Penetrating ureteral trauma at an urban trauma center: 10-year experience

ADULT UROLOGY

PENETRATING URETERAL TRAUMA AT AN URBAN TRAUMA CENTER: 10-YEAR EXPERIENCE LANE S. PALMER, RAYMOND R. ROSENBAUM, MEYER D. GERSHBAUM,

AND

ERIC R. KREUTZER

ABSTRACT Objectives. To review the evaluation and management of patients with penetrating ureteral injuries not associated with iatrogenic etiology. Methods. A retrospective analysis of 20 patients with penetrating ureteral injuries during a 10-year period at a Level 1 trauma center was performed. Data were collected regarding the mechanism of injury, initial urinalysis and radiographic studies, operative procedure, associated injuries, postoperative complications, and outcome. Results. In general, patients were young (mean age 27.8 years) men (95%). All injuries were unilateral (14 left and 6 right), were primarily caused by gunshot wounds (95%), and were associated with other injuries (100%). Three injuries were to the proximal ureter, 7 to the middle, and 10 to the distal ureter. Admission urinalysis failed to show gross or microscopic hematuria in 25% of cases. Preoperative intravenous urography (IVU) was diagnostic in 25% of cases. Fifteen injuries were diagnosed intraoperatively, including 2 with diagnostic IVU. Delayed diagnoses were made in 4 cases at 3 to 11 days; two by IVU postoperatively and the other two by computed tomography. All patients were treated surgically by ureteroneocystostomy, ureteroureterostomy, or pyeloplasty. Every repair was stented for a mean of 38 days (range 10 to 72). All three major complications (ureteral stricture, persistent urinary leak, and ureterocutaneous fistula) were managed successfully. Thirteen patients with long-term follow-up demonstrated no evidence of obstruction. Conclusions. Ureteral injuries must be considered early during the evaluation of penetrating abdominal injuries. The admission urinalysis may be falsely normal and initial IVU may be nondiagnostic. The diagnosis may be made intraoperatively or be delayed. The surgical repair should be stented, and long-term success can be anticipated. UROLOGY 54: 34–36, 1999. © 1999, Elsevier Science Inc.

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reteral injuries by penetrating trauma are uncommon, occurring in 2.3% to 3.1%1–3 of gunshot wounds to the abdomen. The ureters are relatively well protected by surrounding structures, and their small size and mobility contributes to their infrequent injury. However, more of these injuries are now identified with improved evaluation of trauma patients. A high index of suspicion is necessary, however, to make an early diagnosis, as patients typically have multiple, associated injuries, and preoperative testing does not always adequately diagnose this entity. These injuries are frequently delayed in their diagnosis. Similarly, a high index of suspicion is needed in considering this diagnosis in patients From the Department of Urology, Albert Einstein College of Medicine, Bronx, New York Reprint requests: Lane S. Palmer, M.D., 833 Northern Boulevard, Great Neck, NY 11021 Submitted: November 25, 1998, accepted (with revisions): January 4, 1999

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© 1999, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED

with persistent ileus, fever, abdominal or flank tenderness, or persistent urinary drainage. Imaging studies (computed tomography [CT] and intravenous urography [IVU]) are important in helping to make the diagnosis. The management of these cases is similar to that of injuries determined at the time of presentation. We reviewed our experience of penetrating ureteral injuries during a 10-year period in an urban trauma center, with attention to the diagnosis, repair, and outcome of these injuries. MATERIAL AND METHODS All cases of ureteral injury secondary to penetrating trauma that occurred between 1986 and 1995 at a Level 1 trauma center were identified. Twenty-four patients were identified with 20 charts available for review. A total of 20 ureteral injuries were compiled. Each record was reviewed for the mechanism of injury, initial urinalysis and radiographic studies, operative procedure, associated injuries, postoperative complications, and outcome. 0090-4295/99/$20.00 PII S0090-4295(99)00025-4

RESULTS

COMMENT

Among the 20 patients included in this report, 19 were men and 1 was a woman, ranging in age from 15 to 56 years (mean 27.8). The mechanism of injury was a gunshot wound in 19 cases (95%) and a stab wound in 1 case (5%). The ureteral injuries in all 20 patients were unilateral, with 14 on the left and 6 on the right. Three injuries were to the proximal portion of the ureter, 7 to the middle ureter, and 10 to the distal ureter. All patients had associated injuries; 17 patients had bowel injuries, 8 patients vascular injuries, and 4 patients other urologic injuries. The admission urinalysis performed on 16 patients revealed gross hematuria in 6 (37.5%), microscopic hematuria in 6 (37.5%), and no hematuria in 4 (25%). When patients with other urologic injuries were excluded, only 8 (66.7%) of 12 patients had hematuria. IVU was performed on presentation in the emergency room on 4 patients and intraoperatively on 3 patients. All the studies were of limited diagnostic value, as only one of the four studies was diagnostic of the ureteral injury. Fifteen of the ureteral injuries were diagnosed intraoperatively, including 2 with a diagnostic IVU. Four ureteral injuries were initially missed, with delayed diagnoses made at 3 to 11 days. Two of these patients were diagnosed by IVU postoperatively and the other two by CT scan. All 7 patients with midportion injuries underwent stented ureteroureterostomy. Of the 10 patients with distal injury, 5 underwent stented ureteroureterostomy, 4 ureteroneocystostomies with a psoas hitch, and 1 with a missed injury had a nephrostomy tube placed. One patient with a proximal injury underwent dismembered pyeloplasty, and the other two had stented ureteroureterostomies. Every repair was managed with a ureteral stent, either a double-J stent or a feeding tube. Stents remained in place for a mean of 38 days (range 10 to 72). There were three major complications: (a) ureteral stricture presenting at 2 years and treated with reimplantation, (b) persistent urinary leak with reanastomosis performed at the time of exploration for a small bowel obstruction, and (c) a ureterocutaneous fistula that was successfully managed with a nephrostomy tube and antegrade stent. All 13 patients available for long-term follow-up demonstrated no evidence of significant obstruction on imaging studies performed at a mean of 6 months after injury. Despite numerous attempts and contacts, the remaining 7 patients were not available for follow-up medical evaluation.

The early diagnosis of ureteral injury has proved to be difficult despite assessment of hematuria and the use of IVU preoperatively. Patients with penetrating trauma are typically in critical condition, with multiple, associated injuries, and may be too unstable for adequate evaluation before exploration. Even when stable enough for preoperative evaluation, a significant percentage of patients have a nondiagnostic workup. Hematuria is typically absent on presentation, as described in several series, ranging from 23% to 45%.3–9 In our series, 33% of patients without other urologic injuries had a normal urinalysis. IVU or a CT scan should be performed in all patients with penetrating injuries to the abdomen potentially involving the kidney or ureter. In the trauma setting, these studies are limited and can establish the presence and function of the kidneys but may not adequately assess the ureters. Previous studies have described a false-negative rate for IVU ranging from 44% to 73%.4 – 6 Some studies suggest a high success rate in diagnosis with IVU.1,3,10 Of the seven preoperative and intraoperative IVUs obtained in our review, 57% were nondiagnostic. Potential findings that raise suspicion include extravasation, dilation, failure to visualize the ureters, deviation of the ureter, or bladder displacement. Typically, the injuries are identified intraoperatively either by direct inspection and exploration or with the aid of intravenous methylene blue or indigo carmine to identify extravasation. Patients with evidence of retroperitoneal injury or ureteral hematoma should be carefully examined for possible injury. The imaging studies currently available for evaluating the patient with potential blunt or penetrating trauma to the genitourinary tract has shifted from IVU to CT and will shift again to helical (spiral) CT. Among our patients, IVU failed to recognize 25% of the injuries. Although the inefficiency of IVU in demonstrating ureteral injuries has been noted in published reports,7 the use of CT to diagnose ureteral injuries has not been well established except in cases of ureteropelvic junction disruption secondary to blunt trauma.11 CT can demonstrate urinomas in cases of delayed diagnosis, as was true in our cases. The use of helical CT for urinary stone disease is becoming more widespread, and its utility in evaluating the patient with thoracic12 or abdominal13 trauma is well documented. Its use in evaluating upper urinary tract trauma has been documented for staging renal trauma,14 vascular injury,15 and disruption at the ureteropelvic junction.16 The rapidity with which helical CT scanners perform is convenient but may lead to inaccurate studies. Mulligan et al.16 suggest

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that delayed studies be performed to secure adequate contrast excretion, as their case of a ureteropelvic junction disruption was missed on the initial images but was found when scanned 5 to 8 minutes later. The timely recognition of this injury is important, as delayed diagnosis can contribute to increased morbidity.5,17 It is important to be alert for signs of potential missed injury in the postoperative period, including prolonged ileus, low-grade fever, flank tenderness, or persistent drainage from operative sites. If these injuries are identified in the early postoperative period and aggressively managed, preservation of renal function can be anticipated. In our series, a delayed diagnosis did not lead to nephrectomy, and all patients had renal salvage, as was seen in other series with delayed cases.1,2 The cases of delayed diagnosis of ureteral trauma pose an interesting question: do these cases represent a delay in diagnosis of a ureteral disruption or a rapid diagnosis of delayed rupture after ureteral contusion? Among the cases noted at the time of presentation, there were no cases of ureteral contusion found intraoperatively. If a ureteral contusion were encountered, the surgical management would depend on the integrity and length of the contused segment. The intravenous administration of either methylene blue or indigo carmine could be helpful in making this determination. Segmental resection and primary repair over a double-J ureteral stent would probably be sufficient in most cases. The accepted surgical management of ureteral injuries includes adequate debridement of devitalized tissue, a water-tight, tension-free spatulated anastomosis, isolation from associated contamination injuries, adequate drainage, and ureteral stenting.18 The site of injury will dictate the form of ureteral repair. Distal ureteral repairs may necessitate a ureteroneocystostomy with a psoas hitch. Generally, proximal and midureteral injuries may be repaired by ureteroureterostomy. The use and form of ureteral diversion has been debated. Indwelling ureteral stents are typically used by most centers.3,4,6,7,19 An externalized polyvinyl feeding tube has been preferred by some for repair of distal injuries.18 Nephrostomy tube drainage has been recommended in proximal repairs in addition to stenting5,19,20; others suggest its use only in cases of associated pancreatic injury.1,21 We have not routinely used a nephrostomy tube in ureteral repairs and have not regretted it. CONCLUSIONS Urinalysis and preoperative IVU do not guarantee diagnosis of ureteral injury in penetrating ab36

dominal trauma, and a high index of suspicion is necessary. Helical CT may improve the preoperative evaluation of this condition. When promptly recognized, a good outcome can be expected after ureteral trauma, with preservation of renal function. REFERENCES 1. Holden S, Hicks CC, O’Brien DP III, et al: Gunshot wounds of the ureter: a 15-year review of 63 consecutive cases. J Urol 116: 562–564, 1976. 2. Walker JA: Injuries of the ureter due to external violence. J Urol 102: 410 – 413, 1969. 3. Rober PE, Smith JB, and Pierce JM: Gunshot injuries of the ureter. J Trauma 30: 83– 86, 1990. 4. Bright TC, and Peters PC: Ureteral injuries due to external violence: 10 years’ experience with 59 cases. J Trauma 17: 616 – 620, 1977. 5. Campbell EW, Filderman PS, and Jacobs SC: Ureteral injury due to blunt and penetrating trauma. Urology 40: 216 – 220, 1992. 6. Presti JC, Carroll PR, and McAninch JW: Ureteral and renal pelvic injuries from external trauma: diagnosis and management. J Trauma 29: 370 –374, 1989. 7. Brandes SB, Chelsky MJ, Buckman RF, et al: Ureteral injuries from penetrating trauma. J Trauma 36: 766 –769, 1994. 8. Liroff SA, Pontes JES, and Pierce JM Jr: Gunshot wounds of the ureter: 5 years of experience. J Urol 118: 551– 553, 1977. 9. Peterson NE, and Pitts JC: Penetrating injuries of the ureter. J Urol 126: 587–590, 1981. 10. Carlton CE Jr, Guthrie AG, and Scott R Jr: The initial management of ureteral injuries: a report of 78 cases. J Urol 105: 335–340, 1971. 11. Kenney PJ, Panicek DM, and Witanowski LS: Computed tomography of ureteral disruption. J Comput Assist Tomogr 11: 480 – 484, 1987. 12. Gavant ML, Menke PG, Fabian T, et al: Blunt aortic rupture: detection with helical CT of the chest. Radiology 197: 125–133, 1995. 13. Janzen DL, Zwirewich CV, Breen DJ, et al: Diagnostic accuracy of helical CT of blunt bowel and mesenteric injuries. Clin Radiol 53: 193–197, 1998. 14. Carl P: Diagnosis and therapy of kidney traumas. Urologe A 36: 523–530, 1997. 15. Nunez D Jr, Becerra JL, Fuentes D, et al: Traumatic occlusion of the renal artery: helical CT diagnosis. AJR Am J Roentgenol 167: 777–780, 1996. 16. Mulligan JM, Cagiannos I, Collins JP, et al: Ureteropelvic junction disruption secondary to blunt trauma: excretory phase imaging (delayed films) should help prevent missed diagnosis. J Urol 159: 67–70, 1998. 17. Mendez R, and McGinty DM: The management of delayed recognized ureteral injuries: a report of 78 cases. J Urol 119: 192–193, 1978. 18. Guerriero WG: Ureteral injury. Urol Clin North Am 16: 237–248, 1989. 19. Steers WD, Corriere JN Jr, Benson GS, et al: The use of indwelling ureteral stents in managing ureteral injuries due to external violence. J Trauma 25: 1001–1003, 1985. 20. Franco I, Eshghi M, Schutte H, et al: Value of proximal diversion and ureteral stenting in management of penetrating ureteral trauma. Urology 32: 99 –102, 1988. 21. Spirnak JP, Persky L, and Resnick MI: The management of civilian ureteral gunshot wounds: a review of 8 patients. J Urol 134: 733–736, 1985. UROLOGY 54 (1), 1999