URETERAL INJURY DUE TO BLUNT AND PENETRATING TRAUMA EDWARD W. CAMPBELL, JR., M.D. PETER S. FILDERMAN, M.D. STEPHEN C. JACOBS, M.D.
From the Department of Surgery, Division of Urology, University of Maryland School of Medicine, the Sinai Hospital, and the Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland
ABSTRACT-In a period of twenty-seven months, 15 patients with ureteral trauma were encountered, leading us to believe that there is an increasing incidence of these injuries. The injuries were caused by blunt trauma in 3 patients and gunshot wounds in 12. All patients sustained injuries to other organs as well as the ureter. The diagnosis of ureteral injury was frequently delayed beyond the day of presentation (33 %) primarily due to the number and severity of associated injuries. The most accurate methods of diagnosis were surgical exploration and retrograde pyelography. Intravenous pyelography and abdominal computerized tomography scanning were diagnostic in only 33 percent of cases. Hematuria was present in only 63 percent of patients who had no other genitourinary injuries, emphasizing the lack of reliability of this sign in ureteral trauma.
Traumatic injury to the ureter is often undiagnosed at the time of presentation and may have been overlooked in the past due to a number of causes, including the magnitude of injuries to the patient and a low index of suspicion. Today, with improved trauma evacuation and stabilization methods more patients are surviving serious injuries to undergo more in-depth evaluation. As such, the number of recognized ureter-al injuries, from both penetrating and blunt trauma, is increasing. We herein present 15 cases of ureteral injury managed in our trauma centers during the past twenty-seven months, reflecting this increased number. Emphasis in our review is placed on the diagnosis of such injuries, their relation to certain skeletal, vascular and visceral injuries, and a review of treatment methods. Material and Methods Between May 1988 and August 1990, 16 trauma patients with ureteral injuries were attended by the urology service at the University
of Maryland and Sinai Hospitals of Baltimore. There were approximately 8,000 trauma admissions during this period. Twelve of the injuries were due to gunshot wounds, while 4 resulted from blunt trauma. All of the patients with penetrating injuries were male (mean age, 26 years; range 16SS), while 1 of the blunt trauma victims (mean age, 38 years; range 1966) was female. Each case was reviewed for mechanism of injury, associated injuries, method and timing of diagnosis, sensitivity of radiologic procedures, presence or absence of hematuria, method of repair and drainage, presence or absence of complications, and outcome. Results One of the 16 patients reviewed was excluded due to our inability to rule out iatrogenic ureteral injury, Fourteen of the injuries were unilateral, while one of the blunt trauma victims sustained bilateral ureteropelvic junction (UPJ) avulsions. Nine patients had injuries on the left
Associated organ injuries Organ
Small bowel Large bowel, musculoskeletal Iliac vessels, liver Lumbar vertebrae, inferior vena cava, bladder, stomach, pleural cavity Spleen, kidney, gallbladder, pancreas, diaphragm
Percent Incidence 60 38 20 13 7
Admission urinalysis performed on 13 patients revealed grossly bloody urine in 4 (31% )
FIGURE1. Posterior view, DPTA renal scan performed three days after injury. Tracer can be seen to extravasate on right side; there is little renal junction on left side. side, 5 on the right side, and 1 had bilateral injuries. All the blunt trauma injuries were confined to the UPJ. The twelve penetrating injuries were equally distributed between upper, mid, and lower ureters. Ten of the injured ureters, including all UPJ avulsions, were complete and six were partial. Diagnosis was made by preoperative radiologic studies in 5 patients, surgical exploration in 6, by retrograde pyelography in 3, and by nephrostogram in 1 patient. Intravenous pyelogram (IVP) was performed on 12 patients, but was diagnostic only in 4 (33 %). Computerized tomography (CT) scan had the same success rate, being diagnostic in 1 of 3 patients, Arteriography assisted in determining the diagnosis in 1 patient. In the patient who sustained bilateral UPJ avulsions, the IVP and CT scan were not diagnostic. A renal scan which was performed on hospital day 3 for progressing renal failure suggested extravasation on the right side and revealed minimal function on the left (Fig. 1). Fluid which was draining from the patient’s abdominal incision was shown to have an elevated nuclear count, diagnostic of urine. Urologic consultation was obtained and retrograde pyelograms revealed bilateral avulsions. Including this patient, a delay in diagnosis was seen in 5 patients (33 % ), 2 penetrating and all 3 blunt trauma patients.
and was positive for blood on dipstick in 6 (46 % ). When patients with other genitourinary injuries were excluded, there was only a 63 percent positive rate (l/8 grossly positive and 4/8 positive by microscopy), All patients presented with associated injuries (Table I), though 1 patient was found to have only a bladder injury in addition to the intramural ureteral injury Surgical repair was accomplished by primary anastomosis in most cases (11/13 repairs), with ureteroneocystostomy and psoas hitch being used in 2 cases of distal or intramural ureteral injury. Two nephrectomies were performed at the time of initial exploration; in the patient with bilateral injuries and a poorly functioning left kidney on renal scan the proximal left ureter could not be located, and in a second blunt trauma victim a coagulopathy developed intraoperatively, necessitating rapid nephrectomy. All repairs were stented, either with a Double J ureteral stent, a pediatric feeding tube, or a T-tube. The mean duration of stenting, excluding 2 patients who were lost to follow-up for extended periods, was twenty-one days (range 8-69). This includes 2 patients with prolonged anastomotic leaks who required the ureteral stent for forty-four and sixty-nine days. One UPJ repair and one proximal ureteral repair also had nephrostomy tubes placed, for twenty and ten days, respectively. The outcome was favorable in twelve of thirteen repairs (92 % ), as judged by radiologic and function studies. In 1 patient, the repair failed due to tension on the anastomosis and submucosal placement of the Double J catheter. He subsequently underwent a nephrectomy. Renal function remained stable in the 13 patients who underwent repair: with a follow-up of one week to eleven months the mean serum creatinine went from 1.2 on admission to 1.0
mg/dL. Long-term radiologic follow-up was available on only 5 patients. Four (80%) had studies which showed good anatomic result, while the fifth was the patient who underwent nephrectomy. Two patients experienced prolonged urinary extravasation from the anastomosis: one was a blunt trauma victim whose UPJ avulsion was missed for ten days, and the other suffered a penetrating ureteral injury which was not diagnosed until one day after the injury. The complication rate was 10 percent (1110) when the diagnosis was made promptly, and 40 percent (215) when there was a delay. Comment Historically, the incidence of ureteral injury due to external trauma is low. It has been estimated that gunshot wounds to the abdomen result in ureteral injury 2.2-5 percent of the time.’ Blunt trauma is an even rarer cause of ureteral injury, and is most common in children involved in motor vehicle accidents.2,3 The total incidence of ureteral injury has been reported to be less than 1 percent of all urologic trauma.4 Over the past two years, however, we have encountered an unprecedented number of ureteral injuries; other series have required seven to ten years to accumulate similar numbers.1*4,5 This increased number is likely the result of improved trauma evacuation and stabilization methods, with more seriously injured patients surviving the traumatic event and undergoing more in-depth evaluation. A patient who might have died with an unrecognized ureteral injury in the past is now having that same injury diagnosed and treated. This increased number may be most evident in relation to victims of blunt trauma. Blunt trauma injury to the ureter is most commonly manifested by avulsion of the ureteropelvic junction. The mechanisms proposed for this injury include sudden deceleration/acceleration associated with hyperextension,3*6-10 sudden cephalad movement of the kidney associated with downward traction on the ureter,s,10 direct blow to the second or third lumbar vertebra,‘O or compression of the kidney and renal pelvis against the twelfth rib or transverse processes, associated with lateral flexion.‘O The most widely accepted theory-sudden deceleration/ acceleration with hyperextension-was thought to pre-select for children, as it was believed that adults were not flexible enough to survive such an extreme mechanism of injury. It is noteworthy that all of our 3 blunt trauma victims were
adults, including one sixty-nine-year-old woman. The diagnosis of ureteral injury is often delayed in blunt trauma due to the critical condition of the patient. At the time of admission, efforts are directed toward life-threatening injuries. As such, ureteral injuries are either overlooked or addressed at a later time. It must be stressed that unless there is a high index of suspicion for ureteral trauma, many of these injuries will not be diagnosed at the time of presentation, significantly increasing the patient’s morbidity, 11,12In our series, all 3 blunt trauma victims had a delay in diagnosis. Two of these patients underwent nephrectomy (the patient with bilateral injuries also had a successful repair of his contralateral UPJ), and the third had a prolonged urinary leak at the anastomotic site. Delay in diagnosis also appeared to contribute to an increased morbidity in a patient with a penetrating injury. Diagnosis was not made until the day after the traumatic event. A prolonged anastomotic leak followed primary repair and T-tube stenting. The complication rate for patients with a delay in diagnosis was 40 percent (2/5), compared with 10 percent (1110) when the diagnosis was made at the time of presentation. This increased incidence of complications has also been noted by other authors.4 Factors which contribute to a delay in diagnosis include a low index of suspicion, absence of hematuria,2s4*5 and a nondiagnostic IVP4 In our series, significant ureteral injuries occurred in the absence of hematuria in one third of the patients, as also described by others.4,5 The IVP is offered as a valuable diagnostic tool by some authors,” while others have stressed the weaknesses of the limited IVP which is most often performed in a trauma setting.4,13 Our findings of a diagnostic IVP in only 33 percent of the cases are similar to those reported by Presti, Carroll, and McAninch4 (31% ) . Findings which should heighten the suspicion of ureteral injury include deviation of the ureter, ureteral dilatation, nonvisualization of the ureter, and bladder displacement.5 The latter finding was seen in a case of midureteral injury associated with an iliac vein injury (Fig. 2). Though the bladder displacement may have been due to a hematoma, it did alert the surgeons to the possibility of a urologic injury.
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FIGURE 3. Initial abdominal CT scan performed ten days after motor vehicle accident showing medial perirenal extravasation. Retrograde pyelogram confirmed diagnosis of left ureteropelvic junction disruption.
FIGURE 2. Limited preoperative IVP of gunshot wound victim. Neither distal ureter is seen, while bladder is displaced to left. Patient was found to have distal right ureteral injury on surgical exploration.
Abdominal CT scans, like IVPs, are limited in their ability to demonstrate ureteral injury. In our series, only one of three CT scans was diagnostic of the ureteral injury. The CT finding which helps to delineate proximal ureteral injury from renal parenchymal injury is predominantly medial perirenal extravasation of contrast material (Fig. 3). With partial transection of the ureter, the distal ureter past the site of the injury may be seen on both CT scarQ4xr5 and IVP The majority of ureteral injuries were diagnosed by surgical exploration (6/15) or retrograde pyelogram (3/15), as in other series.‘s4 In contrast, only 33 percent (S/15) were diagnosed by preoperative radiologic studies. This demonstrates that trauma surgeons and urologists must have a high index of suspicion and directly visualize the ureter where indicated. Associated injuries seen in our series and others which should raise the index of suspicion for ureteral injury include the iliac vessels,lB
bladder,5 and musculoskeletal system.” Our patient who sustained bilateral UPJ avulsions was found to have bilateral femoral dislocation, L3 vertebral fracture, and 50 percent subluxation of L3 on L4. Any surgeon confronted with a deceleration injury of such force should suspect ureteral disruption until proved otherwise. The management of ureteral injuries has been well reported in the literature. Most authors agree that debridement of devitalized tissue and a watertight, tension-free anastomosis are important concepts in ureteral repair. However, there is controversy regarding the method of stenting and the need for diversion of the urinary stream. While Franc0 et al.’ and Guerriero” believe that repair of all proximal injuries should include a nephrostomy tube, Presti et ~2.~ do not find this to be necessary. Guerriero” also believes that a polyvinyl feeding tube, which diverts the urinary stream and stents the anastomosis, is preferable to a multihole Double J catheter. We believe that a nephrostomy tube with an externalized ureteral stent is the best method for draining and stenting a UPJ or proximal ureteral repair. Another method used in our series of stenting and draining the mid and upper ureter is a T-tube, with the drainage limb proximal to the anastomosis. This affords excellent proximal drainage and ureteral access for postoperative radiographic studies. We have found ureteroneocystostomy with psoas hitch to be a desirable method of dealing with distal and intramural ureteral injuries. Placement of a suprapubic cystostomy and accompanying ureter-al stent may be best tolerated by the young men who constitute a large majority of the patients sustaining gun-
shot wounds. Externalized ureteral stents which are discontinued prior to the patient’s discharge can also be used to avoid long-term difficulties in Double J management, as illustrated by the 2 patients in our series who were lost to follow-up. The blast effect of gunshot wounds is also of concern at the time of repair. One patient in our series was left with a transected distal ureter and nephrostomy tube drainage when a blast injury was not recognized. As has been reported, the blast effect makes surrounding tissue less viable,5 and should be taken into account when examining the ureter. Stenting of a ureter which is contused or injured by a blast effect may afford adequate treatment.4 In summary, the number of ureteral injuries seen by urologists may be increasing due to improved trauma evacuation and stabilization techniques. Preoperative radiologic studies and urinalysis have been shown to have a low sensitivity for ureteral injuries, Therefore, a high index of suspicion, especially when confronted with injuries to the lumbar vertebrae, iliac vessels, or bladder, is required to enable surgeons to make the diagnosis of ureteral injury as promptly as possible. Standard surgical techniques will usually afford a successful outcome. Division of Urology 22 S. Greene Street Baltimore, Maryland 21201 (DR. CAMPBELL)
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