Comparison of ureteral and renal injuries

Comparison

of Ureteral

WILLIAM E. FORSYTHE,

M.D.

AND LESTER PERSKY, M.D., Cleveland,

From the Department of Surger,y, Genito-Urinary Service, Western Reserw University, and the Unitaersity Hospitals, Cleveland, Ohio.

proper management of renaI and uretera trauma is of obvious importance because of the potentia1 Ioss of renaI tissue and function and even at times, of Iife. In this age of increased vehicuIar use, it is not surprising that automobiIe accidents are a major cause of renal damage. Yet we find many injuries from faIIs and blows. Since a11 of these injuries are usualiy due to externa1 force, we thought it would be interesting and informative to compare them with a group of genitourinary which are iatrogenic or physician injuries engendered, nameIy, uretera injuries. A recent

I

I

1

1

CONTUSION

1 ’

CONTUSION

\I

RENAL

Journal

of Surgery,

Volume

LACERATION

RUPTURE

97, May.

19~9

Ohio

TRAUMA

In the management of patients with renal trauma there have in genera1 been two divergent schools of thought. One group has a conservative, non-intervening attitude; the other has a more aggressive approach and favors earIy surgica1 expIoration. The beIiefs of the former group were well expressed by Sargent and Marquardt [2] who thought that no treatment was indicated in the majority- of cases, and that onIy “signs of severe, progressive, exsanguinating hemorrhage” or “pyelographic evidence that the organ was shattered beyond any hope of usefulness” shouId Iead to open surgery. LowsIey and Menning [J], as spokesmen of the opposite schoo1 beIieved that by earIy surgery much disability- and ultimate renaI Ioss might be spared the patient. They believed that gross bleeding of more than twenty-four hours was sufficient indication for prompt surgical intervention. Our management has in genera1 conformed to the former group, and we reserve surgery in most instances for those situations in which Iife is endangered from bIood Ioss or in which there are secondary deveIopments incompatible with the uItimate weII-being of the patient. There is genera1 unanimity of opinion concerning the cIassification of renaI injury. Three groups are generaIIy discussed: (I) contusions, (2) lacerations, and (3) rupture or compIete shattering of’the kidney. Severance of the renal vesseIs is usuaIIy incIuded in the Iatter group. (Fig. I.) Rena1 trauma must be suspected in every patient who has had injury to the thorax or

FIG. I. Types of rend injury. American

Injuries

study [I] of such injuries in virtuaIIy the same hosprta1 popuIations afforded an excellent basis for comparison. As a secondary aim we also hoped to determine if any changes were indicated in our current handling of renal injuries.

HE

T

and Renal

558

UreteraI

and Rena1 Injuries TABLE II POSITIVE X-RAY FINDINGS

TABLE I ETIOLOGICALFACTORS No. of Cases

Etiology

Fat1 or blow. Automobile accident Gunshot wounds.. Stabbing..

Nature of Finding

Percentage

No. of Cases,

Percentage

/ I-60 43 8

~

I

53.5 38.5 7.2 0.8

abdomen and this diagnosis should be considered even in the roentgenographic absence of skeIeta1 abnormality. PhysicaI signs may be minima1 with onIy slight flank tenderness and no signs of peritoneal irritation, or there may be an easiIy recognized overt mass and the cIassicaI signs of peritonea1 irritation with tenderness, rigidity and an abdomen silent to percussion. Urinalysis is the first step in the dehnitive diagnosis and should be foIIowed by urograms which are studied more for the determination of the anatomy and function of the contraIateraI organ than for evaIuation of the status of the damaged kidney. If visualization is poor or if there is any question as to associated abnormality, we perform immediate cystoscopy and retrograde pyeIography. Such examination under a topica anesthetic adds Iittle to the patient’s risk and may permit a more direct approach to a threatening, massive hemorrhage. Our series of renal injuries was collected from the records of the University HospitaIs of Cleveland and associated institutions over the last ten vears, and is composed of I 12 patients. The ‘incidence cIassified according to the type of injury is as foIIows: there were eighty contusions (71.5 per cent), twenty-two lacerations (19.5 per cent), and ten ruptures (9 per cent). In the group there were seventyeight males and thirty-four femaIes (70 per cent and 30 per cent respectively). Table I lists the etiological factors. Athletic which in Iarge part were footbaI1 injuries, accidents, are included in the faIIs and blows and account for 53.5 per cent of the total. AutomobiIe accidents caused 38.5 per cent. The percentage of gunshot wounds (7.2 per cent) appears excessively high for a civilian institution in comparison with other series [4]. This may reflect the active nature of the CIeveland night life.

28

Contusion. Calyceal irregularity. DeIay of visualization. Poor visualization. Mass................. Laceration. Delay.

37.5

15 7

ri

I I2

57

3 2

hhs. Extravasation Intrapelvic clot. Rupture........ Non-visualization. Delay.

5 2 70

z 1

In Table II are shown the nature and number of positive x-ray findings. Urography was not performed in every case, since occasionaIIy the severity of the associated trauma or the minima1 nature of the blow or symptoms did not warrant diagnostic studies. As expected, the greatest percentage of positive x-ray studies were in the group of patients who had the most extensive injuries. A simiIar situation is found when one compares the percentage of associated injuries. (TabIe III.) When the renaI there was injuries were severe, i.e. rupture, associated trauma in IOO per cent of the cases. In these cases the associated trauma was aIso severe, whereas in contusions and lacerations the associated injuries were of a relativeIy abrasions and minor degree, i.e. fractures, contusions of the body wall. The severity of these associated injuries is reflected in TabIe IV which shows the mortaIity figures for the various groups: there was no mortaIity for contusions, approximately I0 per cent in lacerations, and four deaths out of ten injuries (40 per cent), in ruptures. This increased degree of trauma is similarly shown in considering the operative procedures in the TABLE III ASSOCIATEDINJURIES No. of Cases

Type of Injury

I Percentage

Contusion. Laceration. Rupture..

22

. , .I

5

IO

28.6 22

100

Forsythe

and Persky

TABLE 11 MORTALIrY

TABLE

No. of Cases

Type of Injury

Percentage

Type of Injury

VI

No. of Cases

and Therapy

~~ Contusion. Laceratmn. Rupture.

0

0

2

9.5 40

4

Ligation (I 2 cases) : Deligation. Drainage.......................... Notherapy............. Delayed nephrectomy. Section (1 r cases) : Primary anastomosis.

various categories of renaI trauma. (TabIe v.) OnI>- eight cystoscopies were performed for contusions. No other surgery was necessary. For lacerations, there were seven operative procedures; roughIy a third of the patients were explored. In ruptures, seven of ten or 70 per cent of the patients needed surgery. There were a total of ten nephrectomies (8.9 per cent), three incisions and drainages, and one nephrostomy, fourteen operative procedures in a11 for an Incidence of 12.5 per cent. After reviewing these figures we are stiI1 convinced that a conservative approach is the correct one and are reIuctant to explore these patients earIier. The other haIf of this study deaIs with ureteral injuries which usuaIly occur as the resuIt of surgica1 procedures, ordinarily pelvic Iaparotomy. The reported incidence of this complication varies in different series but appears to range from .5 to I per cent [T], (61. However, when carefu1 postoperative studies with urograms are carried out, this percentage increases to 2.5 or 3 [7]. When more radica1 pelvic surgery is undertaken, the incidence of uretera injury has been reported to be as high as 30 per cent. TABLE v OPERATI\‘E PROCEDURE ACCORDING RENAL TRAUMA Type of Trauma

TO

and Procedure

CATEGORY

UreteraI

Delayed nephrectomy. Rupture: Incisions and drainages. Nephrostomy. Nephrectomy......................

3

Nephrectomy. Ligation of ureter.,

4

I

Thirtv-five cases of ureteral injury were studied ;n our series. These have been classified as injury from ligatures, sections, and injuries resuIting in fistuIa formation as shown in Table VI. If, when the abdomen is open, any injury is recognized by the Ieakage of urine or by the visualization of a severed, torn structure, immediate repair is indicated. If a tie has been pIaced about the ureter this shouId be immediately removed, and if the ureter has been crushed, spIinting with a ureteral catheter or T tube wiI1 obviate Iater Ieakage or stricture. When actual division has occurred, reanastomosis over a spIinting catheter by end-to-end suture shouId be carried out. If repair is not possible, reimpIantation into the bIadder or into a flap of

OF

Ligation (No. of Cases)

_

2 I 1 I

Nephrectomy

Non-function. D’red

5

560

Section (No. of Cases

Fistula (No. of Cases)

Percentage

4 I

40 II .4

4 2

31 .4 II.4 5.7

I-

Good. Fair, Poor:

5

.

I

3

catheters..

8

Cystoscopy

7

I I

Contusions:

.

3

Ureteroneocystostomy Ureterosigmoidostomy

No. of Cases

Cystoscopy

3 I

._.......

Ureteroneocystostomy Nephrectomy Fistula (I 2 cases) :

Results

Lacerations: Incisions and drainages..

;,

Ureteroneocystostomy

6 I

4 2

Ureteral

and

Rena1

Injuries

METHOD

OF

ANASTOMOSIS

END-TOEND FLAP

MODERN-DAVALOR BEVEL

BEVEL

REPAIR

ILEAL

(EVERTING SUTURE)

URETERO-NEOCYSTOSTOMY

GRAFT

FIG. 2. Methods of repair of ureteral

injury.

It can be seen when comparing renal and uretera trauma that those injuries occurring during eIective surgery are attended by a very high morbidity and an extremely high percentage of reoperations-thirty-three further surgica1 procedures in thirty-five cases. There were ten nephrectomies in both groups, but in the case of ureteral injuries this approximates a third of the total number compared to 8.9 per cent in those patients with direct renaI trauma. Mortality in both cases was about the same, sIightIy Iess than 6 per cent. This Ieads us to our concIuding remark which we think is a Iogical outgrowth of such a study as this, nameIy, prophylaxis is the single greatest weapon against ureteral harm. When extensive peIvic surgery is contempIated or if an extreme peIvic pathoIogic condition exists, the presence of uretera catheters which can be easily palpated reduces to a minimum the IikeIihood of an unfortunate urinary tract accident. The cystoscopic passage of these catheters can be easiIy accomplished and adds little to the patient’s discomfort or postoperative morbidity. However, when external renaI trauma has occurred, a deliberate course of observation resuIts in the conservation of renaI tissue. These attitudes have been stressed by many urologists but need constant reiteration to spare the patient long periods of hospitalization and needless operative procedures.

bladder may be necessary. Inadequate length is rareIy found but if it should occur, repair utihzing a Ioop of bowe1 may be necessary. (Fig. 2.) If the injury has been unrecognized, flank pain, fever and distension most commonIy deveIop in the patient. Excretory urograms usuaIIy reveai the involved side. Cystoscopy with uretera catheterization will discIose the obstruction or Ioss of uretera continuity. When a catheter can be negotiated past the obstructing Iigature and left indwelling, it will reIieve the obstruction and may aid in heaIing. At times, complete closure wiI1 ensue spontaneousIy. When the bIock cannot be passed, preliminary nephrostomy which we favor shouId at times be bilateral when anuria heraIds a bIock on both sides. Definitive repair wi11 usually invoIve ureteroneocystostomy or some form of ureteral graft at a Iater time. (Fig. 2.) Table VI gives the method of management in cases foIIowed by our group. Table VII outlines the results. When ligation had been performed, seven of tweIve patients ended up with a good resuIt. There were, nevertheIess, three nephrectomies. When the ureter had been transected, three nephrectomies had to be performed out of a tota group of eIeven cases. With fistula formation, four nephrectomies were indicated and onIy five out of twelve cases were deemed a good resuIt. 561

Forsythe

and Persky 5. WEIK, W. C. A statistica report of 1,771 casts of hysterectomy. Am. J. Oh. +ZYGynec., 56: I 15~ 1155. 1948. 6. GRAHAXI, J. W. and GOLIGHER, J. C. The management of accidental injuries and deliberate resections of the ureter during excision of the rectum. Brit. J. Surg., 42: 151-160, 1954. 7. ST. MARTIN, E. C., TRICHEL, B. E., CAhwnELL, J. H. and LOCKE, C. M. UreteraI injuries in gynecologic surgery. J. Ural., 70: 51-57, 1953.

REFERENCES

FORSYTHE, W. E. SurgicaI injuries of the ureter and bladder. Mississippi Doctor, 35: 123-129, 1957. 2. SARGENT, J. C. and MARQUARDT, C. R. Rena1 injuries. J. Ural., 63: 1-8, 1950. 3. LOWSLEY, 0. S. and MENNING, J. H. Treatment of rupture of the kidney. J. urol., 45: 253-271, 1941. 4. LISKA, J. R. Recognition and management of trauma to kidney. J. urol., 78: 525-531, 1957. I.

562