Ureteral Injuries

Traumatic ureteral injuries are uncommon because the ureter is a well-protected retroperitoneal structure with a narrow diameter, accounting for only 1 % of all genitourinary injuries (Brandes et al. 2004; Elliott and McAninch 2003). Blunt ureteral trauma is rare compared to penetrating gunshot ureteral injuries, which constitute 90% of the overall violent ureteral injuries (Peterson 2000). Yet only 2 % - 3 % of gunshot wounds of the abdomen are associated with ureteral injury, and once diagnosed, it is almost always associated with multiple intraabdominal organ injuries (Brandes et al. 2004).

The operative decisions in the presence of a ureteral injury are based on several factors: whether the tear is partial or complete, the segment of the ureter involved, the viability of the ureter and surrounding tissues, associated urological and nonurological injuries and the general condition of the patient. The options for definitive repair of a complete ureteral tear are: ureterourete-rostomy, transureteroureterostomy, ureterocalicosto-my, ureteroneocystostomy with Boari flap, ureterocy-stostomy and psoas hitch, ileal interposition graft, and autotransplantation (Lynch et al. 2003). Though excellent results can be achieved with the above-mentioned reconstructive techniques, they are all time-consuming and occupy precious operating room time and skilled personnel.

During mass casualty events, another variable is added to the equation discussed above. Diagnostic procedures such as intraoperative injection of indigo carmine, intraoperative IVP or retrograde ureteropyelography intended to confirm or rule out ureteral injuries should be discouraged. If a ureteral injury is suspected but not clearly identified, a drain may be left in place, and if urinary leak occurs a nephrostomy tube can be placed postoperatively. If a partial ureteral tear is identified (involving less than half of the circumference) and the ureter looks viable, a double-J stent maybe inserted over a guidewire through the tear and the tear can be closed with interrupted absorbable stitches. This procedure takes about 10 min to perform and seems reasonable even in extreme situations of mass casualty scenarios. However, when complete ureteral injuries are identified, attempts at definitive repair should not be undertaken. Placement of a single-J or an 8-F feeding tube into the ureter, tying the distal end of the ureter over the tube, exteriorizing it (Best et al. 2005; Brandes and McAninch 1999; Coburn 1997; Elliott and McAninch 2003; McAninch and Santucci 2002) through a small stab incision of the skin and tying it to the skin has been advocated as a fast and simple procedure that produces no damage to the ureter and does not compromise delayed elective repair. The distal ure-teral stump does not need to be ligated; any unnecessary manipulation should be avoided.

Tying off the injured ureteral segment and postoperative insertion of percutaneous nephrostomy (Brandes and McAninch 1999; Coburn 1997; Elliott and McAninch 2003; McAninch and Santucci 2002) is a viable alternative but should not be considered as the procedure of choice.

In rare selected cases, nephrectomy is required to treat ureteral injury with severe associated injuries of the ipsilateral kidney or other intraabdominal organs (McAninch and Santucci 2002). Though this recommendation originally refers to a situation in which ureteral injury complicates vascular procedures in which a vascular prosthesis is to be implanted, it is also relevant to the damage control situations discussed herein and should be considered in patients with ureteral injuries and high-grade renal injuries, provided documentation of a functioning contralateral kidney exists.

Hirshberg and Mattox (1994) in their report of their experience with 124 patients with multisystem trauma, describe four cases who had associated ureteral injuries; two managed by stenting, one by exteriorization, and one by ligation.

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