Pathology

Abstract

Editorial CommentKunkle et al. report on their experience with missed ureteral injuries at a busy inner city trauma center. This is a well written and comprehensive paper on delayed diagnosis. Tables 3 and 4 are nice metanalyses demonstrating that roughly 11% of ureteral injuries are missed at laparotomy, resulting in an overall nephrectomy rate of 18% and death at 13%. Even in the busiest of trauma centers, external ureteral injuries are rare, typically with fewer then 10 injuries seen per year. In the literature, there are only a few series with a sizable experience, and they are all retrospective, cover long study periods (10-40 years), and are mostly treated by heterogeneous groups of physicians. Most external ureteral injuries occur from gunshot wounds. Missile path even in proximity to the ureter can cause significant delayed tissue destruction. Such injuries can be difficult to identify initially and often present in a delayed fashion. Penetrating ureteral injuries are almost always associated with multiple intra-abdominal organ injuries (such as, small bowel, colon, liver and iliac vessels. Associated injuries are often more obvious and overshadow the ureteral injury. Ureteral injuries from blunt trauma are equally rare. They usually occur in children during rapid deceleration, causing excessive hyperextension and disruption at the ureteropelvic junction. Such patients are usually poly-traumatized and have associated multiple organ injuries (mostly liver, spleen and skeletal system).In the acute trauma setting, therefore, the diagnosis of ureteral injury can be difficult. When the ureteral injury is missed and not diagnosed till late or the primary repair fails, the complication rate increases considerably, including renal loss and even death.