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Chapter 25

Contents

CHAPTER XXV  

Wounds of the Ureter (27 Casualties) 

Walter L. Byers, M. D.  

There were only 27 wounds of the ureter (0.86 percent) in the 3,154 abdominal injuries in this series. Only 4 ureteral injuries are listed in the records of the American Expeditionary Forces in World War I.1 They constituted 0.1 percent of all abdominal and pelvic injuries. 

The single univisceral injury of the ureter treated by the 2d Auxiliary Surgical Group surgeons was caused by a shell fragment which produced a small laceration of the upper portion. In the 26 multivisceral wounds, the small intestine was involved 21 times and the large intestine 18 times. Injuries to these two structures represented more than half of the coincidental injuries. The bladder and liver were each involved 6 times; the kidney 5 times; the duo­denum, extraperitoneal rectum, and great vessels of the abdomen 4 times each; and the stomach and spleen twice each. The internal iliac vein was the largest vessel involved in the complicating vascular injuries.  

DIAGNOSIS  

The preoperative diagnosis of ureteral injuries was not easy, 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 also damaged. In no instance in the series was there a detectable amount of urine on the 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 or anuria. As a result, there was no telltale urinary leakage to lead to suspicion of a ureteral wound.  

Facilities for cystoscopy, intravenous urography, and ureteral catheterization, as noted in the previous chapter, were not available in field hospitals. Even if they had been, most of these casualties, because of the gravity of their injuries, would not have been suitable candidates for such diagnostic procedures. Accordingly, the usual diagnostic refinements of urologic surgery had to be dispensed with.  

As a result of these various circumstances, the diagnosis of ureteral injury was usually made only at operation, and even then was overlooked in 3 of the 27 cases.  

1The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1.  


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TREATMENT  

It was the accepted practice to expose the ureter fully whenever a missile had passed anywhere along its course. Exposure was often difficult because of the retroperitoneal hemorrhage common in such injuries. When leakage from a wounded colon was also present, technical difficulties were still greater. These difficulties explain the fact already mentioned; namely, that the ureteral wound was overlooked at operation in three cases. In one of the overlooked cases, drainage was instituted because of a wound in the retroperitoneal portion of the colon, but the ureteral injury was not found until autopsy.  

In the 24 cases in which ureteral damage was identified at operation, seven separate surgical techniques were employed, as follows: 

Transplantation of the ureter into the bladder was performed in six cases. This procedure could be utilized only in wounds of the distal ureter. In one instance, the suture line separated on the third postoperative day but was successfully repaired.  

Ureteroanastomosis was performed six times. Four of the operations were done by the telescoping technique, with one failure, as manifested by postoperative urinary drainage. The two patients treated by end-to-end anastomosis died within 48 hours of operation. Both fatalities were caused by shock and were not attributable to the ureteral injuries.  

Nephrectomy was performed five times, in each instance because of extensive renal damage. In no case was the injury to the proximal ureter of clinical significance in comparison to the wound of the kidney.  

Ligation of the ureter at both ends was carried out in three transecting wounds, with extensive loss of substance. In one of these cases, the kidney was also wounded.  

Ureteral lacerations were successfully sutured in two cases. One case was managed by drainage only. Cutaneous ureterostomy was done in one case; destruction of a considerable segment did not permit repair, and the condition of the patient did not warrant extension of the operating time to perform nephrostomy. The latter procedure was not employed in any of these ureteral injuries, though in retrospect it seems that it might have been useful in certain cases.  

The small number of ureteral injuries and the various procedures used in their management make the discussion of any special technique of no value.  

FACTORS OF MORTALITY  

The 11 deaths in these 27 ureteral injuries all occurred in patients with multivisceral wounds. The 8 deaths which occurred within 72 hours of wounding were attributed to shock. There were 2 fatalities in the 4 multivisceral injuries in which the great vessels were involved. One patient died 48 hours after operation, from multiple pulmonary emboli, and the other on the seventh postoperative day, of generalized peritonitis. The ureteral repair  


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did not break down in either instance. The cause of death was not clear in one case.  

In the three cases in which ureteral injuries were overlooked at operation, the error was assigned an important contributory role, though not the primary role, in the fatal outcome.

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