AVULSION
OF URETER
IVAN LABERGE,
M.D.
YVES L. HOMSY,
M.D.
GEORGES GILLES
DADOUR, BELAND,
BY BLUNT TRAUMA
M.D.
M.D.
From the Pediatric Urology for Children, and University
Service, Sainte-Justine of Montreal, Quebec,
Hospital Canada
ABSTRACT
- Six cases of amdsion of the upper ureter by blunt trauma are presented: 5 in children and one in an adult. One of these also inoolned the entire renal pedicle. A review of the literature shows that this type of trauma is rare, about 30 cases having been reported. They are seen mostly in children, and the right kidney is more prone to injury. Often, there is absence of hematuria which leads to considerable delay in diagnosis and surgical repair. On account of this delay, hydronephrosis, infection, and sometimes pseudocyst formation can complicate the initial pathologic condition. Despite these delays, successful repair can be accomplished and the kidney salcaged. In some instances, as we found out in our cases, a retrograde pyelogram was helpful in establishing the diagnosis and localizing the site of the lesion preoperatirely.
Avulsion of the upper ureter after blunt trauma has been found more frequently in recent years, but remains a rare entity. Its symptoms can be imprecise and therefore differentiation from rupture of the renal parenchyma with urinary extravasation can be difficult. Delays in establishing a definite diagnosis are therefore not unusual. This is often due to the absence of hematuria which detracts attention from the urinary tract. We herein report our experience over the past twelve years with 6 cases of ureteral avulsion secondary to blunt trauma. A review of these cases and of the literature helps to illustrate the different facets of the problem. Case Reports Case 1
A three-year-old girl was hit by a car and presented with brain trauma and acute abdominal pain localized mostly in the right flank. No hematuria was observed, either gross or microscopic. X-ray films revealed a fracture of the eleventh rib on the right and a fracture of the right horizontal branches of the pubic rami. X-ray films of the kidney, ureter, and bladder showed evidence of a possible retroperitoneal hematoma. A
172
somewhat dilated right renal pelvis was seen on the intravenous pyelogram (IVP) and the ureter was not visualized on delayed films (Fig. 1A). Extravasation of contrast medium could be seen at the level of the lower pole. Retrograde pyelography was done to determine the site of rupture which appeared to originate either from the renal pelvis or the upper ureter (Fig. 1B). Through a lumbar incision, the kidney was approached and a complete avulsion of the upper ureter at the level of the ureteropelvic junction was revealed. The kidney was otherwise normal. An end to end anastomosis was performed with resection of a small segment of devitalized ureter without splint. A Penrose drain was left in situ. Urinary leakage persisted for three weeks. This leak was rapidly controlled after the passage of a 4 F ureteral catheter that remained in situ for a few days (Fig. 1C). Two years later, an IVP showed a well-functioning kidney with, at most, a slight degree of pyelectasis (Fig. 1D). Case 2
A four-year-old boy was struck by a car and brought to a local hospital with cerebral concussion, left hemiparesis, and fracture of the pubic
UROLOGY
/ FEBRUARY
1979 / VOLUME
XIII,
NUMBER 2
rami. There was no hematuria, and an IVP was not done until two weeks later. This showed extravasation of contrast material at the right ureExploration demonstrated teropelvic junction. complete avulsion of the upper ureter. However, it appeared that the severed ends could not be reapproximated. A nephrostomy tube was inserted and the patient transferred to Sainte-Justine Children’s Hospital. On admission, a retrograde pyelography and simultaneous nephrostography demonstrated a significant gap between the renal pelvis and the upper ureter (Fig. 2A). At operation, after tedious dissection it was possible to perform a
UROLOGY
/ FEBRUARY
1979 / VOLUME
XIII,
NUMBER 2
Davis-type intubated ureteropyelostomy over a ureteral catheter which was left indwelling for three weeks. One year later a moderate degree of hydronephrosis could still be demonstrated (Fig. 2B). This was believed to be due to the formation of scar tissue at the level of the ureteropelvic junction. Case 3 A three-year-old boy was injured in a car accident and brought to a local hospital with cerebral trauma, fracture of the left femur, and superficial abrasions of the left flank. No
173
FIGURE 3. (A) IVP with extravasation of contrast material at lower pole of left kidney. (B) Retrograde pyelogram with retroperitoneal mass crossing middle line. (C) IVP three weeks after surgical drainage of infected (E) Retrograde pyelogram with kink of urinoma. (D) IVP jve months later with progressive hydronephrosis. upper ureter and stricture of ureteropelvicjunction. (F) IVP one and one-half years after excision of pseudocyst and repair.
hematuria could be demonstrated. Nevertheless an IVP was done showing a subcapsular hematoma of the left kidney. Since the child’s condition was deteriorating, with persistent abdominal pain and rigidity along with increasing fever, he was transferred to our hospital where another IVP demonstrated some contrast material extravasating at the lower pole of the left kidney (Fig. 3A). At retrograde pyelography the left ureter was shifted toward the midline with contrast material extravasating into the surrounding tissues (Fig. 3B).
174
At surgery a large mass was found occupying the left flank and a large amount of purulent urine was evacuated. Because of the poor condition of the tissues no further exploration was attempted, and a Penrose drain was left in situ. Full dose parenteral antibiotherapy was begun. Three weeks later control IVP showed satisfactory left renal function with no contrast material outside the kidney (Fig. 3C). Five months later marked hydronephrosis was present (Fig. 3D) and a retrograde pyelogram showed a kink with a stricture at the ureteropelvic junction (Fig. 3E).
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At exploration, fibrosis was marked. A pseudocyst was found, the walls of which were surrounding the renal pelvis above and the upper ureter below. A segment of upper ureter was lying completely free within the pseudocyst. The kidney and upper ureter were dissected free from the dense fibrosis surrounding them and the pseudocyst was excised. A dismembered type anastomosis was performed, thus uniting the pelvis to the spatulated end of the upper ureter after downward mobilization of he kidney. One and one-half years later, renal function 1:iad returned to normal with minimal radiologic C,hanges (Fig. 3F).
c:ase
4
A six-year-old boy was admitted to the emergency room on April 7, 1976, about two and one-half hours after an accident at his parents’ farm. The child had been caught in the machinery of a cogwheel driving wood toward a lumber saw. He was found unconscious and immediately transferred to Sainte-Justine Hospital. On arrival, he was visibly in shock with a pulse rate of 160/min., and blood pressure was not measurable. He had a tender and distended abdomen, and bowel sounds were absent. There was evident contusion of the lateral aspect of the thorax and abdomen on the right. Closed fractures of the right humerus and femoral shaft were observed. Laboratory data revealed: hemoglobin 7.8 Gm./lOO ml.; hematocrit 21.6. Immediate transfusion was started with 500 ml. group 0 Rh negative blood. Abdominal tap was done which yielded massive fresh blood. He was immediately transferred to the operating room. Laparotomy was carried out three and one-half hours after the accident. There was active bleeding which originated from the area of the right renal pedicle where the renal vein was torn off the inferior vena cava with the laceration extending upward for about 2 to 3 cm. along its lateral wall. The right ureter was completely transected at the level of the ureteropelvic junction. The renal parenchyma was not lacerated and other than its ischemic appearance and a few areas with subcapsular hematoma, the organ looked salvageable. Immediate repair of the caval laceration led to stabilization of the patient’s condition. Urine output had been 50 ml. in the preceding hour. Palpation of the left kidney revealed no gross abnormality. Adequate inspection of the torn
UROLOGY
/ FEBRUARY
1979 I VOLUME
XIII,
NUMBER
FIGURE 4. IVP jve months after surgery showing autotransplanted right kidney displaced downward but functioning normally.
renal pelvis was impossible in situ since its margins had completely retracted within the renal sinus. It was decided to remove the kidney for extracorporeal perfusion, bench surgery, and autotransplantation. The renal artery was divided at its junction with the aorta and immediately perfused with cold Sack solution. With fine scissors it was possible to dissect enough of the remaining renal pelvis from the renal sinus on the bench, to anastomose it to the ureter. Autotransplantation was carried out by turning the kidney upside down, thus placing the renal pelvis in an anterior position for easier anastomosis with the ureter, after discarding 4 to 5 cm. of the proximal portion. This also facilitated the vascular anastomosis by bringing the renal pedicle into closer approximation with the vena cava and aorta. Good coloration and perfusion became noticeable upon release of the vascular clamps, and parenchymal turgor was satisfactory. A nephrostomy was carried out, placing a no. 12/4 “rat-tail” Silastic catheter in the renal pelvis and ureter. Pyeloureterostomy was then performed with the Silastic catheter through the anastomotic site. All fractures were treated by traction in extension. Postoperatively the kidney suffered from acute tubular necrosis, with a urine output varying between 0 to 75 ml. per twenty-four hours
2
175
until the seventh postoperative day. Urine output had climbed to 300 and 500 ml. per twentyfour hours by the eleventh day (from the right kidney) and the nephrostomy tube was removed. Seven weeks after surgery control IVP showed immediate opacification and elimination of contrast material from the autotransplanted kidney. However, the right ureter was not visualized. Blood urea nitrogen, creatinine, and blood pressure remained normal five months after surgery. An IVP five months after surgery showed good excretion at three minutes and at six minutes a well-outlined ureter (Fig. 4). The child is still normotensive (100/70 mm. Hg) and well two years post injury. This case is believed to be the first of its kind and has already been reported elsewhere.’
Case 5 A five-year-old girl was struck by a car and brought to the emergency room. Her general condition was satisfactory other than a few bruises on the face and right arm. A fracture of the femoral shaft was treated by traction in extension The abdomen was tender in the right upper quadrant and the right costovertebral angle. Urinalysis showed only microscopic hematuria. An IVP done the next morning showed significant extravasation of contrast material on the six-minute film which progressed as further films were taken (Fig. 5A). The distal ureters were visible. The patient now had a much more tender right upper quadrant and costovertebral angle. She was immediately taken to the operating room. A retrograde pyelogram done with 2 cc. of dye showed extensive extravasation in the region of the upper ureter (Fig. 5B). She was explored through the flank and a complete avulsion of the ureter was found about 1 cm. below the ureteropelvic junction. The ends of the severed ureter were holding together only by loose periureteral areolar tissue. Spatulation and end to end anastomosis with 5-O chromic catgut was performed and a Penrose drain was left in situ. No splints or diversion were used. Since leakage was persistent at three weeks, a catheter was passed up the right ureter into the renal pelvis. This did not stop the leak. A urinoma developed which subsequently became infected and was easily drained at the bedside (Fig. 5C). Recovery was rapid after complete
176
evacuation satisfactory
of the urinoma, (Fig. 5D).
and control
IVP was
Case 6 A thirty-five-year-old belly dancer was hit by a car while crossing the street. On admission she complained of pain in the right flank, nausea, and vomiting. There was no hematuria. On IVP one could see a collection of contrast material around the right renal pelvis. Surgical exploration was refused by the patient. Two weeks later her condition was stationary and retrograde pyelography still showed signs of extravasation. An operation was finally accepted. Operative findings revealed complete avulsion of the ureter at the ureteropelvic junction. An end to end anatomosis without splint or diversion was performed leaving a Penrose drain in situ. IVP prior to discharge showed moderate hydronephrosis. Unfortunately the patient was temporarily lost to follow-up. She two years later without reappeared, however, any complaints. Her IVP showed no function on the right and her kidney had to be removed. Comment In a review of the recent literature back to 1960, we were able to find about 30 cases of complete upper ureteral avulsion by blunt trauma. ‘-13Three cases of bilateral rupture of the ureteropelvic junction were even reported.14-16 We excluded simple tears or injuries caused by penetrating trauma.r5-” Pseudocysts, such as was found in Case 3, were described by Khonsari and associates’* and by other authors,1g-22 but in some of their cases, these were of iatrogenic origin. The most exhaustive study of reported cases was done by Reznichek, Brosman, and Rhodesz3 Diokno,24 followed by Bondonny, Ballanger, and Guinberteau in 1974.25 The foremost aspect of the problem is the absence of hematuria which detracts attention from the urinary tract of patients with multiple trauma. This is largely responsible for delays in establishing accurate diagnosis and proper treatment. Despite these delays surgical repair has permitted a higher rate of kidney salvage in recent years. Diagnosis is not always readily made since dye extravasation, although found in most cases, is not to be invariably expected (e.g., in pedicle injury). Nonvisualization of the ureter on IVP is an important negative finding.
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/ FEBRUARY 1979 / VOLUME
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NUMBER 2
FIGURE 5. (A) Extruvasation below right ureteropelvic junction, but presence of contrast material in lower ureter. (B) Retrograde pyelogram with loss of continuity at upper ureter. (C) Large postoperative urinoma. (0) IVP six months after surge y .
Retrograde pyelography was done in 5 of 6 cases and is helpful in defining the level of injury. The extent of the lesion whether complete or not can only be determined on surgical exploration. The primary goal of surgical repair is to reunite both ureteral stumps without tension, with or without stenting and after careful debridement and spatulation. In Case 4, shock due to massive internal bleeding precluded the usual diagnostic workup and pedicle injury along with the ruptured ureter was discovered at laparotomy. The kidney was suc-
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cessfully salvaged by extracorporeal surgery and autotransplantation.’ Interestingly, ureteral trauma secondary to blunt injury occurs mostly in children presumably because of the sudden hyperextension of a more flexible spine. The right side is more frequently involved than the left, as observed by many authors including ourselves, although there does not appear to be an adequate explanation for this. The localization of the avulsion at or near the ureteropelvic junction is believed to be caused by compression of the kidney and its pelvis against
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the lower rib cage or upper lumbar transverse processes and stretching of the ureter by sudden and extreme lateral flexion of the trunk. Ainsworth, Weems, and Merrell14 postulated that severe hyperextension of the lumbar spine at the moment of impact plus the additional force caused by sudden acceleration imposed enough tension on the ureters to result in avulsion. Greater elasticity and mobility of the truncal structures in children makes them more susceptible to sustain this kind of injury. In conclusion, the presence of a urinary tract lesion must always be kept in mind in cases of abdominal trauma. It is strongly recommended that contrast material be injected as soon as an intravenous line is established. In the course of the multiple x-ray films that the trauma patient is likely to undergo, an IVP of satisfactory quality to verify the integrity of the urinary tract can easily be obtained. If the foregoing criteria of investigation were more closely observed, surgical repair would be made easier before the onset of inflammatory changes and thus improve the rate of kidney salvage. 3175 Chemin C6te Ste-Catherine Montreal, Quebec H3T lC5 Canada (DR. LABERGE) References 1. Guttman F, Homsy Y, and Schmidt E: Avulsion injury to the renal pedicle: successful autotransplantation after bench surgery, J. Trauma 18: 469 (1978). 2. Stickel DL, and Howse RM: Injuries of the ureter due to external violence. A review of the literature and report of 2 cases, Ann Surg. 154: 137 (1961). 3. Zuffal R: Traumatic avulsion of the upper ureter, J. Ural. 85: 246 (1961).
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4. Fruchtman B, and Newman H: Upper ureteral avulsion secondary to non-penetrating trauma, ibid. 93: 452 (1965). 5. Halverstadt DB, and F&y EE: Avulsion of the upper ureter secondary to blunt trauma, Br. J. Ural. 39: 588 (1967). 6. Walker JA: Injuries of the ureter due to external violence, J. Ural. 102: 410 (1969). 7. Rusche C, and Morrow JW: Injury to the ureter, in Campbell MF, and Harrison JH, Eds: Urology, 3rd ed.; Philadelphia, W. B. Saunders Co., 1970, pp. 811-851. 8. Carlton CE, Jr, Scott R, Jr, and Guthrie AG: The initial management of ureteral injuries: a report of 78 cases, J. Ural. 105: 335 (1971). 9. Forbes CD, et al: Rupture of the ureter due to crushing injury in a boy with severe hemophilia, Br. J. Surg. 58: 931 (1971). 10. Slate; RB, and Kirkpatrick JR: A case of closed injury of the unner ureter. Br. 1. Ural. 43: 591 (1971). -il. Carabiona P, Delmas M, ad Bdnnel F: Rupture de I’uret&e lombaire par contusion abdominale. Ur&%orraphie. Chirurgie 98: 421 (1972). 12. Johnson JM, et al: Bilateral ureteral avulsion, J. Pediatr. Surg. 7: 723 (1972). 13. Rao CR: Ureteral avulsion secondary to blunt abdominal injury, J. Ural. 110: 188 (1973). 14. Ainsworth T, Weems WL, and Merrell WH, Jr: Bilateral ureteral injury due to non-penetrating external trauma, ibid. 96: 439 (1966). 15. Del Villar RG, Ireland GW, and Cass AS: Ureteral injury owing to external trauma, ibid. 107: 29 (1972). 16. Boston VE, and Smyth BT: Bilateral pelvi-ureteric avulsion following closed trauma, Br. J. Ural. 47: 149 (1975). 17. Petry JL: Traumatic avulsion of the renal pelvis: repair with capsular flap, J. Ural. 112: 308 (1974). 18. Khonsari H, Morehouse DD, and MacKinnon KJ: Pararenal pseudocysts, Br. J. Urol. 43: 164 (1971). 19. Sturdy DE, and Magell J: Traumatic perinephric cysts (pseudohydronephrosis), Br. J. Surg. 48: 315 (1960). 20. Sauls CL, and Nesbit RM: Pararenal pseudocysts: a report of 4 cases, J. Ural. 87: 288 (1962). 21. Hawthorne NJ, Zincke H, and Kelalis PP: Ureterocalicostomy: an alternative to nephrectomy, ibid. 115: 583 (1976). 22. Thompson IM, et al: Experiences with 16 cases of pararenal pseudocyst, ibid. 116: 289 (1976). 23. Reznichek RC, Brosman SA, and Rhodes DB: Ureteral avulsion from blunt trauma, ibid. 109: 812 (1973). 24. Diokno AC: Avulsion of the proximal ureter secondary to blunt trauma, ibid. 111: 412 (1974). 25. Bondonny JM, Ballanger R, and Guinberteau JC: A propos de 2 observations de rupture traumatique de la jontion py&lou&&ale, J. Ural. Nephrol. 80: 773 (1974).
UROLOGY
/
FEBRUARY
1979
/
VOLUME
XIII,
NUMBER
2
OF URETER
IVAN LABERGE,
M.D.
YVES L. HOMSY,
M.D.
GEORGES GILLES
DADOUR, BELAND,
BY BLUNT TRAUMA
M.D.
M.D.
From the Pediatric Urology for Children, and University
Service, Sainte-Justine of Montreal, Quebec,
Hospital Canada
ABSTRACT
- Six cases of amdsion of the upper ureter by blunt trauma are presented: 5 in children and one in an adult. One of these also inoolned the entire renal pedicle. A review of the literature shows that this type of trauma is rare, about 30 cases having been reported. They are seen mostly in children, and the right kidney is more prone to injury. Often, there is absence of hematuria which leads to considerable delay in diagnosis and surgical repair. On account of this delay, hydronephrosis, infection, and sometimes pseudocyst formation can complicate the initial pathologic condition. Despite these delays, successful repair can be accomplished and the kidney salcaged. In some instances, as we found out in our cases, a retrograde pyelogram was helpful in establishing the diagnosis and localizing the site of the lesion preoperatirely.
Avulsion of the upper ureter after blunt trauma has been found more frequently in recent years, but remains a rare entity. Its symptoms can be imprecise and therefore differentiation from rupture of the renal parenchyma with urinary extravasation can be difficult. Delays in establishing a definite diagnosis are therefore not unusual. This is often due to the absence of hematuria which detracts attention from the urinary tract. We herein report our experience over the past twelve years with 6 cases of ureteral avulsion secondary to blunt trauma. A review of these cases and of the literature helps to illustrate the different facets of the problem. Case Reports Case 1
A three-year-old girl was hit by a car and presented with brain trauma and acute abdominal pain localized mostly in the right flank. No hematuria was observed, either gross or microscopic. X-ray films revealed a fracture of the eleventh rib on the right and a fracture of the right horizontal branches of the pubic rami. X-ray films of the kidney, ureter, and bladder showed evidence of a possible retroperitoneal hematoma. A
172
somewhat dilated right renal pelvis was seen on the intravenous pyelogram (IVP) and the ureter was not visualized on delayed films (Fig. 1A). Extravasation of contrast medium could be seen at the level of the lower pole. Retrograde pyelography was done to determine the site of rupture which appeared to originate either from the renal pelvis or the upper ureter (Fig. 1B). Through a lumbar incision, the kidney was approached and a complete avulsion of the upper ureter at the level of the ureteropelvic junction was revealed. The kidney was otherwise normal. An end to end anastomosis was performed with resection of a small segment of devitalized ureter without splint. A Penrose drain was left in situ. Urinary leakage persisted for three weeks. This leak was rapidly controlled after the passage of a 4 F ureteral catheter that remained in situ for a few days (Fig. 1C). Two years later, an IVP showed a well-functioning kidney with, at most, a slight degree of pyelectasis (Fig. 1D). Case 2
A four-year-old boy was struck by a car and brought to a local hospital with cerebral concussion, left hemiparesis, and fracture of the pubic
UROLOGY
/ FEBRUARY
1979 / VOLUME
XIII,
NUMBER 2
rami. There was no hematuria, and an IVP was not done until two weeks later. This showed extravasation of contrast material at the right ureExploration demonstrated teropelvic junction. complete avulsion of the upper ureter. However, it appeared that the severed ends could not be reapproximated. A nephrostomy tube was inserted and the patient transferred to Sainte-Justine Children’s Hospital. On admission, a retrograde pyelography and simultaneous nephrostography demonstrated a significant gap between the renal pelvis and the upper ureter (Fig. 2A). At operation, after tedious dissection it was possible to perform a
UROLOGY
/ FEBRUARY
1979 / VOLUME
XIII,
NUMBER 2
Davis-type intubated ureteropyelostomy over a ureteral catheter which was left indwelling for three weeks. One year later a moderate degree of hydronephrosis could still be demonstrated (Fig. 2B). This was believed to be due to the formation of scar tissue at the level of the ureteropelvic junction. Case 3 A three-year-old boy was injured in a car accident and brought to a local hospital with cerebral trauma, fracture of the left femur, and superficial abrasions of the left flank. No
173
FIGURE 3. (A) IVP with extravasation of contrast material at lower pole of left kidney. (B) Retrograde pyelogram with retroperitoneal mass crossing middle line. (C) IVP three weeks after surgical drainage of infected (E) Retrograde pyelogram with kink of urinoma. (D) IVP jve months later with progressive hydronephrosis. upper ureter and stricture of ureteropelvicjunction. (F) IVP one and one-half years after excision of pseudocyst and repair.
hematuria could be demonstrated. Nevertheless an IVP was done showing a subcapsular hematoma of the left kidney. Since the child’s condition was deteriorating, with persistent abdominal pain and rigidity along with increasing fever, he was transferred to our hospital where another IVP demonstrated some contrast material extravasating at the lower pole of the left kidney (Fig. 3A). At retrograde pyelography the left ureter was shifted toward the midline with contrast material extravasating into the surrounding tissues (Fig. 3B).
174
At surgery a large mass was found occupying the left flank and a large amount of purulent urine was evacuated. Because of the poor condition of the tissues no further exploration was attempted, and a Penrose drain was left in situ. Full dose parenteral antibiotherapy was begun. Three weeks later control IVP showed satisfactory left renal function with no contrast material outside the kidney (Fig. 3C). Five months later marked hydronephrosis was present (Fig. 3D) and a retrograde pyelogram showed a kink with a stricture at the ureteropelvic junction (Fig. 3E).
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VOLUMEXIII, NUMBER2
At exploration, fibrosis was marked. A pseudocyst was found, the walls of which were surrounding the renal pelvis above and the upper ureter below. A segment of upper ureter was lying completely free within the pseudocyst. The kidney and upper ureter were dissected free from the dense fibrosis surrounding them and the pseudocyst was excised. A dismembered type anastomosis was performed, thus uniting the pelvis to the spatulated end of the upper ureter after downward mobilization of he kidney. One and one-half years later, renal function 1:iad returned to normal with minimal radiologic C,hanges (Fig. 3F).
c:ase
4
A six-year-old boy was admitted to the emergency room on April 7, 1976, about two and one-half hours after an accident at his parents’ farm. The child had been caught in the machinery of a cogwheel driving wood toward a lumber saw. He was found unconscious and immediately transferred to Sainte-Justine Hospital. On arrival, he was visibly in shock with a pulse rate of 160/min., and blood pressure was not measurable. He had a tender and distended abdomen, and bowel sounds were absent. There was evident contusion of the lateral aspect of the thorax and abdomen on the right. Closed fractures of the right humerus and femoral shaft were observed. Laboratory data revealed: hemoglobin 7.8 Gm./lOO ml.; hematocrit 21.6. Immediate transfusion was started with 500 ml. group 0 Rh negative blood. Abdominal tap was done which yielded massive fresh blood. He was immediately transferred to the operating room. Laparotomy was carried out three and one-half hours after the accident. There was active bleeding which originated from the area of the right renal pedicle where the renal vein was torn off the inferior vena cava with the laceration extending upward for about 2 to 3 cm. along its lateral wall. The right ureter was completely transected at the level of the ureteropelvic junction. The renal parenchyma was not lacerated and other than its ischemic appearance and a few areas with subcapsular hematoma, the organ looked salvageable. Immediate repair of the caval laceration led to stabilization of the patient’s condition. Urine output had been 50 ml. in the preceding hour. Palpation of the left kidney revealed no gross abnormality. Adequate inspection of the torn
UROLOGY
/ FEBRUARY
1979 I VOLUME
XIII,
NUMBER
FIGURE 4. IVP jve months after surgery showing autotransplanted right kidney displaced downward but functioning normally.
renal pelvis was impossible in situ since its margins had completely retracted within the renal sinus. It was decided to remove the kidney for extracorporeal perfusion, bench surgery, and autotransplantation. The renal artery was divided at its junction with the aorta and immediately perfused with cold Sack solution. With fine scissors it was possible to dissect enough of the remaining renal pelvis from the renal sinus on the bench, to anastomose it to the ureter. Autotransplantation was carried out by turning the kidney upside down, thus placing the renal pelvis in an anterior position for easier anastomosis with the ureter, after discarding 4 to 5 cm. of the proximal portion. This also facilitated the vascular anastomosis by bringing the renal pedicle into closer approximation with the vena cava and aorta. Good coloration and perfusion became noticeable upon release of the vascular clamps, and parenchymal turgor was satisfactory. A nephrostomy was carried out, placing a no. 12/4 “rat-tail” Silastic catheter in the renal pelvis and ureter. Pyeloureterostomy was then performed with the Silastic catheter through the anastomotic site. All fractures were treated by traction in extension. Postoperatively the kidney suffered from acute tubular necrosis, with a urine output varying between 0 to 75 ml. per twenty-four hours
2
175
until the seventh postoperative day. Urine output had climbed to 300 and 500 ml. per twentyfour hours by the eleventh day (from the right kidney) and the nephrostomy tube was removed. Seven weeks after surgery control IVP showed immediate opacification and elimination of contrast material from the autotransplanted kidney. However, the right ureter was not visualized. Blood urea nitrogen, creatinine, and blood pressure remained normal five months after surgery. An IVP five months after surgery showed good excretion at three minutes and at six minutes a well-outlined ureter (Fig. 4). The child is still normotensive (100/70 mm. Hg) and well two years post injury. This case is believed to be the first of its kind and has already been reported elsewhere.’
Case 5 A five-year-old girl was struck by a car and brought to the emergency room. Her general condition was satisfactory other than a few bruises on the face and right arm. A fracture of the femoral shaft was treated by traction in extension The abdomen was tender in the right upper quadrant and the right costovertebral angle. Urinalysis showed only microscopic hematuria. An IVP done the next morning showed significant extravasation of contrast material on the six-minute film which progressed as further films were taken (Fig. 5A). The distal ureters were visible. The patient now had a much more tender right upper quadrant and costovertebral angle. She was immediately taken to the operating room. A retrograde pyelogram done with 2 cc. of dye showed extensive extravasation in the region of the upper ureter (Fig. 5B). She was explored through the flank and a complete avulsion of the ureter was found about 1 cm. below the ureteropelvic junction. The ends of the severed ureter were holding together only by loose periureteral areolar tissue. Spatulation and end to end anastomosis with 5-O chromic catgut was performed and a Penrose drain was left in situ. No splints or diversion were used. Since leakage was persistent at three weeks, a catheter was passed up the right ureter into the renal pelvis. This did not stop the leak. A urinoma developed which subsequently became infected and was easily drained at the bedside (Fig. 5C). Recovery was rapid after complete
176
evacuation satisfactory
of the urinoma, (Fig. 5D).
and control
IVP was
Case 6 A thirty-five-year-old belly dancer was hit by a car while crossing the street. On admission she complained of pain in the right flank, nausea, and vomiting. There was no hematuria. On IVP one could see a collection of contrast material around the right renal pelvis. Surgical exploration was refused by the patient. Two weeks later her condition was stationary and retrograde pyelography still showed signs of extravasation. An operation was finally accepted. Operative findings revealed complete avulsion of the ureter at the ureteropelvic junction. An end to end anatomosis without splint or diversion was performed leaving a Penrose drain in situ. IVP prior to discharge showed moderate hydronephrosis. Unfortunately the patient was temporarily lost to follow-up. She two years later without reappeared, however, any complaints. Her IVP showed no function on the right and her kidney had to be removed. Comment In a review of the recent literature back to 1960, we were able to find about 30 cases of complete upper ureteral avulsion by blunt trauma. ‘-13Three cases of bilateral rupture of the ureteropelvic junction were even reported.14-16 We excluded simple tears or injuries caused by penetrating trauma.r5-” Pseudocysts, such as was found in Case 3, were described by Khonsari and associates’* and by other authors,1g-22 but in some of their cases, these were of iatrogenic origin. The most exhaustive study of reported cases was done by Reznichek, Brosman, and Rhodesz3 Diokno,24 followed by Bondonny, Ballanger, and Guinberteau in 1974.25 The foremost aspect of the problem is the absence of hematuria which detracts attention from the urinary tract of patients with multiple trauma. This is largely responsible for delays in establishing accurate diagnosis and proper treatment. Despite these delays surgical repair has permitted a higher rate of kidney salvage in recent years. Diagnosis is not always readily made since dye extravasation, although found in most cases, is not to be invariably expected (e.g., in pedicle injury). Nonvisualization of the ureter on IVP is an important negative finding.
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FIGURE 5. (A) Extruvasation below right ureteropelvic junction, but presence of contrast material in lower ureter. (B) Retrograde pyelogram with loss of continuity at upper ureter. (C) Large postoperative urinoma. (0) IVP six months after surge y .
Retrograde pyelography was done in 5 of 6 cases and is helpful in defining the level of injury. The extent of the lesion whether complete or not can only be determined on surgical exploration. The primary goal of surgical repair is to reunite both ureteral stumps without tension, with or without stenting and after careful debridement and spatulation. In Case 4, shock due to massive internal bleeding precluded the usual diagnostic workup and pedicle injury along with the ruptured ureter was discovered at laparotomy. The kidney was suc-
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cessfully salvaged by extracorporeal surgery and autotransplantation.’ Interestingly, ureteral trauma secondary to blunt injury occurs mostly in children presumably because of the sudden hyperextension of a more flexible spine. The right side is more frequently involved than the left, as observed by many authors including ourselves, although there does not appear to be an adequate explanation for this. The localization of the avulsion at or near the ureteropelvic junction is believed to be caused by compression of the kidney and its pelvis against
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the lower rib cage or upper lumbar transverse processes and stretching of the ureter by sudden and extreme lateral flexion of the trunk. Ainsworth, Weems, and Merrell14 postulated that severe hyperextension of the lumbar spine at the moment of impact plus the additional force caused by sudden acceleration imposed enough tension on the ureters to result in avulsion. Greater elasticity and mobility of the truncal structures in children makes them more susceptible to sustain this kind of injury. In conclusion, the presence of a urinary tract lesion must always be kept in mind in cases of abdominal trauma. It is strongly recommended that contrast material be injected as soon as an intravenous line is established. In the course of the multiple x-ray films that the trauma patient is likely to undergo, an IVP of satisfactory quality to verify the integrity of the urinary tract can easily be obtained. If the foregoing criteria of investigation were more closely observed, surgical repair would be made easier before the onset of inflammatory changes and thus improve the rate of kidney salvage. 3175 Chemin C6te Ste-Catherine Montreal, Quebec H3T lC5 Canada (DR. LABERGE) References 1. Guttman F, Homsy Y, and Schmidt E: Avulsion injury to the renal pedicle: successful autotransplantation after bench surgery, J. Trauma 18: 469 (1978). 2. Stickel DL, and Howse RM: Injuries of the ureter due to external violence. A review of the literature and report of 2 cases, Ann Surg. 154: 137 (1961). 3. Zuffal R: Traumatic avulsion of the upper ureter, J. Ural. 85: 246 (1961).
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4. Fruchtman B, and Newman H: Upper ureteral avulsion secondary to non-penetrating trauma, ibid. 93: 452 (1965). 5. Halverstadt DB, and F&y EE: Avulsion of the upper ureter secondary to blunt trauma, Br. J. Ural. 39: 588 (1967). 6. Walker JA: Injuries of the ureter due to external violence, J. Ural. 102: 410 (1969). 7. Rusche C, and Morrow JW: Injury to the ureter, in Campbell MF, and Harrison JH, Eds: Urology, 3rd ed.; Philadelphia, W. B. Saunders Co., 1970, pp. 811-851. 8. Carlton CE, Jr, Scott R, Jr, and Guthrie AG: The initial management of ureteral injuries: a report of 78 cases, J. Ural. 105: 335 (1971). 9. Forbes CD, et al: Rupture of the ureter due to crushing injury in a boy with severe hemophilia, Br. J. Surg. 58: 931 (1971). 10. Slate; RB, and Kirkpatrick JR: A case of closed injury of the unner ureter. Br. 1. Ural. 43: 591 (1971). -il. Carabiona P, Delmas M, ad Bdnnel F: Rupture de I’uret&e lombaire par contusion abdominale. Ur&%orraphie. Chirurgie 98: 421 (1972). 12. Johnson JM, et al: Bilateral ureteral avulsion, J. Pediatr. Surg. 7: 723 (1972). 13. Rao CR: Ureteral avulsion secondary to blunt abdominal injury, J. Ural. 110: 188 (1973). 14. Ainsworth T, Weems WL, and Merrell WH, Jr: Bilateral ureteral injury due to non-penetrating external trauma, ibid. 96: 439 (1966). 15. Del Villar RG, Ireland GW, and Cass AS: Ureteral injury owing to external trauma, ibid. 107: 29 (1972). 16. Boston VE, and Smyth BT: Bilateral pelvi-ureteric avulsion following closed trauma, Br. J. Ural. 47: 149 (1975). 17. Petry JL: Traumatic avulsion of the renal pelvis: repair with capsular flap, J. Ural. 112: 308 (1974). 18. Khonsari H, Morehouse DD, and MacKinnon KJ: Pararenal pseudocysts, Br. J. Urol. 43: 164 (1971). 19. Sturdy DE, and Magell J: Traumatic perinephric cysts (pseudohydronephrosis), Br. J. Surg. 48: 315 (1960). 20. Sauls CL, and Nesbit RM: Pararenal pseudocysts: a report of 4 cases, J. Ural. 87: 288 (1962). 21. Hawthorne NJ, Zincke H, and Kelalis PP: Ureterocalicostomy: an alternative to nephrectomy, ibid. 115: 583 (1976). 22. Thompson IM, et al: Experiences with 16 cases of pararenal pseudocyst, ibid. 116: 289 (1976). 23. Reznichek RC, Brosman SA, and Rhodes DB: Ureteral avulsion from blunt trauma, ibid. 109: 812 (1973). 24. Diokno AC: Avulsion of the proximal ureter secondary to blunt trauma, ibid. 111: 412 (1974). 25. Bondonny JM, Ballanger R, and Guinberteau JC: A propos de 2 observations de rupture traumatique de la jontion py&lou&&ale, J. Ural. Nephrol. 80: 773 (1974).
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