in the perineal wound was noted 9 days postoperatively. A cystogram was normal and the patient was watched carefully. The daily perineal urine fistulization gradually CASE REPORT increased to 400 cc. The patient became pyrexial An 8-year-old boy was admitted to the hospital 12 days postoperatively and his temperature on May 31, 1973, following an automobile accident remained at 39C for the next 3 days. A firm in which he was hurled throu~h the windshield. swelling the size of a child's head became evident Admission blood pressure was 80/40 mm. Hg, pulse in the right hypochondrium and loin. An excretory urogram (IVP) showed moderate 140 per minute and there were no symptoms of shock. The level of consciousness was slightly pyelocaliectasis on the right side, some upward disturbed as a result of a commotio cerebri. X-rays displacement of the kidney and extravasation of revealed a normal abdomen, a closed fracture contrast medium (fig. 1, A). Because of the precarious condition of the through the diaphyseal portion of the femur and a patient we performed only a simple incision and fracture of the right ilium immediately lateral to the sacro-iliac joint with a severe diastasis of the drainage of the mass. After 1 1. of infected but non-hemorrhagic urine gushed out, the fever and pubis. The most important injury was a deep perineal perineal urine fistulization rapidly disappeared. In the following weeks there was improvement in wound extending from the left groin to the anus. With the patient under general anesthesia the general condition and neurological state of the exploration showed that the tear extended into the patient. However, an IVP demonstrated a definite anus and rectum and that there was a complete worsening of the right hydronephrosis (fig. 1, B) disruption of the left crus penis, the left and an exploratory operation was done. A right ischiocavernosus muscle, the urogenital lumbotomy was performed 21 days later. The diaphragm, and the external and internal anal ureter was completely severed at the level of the sphincter. In the depth of the wound the perineal ureteropelvic junction with a 4 cm. diastasis of the urethra could be seen but the bulbous and distal avulsed ends. Dissection and debridement were portion of the corpus spongiosum could not be difficult. Every effort was made to prevent injury identified. A rupture of the levator ani enabled us to the ureteral blood vessels. The necrotic ends of pelvis and ureter were carefully freshened and the to see a small part of a slightly distended bladder. A balloon catheter was inserted without ureter was spatulated. Downward displacement of difficulty and 300 cc clear urine was passed. A the kidney was performed after its complete mobilization. A splinting ureteral catheter was Accepted for publication April 25, 1975. introduced into the ureter and brought out * Requests for reprints: Department of Urology, alongside a nephrostomy tube. Reanastomosis was Akademisch Ziekenhuis, De Pintelaan 135, 9000 Ghent, Belgium. accomplished using interrupted sutures of 4-zero Rupture of the ureter resulting from penetrative injuries to the abdomen, such as gunshot and war injuries, or from extensive pelvic and retroperitoneal operations is not uncommon. There have been few reports on ureteral avulsion caused by blunt abdominal trauma because this condition is rare. Herein we report a case of closed ureteral rupture, namely urine fistulization in a deep perineal wound.
942
BLUNT URETERAL TRAUMA WITH PERINEAL URINE FISTULIZATION
943
FIG. 1. A, IVP shows right hydronephrosis and extravasation of contrast medium. B, IVP shows worsening of hydronephrosis.
catgut and the area of anastomosis was surrounded by live fat to prevent adhesions. The external drainage was provided by a periureteral redon drain. Convalescence was uneventful. The nephrostomy tube and ureteral catheter were removed 16 days postoperatively. An IVP on June 5, 1974 showed a normal right kidney (fig. 2). DISCUSSION
In a review of the literature from 1868, when the first case was reported by Poland, 1 to 1950 Wilenius found only 30 cases of subcutaneous rupture of the ureter. 2 Frequently, it was an accidental post mortem finding and in the other cases the first symptom was urinoma in the loin. Treatment was exclusively nephrectomy. The number of case reports on this pathology has been increasing lately. In a survey of the literature since Wilenius, we were able to list another 49 cases of proved blunt ureteral avulsion. This clearly shows that the condition, although rare, is of clinical as well as academic importance. Sixteen publications were not included in our review because description of the lesion, treatment and/or followup was not complete. Of the 33 remaining cases traffic accidents were responsible for all but 2. The victims are generally young (66 per cent are less than 14 years old) and most of them have sustained other serious visceral or bony traumas. The mechanism of this type of injury was already understood by Kusher in 1896. 3 He stated that ureteral rupture was caused by torsion and stretching of the ureter over the transverse processes on violent lateral flexion of the lumbar spine. However, according to the experimental
FIG. 2. IVP 1 year after accident shows normal right kidney.
944
W ALLIJN, DE SY AND FONTEYNE
studies of Wilenius in 1950, rupture of the ureter and renal pelvis could be produced by compressing them against the 12th rib or the upper transverse processes. Reznichek and associates explained avulsion by a rapid succession of 2 separate events: a tensing of the ureter by its stretching like a bowstring and a snap or lash against the vertebral column with disruption of the ureter.• Children are predominantly inflicted by this type of injury because they have a greater elasticity and mobility of the truncal structures, and because there is a sparsity of retroperitoneal supporting fat. It may also be expected that the rupture commonly occurs at or near the pelvioureteral junction, where the surrounding supporting structures are loosely composed. Indeed, in our review only 4 avulsions were localized in the middle third of the ureter and only 2 in the inferior third. Ureteral trauma always leads to urinary extravasation, aseptic inflammation, lipolysis and fibrosis. In cases of incomplete rupture the urinary leakage quickly ceases and healing of the ureter occurs with more or less serious scarring. However, complete avulsion gives a persistent retroperitoneal urine efflux with pocketing of urine in the retroperitoneal tissues. In this way disruptions of the middle and inferior third may create paraureteral urinary pseudocysts, whereas avulsions of the upper third and the pelvioureteral junction give rise to the better known pararenal pseudocysts. • These encysted urine collections are surrounded by a thick fibrotic wall and an intact periureteral or renal fascia. If those fasciae are also torn by the injury, extensive retroperitoneal urinary phlegmons may arise. 6 In our case the urine extravasation had expanded gradually until the urine tracked into the pelvic cellular tissues and finally reached the perineal wound. In 1960 Sturdy and Magell described an analogous case of pre-sacral edema caused by urine extravasation along the foramen ischiadicum majus as the first symptom of a ureteropelvic junction disruption. 7 When the dorsal peritoneum is also torn, urinary ascites may arise. However, this is rare since only 1 case of ascites in relation to blunt ureteral avulsion has been published. 8 Our review stresses the difficulty of early diagnosis. The pathology was recognized after an average of 28 days in 33 cases and the diagnosis was made within 14 days in only 11. In the initial period urologic symptoms and urinary findings are sometimes negative. Hematuria is the most consistent finding"· 10 and, because it is often transient, early and frequent urine examinations for blood are important. We found only 14 cases of gross hematuria. The development of a soft tissue mass in the loin, usually within a few days or weeks, is a more reliable finding and has been described 16 times. In 7 cases high fever suggested that retroperitoneal urine collections are frequently infected.
The vague urologic symptoms are often overshadowed by more important and vital associated traumatology, thus delaying urologic investigation. An IVP should be done in any polytraumatized patient. In cases of a heavy abdominal or flank trauma this investigation is obligatory, even in the absence ofhematuria. Early urography usually shows dye extravasation but because the seriousness and accurate localization of the rupture are often difficult to judge, immediate cystoscopy with retrograde pyelography should be done. When an accurate diagnosis is made, the catheter is brought up as high as possible in the ureter and left in place, thus making detection of the ureter easier during the operation. Formerly, nephrectomy was the only therapeutic outcome. However, since 1958 when Seright 11 performed the first successful reanastomosis of a ruptured ureter, reconstructive surgery has been applied 24 times with fair results. In view of those successes, every attempt at repair of the ureter has to be commended. The operative technique depends on the localization of the rupture. For an avulsion in the neighborhood of the pyeloureteral junction a dismembered Anderson-Hynes pyeloplasty is suitable. On a lower level an end-to-end reanastomosis should be performed with interrupted 4-zero catgut sutures after freshening and spatulating the severed ureteral ends. To reduce tension on the reanastomosis the kidney frequently has to be mobilized to allow maximal descent. Disruptions near the bladder can be treated by performing a ureteroneocystostomy. Sometimes retraction and necrosis of the ureteral ends are so important that reapproximation is impossible. When this occurs we can choose among ureterocalicostomy, 12 transureteroureterostomy, ureteroil eocystostomy, Boari-plasty or even autotransplantation of the kidney. In many of these techniques, temporary diversion of urine by a nephrostomy tube or a splinting ureteral catheter is desirable. REFERENCES
1. Poland, A.: Cited by Slater, R. B. and Kirkpatrick, J. R.: A case of closed injury of the upper ureter. Brit. ,J. Ural., 43: 591, 1971. 2. Wilenius, R.: Subcutaneous rupture of the ureter. Ann. Chir. et Gynaec. Fenniae, 39: 1, 1950. 3. Kiisher: cited by Seright. 11 4. Reznichek, R. C., Brosman, S. A. and Rhodes, D. B.: Ureteral avulsion from blunt trauma. J. Ural., 109: 812, 1973. 5. Crabtree, G. E.: Pararenal pseudo-hydronephrosis with report of three cases. Trans. Amer. Ass. Genito- Urin. Surg., 28: 9, 1935. 6. Bartley, 0., Ekdahl, P. H. and Wahlqvist, L.: Rupture of the ureter with pseudocyst formation. Acta Chir. Scand., 132: 390, 1966. 7. Sturdy, D. E. and Magell, J.: Traumatic perinephric cysts ('pseudohydronephrosis'). Brit. J. Surg., 48: 315, 1960. 8. Carabalona, P., Delmas, M. and Bonnel, F.: Rupture
BLUNT URETERAL TRAUMA WITH PERINEAL URINE FISTULIZATION
9. 10. 11. 12. I
de l'uretere lumbaire par contusion abdominale. Ureterorraphie. Resultat a 4 ans. Chirurgie, 98: 421, 1972. Ainsworth, T., Weems, W. L. and Merrell, W. H., Jr.: Bilateral ureteral injury due to non-penetrating external trauma. J. Urol., 96: 439, 1966. Fruchtman, B. and Newman, H.: Upper ureteral avulsion secondary to non-penetrating injury. J. Urol., 93: 452, 1965. Seright, W.: Traumatic closed rupture of the upper ureter. Brit. J. Surg., 46: 511, 1959. Moloney, G. E.: Avulsion of the renal pelvis treated by ureterocalycostomy. Brit. J. Urol., 42: 519, 1970.
I.
COMMENT These authors call our attention to the problem of avulsion injuries of the ureter at the level of the ureteropelvic junction, which in our experience is being seen with in-
945
creasing frequency. This injury and intimal thrombosis of the renal artery are seen primarily in severe cases of trauma to the trunk, which occur with automobile-pedestrian accidents, when a person is thrown from an automobile as in the case reported or in sudden deceleration injuries. When a patient is seen after any of these circumstances, it is wise to obtain an IVP, which will suggest intimal thrombosis of the renal artery by failure to visualize the involved kidney or suggest ureteral avulsion by the presence of extravasation. We favor early surgical debridement and watertight repair of avulsion injuries of the ureter and do not use urinary diversion or stenting catheters if the anastomosis can be achieved with healthy tissue in a watertight fashion in the absence of tension or gross contamination.
C. Eugene Carlton, Jr. Baylor College of Medicine Houston, Texas
