SURGICAL AND EXTERNAL URETERIC TRAUMA RONALD B. BROWN Alfred Hospital, Melbourne T h i s paper detalls t h e ;Etiology, Presentation, diagnosis, prophylaxis, treatment, and results, of 84 surgical and external ureteric injuries. Although the incidence o f surgical ureteric trauma w a s found to be low it was related to both the particular operation performed and certain faults i n surgical technique. T h e series emphasizes t h e importance of prophylaxis, early diagnosis, and specific therapy. There were 94 operations carried out on the 84 ureters, resulting in 22 nephrectomies and 63 open repair procedures, of which 55 were regarded as successful and 8 as failures.
BECAUSE of its size, position, mobility, and relatively thick wall, the ureter is rarely damaged. Surgical accidents or procedures were responsible for 71 injuries in this series, whilst deep X-ray therapy, external penetration, and external blunt injuries contributed 13 cases. The resultant 84 surgical and external ureteric injuries, followed after 94 operative procedures for a minimum period of two years, were analysed in terms of the atiology, presentation, diagnosis, prophylaxis, treatment. and results. In addition to the accidental and external injuries, all surgical ureteric procedures which resulted in urinary extravasation for more than three weeks were included in the series. Injuries to the vesicoureteric junction were not included in the series (Roper and Smith, 1965). I n order to determine the atiology of the surgical group, the traumatic incidence was related to the operations performed, whilst a retrospective questionnaire was completed by the referring surgeon detailing any possible contributing errors in surgical technique. Type of injury. - The ureter may be partially or completely divided, ligated, crushed, fulgurated, irradiated, or devascularized. The injury may be single or multiple and may involve one or both sides. The injury may be unrecognized, or may be detected at the time of its infliction. There may also be associated bladder or other injuries present. Address for reprints: Mr R. B. Brown, Senior Urologist, Alfred Hospital, Commercial Road, Prahran, Victoria 3181. AuST. N.Z. J. SURG., V ~ L47-"o. .
ETIOLOGY OF URETERIC TRAUMA Tables I and 2 emphasize the surgical atiology of the ureteric injuries in this series as well as indicating those surgical specialities which have an increased risk. TABLE I Artiology of Ureteric Trauma--84 Cases
External penetration blunt injury ., (3)
Gynaecology Renal homotransDiantation Open urological Latee bowel UreGricligation Endoscopic urological Vascular Orthopaedic Appendicectomy
18 16 10 0
Deep X-ray therapy (10)
The majority of gynacological injuries resulted from vaginal repair and/or hysterectomy operations, and not from radical cancer surgery. The majority (6) of large-bowel injuries resulted from abdominoperineal resections. Ureteroureteric renal homo-transplantation provided the majority ( 1 2 ) of the cases resulting from this speciality whilst difficult low ureterolithotomy operations (7) provided the major reason for extended open urological fistula. All of the seven ureteric ligations in this series were performed because of suspected or known ureteric trauma, usually 471
resulting from pelvic surgery. The seven endoscopic urological traumas resulted five attempted endoscopic calculus extraction operations and two attempted retrograde pyelograms. Only three injuries resulted from external penetration, whilst ten injuries resulted from the effects of deep, X-ray therapy. In an endeavour to obtain further ztiological details of these injuries, it was postulated that the surgical trauma resulted from a poor choice of operation, or to a fault or faults in TABLE2 Ureter% Trauma-A etiology and Incidence (1965-1975)-71 R8sulting from 7,323 Operations Nos. Postureteroureteric renal homotransplant Ureteric ligation Ureter-To-Bowel anas’tomosi; Ureteroureterostomy . . .. . Vascular operations , . ,. .. .. Ureterolithotomy . . .. Radical hysterectomy .. Sigmoid colon surgery Vaginal repair and/or hyste&ctomy Benign abdominal hysterectomy . . . Anterior vertebral fusion . , .. . Retrocaecal appendicectomy .. .. External trauma .. . . . .. Endoscopic manipulations . . .. Deep X-ray therapy.. ..
.. :.: .
9/900 8/811 51621
Assuming that the “correct” operation has been performed, certain faults in surgical technique can still result in fistula formation, and a retrospective analysis of such possible faulty techniques, as illustrated in Table 3, indicates that almost 50% of the surgeons responsible for the fistula formation felt that absent, poor, or incompetent assistants had contributed to the result. In at least 22 cases the exposure and haemostasis throughout the procedure were unsatisfactory, and consequent failure to identify the ureter had largely contributed to the fistula formation. The failure to use silastic splints and/or proximal urinary diversion, particularly in difficult cases, had contributed on retrospective analysis to the persistence of many fistuh. The use of such splints usually overcomes the problem of assuming that the diagnosed TABLE 3 Surgzcal Ureteric Trauma : Possible Faulty Techniques-71 Cases No. Poor or no assistance Non-visualization of ureter . . Poor haemostasis . . .. Noprimarysplint ._ No proximal diversion .. Primary disease .. Poor suture technique . .. Distal obstruction .. , . Ischaernia, tension, or torsion of ureter (S) Partial or complete anastomitic obstruction . . .. . . Nosecondarysplint . . . Excesslve suction drainage . .
36 25 22 20
technique during the operation, or to both factors. Table 2 was obtained by reviewing, with the referring surgeon, all of his last 100 cases of the same operation, in order to detect any other possible cases of ureteric trauma. In considering operations such as postureteroureteric renal homotransplantation, ureteric ligation and endoscopic trauma, all of the cases known to myself were included in the series. Table 2 indicates that certain operations, including ureteroureteric renal homotransplantation, ureteric ligation, and ureteric bowel urinary diversion, were found to have a high incidence of fistula formation, whilst most other operations had a low incidence. The methods of referral meant that in some cases the incidence quoted was artificially inflated, both because of the absence of many similar operations carried out by other surgeons which had not been followed by a fistula, and because many of the operations were performed by trainee surgeons. Nevertheless, certain operations were found to have an unacceptably high incidence of fistula formation.
injury is the only ureteric injury present, and also, as a rule, the problem of undiagnosed distal obstruction. Primary diseases such as inflammation, obstruction, degeneration, and neoplasia, or the presence of large masses or post-radiation changes, were felt to be major causes in 12 cases (17%). Poor suture technique resulted in the persistence of eight fistulae ( 1 1 % ) ~ whilst undiagnosed distal obstruction resulted in at least six. Excessive postoperative suction drainage was largely responsible for the persistence of two fistulae. Although endoscopic calculus extractions require both a skilled operator and a reasonable period of attempted spontaneous expulsion (Badenoch, 1963), excessive trauma at the time of such attempted extraction may result
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in ureteric perforation as described earlier. Five such cases are included in this series, together with two perforated lower ureters following attempted retrograde pyelographic studies. DIAGNOSIS Clinical presentation. -There is usually a history of a recent operation, or, rarely, of blunt or penetrating external trauma. Only nine out of 36 accidental injuries in this series were diagnosed at the time of the particular operation. The early posttraumatic period finds the patient more restless, more uncomfortable, and more febrile than could be explained by the particular operation performed. Renal or wound pain, tenderness, and a presenting fistula commonly occur. The onset of the fistula usually relieves the renal pain caused by the ureteric obstruction. In this series, presumably because of the difficulty in distinguishing the early symptoms and signs of urinary extravasation and obstruction from those of the particular operation performed, 68% of the accidental injuries were not diagnosed until after the second postoperative day. As urinary extravasation increases, retroperitoneal or intraperitoneal collections or both may produce partial or complete ileus. Ohstruction or septiczmia may produce oliguria or anuria. All cases of postoperative anuria should be regarded as being due to ureteric trauma unless retrograde pyleoureterograms prove otherwise. It is well known that some patients with ureteric trauma may produce few or no symptoms, whilst the kidney progresses to a hydronephrotic state (Badenoch, 1959). Such abnormalities may produce delayed symptoms, but are usually asymptomatic and only detected radiographically. I t is possible that these injuries are more common than is generally thought. Investigation. - The development of an accidental postoperative or external urinary fistula or extravasation requires a full investigation of the genitourinary system. Assumptions that such fistulz are due to a known healing bladder or ureteric trauma, without eliminating the possibility of a second bladder or ureteric injury, or establishing the normality
or otherwise of the uninvolved remainder of the system, occurred on several occasions in this series. An intravenous pyelogram, and an assessment panendoscopy, with ureteric catheter passage and associated pyeloureterograms, under image intensifier and television control, and, often, the use of intravenous indigocarmine or intravesical methylene blue and vaginal packing, almost always provide sufficient information for treatment to be commenced. I n those situations in which a poorly functioning obstructed kidney is present, but ureterography or the passage of ureteric catheters is not possible antegrade percutaneous pyelography ( Goodwin et alii, 1955) usually enables an adequate pyeloureterogram to be obtained.
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TREATMENT 1. Surgical (Injuries Preoperative prophylaxis. - Prophylactic treatment requires an accurate assessment of the local pathology. A full history and physical examination, together with midstream urine microscopy and culture, are essential. Intravenous pyelography should always be performed if there has been a history of previous surgery or deep X-ray therapy or if there are large masses present or other evidence to suggest a difficult operation. The preoperative retrograde passage of ureteric catheters, either to obtain pelviureterograms or to act as an operative guide, may also be necessary in difficult situations. Intraoperative prophylaxis. - As indicated earlier, a “correct” choice of operation must be made, adequate assistance must be available, and the use of accepted exposure and haemostatic techniques made to ensure visualization of one or both ureters during the procedure. Specific )Treatment and Results Treatment of the injury depends upon a pattern of factors. These are as follows. Type of injury.-The extravasation resuhing from perforation of the ureteric wall by a ureteric catheter usually resolves spontaneously, whilst a severe crush injury of the ureter may require wide excision of the damaged area. Time of injury.-Delays in the management of injuries to the upper ureter result in exten-
sive fibrosis and consequent loss of mobility. This resultant lack of mobility usually necessitates a nephrectomy or, in the case of a solitary kidney, partial or complete ileal transplant or conduit construction between the upper ureter, the pelvis, or the lowermost calyx, and the bladder. Delays in the management of lower ureteric injuries are not as potentially serious because the traumatized area can be bypassed by either a transverse ureteroureterostomy (Anderson et alii, 1960) or a ureteroneocystostomy. Total renal function and pathology. Anatomically or physiologically healthy solitary kidneys require sophisticated conservative conduit therapy, whilst anatomically or physiologically abnormal kidneys, with normal contralateral organs, are often best treated by nephrectomy. General condition of the patient.-Restoration of vital functions by general antibiotic and circulatory therapy, together with local drainage of any infected urine collections, is occasionally necessary following delays in diagnosis before any further definitive treatment of the specific injury can be achieved. Such situations usually require at least temporary proximal urinary diversion. Site of injury.-As mentioned earlier, the extensive fibrosis resulting from delays in diagnosis of npper ureteric injuries usually results in nephrectomy, whilst similar situations occurring in lower ureteric injuries can still he managed conservatively either by ureteroneocystostomy or by transverse ureteroureterostomy . Passage of ureteric cathefers.-The ability to pass a ureteric catheter beyond the point of injury usually means that more difficult open surgical procedures will not be needed, but when such catheter passage is obstructed by the injury the procedure is restricted to the status of an important diagnostic ureterographic aid. Life expectancy. - I n the presence of a normal contralateral system and a terminal illness, most severe ureteric injuries are best treated by nephrectomy rather than by more time-consuming sophisticated methods. The swgeon’s skill and experience.-Sophisticated ureteric reconstruction or bypass 474
surgery should only be performed by experienced surgeons under ideal conditions on patients who have a good long-term prognosis. Early Treatwent Should a severe injury be recognized at the time of operation or shortly after, then the ureteric edges should be debrided and an oblique side-to-side ureteroureteric spatulated anastomosis performed using fine, interrupted, 3/0 chromicized catgut suture material. The anastoinosed area should be drained extraperitoneally, and a silastic splint should be inserted through the anastomosis with a free distal end left in the bladder for subsequent extraction in seven to ten days time. The use of a primary silastic splint aids healing and, by the passage of a splint into the bladder, overcomes the risk of the presence of a possible unknown second distal injury or obstruction. I use long lengths of 5Ch silastic tubing such that the proximal end is situated within the renal pelvis, whilst the distal end is coiled free within the bladder whence it may be sub sequently extracted. Such long lengths, prevent expulsion of the splint into the bladder. Should an associated nephrostomy be necessary, then the splint is delivered through the nephrostomy tube and subsequently extracted after a postoperative descending pyeloureterogram has indicated that the traumatized ureter has healed satisfactorily. Should the injury be very severe, then the side-to-side anastomosis should be protected by proximal urinary diversion, either in the form of a ureterostomy or a nephrostomy. Any possible distal ureteric obstruction should be diagnosed by adequate preoperative ureterogranis and corrected at the time of operation. The blood supply to the ureter should be preserved by careful extraadventitial dissection, such that the divided margins are healthy and bleed actively before the anastomosis. The anastomosis Fhould be performed without tension or torsion. Adequate drainage, without excessive suction, should be maintained until urinary extravasation ceases. Should a side-to-side anastomosis then not be possible in the upper ureter, an oblique end-to-side transverse ureteroureterostomy is the operation of choice, whilst in the lower ureter, bypass ureteroneocystostomy, with or without a Boari flap (Gow, 1965) or a psoas AUST.N.Z. J. SURG., VOL.47-No.
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hitch procedure (Turner-Warwick, [email protected]
), is still the most favoured operation, although transverse ureteroureterostoiny has again proved to be a sound procedure. Should the injury to the ureter and the circumstances be such that an immediate nephrectomy is considered, then this should only be performed if an intravenous pyelogram, performed either prior to the operation, or on the operating table, indicates the presence of a normal kidney on the nontraumatized side. Palpation of the nontraumatized kidney by laparotomy is not necessarily an indication of potential future function (Anderson and Harrison, 1965). Should the injury be so severe or the area so infected that a primary anastomosis cannot be performed, and there is doubt as to the future function of the non-traumatized kidney, then either a proximal ureterostomy or a nephrostomy should be performed until further investigations and therapy can be continued. Should the injury not be severe as indicated in the intravenous pyelogram by presence of dye beyond the point of trauma, a small amount of extravasation, and a minimally distended, well functioning, related kidney, then it is occasionally possible to manage recent cases of surgical ureteric trauma by either careful ohservation or by the passage of a splinting arid proximal diverting urinary drainage retrograde catheter. I n this series six out of nine cases responded successfully to closed retrograde continuous drainage and six out of eight cases to careful observation. Ureteric ligation is an unsatisfactory procedure, and 27% of such cases in this series developed a urinary fistula or a pyonephrosis or both, requiring a difficult secondary nephrectomy. Should the injury be diagnosed following endoscopic manipulations, then the offending instrument should be withdrawn, following which either the patient is carefully observed, or an attempted splinting and proximal urine diverting ureteric catheter should be passed and left in sifu for seven to ten days. Should the endoscopic injury be of greater severity, then open surgical exploration and drainage of the area should be carried out, and either an open primary repair or a urinary bypass operation performed.
Delayed Treatme& As described earlier, the specific treatment is greatly influenced by the type of injury, the time delay in diagnosis and the site of the injury. Six patients in this series required lifesaving abscess drainage and temporary urinary diversion before any reconstructive surgery could he attempted. Injuries of the upper ureter in which there has been a delay in diagnosis may be suitable for transverse ureteroureterostomy, but usually require nephrectomy. Lower ureteric injuries presenting late can usually lie bypassed by ureteroneocystostomy or transverse ureteroureterostomy. The specific operations carried out in this series are detailed in Table 4.
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TABLE. 4 Specific Treatment 84 Palrewts-94
Nephrectomy (Primary 14, Secondary 8) . . Ureteroneocystostomy, i Boari flap, f Psoas hitch . , Open primary or secondary rcanastomo& and drainage, 6 Splint, f 'Proximal diversion . . Transverse ureteroureterostomy .. .. Ureteric catheter drainage . . Proximal nephrostomy or proxim'al ureterostomy ., .. .. ., Observation . . .. .. .. .. Abscess drainage . . . . . . .. Ileal ureter .. ,. ., .. .. IJreteroileal neocystostomy . . .. .. Observation (acute deep X-ray therapv) . .
There were 94 operations carried out on the 84 ureters, including 22 nephrectomies and 63 open repair procedures, of which 55 were regarded as successful and eight as failures. Eight patients required urinary diversion by primary nephrostomy or proximal ureterostomy and local abscess drainage before a definitive secondary repair could he carried out. Two cases of total and one of partial ileal ureteric replacement were performed and regarded as successful. No cases of permanent urinary diversion occurred in the series, nor were there any operative deaths. Tinting of delayed operations. - As with renal injuries, most delayed operations are best performed between the fourth and seventh post-traumatic days, as this usually allows the initial severe tissue reaction to partly resolve without sufficient time elapsing for a dense fibrotic reaction to have occurred. Transverse ureteroureterostomy, by avoiding the traumatized area, overcomes this timing disadvantage, and in recent years has been used more often than ureteroneocystostomy.
Medicolegal Considerations What therefore God has joined together let no man put asunder. Bible, Matthew, 19.6.
There would undoubtedly be less suggested or actual litigation following surgical ureteric accidents if suggestive symptoms and signs were early and fully investigated and if the special relationship between the surgeon and his patient was maintained throughout the following investigation and therapy stages.
2. Deep X-ray Therapy Injuries Obstruction to the lower ureter may result following X-ray therapy to the pelvis for malignant tumours. The acute obstructive phase usually resolves spontaneously and rarely requires surgical intervention, but the delayed fibrotic reactions of such therapy may produce chronic ureteric obstruction and require bypass surgery as described above. None of the acute but all of the delayed cases in this series required such open surgical correction. It is often difficult to distinguish delayed fibrotic ureteric obstruction from the more common persistent pelvic malignancy, and laparotomy with biopsy of the indurated area is often necessary in order to establish an accurate diagnosis. 3. External Penetrating Ilzjuries Although uncommon in our community, these injuries should always be carefully investigated and explored. It is essential that the damaged ureteric and related tissue be completely excised to the extent that healthy, bleeding margins are displayed before an attempt at any reconstructive procedure is made. An associated laparotomy is mandatory, as liver and small-bowel injuries are commonly associated. 4. External Blunt Injuries These are extremely rare injuries and are usually associated with renal trauma. Such an injury may result in the accumulation of a
periureteric collection of urine requiring subsequent surgical drainage with repair of the ureter. The delayed effects of such injuries a t the pelviureteric junction may produce a hydronephrosis requiring subsequent pyeloplasty (Howard and Hinman, 1952) or calycoureterostomy (Moloney, 1970).
CONCLUSION Ureteric trauma is rare and is mainly of surgical ztiology. Certain operations are followed by a high incidence of fistula formation, whilst other operations have a low incidence. Surgical errors of technique, large masses, and difficult operations, increase the chances of accidental ureteric trauma, and these situations always justify preoperative intravenous pyelograms and/or passage of ureteric catheters. The early signs and symptoms of ureteric trauma are easily confused with those that follow the particular operation performed, but injury should always be suspected if the postoperative course is not consistent with the operation carried out. The treatment of ureteric trauma depends upon the precise situation, but the best results are obtained from early diagnosis and early repair, whilst the worst results follow delay in diagnosis and, particularly in the upper ureter, often require nephrectomy.
REFERENCES ANDERSON, H. V., HODGES, C . V., BEHNAM, A. N. and OCKER,J. M., J R ([email protected]
), J. Urol. (Balfimore), 83: 593. ANDERSON, E. E. and HARRISON, J. H. ( I & ) ~ New Eizgl. J . M e d , 273: 683. BADENOCII, A. W. (1959), Proc. roy. SOC.Med., 5 2 : 101. BADENOCH, A. W. (1963),Observations on the Munagcment of the Obstructed Ureter: 386. GOODWIN,W. E., CASEY, W. C. and WOOLF, W. (I955), J. Amer. med. Ass., 157: 891. Gow, J. G. (r968), Proc. m y . SOC.Med., 61: 1%. HOWARD, F. S. and HINMAN,F., J R (1952), J . Urol. (Baltimore), 68 : 148. MOLONEY, G. E. (1970), Brit. J . Urol., 42: 519. ROPER,B. A. and SMITH,J. C. (rgfjs), Brit. J. UrOl., 38: 531. TURNER-WARWICK, R. T. (1965), Institute of Urology film, London.
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