Short Case Report
British Journal of Urology (1975).41, 386 0
Bilateral Avulsion of the Upper Ureters Avulsion of the upper ureter is a rare urinary tract injury. We report the case of a young girl who sustained bilateral avulsion which was recognised immediately, a satisfactory result being obtained with primary repair. Case History S . G., aged 3 years, fell from a car moving at 40 miles per hour but sustained only moderate external injuries. 4 hours later she developed painful flank distension. An intravenous pyelograrn showed bilateral extravasation at the pelvi-ureteric junction (Fig.) and rupture at this level was diagnosed. The ureters were explored trans-abdominally and the cleanly ruptured ends were found in collections of blood and urine. Oblique end-to-end anastomoses were performed over polyvinyl splints and the patient made anexcellent recovery.
Comment
This injury is exceptionally rare and occurs predominantly in children under the age of 11 years (Boston and Smyth, 1975). Separation is almost always within one or two centimetres of the pelvi-ureteric junction. The diagnosis is often delayed, as in some reported cases for a month or more, particularly where severe multiple injuries co-exist. Intravenous pyelography is essential for diagnosis and reveals a characteristic appearance (Beckley and Waters, 1972). Clinical features are unreliable in diagnosis, and haematuria, normally the commonest associated finding, was not seen in this case. A feature we consider was significant, however, was the lack of urine in the bladder on catheterisation or its subsequent production and this aspect has not previously received comment. No convincing explanation exists for the mechanism producing the injury, but the evidence from this case (tears in the posterior peritoneum) suggests a sudden traction on the ureter transmitted via the attached peritoneum from the rapidly moving abdominal viscera.
Acknowledgement We thank Mr Neil1 Freeman for permission to report this case. A. D. HEATHand A. MAY Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ
References BECKLEY, D. E. and WATERS, E. A. (1972). Avulsion of the pelvi-uretericjunction-a rare consequence of non-penetrative trauma. British Journal of Radiology, 45, 423-426. BOSTON,V. E. and SMYTH,B. T. (1975). Bilateral pelvi-ureteric avulsion following closed trauma. British Journal of Urology, 47, 149-151.
386
British Journal of Urology (1975).41, 386 0
Bilateral Avulsion of the Upper Ureters Avulsion of the upper ureter is a rare urinary tract injury. We report the case of a young girl who sustained bilateral avulsion which was recognised immediately, a satisfactory result being obtained with primary repair. Case History S . G., aged 3 years, fell from a car moving at 40 miles per hour but sustained only moderate external injuries. 4 hours later she developed painful flank distension. An intravenous pyelograrn showed bilateral extravasation at the pelvi-ureteric junction (Fig.) and rupture at this level was diagnosed. The ureters were explored trans-abdominally and the cleanly ruptured ends were found in collections of blood and urine. Oblique end-to-end anastomoses were performed over polyvinyl splints and the patient made anexcellent recovery.
Comment
This injury is exceptionally rare and occurs predominantly in children under the age of 11 years (Boston and Smyth, 1975). Separation is almost always within one or two centimetres of the pelvi-ureteric junction. The diagnosis is often delayed, as in some reported cases for a month or more, particularly where severe multiple injuries co-exist. Intravenous pyelography is essential for diagnosis and reveals a characteristic appearance (Beckley and Waters, 1972). Clinical features are unreliable in diagnosis, and haematuria, normally the commonest associated finding, was not seen in this case. A feature we consider was significant, however, was the lack of urine in the bladder on catheterisation or its subsequent production and this aspect has not previously received comment. No convincing explanation exists for the mechanism producing the injury, but the evidence from this case (tears in the posterior peritoneum) suggests a sudden traction on the ureter transmitted via the attached peritoneum from the rapidly moving abdominal viscera.
Acknowledgement We thank Mr Neil1 Freeman for permission to report this case. A. D. HEATHand A. MAY Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ
References BECKLEY, D. E. and WATERS, E. A. (1972). Avulsion of the pelvi-uretericjunction-a rare consequence of non-penetrative trauma. British Journal of Radiology, 45, 423-426. BOSTON,V. E. and SMYTH,B. T. (1975). Bilateral pelvi-ureteric avulsion following closed trauma. British Journal of Urology, 47, 149-151.
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