002-5347/78/1192-0192$02.00/0 Vol. 119, February Printed in U .SA.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
THE MANAGEMENT OF DELAYED RECOGNIZED URETERAL INJURIES ROBERT MENDEZ
AND
DENIS M. MCGINTY
From the Department of Urology, Los Angeles County-University of Southern California Medical Center, Los Angeles, California
ABSTRACT
Of the 90 cases of ureteral injuries reviewed 51 injuries were recognized immediately, while 39 were recognized in the delayed period. Although the over-all difference in results between those treated immediately and those receiving delayed treatment was relatively small, when the cases were further subdivided by etiology and time ofrecognition into immediate and delayed iatrogenic injuries and traumatic injuries the difference in results was striking. This fact had been suspected clinically but not well documented previously in the urologic literature. During the last decade discussion on ureteral injury has centered around the diagnosis and surgical repair. 1- 4 Few investigators have reported on the difference in management and prognosis between patients with injuries diagnosed and treated immediately and those in whom the diagnosis and treatment were delayed. 5 Our results in the management of the delayed recognized ureteral injury are described. Patients with delayed recognized injuries have a poorer prognosis than patients with similar injuries but early treatment. METHODS
Retrospective study revealed that 90 ureteral injuries were recognized and treated at our medical center between 1965 and 1975 (table 1). Of these injuries 46 were from external trauma and 44 were surgical injuries. Of the 46 external injuries 37 were recognized and treated immediately, while 9 escaped early detection. Conversely, 14 of the 44 surgical injuries received immediate diagnosis and treatment, while in 30 recognition and therapy were delayed. The 9 external and 30 surgical injuries escaping early detection and treatment are the subject of this report. RESULTS
Initial recognition of a ureteral injury in the delayed period was made clinically in essentially all cases (table 2). Most common signs and symptoms were non-specific (ileus, fever and abdominal discomfort), although localizing symptoms such as flank pain did occur. Urinary fistulas occurred in 12 cases - 2 traumatic and 10 iatrogenic injuries. Once the injury was suspected 30 of the 39 cases were confirmed by high dose excretory urography (IVP). Findings on the IVPs included delayed excretion, hydronephrosis, extravasation and nonfunction. In 9 cases retrograde ureterography was required for more precise definition or localization. Once the injury was diagnosed 38 of 39 cases received some form of immediate therapy, while 1 case was observed only (table 3). Of the 6 patients treated initially by primary diversion there were 4 nephrostomies and 2 ureterostomies. The remaining patients underwent a variety of procedures. Most lower ureteral injuries of either traumatic or iatrogenic origin were treated by ureteroneocystostomy. When possible, a submucosal tunnel was fashioned but not at the expense of creating undue tension. All neostomas were stented. In all cases treated by ureteroureterostomy a 4-zero chromic end-toend anastomosis was used after generous debridement and spatulation. The use of a stent or proximal vent varied. No Accepted for publication May 13, 1977. Read at annual meeting of Western Section, American Urological Association, San Francisco, California, March 13-17, 1977. 192
patient had a separate proximal diversion by nephrostomy at the time of ureteroureterostomy. All patients were drained adequately. The results of treatment were judged good if the patient had a normal IVP or one with minimal hydronephrosis but significant improvement from the operative IVP, was free of infection and had no major postoperative complication. The results were deemed poor if dilation or diminished function persisted, if infection remained or if another operation was required. Nephrectomy, the ultimate poor result, was considered separately. Of the 39 cases 34 were available for followup analysis. Based on the aforementioned criteria 21 of 34 cases had good results, 10 had poor results and 3 underwent primary nephrectomy. Of the 10 patients with poor results 3 underwent secondary nephrectomy without further complication and 1 underwent a transabdominal ureteroureterostomy. with subsequent success. The other 6 patients either refused an additional operation or failed long-term followup care. DISCUSSION
In each of his reports on ureteral injury Higgins made a strong theological point of great interest to the urologist seeking salvation, "The venial sin is injury to the ureter, but the mortal sin is failure ofrecognition". 2 This point is certainly corroborated by our experience. When compared to an internal control series of patients treated with the same techniques and by the same urologic surgeons those with immediate treatment fared far better than those receiving delayed treatment. In the control series 46 of 51 patients with immediate diagnosis and management were available for followup and 36 patients had good results, 7 had poor outcome and 3 underwent primary nephrectomy (table 4). In the iatrogenic injury subgroup all 13 patients had a good result when treated immediately. In the external trauma subgroup with immediate treatment 23 of 33 patients had a good result and 7 had a poor one. Three nephrectomies were performed. All procedures were deemed necessary for associated renal or gastrointestinal injury. Conversely, in the over-all delayed treatment group available for followup 21 of 34 patients were believed to have good results and 10 had a poor outcome. Three patients underwent primary nephrectomy (table 4). The total rate ofnephrectomy as a primary and a secondary procedure (6 of 34, 17 .6 per cent) was much higher than in the immediately treated group. It usually was elected as the procedure of choice because of the technical difficulty and morbidity associated with attempting ureteral repair. When subdivided further the patients with external trauma fare particularly poorly within the group of late recognition
193
MANAGEMENT OF DELAYED RECOGNIZED URETERAL INJURIES TABLE
l. Time of recognition of injury
TABLE
Immediate
Delayed
35 2 0
7
7 3 2 2 51
23 2 3 2 39
External: Gunshot wound Stab wound Blunt trauma Iatrogenic: Obstetric-gynecologic General surgical Urologic-endoscopic Urologic - open Totals
5. External injuries: immediate versus delayed management Immediate No. (%)
Good Poor Nephrectomy Lost Totals
0 2
23 (69.7) 7 (21.2) 3 (9.1)
437 (100)
TABLE
2. Delayed recognition of ureteral injury 24
TABLE
12 2 1 39
3. Primary method of management for 39 delayed ureteral
injuries No. Cases Ureteroneocystostomy Primary diversion only Ureteral stent and drainage Ureteroureterostomy Nephrectomy Dilations Miscellaneous Observation only Total TABLE
13 6 4
3
3 3 6
1
39
4. Over-all results: immediate versus delayed management Immediate No.(%)
Good Poor Nephrectomy Lost Totals
36 (78.3) 7 (15.2) 3 (6.5) 551 (100)
Delayed No.(%) 21 (61.8) 10 (29.4)* 3 (8.8) 539 (100)
* Additional operations were necessary in 4 cases, including 3 secondary nephrectomies.
ureteral injuries (table 5). Our series included 9 such cases. Four of them required nephrectomy either primarily or after failed primary repair. Three patients did well. They were seen early in the series and were treated simply with longterm ureteral catheterization and local drainage and not by attempted ureteral repair. The 1 patient who had a primary anastomosis suffered extensive stricture and anastomotic disruption requiring delayed nephrectomy. Two patients were lost to followup. The delayed recognized surgical injuries were more successfully managed but again were less successful than those surgical injuries diagnosed and treated immediately (table 6). Twenty-seven surgical injuries were treated late and the patients were available for followup. Eighteen had a good outcome,, 8 had a poor outcome and 1 underwent primary nephrectomy. In addition to the specific results mentioned of interest to us were the following observations - primary diversion did not appear helpful in improving success in those 6 patients so
29 (100)
6. Iatrogenic injuries: immediate versus delayed management
Good Poor Nephrectomy Lost Totals
No. Cases Clinical Fistulas Followup IVP Hypertension Total
3 (42.8) 2 (28.6)* 2 (28.6)
* Required secondary nephrectomy. Immediate No.(%)
TABLE.
Delayed No. (%)
13 (100) 0 0 1 14 (100)
Delayed No.(%) 18 (66. 7) 8 (29.6) 1 (3.7) 330 (100)
diverted. Three still required ultimate nephrectomy, while 2 were successful and 1 resulted in a poor outcome. Second, in the difficult group of traumatic delayed injuries long-term stenting alone was not usually successful. We attribute this finding to the small number of patients in this subgroup and to the fact that most of the injuries occurred early in the series when techniques of ureteral repair were less well established. Third, ureteroneocystostomy offers a higher success rate than ureteroureterostomy. As a result of our experience we ascribe to the following approach in suspected ureteral injuries in the delayed period initial IVP with appropriate delayed exposures followed by retrograde ureterography and an attempt to pass a ureteral catheter cystoscopically. If this form of treatment fails an operation is indicated. Direct intervention with a variety of primary techniques may be used, depending on the level and nature of the injury. These may include simple deligation, ureteroureterostomy for proximal and middle injuries or reimplantation for distal injuries. We have seldom needed more extensive procedures, although use of the bladder flap or vesical-psoas hitch may be included in primary treatment for distal injuries too cephalad for simple reimplantation. We performed 1 transabdominal ureteroureterostomy but only after primary repair failed. The operation was successful. Further use of the transabdominal ureteroureterostomy may prove desirable as a primary procedure in selected cases. We have had no experience with bowel replacements or autotransplantation but believe that these procedures are needed only in rare instances. REFERENCES
1. Carlton, C. E., Jr., Scott, R., Jr. and Guthrie, A. G.: The initial
2. 3. 4. 5.
management of ureteral injuries: a report of 78 cases. J. Urol., 105: 335, 1971. . Higgins, C. C.: Ureteral injuries during surgery. A review of87 cases. J.A.M.A., 199: 118, 1967. Hoch, W. H., Kursh, E. D. and Persky, L.: Early aggressive management ofintraoperative ureteral injuries. J. Urol., 114: 530, 1975. Gangai, M. P., Agee, R. E. and Spence, C. R.: Surgical injury to ureter. Urology, 8: 22, 1976. Bright, T. C., III and Peters, P. C.: Ureteral injuries secondary to operative procedures: report of 24 cases. Urology, 9: 22, 1977.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
THE MANAGEMENT OF DELAYED RECOGNIZED URETERAL INJURIES ROBERT MENDEZ
AND
DENIS M. MCGINTY
From the Department of Urology, Los Angeles County-University of Southern California Medical Center, Los Angeles, California
ABSTRACT
Of the 90 cases of ureteral injuries reviewed 51 injuries were recognized immediately, while 39 were recognized in the delayed period. Although the over-all difference in results between those treated immediately and those receiving delayed treatment was relatively small, when the cases were further subdivided by etiology and time ofrecognition into immediate and delayed iatrogenic injuries and traumatic injuries the difference in results was striking. This fact had been suspected clinically but not well documented previously in the urologic literature. During the last decade discussion on ureteral injury has centered around the diagnosis and surgical repair. 1- 4 Few investigators have reported on the difference in management and prognosis between patients with injuries diagnosed and treated immediately and those in whom the diagnosis and treatment were delayed. 5 Our results in the management of the delayed recognized ureteral injury are described. Patients with delayed recognized injuries have a poorer prognosis than patients with similar injuries but early treatment. METHODS
Retrospective study revealed that 90 ureteral injuries were recognized and treated at our medical center between 1965 and 1975 (table 1). Of these injuries 46 were from external trauma and 44 were surgical injuries. Of the 46 external injuries 37 were recognized and treated immediately, while 9 escaped early detection. Conversely, 14 of the 44 surgical injuries received immediate diagnosis and treatment, while in 30 recognition and therapy were delayed. The 9 external and 30 surgical injuries escaping early detection and treatment are the subject of this report. RESULTS
Initial recognition of a ureteral injury in the delayed period was made clinically in essentially all cases (table 2). Most common signs and symptoms were non-specific (ileus, fever and abdominal discomfort), although localizing symptoms such as flank pain did occur. Urinary fistulas occurred in 12 cases - 2 traumatic and 10 iatrogenic injuries. Once the injury was suspected 30 of the 39 cases were confirmed by high dose excretory urography (IVP). Findings on the IVPs included delayed excretion, hydronephrosis, extravasation and nonfunction. In 9 cases retrograde ureterography was required for more precise definition or localization. Once the injury was diagnosed 38 of 39 cases received some form of immediate therapy, while 1 case was observed only (table 3). Of the 6 patients treated initially by primary diversion there were 4 nephrostomies and 2 ureterostomies. The remaining patients underwent a variety of procedures. Most lower ureteral injuries of either traumatic or iatrogenic origin were treated by ureteroneocystostomy. When possible, a submucosal tunnel was fashioned but not at the expense of creating undue tension. All neostomas were stented. In all cases treated by ureteroureterostomy a 4-zero chromic end-toend anastomosis was used after generous debridement and spatulation. The use of a stent or proximal vent varied. No Accepted for publication May 13, 1977. Read at annual meeting of Western Section, American Urological Association, San Francisco, California, March 13-17, 1977. 192
patient had a separate proximal diversion by nephrostomy at the time of ureteroureterostomy. All patients were drained adequately. The results of treatment were judged good if the patient had a normal IVP or one with minimal hydronephrosis but significant improvement from the operative IVP, was free of infection and had no major postoperative complication. The results were deemed poor if dilation or diminished function persisted, if infection remained or if another operation was required. Nephrectomy, the ultimate poor result, was considered separately. Of the 39 cases 34 were available for followup analysis. Based on the aforementioned criteria 21 of 34 cases had good results, 10 had poor results and 3 underwent primary nephrectomy. Of the 10 patients with poor results 3 underwent secondary nephrectomy without further complication and 1 underwent a transabdominal ureteroureterostomy. with subsequent success. The other 6 patients either refused an additional operation or failed long-term followup care. DISCUSSION
In each of his reports on ureteral injury Higgins made a strong theological point of great interest to the urologist seeking salvation, "The venial sin is injury to the ureter, but the mortal sin is failure ofrecognition". 2 This point is certainly corroborated by our experience. When compared to an internal control series of patients treated with the same techniques and by the same urologic surgeons those with immediate treatment fared far better than those receiving delayed treatment. In the control series 46 of 51 patients with immediate diagnosis and management were available for followup and 36 patients had good results, 7 had poor outcome and 3 underwent primary nephrectomy (table 4). In the iatrogenic injury subgroup all 13 patients had a good result when treated immediately. In the external trauma subgroup with immediate treatment 23 of 33 patients had a good result and 7 had a poor one. Three nephrectomies were performed. All procedures were deemed necessary for associated renal or gastrointestinal injury. Conversely, in the over-all delayed treatment group available for followup 21 of 34 patients were believed to have good results and 10 had a poor outcome. Three patients underwent primary nephrectomy (table 4). The total rate ofnephrectomy as a primary and a secondary procedure (6 of 34, 17 .6 per cent) was much higher than in the immediately treated group. It usually was elected as the procedure of choice because of the technical difficulty and morbidity associated with attempting ureteral repair. When subdivided further the patients with external trauma fare particularly poorly within the group of late recognition
193
MANAGEMENT OF DELAYED RECOGNIZED URETERAL INJURIES TABLE
l. Time of recognition of injury
TABLE
Immediate
Delayed
35 2 0
7
7 3 2 2 51
23 2 3 2 39
External: Gunshot wound Stab wound Blunt trauma Iatrogenic: Obstetric-gynecologic General surgical Urologic-endoscopic Urologic - open Totals
5. External injuries: immediate versus delayed management Immediate No. (%)
Good Poor Nephrectomy Lost Totals
0 2
23 (69.7) 7 (21.2) 3 (9.1)
437 (100)
TABLE
2. Delayed recognition of ureteral injury 24
TABLE
12 2 1 39
3. Primary method of management for 39 delayed ureteral
injuries No. Cases Ureteroneocystostomy Primary diversion only Ureteral stent and drainage Ureteroureterostomy Nephrectomy Dilations Miscellaneous Observation only Total TABLE
13 6 4
3
3 3 6
1
39
4. Over-all results: immediate versus delayed management Immediate No.(%)
Good Poor Nephrectomy Lost Totals
36 (78.3) 7 (15.2) 3 (6.5) 551 (100)
Delayed No.(%) 21 (61.8) 10 (29.4)* 3 (8.8) 539 (100)
* Additional operations were necessary in 4 cases, including 3 secondary nephrectomies.
ureteral injuries (table 5). Our series included 9 such cases. Four of them required nephrectomy either primarily or after failed primary repair. Three patients did well. They were seen early in the series and were treated simply with longterm ureteral catheterization and local drainage and not by attempted ureteral repair. The 1 patient who had a primary anastomosis suffered extensive stricture and anastomotic disruption requiring delayed nephrectomy. Two patients were lost to followup. The delayed recognized surgical injuries were more successfully managed but again were less successful than those surgical injuries diagnosed and treated immediately (table 6). Twenty-seven surgical injuries were treated late and the patients were available for followup. Eighteen had a good outcome,, 8 had a poor outcome and 1 underwent primary nephrectomy. In addition to the specific results mentioned of interest to us were the following observations - primary diversion did not appear helpful in improving success in those 6 patients so
29 (100)
6. Iatrogenic injuries: immediate versus delayed management
Good Poor Nephrectomy Lost Totals
No. Cases Clinical Fistulas Followup IVP Hypertension Total
3 (42.8) 2 (28.6)* 2 (28.6)
* Required secondary nephrectomy. Immediate No.(%)
TABLE.
Delayed No. (%)
13 (100) 0 0 1 14 (100)
Delayed No.(%) 18 (66. 7) 8 (29.6) 1 (3.7) 330 (100)
diverted. Three still required ultimate nephrectomy, while 2 were successful and 1 resulted in a poor outcome. Second, in the difficult group of traumatic delayed injuries long-term stenting alone was not usually successful. We attribute this finding to the small number of patients in this subgroup and to the fact that most of the injuries occurred early in the series when techniques of ureteral repair were less well established. Third, ureteroneocystostomy offers a higher success rate than ureteroureterostomy. As a result of our experience we ascribe to the following approach in suspected ureteral injuries in the delayed period initial IVP with appropriate delayed exposures followed by retrograde ureterography and an attempt to pass a ureteral catheter cystoscopically. If this form of treatment fails an operation is indicated. Direct intervention with a variety of primary techniques may be used, depending on the level and nature of the injury. These may include simple deligation, ureteroureterostomy for proximal and middle injuries or reimplantation for distal injuries. We have seldom needed more extensive procedures, although use of the bladder flap or vesical-psoas hitch may be included in primary treatment for distal injuries too cephalad for simple reimplantation. We performed 1 transabdominal ureteroureterostomy but only after primary repair failed. The operation was successful. Further use of the transabdominal ureteroureterostomy may prove desirable as a primary procedure in selected cases. We have had no experience with bowel replacements or autotransplantation but believe that these procedures are needed only in rare instances. REFERENCES
1. Carlton, C. E., Jr., Scott, R., Jr. and Guthrie, A. G.: The initial
2. 3. 4. 5.
management of ureteral injuries: a report of 78 cases. J. Urol., 105: 335, 1971. . Higgins, C. C.: Ureteral injuries during surgery. A review of87 cases. J.A.M.A., 199: 118, 1967. Hoch, W. H., Kursh, E. D. and Persky, L.: Early aggressive management ofintraoperative ureteral injuries. J. Urol., 114: 530, 1975. Gangai, M. P., Agee, R. E. and Spence, C. R.: Surgical injury to ureter. Urology, 8: 22, 1976. Bright, T. C., III and Peters, P. C.: Ureteral injuries secondary to operative procedures: report of 24 cases. Urology, 9: 22, 1977.
