Ureteric injuries: diagnosis, management, and outcome

To define the current causes and the optimal methods of early diagnosis and management of ureteric injuries, both iatrogenic (excluding endourologic) and traumatic, and to determine the outcome of these injuries and which identifiable factors affect this outcome.

A retrospective analysis was performed of all the 35 patients who sustained 40 ureteric injuries over a 5-year period (1991-1996). The methods used for diagnosis and management were reviewed. The outcome was assessed in terms of preservation of renal function.

The study group was composed of 28 patients with 32 iatrogenic injuries and 7 patients with 8 injuries caused by external trauma. Gynecologic procedures accounted for 63% (20 of 32) of the iatrogenic injuries, whereas motor vehicle crashes accounted for 75% of the external injuries (6 of 8 injuries). The successful diagnostic rate for direct inspection (intraoperatively), intravenous urogram, retrograde pyelogram, and anterograde pyelogram were 33% for the former two and 100% for the latter two. Treatment consisted of primary open repair in 26 cases, a staged procedure in 7 cases, and endoscopic stenting in 5 cases. Of 36 cases with follow-up, complications developed in 9 cases (25%), 7 cases of which were corrected surgically. Overall incidence of nephrectomy was 8%, and the factors that seemed to affect the outcome adversely were pediatric age (< or =12 years), injury to upper ureter, delay in recognition, the presence of a urinoma, and/or associated organ injury.

Iatrogenic trauma is the leading cause of ureteric injuries. The single controllable factor adversely affecting the outcome of this rather uncommon injury seems to be delayed diagnosis. Wound inspection and intravenous urogram are not reliable for early and accurate diagnosis, and a retrograde pyelogram or an anterograde pyelogram may be needed. Uncontrollable factors adversely affecting the outcome include young age, injury to upper ureter, and associated injuries all seen in association with external trauma rather than iatrogenic injuries.