Traumatic Ureteral Injuries with Delayed Diagnosis

David A Kunkle*, Bryan T Kansas*, Abhijit S Pathak*, Amy J Goldberg*, Jack H Mydlo
Temple University Hospital, Philadelphia, PA

Introduction: Ureteral injuries resulting from external trauma are rare and are usually identified at laparotomy. We review our experience with missed ureteral injuries and conduct a meta-analysis to determine factors contributing to missed injury and compare outcomes of early versus late diagnosis.
Methods: From 1995 through 2004, 6378 patients were evaluated by the trauma service. Retrospective analysis reveals 550 patients suffering genitourinary injuries and 40 patients with penetrating ureteral injuries.
Results: Of 40 penetrating ureteral injuries, 5 (12.5%) were discovered an average of 6.0 days after laparotomy - usually manifesting as urinoma (80%.) Management included percutaneous nephrostomy (PCN) in 4 cases. Hospital stay increased from 19.2 to 36.6 days with delayed diagnosis. Only 2 patients achieved satisfactory results during initial hospitalization. Interestingly, patients with missed injuries did not have a greater number of associated injuries (2.6 injuries versus 3.7 for early diagnosis.) Literature review reveals 51 patients with ureteral injuries missed at exploration, representing 9.8% of patients with ureteral injuries undergoing laparotomy. Missed injuries occurred most often at the proximal ureter (57.1%.) Overall rates of nephrectomy and death were 18.4% and 13.2%. Satisfactory results were achieved in 63.9% of patients.
Conclusions: Despite preoperative analysis and intraoperative inspection, traumatic ureteral injury may remain undiagnosed until the postoperative period. Delayed diagnosis of ureteral injuries is associated with prolonged hospital stay and greater rates of complications. Nonetheless, satisfactory results allowing preservation of the renal unit may be achieved in many patients, and PCN may provide a means of temporization or, occasionally, definitive treatment.

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