of drainage is necessary. Placement of a ureteral

right and typically in association with major

stent is rarely necessary, but if it is placed, a

abdominal and retroperitoneal injuries.27 Radio-

Foley catheter is necessary to ensure adequate

graphically, the hematoma is usually round or

decompression of the collecting system.

ovoid, with periadrenal stranding present in the

vast majority of patients. Adrenal injuries are

Reno-Vascular Injuries

thought to result from severe hyperextension

and compression against the spine and rarely

Injury to the renal pedicle or segmental renal

occur as a result of penetrating injury. Though

operative management has been reported, the

vessels typically occurs during rapid decelera-

majority of these patients can be managed con-

tion injuries and can result in avulsion, lacera-

servatively with respect to the adrenal injury.

tion,or occlusion from thrombosis or dissection.

Long-term sequelae, specifically adrenal insuffi-

Major injury to or avulsion of the renal pedicle

ciency, have not been reported.28,29

usually requires immediate exploration for

hemorrhage. Less acute injuries should be man-

Ureter

aged nonoperatively, as revascularization – even

when technically successful – is unlikely to result

in a functioning renal unit or prevent the devel-

Injuries to the ureter resulting from external

opment of hypertension.23 Our practice has

trauma are rare, representing less than 1% of all

been to treat the initial injury non-operatively,

genitourinary injuries from violent trauma.

with delayed nephrectomy if intractable hyper-

They typically result from gunshot wounds, with

tension develops. The exception is patients with

blunt trauma and stab wounds responsible for

bilateral renal artery occlusion or unilateral

less than 20% of ureteral injuries. Diagnosis of

occlusion in a solitary kidney, as up to 50% of

ureteral injury requires a high index of suspi-

these patients can avoid long-term dialysis if

cion, because except for entrance and exit

revascularization is performed.24

wounds there are usually no other physical signs

of injury. Hematuria (gross or microscopic) is

Pediatric Renal Injuries

unreliable, as it is absent in about 26% of cases.30

Furthermore, patients with ureteral injuries

Children have a high catecholamine output after

typically have multiple associated injuries, and

complications resulting from a missed ureteral

trauma and can sustain a normal blood pressure

injury could be fatal in this patient population.

until approximately half of the blood volume has

been lost. Therefore, shock is a poor indicator of

significant renal injury in children.Furthermore,

Diagnosis

gross hematuria is frequently absent.25 In an

effort to limit diagnostic workup in children

Retrograde pyelography is the gold standard for

without significant injuries, it has been sug-

diagnosing ureteral injury, but is often impracti-

gested that only children with hematuria (>50

cal in the trauma patient. CT with delayed

RBC/HPF following blunt trauma or >5 RBC/

images is an acceptable alternative, but clinical

HPF following penetrating trauma) or clinical

suspicion is paramount and if injury is sus-

signs of injury, such as abdominal, flank or pel-

pected, further diagnostic or therapeutic man-

vic pain, ecchymosis, or a history of rapid decel-

agement should occur.

eration injury undergo CT. When this protocol

When inspecting the ureter, it should be

was followed, grade II or greater injuries were

mobilized along its course and inspected for

detected with a sensitivity of 98% after blunt

continuity, hemorrhage, and contusion. Indigo

trauma and 95% after penetrating trauma.26

carmine or methylene blue can be given intrave-

nously (typically 5 cc), or 1–2 cc of dilute dye

Adrenal

can be directly injected into the renal pelvis to

assist with identification of an occult injury.

Significant adrenal injuries are rare. Adrenal

Ureteral injuries are graded according to a sys-

tem developed by American Association for

hematomas have been reported in approximately

the Surgery of Trauma Organ Injury Scaling

2% of patients undergoing CT for blunt abdomi-

Committee,31 which has been prospectively vali-

nal trauma. They occur more commonly on the

dated32 and correlates with complexity of repair,

502

Practical Urology: EssEntial PrinciPlEs and PracticE

number of associated injuries, and mortality.

must be emphasized that this has not been well

Grade I is a hematoma; grade II is a laceration

studied.

with <50% transection; grade III is a laceration

Injuries to the upper and middle two thirds of

with >50% transection; grade IV is a complete

the ureter can usually be primarily repaired

transection with 2 cm or less of devascularized

according to the principles outlined above. The

tissue; and grade V is an avulsion with more

ureter will usually need to be mobilized in order

than 2 cm of devascularization.

to acquire enough length; if necessary, the kidney

can be mobilized downward and fixed to the

Treatment

psoas tendon with 0 prolene. For lower ureteral

injuries, the ureter can usually be reimplanted

The ureter has a tenuous blood supply, and

directly into the bladder, with or without a psoas

treatment of ureteral injuries is generally

hitch. When possible, the anastomosis should be

focused on minimizing disruption of blood flow

nonrefluxing,which is accomplished by creating a

and avoiding complications related to anasta-

submucosal tunnel that is at least three times as

motic breakdown from ischemia. The ureter is

long as the ureter is wide.Psoas hitch is performed

perfused by an anastomotic network of arteries

by dividing the contralateral inferior pedicle and

within the adventitia that is supplied by the

tacking the bladder to the psoas muscle with non-

renal arteries in the upper ureter; by the aorta

absorbable suture. Psoas hitch following ureteral

and iliac arteries in the mid-ureter; and by the

injury has an excellent success rate and is rela-

superior vesical, vaginal, middle hemorrhoidal,

tively quick and easy to accomplish. An indwell-

and uterine arteries in the lower ureter. As a

ing stent should be placed following all attempts

result of this tenuous blood supply, even small

at ureteral repair and left in place for 8 weeks.

contusions or proximity gunshot wounds can

A number of other techniques have been

result in stricture or leak as a result of microvas-

described for bridging longer defects in the

cular damage and should be stented. We typi-

trauma patient, such as bowel interposition,

cally stent these patients for at least 8 weeks in

autotransplant, and Boari flap, but these are

order to allow adequate time for healing.

time-consuming and in these situations delayed

For more severe injuries, formal repair –

repair may be most appropriate. In certain situ-

either at the time of diagnosis or delayed – is

ations – such as severe hemorrhagic shock,

required. Principles of ureteral repair include:

uncontrolled intraoperative bleeding, or severe

careful mobilization; adequate debridement of

associated injuries – damage control is an

nonviable tissue to bleeding edges; spatulated,

acceptable alternative to definitive repair. If the

tension-free, water-tight anastomosis over a

repair is likely to occur within 24 h, no interven-

stent; use of fine, nonreactive suture; retroperi-

tion is necessary. If a delayed repair is planned,

toneal drainage; and omental interposition wrap

the ureter can be tied off with a long silk tie (to

when possible.

aid in dissection during the second-stage repair)

It is important to note that microvascular

and the kidney can be drained percutaneously,

damage following gunshot wound or thermal

though this is best performed postoperatively

injury can extend for up to 2 cm beyond evi-

because open nephrostomy placement can be

dence of gross injury.33 Historically, high-veloc-

too time-consuming in an unstable patient.

ity gunshot wounds have been thought to impart

greater tissue damage than low-velocity gun-

shot wounds, thereby requiring wider debride-

Delayed Diagnosis

ment.However,thisislikelyanoversimplification

and may result in debridement of unnecessary

Delayed diagnosis of ureteral injuries is com-

tissue in certain cases.34 Therefore, ureteral

mon. Signs and symptoms of a possible missed

injuries resulting from gunshot wounds or ther-

injury include prolonged ileus, high output from

mal injuries should be debrided to bleeding

drains, persistent flank or abdominal pain, uri-

edges, but not further. Examination of the ure-

nary obstruction, elevated creatinine or BUN,

ter with a Wood’s lamp after injection of intra-

and flank mass.36 When a delayed diagnosis is

venous fluorescein (5 cc, 10% solution) may

recognized, it is usually best managed by per-

help identify devascularized areas,35 though it

cutaneous nephrostomy and, when possible,