Ureteral injury due to penetrating trauma.

Objectives: We sought to evaluate the diagnosis and management of penetrating ureteral injuries at our trauma center.

Methods: We retrospectively reviewed the cases of 12 patients with ureteral injuries secondary to penetrating ureteral trauma.

Results: From January 1995 to December 2000, a total of 12 patients were diagnosed and treated for penetrating ureteral injuries. The diagnosis was made acutely in nine patients, and a delayed diagnosis was made in three patients. Hematuria was present in the nine patients diagnosed acutely, and these patients had either preoperative or intraoperative imaging. All patients underwent exploratory laparotomy, and ureteral injuries were missed in the three patients without radiologic imaging or hematuria. Repair of the ureteral injuries was highly successful, and patients diagnosed acutely had decreased morbidity.

Conclusions: Traumatic ureteral injuries from penetrating trauma are uncommon, and a high index of suspicion is necessary to diagnose ureteral injuries when hematuria is not present and imaging is nondiagnostic.

Key Words: penetrating trauma, ureteral injury

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The diagnosis and management of a ureteral injury due to penetrating trauma is often challenging. The incidence of penetrating ureteral trauma has been reported to occur in 2.3 to 3.1% of all gunshot wounds to the abdomen. (1-3) With penetrating abdominal trauma, patients typically have multiple associated injuries, and a high index of suspicion is necessary to diagnose a ureteral injury. Failure to promptly recognize a ureteral injury frequently results in loss of functioning renal parenchyma, sepsis, and possibly death. (4,5) With this in mind, when managing the critically ill trauma patient, one must evaluate the genitourinary tract thoroughly. We report on our experience in managing penetrating ureteral injuries over a 6-year period at our level I trauma center.

Materials and Methods

From January 1995 to December 2000, a total of 12 patients at our level I trauma center were identified as having a ureteral injury secondary to penetrating abdominal trauma. In all cases, a urology consultation was requested by the trauma surgery service. Medical records of these patients were reviewed retrospectively. Information was collected regarding patient demographics, mechanism of injury, status on presentation to the trauma center, initial urinalysis and laboratory data, associated injuries, timing of urology consultation, method of diagnosis, site of injury, operative treatment, and results of patient follow-up.

Results

In our population of 428 trauma patients treated for penetrating abdominal injuries between January 1995 and December 2000, 12 (2.8%) were diagnosed with a ureteral injury. All patients were initially evaluated by trauma surgery and resuscitated according to the Advanced Trauma Life Support protocol. A thorough clinical examination, laboratory tests, and radiographic studies were performed as indicated. A urology consultation was obtained when there was a clinical suspicion of genitourinary trauma.

Of the 12 patients with ureteral injuries, 11 were male and 1 was female. The mean age of the patients was 30.3 years. Gunshot wounds to the abdomen or flank were the cause of ureteral trauma in 11 patients, and the remaining patient had a ureteral injury secondary to multiple knife stab wounds to the flank. Initial urinalysis showed evidence of hematuria in 9 (75%) of the 12 patients. Microscopic hematuria was present in five patients, and gross hematuria was present in four patients. All patients had associated nonurologic injuries (Table 1). The location of the ureteral injuries was the proximal ureter in three cases, the mid ureter in six cases, and the distal ureter in three cases.

All 12 patients underwent exploratory laparotomy. The diagnosis of ureteral injury was established in the acute setting in 9 of the 12 patients. In all cases when the ureteral injury was diagnosed acutely, hematuria was present and the urology department was consulted immediately. Only the nine patients with hematuria received either preoperative or intraoperative imaging. A preoperative computed tomographic (CT) scan was obtained in five cases and an intraoperative IV pyelogram (IVP) was obtained in four patients. All of the IVPs were diagnostic and four of the five CT scans accurately diagnosed a ureteral injury. The one patient with a ureteral injury missed on CT scan subsequently had the injury diagnosed and repaired during exploratory laparotomy (Table 2).

Ureteral injury was diagnosed in the delayed setting in three patients, and none had microscopic or gross hematuria. All three patients were taken emergently to the operating room secondary to life-threatening injuries and no preoperative or intraoperative imaging was performed. In all three patients, CT scanning facilitated the diagnosis and was performed secondary to either prolonged ileus or increased drain output.

Treatment of the ureteral injuries diagnosed in the acute setting consisted of primary ureteroureterostomy in five, ureteroneocystostomy in two, and cystoscopy with placement of a ureteral stent in two patients with a partial ureteral injury. In the three patients with a delayed diagnosis, treatment consisted of ureteroneocystostomy, nephrectomy secondary to an associated renal injury, and cystoscopy with ureteral stenting. All repairs were stented for 6 weeks.

One patient diagnosed in the acute setting died during initial exploratory laparotomy from a cardiac event. The remaining eight patients diagnosed acutely had a mean hospital stay of 6.1 days, with a range of 3 to 12 days. The three patients diagnosed in the delayed setting has a mean hospital stay of 21.0 days, with a range of 9 to 44 days.

Follow-up was documented for all 10 patients who underwent ureteral repair. All of these patients returned at approximately 6 weeks and underwent cystography confirming no extravasation and their ureteral stent was removed. All patients had follow-up IVPs scheduled approximately 3 months after stent removal, but only 6 of the 11 patients (55%) returned for their follow-up IVP. Each of the six patients with IVPs was documented to have normal function and excretion on the side of the ureteral injury, with no evidence of a ureteral stricture or fistula.

Discussion

Ureteral injury from penetrating abdominal trauma is often a diagnostic challenge. Patients typically present with multiple associated injuries, and one must not overlook thoroughly evaluating the genitourinary system in a critically ill patient. Previous reports have shown false-negative rates in radiologic imaging ranging from 44 to 73%, and hematuria has been shown to be absent in approximately 33% of patients. (6-8) In our series, hematuria was present in 9 of 12 patients (75%), and all of these patients had their ureteral injuries diagnosed in the acute setting. Also, eight of nine patients (89%) had their ureteral injuries accurately diagnosed by either preoperative or intraoperative imaging.

It has been well reported that the absence of hematuria or a negative radiographic study does not exclude a ureteral injury, and careful attention should be paid to the genitourinary tract and retroperitoneum at the time of surgical exploration. The three patients without hematuria had delayed diagnosis, and this was likely related to the fact that a genitourinary tract injury was not suspected. Ureteral injuries can be diagnosed through open or endoscopic means; in our series, all ureteral injuries were noted intraoperatively by either exploration with injection of indigo carmine directly into the ureter or by cystoscopy with retrograde ureterography.

The surgical management of the ureteral injury typically depends on the location of the injury. Proximal and mid ureteral injuries can often be managed by primary ureteroureterostomy. Distal ureteral injuries can be managed by primary repair, but usually ureteroneocystostomy and a psoas hitch are required. The principles of ureteral repair should include debridement of nonviable tissue with a mucosa-to-mucosa, spatulated, and tension-free anastomosis. We prefer to repair the ureter over a double-J ureteral stent that typically remains in place for 6 weeks. Follow-up consists of a cystogram at 6 weeks, at which time the stent is removed if there is no extravasation. Also, IVPs are ordered at approximately 3 months after stent removal to evaluate for ureteral stricture or fistula formation.

Delayed diagnosis of a ureteral injury is associated with significant morbidity. Complications associated with a delayed diagnosis have been reported to occur in 40 to 50% of patients and include sepsis, loss of renal function, and death. (4,5) In our series, the patients with missed injuries were noted to have much longer hospital stays, and one patient had to undergo nephrectomy.

Overall, ureteral repair in our series was highly successful. There were no complications related to the ureteral repair for promptly recognized injuries. Follow-up of our patients is limited, though, with only six patients returning for follow-up visits. However, all of the patients who had long-term follow-up had normal IVPs and had suffered no sequelae from repair of the ureteral injury.

Conclusion

The diagnosis and management of traumatic ureteral injury secondary to penetrating trauma is often a challenge. Both urinalysis and radiographic studies can be nondiagnostic, and a high index of suspicion is necessary during abdominal exploration of penetrating abdominal trauma. When diagnosed promptly, repair of the ureteral injury is highly successful and patients experience significantly less morbidity.

Table 1. Associated injuries in patients with penetrating ureteral
trauma

Associated injury  Patients (%)

Enterotomy         83.3
Vascular           33.3
Bladder            16.6
Diaphragm           8.3
Renal               8.3

Table 2. Summary of patients with penetrating ureteral injuries

                         Diagnosis of
Patient age  Hematuria  ureteral injury  Imaging

29 M         Yes        Immediate        Preoperative CT scan
28 M         Yes        Immediate        Intraoperative IVP
24 M         Yes        Immediate        Preoperative CT scan
70 M         Yes        Immediate        Preoperative CT scan
17 M         Yes        Immediate        Intraoperative IVP
16 M         Yes        Immediate        Preoperative CT scan
22 M         Yes        Immediate        Intraoperative IVP
32 M         Yes        Immediate        Intraoperative IVP
29 M         Yes        Immediate        Preoperative CT scan
27 M         No         Delayed          Postoperative CT scan
26 F         No         Delayed          Postoperative CT scan
44 M         No         Delayed          Postoperative CT scan

Patient age  Treatment             Hospital days

29 M         Ureteroneocystostomy   4
28 M         Ureteroneocystostomy   6
24 M         Ureteroneocystostomy   3
70 M         Ureteral stent         8
17 M         Ureteroneocystostomy   5
16 M         Ureteroneocystostomy  12
22 M         Ureteroureterostomy   Intraoperative death
32 M         Ureteroneocystostomy   5
29 M         Ureteroureterostomy    6
27 M         Nephrectomy           10
26 F         Ureteral stent        44
44 M         Ureteroneocystostomy   9

CT, computed tomographic: IVP, intravenous pyelogram: M, male; F,
female.

Accepted February 15, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9705-0462

References

1. Holden S, Hicks CC, O'Brien DP, et al. Gunshot wounds of the ureter: A 15-year review of 63 consecutive cases. J Urol 1976;116:562-564.

2. Walker JA. Injuries of the ureter due to external violence. J Urol 1969;102:410-413.

3. Rober PE. Smith JB, Pierce JM Jr. Gunshot injuries of the ureter. J Trauma 1990;30:83-86.

4. Campbell EW Jr, Filderman PS, Jacobs SC. Ureteral injury due to blunt and penetrating trauma. Urology 1992;40:216-220.

5. Presti JC Jr, Carroll PR, McAninch JW. Ureteral and renal pelvic injuries from external trauma: Diagnosis and management. J Trauma 1989;29:370-374.

6. Bright TC III, Peters PC. Ureteral injuries due to exteranl violence: 10 years' experience with 59 cases. J Trauma 1977;17:616-620.

7. Brandes SB, Chelsky MJ, Buckman RF, et al. Ureteral injuries from penetrating trauma. J Trauma 1994;36:766-769.

8. Liroff SA, Pontes JE, Pierce JM Jr. Gunshot wounds of the ureter: 5 years of experience. J Urol 1977;118:551-553.

RELATED ARTICLE: Key Points

* Patients with hematuria are more likely to be diagnosed with a ureteral injury.

* Radiologic studies are good diagnostic tools but can miss penetrating ureteral injuries.

* A high index of suspicion is necessary during exploratory laparotomy to diagnose a penetrating ureteral injury.

* Delayed diagnosis of a penetrating ureteral injury results in significant morbidity.

* Repair of penetrating ureteral injuries is highly successful.

Brett S. Carver, MD, Caleb B. Bozeman, MD, and Dennis D. Venable, MD

From the Department of Urology, Louisiana State University Health Sciences Center, Shreveport, LA.

Reprint requests to Brett S. Carver, MD, 504 E. 63rd Street, Apt. 15R, New York, NY 10021. Email: [e-mail]