The late treatment of 63 overlooked or complicated ureteral missile injuries: the promise of nephrostomy and role of autotransplantation.

PURPOSE: Nephrostomy was emphasized as an initial treatment for ureteral fistulas, internal leakage (urinoma or urinary ascites) or ureteral obstruction due to a high velocity missile injury that was overlooked during the acute phase of management or manifested after primary surgery. Autotransplantation is introduced as an option for treatment of such late sequelae. We report a large series of complicated penetrating ureteral injuries of war.
MATERIALS AND METHODS: A series of 63 patients with war related ureteral injuries secondary to high velocity missile wounds presented with external fistulas, internal leakage or ureteral obstruction. No patient presented in the acute phase of injury, and they were referred from frontline hospitals or other departments at our hospital. The ureteral injury was missed during exploratory laparotomy in 47 patients (75%), while 16 (25%) had undergone a primary ureteral procedure elsewhere. A total of 59 patients (94%) had associated injuries elsewhere in the body. Nephrostomy was performed initially in 51 patients (81%) and various reconstructions were done in 39, including autotransplantation in 2.
RESULTS: Leakage, internal or external, ceased in all 46 patients who underwent nephrostomy, of whom 20 (44%) had a patent ureter after 3 to 8 weeks and no further reconstruction was needed. Patients were followed for 13 to 24 months (average 15), after which they had a normal excretory urogram or mild residual dilatation of the pelvicaliceal system with sterile urine. Two kidneys (3.2% of cases) were removed due to chronic sepsis. One patient (1.6%) died of septicemia related to the ureteral injury and 3 (5%) died of associated injuries although leakage had ceased. Both autotransplanted kidneys were normal.
CONCLUSIONS: When treating fistulas, urinomas, urinary ascites and obstruction due to a missed ureteral injury or a complication of the primary operation, the best results are achieved with initial nephrostomy followed by reconstruction when needed. Nephrostomy was a definitive treatment in 44% of our cases with leakage and it protected any required reconstruction. The option of autotransplantation for an otherwise unsalvagable kidney is emphasized.