Vol. 118, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
GUNSHOT WOUNDS OF THE URETER: 5 YEARS OF EXPERIENCE S. A. LIROFF, J. E. S. PONTES
AND
J. M. PIERCE, JR.
From the Department of Urology, Wayne State University School of Medicine, Detroit, Michigan
ABSTRACT
During 5 consecutive years 20 patients with ureteral gunshot wounds were treated at the Detroit General Hospital. Among the 19 patients treated surgically 4 unrelated deaths occurred and 3 patients underwent a second exploration. No kidney was lost. Our surgical technique involving a tension-free, watertight anastomosis and diversion is emphasized. We believe that better results are obtained with stented repairs. Management of patients with ureteral gunshot wounds has been evolving primarily during the last 35 years. Although military experience has contributed much, problems facing the military and civilian surgeons are often different in terms of population, extent of injury and evaluation. This injury is noted infrequently but it is serious and difficult to manage. Late nephrectomy rates of up to 28 per centL 2 and recurring reports of diagnosis after initial laparotomy attest to this fact. experience with ureteral gunshot wounds at the Detroit General Hospital was reported in 1972. 3 During the ensuing 5 years we have treated 20 additional patients. We have been gratified with the knowledge and results gained with these cases. METHODS AND MATERIAL
The 20 patients were seen between August 1971 and September 1976 (fig. 1). The patients ranged in age from 16 to 50 years and they were all surgical candidates, although 1 patient died in the recovery room. In addition 1 patient died of late sepsis (apparently not of genitourinary etiology), 1 died of late hemorrhage and 1 died of a late cardiopulmonary arrest. Since none of the patients dead on arrival was considered, a true incidence of this lesion cannot be calculated. was obtained from 13 patients and was devoid of red cells in 1 case. In 3 cases only O to 3 red blood cells vvere demonstrated. A drip infusion excretory urogram (IVP) was performed in 10 cases. Nine patients were evaluated at for associated injuries, 6 of these being too gravely to undergo preoperative studies. One chart did not include data regarding diagnosis. We do our IVPs in the emergency x-ray department since those done on the operating table have been quite inadequate in our experience. Retrograde pyelograms, as recommended by some, 4 • 5 would have been impossible in most of our cases and would not have additional information.
were repaired with fine, absorbable sutures with end-to-end anastomosis after debridement. Eight of these 10 cases had stents. One injury involving a gunshot wound to the abdomen was missed at initial laparotomy and was managed antly in view of the gravity of the patient's total condition. 5 upper ureteral injuries were treated by end-to-end anastomosis after debridement and 4 had stents. In general, patients were managed conservatively the postoperative period, especially in the most recent cases, with stents left indwelling for approximately 3 weeks. Stentograms functioned to help make decisions regarding removal. In some cases stents fell out early, such as in the case of intramural repair, and the patients were observed expectantly. If a fistula was observed but ureteral continuity was demonstrated on an IVP or retrograde pyelogram a catheter was passed endoscopically. ASSOCIATED INJURIES
Only 2 cases involved injuries isolated to the genitourinary system. One striking observation was that of the 11 middle ureteral injuries 6 were associated with injuries of the iliac vessels. The most frequently associated injuries included
SURGICAL MANAGEMENT
Generally, surgical repair was directed towards a tensionfree primary anastomosis and included 1) adequate mobilization (tension-free anastomosis), 2) debridement, 3) spatulation, 4) watertight anastomosis and 5) stent. Techniques to obtain the anastomosis varied owing to various situations existing in each case at the time of operation. The 4 injuries of the lower ureter were approached in 4 ways: 1) psoas hitch and ureteroneocystostomy, 2) approximation over a stent (intramural ureteral lesion), 3) primary approximation of the edges in a partial laceration and 4) spatulated end-toend anastomosis over a stent. The middle ureteral injuries Accepted for publication January 21, 1977. Read at annual meeting of North Central Section, American Urological Association, Palm Beach, Florida, October 17-24, 1977. Supported by the Detroit General Hospital Research Corp., Detroit, Michigan.
551
MIDDLE URETEPl
n
FIG. 1. Locations of ureteral injuries
552
LIROFF, PONTES AND PIERCE
small bowel-10 cases, large bowel- 9 cases, iliac vessels-8 cases, mesentery-5 cases, duodenum-4 cases, ureter only-2 cases and inferior vena cava-1 case. COMPLICATIONS
Three re-explorations were performed. One of these was performed 3 days after repair for what was thought to be excessive urinary drainage via the Penrose drains. Leakage through the anterior intact suture line was found with treatment limited to suturing a piece of adventitia over the area. Two re-explorations were performed for anastomotic dehiscence. One of these involved a non-stented ureter that showed lack of continuity on the retrograde pyelogram 31 days after repair. Repeat repair over a stent with continuous 4-zero
FIG.
4. Ureteral repair with nephropexy
Ureteral gunshot wounds: surgical management and complications No Operation Stent No Stent Re-Exploration Upper ureter (5 cases) Middle ureter (11 cases) Lower ureter (4 cases)
Right ureteral gunshot wound. Note proximal ureteral dilatation and failure to visualize ureter beyond area of injury. FIG. 2.
1
4 8
1 2
0
3
1
0
1 2 0
chromic sutures and nephropexy was then performed successfully. In the third case obstruction of a No. 5 ureteral catheter stent resulted in complete dehiscence with fibrotic obstruction at the distal side of the anastomosis, which was noted 23 days postoperatively. Another operation with nephropexy and stented repair using a continuous 4-zero chromic suture resulted in success. Four operative procedures not directly approaching the initial repair were performed. A distal ureterotomy to retrieve a stent initially left curled in the bladder was required in 1 case. Three cases required endoscopic passage of ureteral catheters to provide short-term urinary diversion and stenting. DISCUSSION
FIG. 3.
Right ureteral gunshot wound. Note extravasation
The treatment of ureteral injuries must start with evaluation. Of paramount importance is the maintenance of a high level of suspicion in every case. As has been observed previously not all ureteral injuries are associated with hematuria. 4· &-s Therefore, any injury that might have a ureteral component needs evaluation regardless of the urinalysis. In this regard, radiographic findings, which we emphasize, are extravasation, mild dilatation (secondary to ureteral ileus 7) proximal to the site of injury and failure to visualize the entire length of the ureter (figs. 2 and 3). The technique of surgical exploration deserves comment, particularly since 1 ureter was explored in our series and the injury was missed. The full length of suspicious ureter was not exposed in preference to digital examination. It must be emphasized that without devascularizing the ureter, any area at risk must be mobilized and visualized. Certainly, periureteral hematoma does not equal disruption (as suggested in at least 1
553
GUNSHOT WOUNDS OF URETER
paper") as we have seen in the course of negative explorations. We were quite impressed with the association between middle ureteral injuries and iliac vessel injuries, which has not been noted previously. We believe that any vascular injury in this area demands a thorough local exploration of the ipsilateral ureter. The true extent of injury is not immediately obvious owing to the "blast effect", 6 even with the relatively low velocity bullets encountered in civilian circumstances (shotgun pellet injuries excepted). Therefore, adequate debridement on both sides of the injury is required. Mentioned in other reports but not emphasized is a tensionfree anastomosis. The definition of tension-free is not straightforward since the determination is made prior to reperitonealization posteriorly and replacing abdominal viscera. Often distal ureteral mobilization as well as nephropexy must be performed to achieve the necessary overlap of ureteral ends prior to repair (fig. 4). Of our 19 patients operated upon 4 did not have stents. Of these 4, 1 had a reimplant with psoas hitch, 2 had middle ureteral injuries and 1 had an upper ureteral injury. The patient with the upper ureteral injury required re-exploration. One of the patients with a middle ureteral injury required endoscopic passage of a ureteral catheter when failure to stop draining with urinoma was diagnosed 18 days postoperatively. Of the 15 stented repairs 2 required re-exploration, while in 3 cases late endoscopic ureteral stenting was performed. No nephrectomies were done (see table). We believe that all of these repairs (with the possible exception of reimplants)
should be stented with the stent brought out through the abdomen via the bladder. Conservative postoperative management with close followup must be the rule. In our cases there was no standardized time for removing stents, although we recommend a minimum of 3 weeks with stentograms to decide upon removal. All cases were followed closely with IVPs and retrograde pyelograms when re-evaluation was necessary. However, re-exploration was truly indicated only when complete disruption of the anastomosis was proved. REFERENCES
1. Carlton, C. E., Jr., Guthrie, A. G. and Scott, R., Jr.: Surgical correction ofureteral injury. J. Trauma, 9: 457, 1969. 2. Kimbrough, J.C.: War wounds of the urogenital tract. J. Urol., 55: 179, 1946. 3. Fisher, S., Young, D. A., Malin, J.M., Jr. and Pierce, J.M., Jr.: Ureteral gunshot wounds. J. Urol., 108: 238, 1972. 4. Heller, E.: War injuries of the upper urinary tract. J. Urol., 72: 149, 1954. 5. Henkel, H. B.: The urologic battle injury in the Korean conflict. J. Urol., 70: 637, 1953. 6. Carlton, C. E., Jr., Scott, R., Jr, and Guthrie, A.G.: The initial management ofureteral injuries: a report of78 cases. J. Urol., 105: 335, 1971. 7. Pumphrey, J. D., Joslin, A.H. and Lick, R., Jr.: Missile wounds of the ureter. J. Trauma, 2: 89, 1962. 8. Walker, J. A.: Injuries of the ureter due to external violence. J. Urol., 102: 410, 1964. 9. Kimbrough, J. C.: Urology in the European Theater of operations. J. Urol., 57: 1105, 1947.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
GUNSHOT WOUNDS OF THE URETER: 5 YEARS OF EXPERIENCE S. A. LIROFF, J. E. S. PONTES
AND
J. M. PIERCE, JR.
From the Department of Urology, Wayne State University School of Medicine, Detroit, Michigan
ABSTRACT
During 5 consecutive years 20 patients with ureteral gunshot wounds were treated at the Detroit General Hospital. Among the 19 patients treated surgically 4 unrelated deaths occurred and 3 patients underwent a second exploration. No kidney was lost. Our surgical technique involving a tension-free, watertight anastomosis and diversion is emphasized. We believe that better results are obtained with stented repairs. Management of patients with ureteral gunshot wounds has been evolving primarily during the last 35 years. Although military experience has contributed much, problems facing the military and civilian surgeons are often different in terms of population, extent of injury and evaluation. This injury is noted infrequently but it is serious and difficult to manage. Late nephrectomy rates of up to 28 per centL 2 and recurring reports of diagnosis after initial laparotomy attest to this fact. experience with ureteral gunshot wounds at the Detroit General Hospital was reported in 1972. 3 During the ensuing 5 years we have treated 20 additional patients. We have been gratified with the knowledge and results gained with these cases. METHODS AND MATERIAL
The 20 patients were seen between August 1971 and September 1976 (fig. 1). The patients ranged in age from 16 to 50 years and they were all surgical candidates, although 1 patient died in the recovery room. In addition 1 patient died of late sepsis (apparently not of genitourinary etiology), 1 died of late hemorrhage and 1 died of a late cardiopulmonary arrest. Since none of the patients dead on arrival was considered, a true incidence of this lesion cannot be calculated. was obtained from 13 patients and was devoid of red cells in 1 case. In 3 cases only O to 3 red blood cells vvere demonstrated. A drip infusion excretory urogram (IVP) was performed in 10 cases. Nine patients were evaluated at for associated injuries, 6 of these being too gravely to undergo preoperative studies. One chart did not include data regarding diagnosis. We do our IVPs in the emergency x-ray department since those done on the operating table have been quite inadequate in our experience. Retrograde pyelograms, as recommended by some, 4 • 5 would have been impossible in most of our cases and would not have additional information.
were repaired with fine, absorbable sutures with end-to-end anastomosis after debridement. Eight of these 10 cases had stents. One injury involving a gunshot wound to the abdomen was missed at initial laparotomy and was managed antly in view of the gravity of the patient's total condition. 5 upper ureteral injuries were treated by end-to-end anastomosis after debridement and 4 had stents. In general, patients were managed conservatively the postoperative period, especially in the most recent cases, with stents left indwelling for approximately 3 weeks. Stentograms functioned to help make decisions regarding removal. In some cases stents fell out early, such as in the case of intramural repair, and the patients were observed expectantly. If a fistula was observed but ureteral continuity was demonstrated on an IVP or retrograde pyelogram a catheter was passed endoscopically. ASSOCIATED INJURIES
Only 2 cases involved injuries isolated to the genitourinary system. One striking observation was that of the 11 middle ureteral injuries 6 were associated with injuries of the iliac vessels. The most frequently associated injuries included
SURGICAL MANAGEMENT
Generally, surgical repair was directed towards a tensionfree primary anastomosis and included 1) adequate mobilization (tension-free anastomosis), 2) debridement, 3) spatulation, 4) watertight anastomosis and 5) stent. Techniques to obtain the anastomosis varied owing to various situations existing in each case at the time of operation. The 4 injuries of the lower ureter were approached in 4 ways: 1) psoas hitch and ureteroneocystostomy, 2) approximation over a stent (intramural ureteral lesion), 3) primary approximation of the edges in a partial laceration and 4) spatulated end-toend anastomosis over a stent. The middle ureteral injuries Accepted for publication January 21, 1977. Read at annual meeting of North Central Section, American Urological Association, Palm Beach, Florida, October 17-24, 1977. Supported by the Detroit General Hospital Research Corp., Detroit, Michigan.
551
MIDDLE URETEPl
n
FIG. 1. Locations of ureteral injuries
552
LIROFF, PONTES AND PIERCE
small bowel-10 cases, large bowel- 9 cases, iliac vessels-8 cases, mesentery-5 cases, duodenum-4 cases, ureter only-2 cases and inferior vena cava-1 case. COMPLICATIONS
Three re-explorations were performed. One of these was performed 3 days after repair for what was thought to be excessive urinary drainage via the Penrose drains. Leakage through the anterior intact suture line was found with treatment limited to suturing a piece of adventitia over the area. Two re-explorations were performed for anastomotic dehiscence. One of these involved a non-stented ureter that showed lack of continuity on the retrograde pyelogram 31 days after repair. Repeat repair over a stent with continuous 4-zero
FIG.
4. Ureteral repair with nephropexy
Ureteral gunshot wounds: surgical management and complications No Operation Stent No Stent Re-Exploration Upper ureter (5 cases) Middle ureter (11 cases) Lower ureter (4 cases)
Right ureteral gunshot wound. Note proximal ureteral dilatation and failure to visualize ureter beyond area of injury. FIG. 2.
1
4 8
1 2
0
3
1
0
1 2 0
chromic sutures and nephropexy was then performed successfully. In the third case obstruction of a No. 5 ureteral catheter stent resulted in complete dehiscence with fibrotic obstruction at the distal side of the anastomosis, which was noted 23 days postoperatively. Another operation with nephropexy and stented repair using a continuous 4-zero chromic suture resulted in success. Four operative procedures not directly approaching the initial repair were performed. A distal ureterotomy to retrieve a stent initially left curled in the bladder was required in 1 case. Three cases required endoscopic passage of ureteral catheters to provide short-term urinary diversion and stenting. DISCUSSION
FIG. 3.
Right ureteral gunshot wound. Note extravasation
The treatment of ureteral injuries must start with evaluation. Of paramount importance is the maintenance of a high level of suspicion in every case. As has been observed previously not all ureteral injuries are associated with hematuria. 4· &-s Therefore, any injury that might have a ureteral component needs evaluation regardless of the urinalysis. In this regard, radiographic findings, which we emphasize, are extravasation, mild dilatation (secondary to ureteral ileus 7) proximal to the site of injury and failure to visualize the entire length of the ureter (figs. 2 and 3). The technique of surgical exploration deserves comment, particularly since 1 ureter was explored in our series and the injury was missed. The full length of suspicious ureter was not exposed in preference to digital examination. It must be emphasized that without devascularizing the ureter, any area at risk must be mobilized and visualized. Certainly, periureteral hematoma does not equal disruption (as suggested in at least 1
553
GUNSHOT WOUNDS OF URETER
paper") as we have seen in the course of negative explorations. We were quite impressed with the association between middle ureteral injuries and iliac vessel injuries, which has not been noted previously. We believe that any vascular injury in this area demands a thorough local exploration of the ipsilateral ureter. The true extent of injury is not immediately obvious owing to the "blast effect", 6 even with the relatively low velocity bullets encountered in civilian circumstances (shotgun pellet injuries excepted). Therefore, adequate debridement on both sides of the injury is required. Mentioned in other reports but not emphasized is a tensionfree anastomosis. The definition of tension-free is not straightforward since the determination is made prior to reperitonealization posteriorly and replacing abdominal viscera. Often distal ureteral mobilization as well as nephropexy must be performed to achieve the necessary overlap of ureteral ends prior to repair (fig. 4). Of our 19 patients operated upon 4 did not have stents. Of these 4, 1 had a reimplant with psoas hitch, 2 had middle ureteral injuries and 1 had an upper ureteral injury. The patient with the upper ureteral injury required re-exploration. One of the patients with a middle ureteral injury required endoscopic passage of a ureteral catheter when failure to stop draining with urinoma was diagnosed 18 days postoperatively. Of the 15 stented repairs 2 required re-exploration, while in 3 cases late endoscopic ureteral stenting was performed. No nephrectomies were done (see table). We believe that all of these repairs (with the possible exception of reimplants)
should be stented with the stent brought out through the abdomen via the bladder. Conservative postoperative management with close followup must be the rule. In our cases there was no standardized time for removing stents, although we recommend a minimum of 3 weeks with stentograms to decide upon removal. All cases were followed closely with IVPs and retrograde pyelograms when re-evaluation was necessary. However, re-exploration was truly indicated only when complete disruption of the anastomosis was proved. REFERENCES
1. Carlton, C. E., Jr., Guthrie, A. G. and Scott, R., Jr.: Surgical correction ofureteral injury. J. Trauma, 9: 457, 1969. 2. Kimbrough, J.C.: War wounds of the urogenital tract. J. Urol., 55: 179, 1946. 3. Fisher, S., Young, D. A., Malin, J.M., Jr. and Pierce, J.M., Jr.: Ureteral gunshot wounds. J. Urol., 108: 238, 1972. 4. Heller, E.: War injuries of the upper urinary tract. J. Urol., 72: 149, 1954. 5. Henkel, H. B.: The urologic battle injury in the Korean conflict. J. Urol., 70: 637, 1953. 6. Carlton, C. E., Jr., Scott, R., Jr, and Guthrie, A.G.: The initial management ofureteral injuries: a report of78 cases. J. Urol., 105: 335, 1971. 7. Pumphrey, J. D., Joslin, A.H. and Lick, R., Jr.: Missile wounds of the ureter. J. Trauma, 2: 89, 1962. 8. Walker, J. A.: Injuries of the ureter due to external violence. J. Urol., 102: 410, 1964. 9. Kimbrough, J. C.: Urology in the European Theater of operations. J. Urol., 57: 1105, 1947.
