鈍性輸尿管損傷：暫時性尿路改道與機器人輔助重建

胡蔚祥、翁瑋駿、歐宴泉、許兆畬、童敏哲

童綜合醫院 外科部 泌尿科

Integrative Management of Blunt Ureteral Trauma: Temporary Diversion and Robotic Reconstruction

Wei-Shiang Hu, Wei-Chun Weng, Yen-Chuan Ou, Jow-Yu Shu, Min-Che Tung

Division of Urology, Department of Surgery,

Tungs' Taichung Metroharbor Hospital, Taichung, Taiwan

Abstract

We present a case of a 23-year-old male trauma patient with an incidental finding of blunt ureteral injury post-stabilization from other traumatic injuries. This case highlights the importance of multidisciplinary management involving urology, the utility of temporary urinary diversion, and the successful delayed reconstruction of the ureter.

Case Presentation

A 23-year-old previously healthy male was admitted following a motorcycle accident. Initial assessment revealed multiple abrasions, and imaging identified a right hemothorax, liver injury, and pelvic fracture. A chest tube was placed emergently for hemothorax management. During his intensive care unit stay, the patient developed a massive hemothorax, necessitating ongoing drainage and blood transfusions to manage suspected hypovolemic shock. Emergency thoracoscopy and laparoscopy disclosed multiple internal injuries, including diaphragmatic rupture, hepatic laceration, and serosal tear of the ascending colon. Postoperatively, the patient was managed in the ICU until stabilization, after which he was extubated and transferred to the general ward.

One week into his postoperative recovery, a CT scan, conducted for persistent right chest tube drainage, inadvertently revealed a retroperitoneal fluid collection, leading to a percutaneous drainage procedure. The retrograde pyelography indicated an upper ureteral injury, demonstrated by contrast extravasation from the renal pelvis and upper ureter. Attempts to pass a guidewire through the transection site failed, confirming the injury.

A multidisciplinary approach was adopted, and after discussing with the urology team, a decision was made to insert a right percutaneous nephrostomy for urinary diversion, facilitating renal drainage and allowing time for the patient's recovery before definitive surgical repair.

The patient was discharged in a stable condition with a plan for close outpatient monitoring and scheduled revisions of percutaneous nephrostomy drainage. Approximately three months post-discharge, a definitive surgical repair was undertaken utilizing robot-assisted ureterolysis and ureteroureterostomy, which was facilitated by the use of intraoperative indocyanine green (ICG) fluorescence to enhance the visualization of the injury site. Concurrently, a double J stent was placed to ensure ureteral patency. The postoperative period was unremarkable, and the patient was subsequently discharged after seven days with all vital parameters remaining within normal ranges.

Discussion

The rarity of ureteral injuries in trauma, particularly from blunt mechanisms, presents a diagnostic challenge due to the lack of specific symptoms and the subtlety of imaging findings. With less than 1% of blunt trauma cases involving ureteral injuries, there's a need for a high index of suspicion, especially in the absence of reliable signs such as hematuria, which is present in less than half of those with ureteral injury. Diagnosis is further complicated by the limitations of imaging modalities; while ultrasound is commonly used in trauma assessments, it often proves inadequate for ureteral injury evaluation due to the ureters' small size and retroperitoneal position.

Computed tomography (CT) and intra-operative single-shot intravenous pyelogram (IVP) are considered the most useful tools per European Association of Urology guidelines, though their reliability has been contested. A comprehensive IVP remains a reliable method for stable patients, but is typically impractical for those in critical condition. Retrograde pyelography, although highly accurate, is not suitable for hemodynamically unstable patients. For stable patients, delayed excretory phase CT imaging is beneficial in revealing both the ureteral injury and associated lesions.

Treatment follows the American Association for the Surgery of Trauma (AAST) injury scale, with conservative management including stenting for lower grades, while higher grade injuries necessitate surgical intervention, tailored to the injury location, with various techniques ranging from ureteroureterostomy to reconstruction for lower ureteral damage.