Skip to main content

Advertisement

SpringerLink
Log in

Evaluation and Management of Non-iatrogenic Ureteral Trauma

  • Urologic Trauma (S Hudak, Section Editor)
  • Published:
Current Trauma Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Ureteral injuries are rare and represent a minority of genitourinary injuries in trauma patients. Their association with complex polytrauma and propensity for delayed recognition present diagnostic and therapeutic challenges. Herein, we present a review of the available literature on the evaluation and management of non-iatrogenic ureteral injuries.

Recent Findings

The incidence of traumatic ureteral injury appears to be increasing as a result of improved trauma survivability and enhanced imaging techniques. While most of the ureteral trauma literature reports on penetrating mechanisms of injury, blunt ureteral injuries are typically associated with more severe injury scores. Diagnosing traumatic ureteral injuries continues to be challenging and clinical suspicion should guide subsequent evaluation based on the patient’s condition. Computerized tomography with intravenous contrast and excretory phase imaging is the gold standard for evaluating suspected ureteral injuries in clinically stable trauma patients. Many ureteral injuries will still be diagnosed intraoperatively and may be successfully temporized or definitively reconstructed acutely. In unstable patients, damage control principles have been adapted to ureteral trauma permitting delayed reconstruction. Delayed diagnosis of these injuries has been associated with increased morbidity, mortality, length of stay, and renal loss.

Summary

Traumatic ureteral injuries are rare and require a high index of suspicion. Patient physiology may guide the evaluation and eventual treatment of these injuries. Improved detection, management, and vigilance for potential complications of traumatic ureteral injuries can improve patient outcomes and decreased resource utilization.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. WHO. The top 10 causes of death. Fact Sheet. World Health Organization; 2015.

  2. National Hospital Ambulatory Medical Care Survey: 2013 Emergency Department Summary Tables [database on the Internet]2013. Available from: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2013_ed_web_tables.pdf. Accessed 15 Jul 2017.

  3. • McGeady JB, Breyer BN. Current epidemiology of genitourinary trauma. Urol Clin North Am. 2013;40(3):323–34. https://doi.org/10.1016/j.ucl.2013.04.001. Comprehensive literature review of genitourinary trauma epidemiology and management in contemporary practice.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Tezval H, Tezval M, von Klot C, Herrmann TR, Dresing K, Jonas U, et al. Urinary tract injuries in patients with multiple trauma. World J Urol. 2007;25(2):177–84. https://doi.org/10.1007/s00345-007-0154-y.

    Article  PubMed  Google Scholar 

  5. Presti JC Jr, Carroll PR, McAninch JW. Ureteral and renal pelvic injuries from external trauma: diagnosis and management. J Trauma. 1989;29(3):370–4.

    Article  PubMed  Google Scholar 

  6. Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol. 2003;170(4 Pt 1):1213–6. https://doi.org/10.1097/01.ju.0000087841.98141.85.

    Article  PubMed  Google Scholar 

  7. Siram SM, Gerald SZ, Greene WR, Hughes K, Oyetunji TA, Chrouser K, et al. Ureteral trauma: patterns and mechanisms of injury of an uncommon condition. Am J Surg. 2010;199(4):566–70. https://doi.org/10.1016/j.amjsurg.2009.11.001.

    Article  PubMed  Google Scholar 

  8. Ghali AM, El Malik EM, Ibrahim AI, Ismail G, Rashid M. Ureteric injuries: diagnosis, management, and outcome. J Trauma. 1999;46(1):150–8.

    Article  CAS  PubMed  Google Scholar 

  9. Best CD, Petrone P, Buscarini M, Demiray S, Kuncir E, Kimbrell B, et al. Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale. J Urol. 2005;173(4):1202–5. https://doi.org/10.1097/01.ju.0000155526.37963.ef.

    Article  PubMed  Google Scholar 

  10. Holden S, Hicks CC, O'Brien DP, Stone HH, Walker JA, Walton KN. Gunshot wounds of the ureter: a 15-year review of 63 consecutive cases. J Urol. 1976;116(5):562–4.

    Article  CAS  PubMed  Google Scholar 

  11. Rober PE, Smith JB, Pierce JM Jr. Gunshot injuries of the ureter. J Trauma. 1990;30(1):83–6.

    Article  CAS  PubMed  Google Scholar 

  12. Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am. 2006;33(1):55–66, vi. https://doi.org/10.1016/j.ucl.2005.11.005.

    Article  PubMed  Google Scholar 

  13. Pereira BM, Ogilvie MP, Gomez-Rodriguez JC, Ryan ML, Pena D, Marttos AC, et al. A review of ureteral injuries after external trauma. Scand J Trauma Resusc Emerg Med. 2010;18:6. https://doi.org/10.1186/1757-7241-18-6.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Moore EE, Cogbill TH, Jurkovich GJ, McAninch JW, Champion HR, Gennarelli TA, et al. Organ injury scaling. III: chest wall, abdominal vascular, ureter, bladder, and urethra. J Trauma. 1992;33(3):337–9.

    Article  CAS  PubMed  Google Scholar 

  15. Perez-Brayfield MR, Keane TE, Krishnan A, Lafontaine P, Feliciano DV, Clarke HS. Gunshot wounds to the ureter: a 40-year experience at Grady Memorial Hospital. J Urol. 2001;166(1):119–21.

    Article  CAS  PubMed  Google Scholar 

  16. Kunkle DA, Kansas BT, Pathak A, Goldberg AJ, Mydlo JH. Delayed diagnosis of traumatic ureteral injuries. J Urol. 2006;176(6 Pt 1):2503–7. https://doi.org/10.1016/j.juro.2006.08.003.

    Article  PubMed  Google Scholar 

  17. Medina D, Lavery R, Ross SE, Livingston DH. Ureteral trauma: preoperative studies neither predict injury nor prevent missed injuries. J Am Coll Surg. 1998;186(6):641–4.

    Article  CAS  PubMed  Google Scholar 

  18. Digiacomo JC, Frankel H, Rotondo MF, Schwab CW, Shaftan GW. Preoperative radiographic staging for ureteral injuries is not warranted in patients undergoing celiotomy for trauma. Am Surg. 2001;67(10):969–73.

    CAS  PubMed  Google Scholar 

  19. Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int. 2004;94(3):277–89. https://doi.org/10.1111/j.1464-410X.2004.04978.x.

    Article  PubMed  Google Scholar 

  20. •• Morey AF, Brandes S, Dugi DD 3rd, Armstrong JH, Breyer BN, Broghammer JA, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–35. https://doi.org/10.1016/j.juro.2014.05.004. Systematic review and clinical practice guidelines for the management of genitourinary trauma by the American Urological Association.

    Article  PubMed  PubMed Central  Google Scholar 

  21. •• Serafetinides E, Kitrey ND, Djakovic N, Kuehhas FE, Lumen N, Sharma DM, et al. Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 2015;67(5):930–6. https://doi.org/10.1016/j.eururo.2014.12.034. Systematic review and clinical practice guidelines for the management of upper urinary tract injuries by the European Association of Urology.

    Article  PubMed  Google Scholar 

  22. Ortega SJ, Netto FS, Hamilton P, Chu P, Tien HC. CT scanning for diagnosing blunt ureteral and ureteropelvic junction injuries. BMC Urol. 2008;8:3. https://doi.org/10.1186/1471-2490-8-3.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Fraga GP, Borges GM, Mantovani M, Ferreira U, Laurito TL, Netto NR Jr. Penetrating ureteral trauma. Int Braz J Urol. 2007;33(2):142–8. discussion 9-50

    Article  PubMed  Google Scholar 

  24. Abid AF, Hashem HL. Ureteral injuries from gunshots and shells of explosive devices. Urol Ann. 2010;2(1):17–20. https://doi.org/10.4103/0974-7796.62920.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Azimuddin K, Milanesa D, Ivatury R, Porter J, Ehrenpreis M, Allman DB. Penetrating ureteric injuries. Injury. 1998;29(5):363–7.

    Article  CAS  PubMed  Google Scholar 

  26. Cass AS. Ureteral contusion with gunshot wounds. J Trauma. 1984;24(1):59–60.

    Article  CAS  PubMed  Google Scholar 

  27. Santucci RA, Chang YJ. Ballistics for physicians: myths about wound ballistics and gunshot injuries. J Urol. 2004;171(4):1408–14. https://doi.org/10.1097/01.ju.0000103691.68995.04.

    Article  PubMed  Google Scholar 

  28. Knight RB, Hudak SJ, Morey AF. Strategies for open reconstruction of upper ureteral strictures. Urol Clin North Am. 2013;40(3):351–61. https://doi.org/10.1016/j.ucl.2013.04.005.

    Article  PubMed  Google Scholar 

  29. Armenakas NA. Current methods of diagnosis and management of ureteral injuries. World J Urol. 1999;17(2):78–83.

    Article  CAS  PubMed  Google Scholar 

  30. Palmer LS, Rosenbaum RR, Gershbaum MD, Kreutzer ER. Penetrating ureteral trauma at an urban trauma center: 10-year experience. Urology. 1999;54(1):34–6.

    Article  CAS  PubMed  Google Scholar 

  31. Chovanes J, Cannon JW, Nunez TC. The evolution of damage control surgery. Surg Clin North Am. 2012;92(4):859–875, vii-viii. https://doi.org/10.1016/j.suc.2012.04.002.

    Article  PubMed  Google Scholar 

  32. • Smith TG, 3rd, Coburn M. Damage control maneuvers for urologic trauma. Urol Clin North Am. 2013;40(3):343–350. doi:https://doi.org/10.1016/j.ucl.2013.04.003. Multidisciplinary management urologic trauma is enhanced by adaptation of damage control maneuvers that can improve patient recovery and facilitate eventual urologic reconstruction.

  33. McGinty DM, Mendez R. Traumatic ureteral injuries with delayed recognition. Urology. 1977;10(2):115–7.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. San Antonio Military Medical Center, 3551 Roger Brooke Dr., JBSA, Fort Sam Houston, TX, 78234, USA

    Humberto Villarreal & Steven J. Hudak

Authors
  1. Humberto Villarreal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Steven J. Hudak
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Humberto Villarreal.

Ethics declarations

Conflict of Interest

None.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Disclaimer

The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army or the Department of Defense, or the U.S. Government.

Additional information

This article is part of the Topical Collection on Urologic Trauma

Appendix

Appendix

Table 1 Mechanism and anatomic location of ureteral trauma: literature reprts
Full size table
Table 2 Ureter organ injury scale
Full size table

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Villarreal, H., Hudak, S.J. Evaluation and Management of Non-iatrogenic Ureteral Trauma. Curr Trauma Rep 3, 257–264 (2017). https://doi.org/10.1007/s40719-017-0108-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40719-017-0108-9

Keywords

Search

Navigation