Renal Autotransplantation in Management of Bilateral Ureteral Mortar Shell Injuries: A Case Report

Military Medicine, Nov 2004 by Kastelan, Zeljko, Derezic, Daniel, Pasini, Josip, Sosic, Hrvoje

We present a 36-year-old female patient who was injured in the pelvic region by a mortar shell fragment. The trauma comprised a complex lesion to both ureters, to the urinary bladder, and to the pelvic brim. The ruptured urinary bladder was sutured and a bilateral ureterocutaneostomy was performed in a hospital near the front line. Because of a large scar and the right ureter necrosis, a kidney autotransplant was performed 3 months later. A left ureterocystoneostomy was done. Five years later, because of urosepsis and hydronephrosis caused by a ureteral calculus, a nephrostomy was placed in the proximal right ureter, antibiotic treatment was prescribed, and the calculus was managed by crushing the stones using extracorporeal shock wave lithotripsy. Ten years after the initial trauma, the patient is well, has normal micturition, and both of her kidneys are functioning normally.

Introduction

War injuries to the ureters occur rarely and are usually accompanied by injuries to neighboring structures. Most often, the ureteric injury is a result of a gunshot wound or penetrating fragments from explosive devices to the abdomen or pelvis, representing 2.2 to 4.2% of genitourinary war injuries.1'3 The presented patient with ureteric and bladder injuries demonstrates urgent diversion of the urine (bilateral cutaneous ureteroneostomy) performed near the front line. Reconstructive surgery including renal autotransplantation on one side and the urctcroncocystostomy on the other side was performed later.

Case Report

A 36-year-old woman sustained an injury to the pelvic region from a mortar shell fragment in October 1991. Pelvis radiography displayed a fracture of the right ramus of the pubis and the ischium on the right side without any significant dislocation. She also sustained the rupture of the urinary bladder and both pelvic ureters as well as a pelvic hematoma along with the leakage of urine. At the initial exploratory surgery at a hospital near the front line, the penetrating fragment (a single mortar shell) was removed, rupture of the urinary bladder was sutured, and a bilateral cutaneous ureteroneostomy was performed.

Three months later, the patient was hospitalized at the University Hospital Centre Zagreb, Rebro, for further treatment. Because of a ureteric stricture and the resulting ureterohydronephrosis, both cutaneous ureters were intubated for decompression and drainage. Retrograde ureteropyelography showed the intact distal stumps of both ureters (Fig. 1). Urodynamic analysis confirmed a reduced but still adequate functional caparity of the urinary bladder (250 mL). The patient remained continent, and micturition was normal. Angiography disclosed that each kidney was supplied by one artery. Pelvic blood vessels were normal.

At reoperative surgery, a large segment of the right pelvic ureter was seen to be scarred and necrotic. Au to transplantation of the right kidney was performed using an end-to-end anastomosis of the right renal artery to the right internal iliac artery and an end-to-side anastomosis of the renal vein to the external iliac vein. A ureteroneocystostomy was performed.

The postoperative course was uneventful. Six weeks later, left ureteric repair with the placement of the internal ureteric stenting tube (double "J" or "pigtail" stent) reaching from the kidney into the bladder was performed, and this stent was removed 6 weeks later. Subsequent intravenous urography of both kidneys demonstrated normal function (Fig. 2). Serum creatinine and blood urea nitrogen values were normal.

Five years after the initial trauma, the patient was hospitalized with a severe urinary tract infection and pain in the area of the autotransplanted right kidney. Evaluation disclosed right hydronephrosis and a stone in the proximal right ureter. A percutaneous nephrostomy was done and antibiotic treatment was initiated. The stone was successfully managed by means of extracorporeal crushing using shock waves. Ten years after the initial injury, the patient is well, has normal micturition, and renal function remains normal.

Discussion

Ureteral trauma is an important diagnostic problem, as it may be covered by coexisting injuries to surrounding organs and the pelvic wall. The ruptured ureter is likely to cause urine leakage, threatening the patient's life if surgically untreated. Radiological contrast medium leakage during excretoiy urography indicating ureteric injury may be difficult to discover on the X-ray.

The rupture of the ureter is usually associated with abdominal injuries,4"6 and they may remain unrecognized if preoperative intravenous urography is not done. Oddly enough, no abdominal organ injury was present in our patient. Frequently, the first sign of ureteral injury is urine leakage through the wound. Endoscopie intubation of the ureter from the kidney to the bladder using a stent or nephrostomy is not safe, because stenting may lead to scarring, strictures, or fistulas. If the distal ureter is injured, a ureteroneocystostomy could be performed by cutting the ureter above the site of the injury and implanting it into the bladder. If the ureter is too short, the bladder wall can be "pulled up" toward the junction with the ureter and fixed to the psoas muscle ("psoas-hitch"). In smaller defects to the ureteral wall, a resection of devitalized tissue and end-to-end anastomosis can be considered.