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Case Report

ilateral Partial Ureteropelvic Junctionisruption After Blunt Trauma Treated with

ndwelling Ureteral Stentsichael A. White, John P. Kepros, and Leonard J. Zuckerman

reteral injury secondary to blunt trauma is rare. Bilateral ureteropelvic disruptions have only been reported eightimes previously. A high index of suspicion must guide the appropriate evaluation, and the severity of the disruptionill determine the management options. We present the case of a 63-year-old man who had fallen from his roof and

ubsequently partially disrupted both ureteropelvic junctions and was treated conservatively with indwelling ureteraltents. To our knowledge, this is the first documented case of conservative management of bilateral ureteropelvic

unction disruption with indwelling ureteral stents. UROLOGY 69: 384.e15–384.e17, 2007. © 2007 Elsevier Inc.

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ilateral ureteropelvic junction (UPJ) disruption asa result of blunt trauma is rare, with only eightpreviously reported cases. Most cases are complete

vulsions and are associated with multiple organ injuries.reatment usually involves open reconstruction but in

elect cases can be managed with ureteral stenting alone.e report a case of bilateral partial UPJ disruption,

econdary to blunt trauma, that was treated with indwell-ng ureteral stents.

ASE REPORT63-year-old man fell 12 ft through the rafters of his

oof, landing on his left side, with a 4 � 4 block of woodetween him and the concrete floor. He had no neuro-ogic or orthopedic injuries and was able to drive himselfo an outside hospital. He was complaining of low backain and left flank pain, but on physical examination nobvious external signs of flank or back injury were found.o blood was at the urethral meatus, but at placement of

he Foley catheter, gross hematuria was evident.Computed tomography (CT) of the abdomen and pel-

is showed a disruption of the collecting systems of bothidneys and the renal pelvis, with extraluminal contrastn the retroperitoneum bilaterally, with the left greaterhan the right. Associated left-sided transverse processractures of L1 and L2 were also present. Renal vascularnjury was not evident. The patient was transferred to ourrauma center for additional evaluation and treatment.ne day after the injury, he underwent cystoscopy and

rom the Urologic Consortium, Michigan State University College of Osteopathicedicine, East Lansing; Metro Health Hospital, Grand Rapids; Department of Sur-

ery, Michigan State University College of Human Medicine, East Lansing; andansing Institute of Urology, Lansing, MichiganAddress for correspondence: Michael A. White, D.O., Urologic Consortium, Mich-

gan State University College of Osteopathic Medicine, 1919 Boston Southeast, Grand

rapids, MI 49506. E-mail: mikeawhite@sbcglobal.netSubmitted: February 10, 2006; accepted (with revisions): November 28, 2006

2007 Elsevier Inc.ll Rights Reserved

ilateral retrograde pyelography, which showed that thenjuries were both incomplete lacerations and not com-lete avulsions. Bilateral double-J ureteral stents werelaced, and a follow-up CT scan 2 days later showed onlyinimal extravasation of contrast from the urinary sys-

em, with complete resolution of the urinoma. No othernjuries were identified, and his renal function remainedormal throughout the course of treatment.The stents were removed 6 weeks after the injury, andfollow-up CT scan showed complete resolution of the

acerations. No stricture or other delayed complicationsere evident on follow-up.

OMMENTreteral injuries from external violence are not common

nd bilateral disruption of the UPJ have only been pre-iously reported eight times.1–7 Bilateral injury to theatient’s upper ureters could be seen on the initial CTcan and in conjunction with a delayed plain abdominallm (Figs. 1 and 2). On retrograde pyelograms, theseisruptions appeared partial, because contrast extravasa-ion was seen, yet all calices filled completely (Fig. 3).reteral injuries represent less than 1% of all genitouri-ary injuries from violent trauma. The rarity of ureteral

njury from external violence is at least in part becausehe ureters are relatively well protected in the retroperi-oneum.8

UPJ injury is often missed. A delay of 36 hours oronger occurs in more than 50% of patients. Most delaysccur secondary to hemodynamic instability and under-ying injuries, both of which are common with traumaevere enough to result in blunt ureteral injury.9

The etiology of ureteral injury, just as for renal injury,s divided into blunt and penetrating. Blunt traumand stab wounds rarely result in injury to the ureter,epresenting 4.1% and 5.2% of all ureteral trauma,

espectively, and vary in location. The etiology of

0090-4295/07/$32.00 384.e15doi:10.1016/j.urology.2006.11.022

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lunt ureteral injury includes two successive events.irst, stretching of the ureter occurs as a result of

igure 1. Bilateral extravasation of contrast seen adjacento collecting systems.

Figure 2. Extravasation of contrast bilaterally.

yperextension of the body.10 Second, sudden decel- w

84.e16

ration causes ureteral compression against a trans-erse process or the twelfth rib. Our patient had bothf these risk factors after he had fallen and had left-ided transverse process fractures.

The classic findings of ureteral injury include grossematuria, blunt abdominal trauma, fracture of a transverserocess of a lumbar vertebra, or deceleration injury.11 Sel-om are all these findings found; therefore, their absenceoes not rule out an injury. Gross hematuria has beeneported in 46% of patients and microscopic hematurianly in 38%. The reasons for the absence of hematuriaan include an adynamic partially transected ureter oromplete ureteral transection.

Retrograde pyelography is the reference standard foriagnostic imaging but is often time-consuming and im-ractical in an unstable patient. Therefore, if ureteralnjury is suspected, spiral CT should be performed andhould include delayed images during the excretoryhase.12 If the patient is unstable and taken for laparot-my, a “one-shot intravenous urogram” can be performed0 minutes after injection of intravenous contrast whilehe patient is on the operating table or trauma gurney tossess the upper urinary tracts and functioning renaloieties.13

The principle of ureteral repair should include debride-ent of nonviable tissue and a tension-free, spatulated

nastomosis with precise mucosal approximation andoverage of the repair with fat or omentum.14 Primarylosure without debridement can often be performed inartial transections resulting from stab wounds. Anotherption, which was used in the current case and has beensed for transections in unilateral injuries, is diversion

igure 3. Retrograde pyelogram demonstrating partial UPJisruption (right side not shown).

ith the use of internal ureteral stents.13,15 This method

UROLOGY 69 (2), 2007

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as used in our patient, and near complete resolution ofxtravasation was seen on the CT scan (Fig. 4).

This is the first documented case of conservative man-gement of bilateral partial UPJ disruption with indwell-ng ureteral stents. The previously documented cases ofilateral injuries all involved at least one complete tran-ection. In contrast, our patient had only partial transec-ions. This method of treatment was chosen because 24ours after admission the patient remained hemodynam-

cally stable, his urinary output was adequate, and theross hematuria had resolved. Therefore, we offer an

Figure 4. Resolution of extravasated contrast.

lternative approach to open exploration and primary

ROLOGY 69 (2), 2007

epair of bilateral UPJ partial transections. If the patients an appropriate candidate, the injury can be successfullyanaged with bilateral stent placement in a similar fash-

on as for unilateral UPJ disruptions.

eferences1. Yagi H, Igawa M, Shiina H, et al: Bilateral upper ureteric disrup-

tions caused by a traffic accident. Injury 30: 221–223, 1999.2. Smedley FH, Kerwin R, MacFarlane DA, et al: Bilateral

pelviureteric rupture following blunt injury. Injury 17: 59 – 60,1986.

3. Lowe P, and Hardy BR: Isolated bilateral blunt renal trauma withpelviureteric disruption. Urology 29: 420–422, 1982.

4. Drago JR, Wisinia LG, Palmer JM, et al: Bilateral ureteropelvicjunction avulsion after blunt abdominal trauma. Urology 28: 169–171, 1981.

5. Boston VE, and Smyth BT: Bilateral pelviureteric avulsion follow-ing closed trauma. Br J Urol 47: 149–151, 1975.

6. Johnson JM, Chernov MS, Cloud DT, et al: Bilateral ureteralavulsion. J Pediatr Surg 7: 723, 1972.

7. Ainsworth T, Weems WL, and Merrell WH Jr: Bilateral ureteralinjury due to nonpenetrating external trauma. J Urol 96: 439–442,1966.

8. Elliot SP, and McAninch JW: Ureteral injuries from externalviolence: the 25 year experience at San Francisco General Hospi-tal. J Urol 170: 1213–1216, 2003.

9. Boone TB, Gilling PJ, and Husmann DA: Ureteropelvic disruptionfollowing blunt abdominal trauma. J Urol 150: 33–36, 1993.

0. Reznichek RC, Brosman SA, and Rhodes DB: Ureteral avulsionfrom blunt trauma. J Urol 109: 812–816, 1973.

1. Kawashima A, Sandler CM, Corriere JN, et al: Ureteropelvicjunction injuries secondary to blunt abdominal trauma. Radiology205: 487–492, 1997.

2. Cass AS: Immediate radiological evaluation and early surgicalmanagement of genitourinary injuries from external trauma. J Urol122: 772–774, 1979.

3. Morey AF, McAninch JW, Tiller BK, et al: Single shot intraoper-ative excretory urography for the immediate evaluation of renaltrauma. J Urol 161: 1088–1092, 1999.

4. Carlton CE, Scott R, and Guthrie AG: The initial management ofureteral injuries: a report of 78 cases. J Urol 105: 335–340, 1971.

5. Steer WD, Carriere JN, Benson GS, et al: The use of indwellingureteral stents in managing ureteral injuries due to external vio-

lence. J Trauma 25: 1001–1003, 1985.

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