Ureteral injuries from external violence: The 25-year experience at San Francisco General Hospital

Purpose: We review our 25-year experience with traumatic ureteral injury, for which the approach to management differs from the far more common iatrogenic injury. Materials and Methods: Review of our trauma data base disclosed 36 patients with 38 ureteral injuries (33 penetrating [24 gunshot, 9 stab wounds] and 5 blunt) from 1977 to 2003, a period during which we treated approximately 4,000 traumatic genitourinary injuries. Results: The site of injury was the upper ureter in 70%, mid in 8% and distal in 22%. Major intra-abdominal injuries were often associated, but hematuria and hypotension were not consistent findings (75% and 50%, respectively). Excretory urograms performed in 24 patients was diagnostic in only 40%. Computerized tomography and retrograde pyelogram were diagnostic in 4 of 4 and 1 of 1 injuries, respectively (100%). Overall, diagnosis was by radiographic findings in 13 of the 36 injuries (36%) and by laparotomy in 23 (64%). Management was with stenting in 2 patients, primary closure in 12, ureteroureterostomy in 12, ureteroneocystostomy in 5, transureteroureterostomy in 1, Boari flap in 1 and nephrectomy in 1. The complication rate was 18%. Conclusions: Although traumatic ureteral injury is rare these patients are often critically ill and delay in diagnosis will increase the risk of complications. Contrast enhanced imaging in patients who are not undergoing laparotomy for associated injury should not be limited to those with hematuria and hypotension since these are not entirely sensitive. Most injuries are short segment loss in the upper ureter and can be repaired with debridement and tension-free anastamosis.