Ureteral trauma: preoperative studies neither predict injury nor prevent missed injuries

Ureteral injuries are uncommon, and the necessity, accuracy, and optimal use of perioperative testing remains unknown. Delays in diagnosis have also been associated with significant morbidity, including loss of renal function.

The records of all patients (n = 20) admitted with ureteral injuries to two Level I trauma centers during a 5-year period were reviewed. Data collected included patient demographics, mechanism of injury, degree of associated injuries, and presence of gross or microscopic hematuria. The use of any pre- or intraoperative testing was specifically noted. The location of the ureteral injury was obtained from the operative notes. The morbidity and mortality associated with ureteral injuries in the primarily diagnosed and the delayed groups were assessed. Presenting signs and symptoms, diagnostic testing, and the urologic management of the patients in the delayed group were reviewed.

All patients were men whose ages ranged from 15 to 72 years, with a mean age of 29. The mechanisms of injury were gunshot wounds in 15, stab wounds in 4, and blunt vehicular trauma in 1. Excluding other urologic injuries, the incidence of hematuria related to the ureteral injury alone was 53%. A total of 10 pre- and intraoperative studies were performed, only 2 demonstrated the ureteral injury. Seventeen patients had their injuries diagnosed primarily. In this group, the ureter was repaired by suturing and stenting in 12, suturing without a stent in 1 and ureterocystostomy in 4. Delayed diagnosis of their ureteral injuries occurred in three patients. All three missed injuries occurred in the upper portion of the left ureter. All ureters were successfully repaired. There were no mortalities in this group, nor did any patient require a nephrectomy.

Direct visualization of the injury is the best and most accurate diagnostic modality in ureteral trauma. These results reinforce that a thorough exploration of all retroperitoneal hematomas after penetrating trauma remain an integral part of the total abdominal exploration for trauma.