CHAPTER XXV
Wounds of the Ureter (27 Casualties)
WalterL. Byers, M. D.
There were only 27wounds of the ureter (0.86percent) in the 3,154 abdominal injuries in this series.Only 4 ureteral injuries are listed in the records of the American ExpeditionaryForces in World War I.1 They constituted 0.1 percent of all abdominaland pelvic injuries.
Thesingle univisceral injury of the ureter treated by the 2d Auxiliary SurgicalGroup surgeons was caused by a shell fragment which produced a small lacerationof the upper portion. In the 26 multivisceral wounds, thesmall intestine was involved 21 times and the large intestine18 times. Injuries to these two structures represented more than half of thecoincidental injuries. The bladder and liver were each involved 6times; the kidney 5 times;the duo?denum, extraperitoneal rectum, and great vessels of the abdomen 4 timeseach; and the stomach and spleen twice each. The internal iliac vein was thelargest vessel involved in the complicating vascular injuries.
DIAGNOSIS
The preoperative diagnosis of ureteral injuries was noteasy, particularly when other structures within the abdomen were also injured,as they were in all but one case in this series. Hematuria was not pathognomonic;it was present in only three cases in which the bladder or a kidney was not alsodamaged. In no instance in the series was there a detectable amount of urine onthe dressing or about the wound. The explanation, at least in part, was shock;it was frequent in these patients, and it was usually accompanied by oliguria oranuria. As a result, there was no telltale urinary leakage to lead to suspicionof a ureteral wound.
Facilities for cystoscopy, intravenous urography, andureteral catheterization, as noted in the previous chapter, were not availablein field hospitals. Even if they had been, most of these casualties, because ofthe gravity of their injuries, would not have been suitable candidates for suchdiagnostic procedures. Accordingly, the usual diagnostic refinements ofurologic surgery had to be dispensed with.
As aresult of these various circumstances, the diagnosis of ureteral injury wasusually made only at operation, and even then was overlooked in 3 of the 27cases.
1The Medical Department of the United States Army in theWorld War. Washington: U. S.Government Printing Office, 1927, vol. XI, pt. 1.
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TREATMENT
It wasthe accepted practice to expose the ureter fully whenever a missile had passedanywhere along its course. Exposure was often difficult because of theretroperitoneal hemorrhage common in such injuries. When leakage from a woundedcolon was also present, technical difficulties were still greater. Thesedifficulties explain the fact already mentioned; namely, that the ureteral woundwas overlooked at operation in three cases. In one of the overlooked cases,drainage was instituted because of a wound in the retroperitoneal portion ofthe colon, but the ureteral injury was not found until autopsy.
Inthe 24cases in whichureteral damage was identified at operation, seven separate surgical techniqueswere employed, as follows:
Transplantation of the ureter into the bladder wasperformed in six cases. This procedure could be utilized only in wounds of thedistal ureter. In one instance, the suture line separated on the third postoperative daybut was successfully repaired.
Ureteroanastomosiswas performed six times. Fourof the operations were done by the telescoping technique, with one failure, asmanifested by postoperative urinary drainage. The two patients treated byend-to-end anastomosis died within 48 hours of operation. Both fatalities were caused by shock and were not attributable to theureteral injuries.
Nephrectomywas performed five times, in each instance because of extensive renal damage.In no case was the injury to the proximal ureter of clinical significance incomparison to the wound of the kidney.
Ligationof the ureter at both ends was carried out in three transecting wounds, withextensive loss of substance. In one of these cases, the kidney was also wounded.
Ureterallacerations were successfully sutured in two cases. One case was managed bydrainage only. Cutaneous ureterostomy was done in one case; destruction of aconsiderable segment did not permit repair, and the condition of the patientdid not warrant extension of the operating time to perform nephrostomy. Thelatter procedure was not employed in any of these ureteral injuries, though inretrospect it seems that it might have been useful in certain cases.
Thesmall number of ureteral injuries and the various procedures used in theirmanagement make the discussion of any special technique of no value.
FACTORSOF MORTALITY
The 11 deaths in these 27 ureteralinjuries all occurred in patients with multivisceral wounds. The 8deaths which occurredwithin 72hours of wounding wereattributed to shock. There were 2fatalities in the 4multivisceralinjuries in which the great vessels were involved. One patient died 48hours after operation,from multiple pulmonary emboli, and the other on the seventh postoperative day,of generalized peritonitis. Theureteral repair
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did notbreak down in either instance. Thecause of death was not clear in one case.
In the three cases in which ureteral injuries wereoverlooked at operation, the error was assigned an important contributory role,though not the primary role, in the fatal outcome.
