URETERAL TRAUMA

Ureteral injuries are nearly always secondary to penetrating trauma. A high index of suspicion based upon suspected bullet or fragment trajectory is necessary to avoid missing injuries; careful exploration of the ureter is needed in this setting (Figure 6).21,22 Gross hematuria may be absent, and the only clue may be injuries to organs close to the path of the ureter or an unexplained rise in serum creatinine. Injuries may be primarily repaired if ureteral damage is identified during initial exploration. Care should be taken not to skeletonize the ureter during exploration, and if a stented, tension-free, and watertight anastomosis or reimplant is not possible, the ureter should be 'tagged' for later repair and widely drained at a minimum. If primary repair is not an option, extracorporeal drainage with a small feeding tube, stent, or percutaneous nephrostomy tube (if available in theater) should be initiated as a temporizing treatment until the patient is stable and can be evaluated at a tertiary care facility (Figure 7).21

Ureteral contusions require stenting or excision and primary anastomosis with wide spatulation of the injured portion. Simple lacerations need a primary closure, while complete transections of the ureter proximal to the iliac vessels can be repaired using a tension-free end-to-end, spatulated anastomosis over a stent placed in the ureter. Transections distal to the vessels should be fixed with ureteral reimplantation over a stent. In some circumstances, a psoas hitch or Boari flap may be required for additional length. Again, if local tissue destruction prevents the ability to create a tension-free anastomosis, or there is the presence of hemodynamic instability dictating management, a pediatric feeding tube or open-ended ureteral catheter may be placed in the proximal ureter and traversed through the skin to close drainage alternatively. Interim temporizing repair techniques pending an evacuation to a tertiary care center are often appropriate.1,21 (See Appendix A: Urological Diagnosis and Treatments.)