Pediatric emergency medicine trisk 3321 3321
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CLINICAL PEARLS AND PITFALLS
Ureteral injuries are often missed during the initial evaluation with less
than 50% of patients diagnosed within 24 hours of presentation. Avulsion
of the ureter should be suspected when the CT urogram (10-minute
delayed imaging after IV contrast administration) demonstrates
extravasation of contrast material and nonfilling of the affected ureter. CT
findings suggestive of renal pelvis or ureteral injury include medial
perirenal extravasation of contrast material, a circumrenal urinoma, and
the lack of opacification of the ureter distal to the injury. However, CT
scan has been shown to be poorly sensitive for ureteral injury, identifying
only 33% of cases in some series. In case in which suspicion for ureteral
injury is high, urologic consultation is necessary as retrograde pyelogram
is a more reliable examination and offers the potential opportunity for
therapeutic intervention.
Current Evidence
Blunt trauma usually involves the UPJ. Disruption of the ureter from the renal
pelvis results from stretching of the ureter by sudden hyperextension of the trunk.
Traditionally, this injury has been described more often in children.
Penetrating injuries may occur at any point along the length of the ureter and
are associated with injuries to other intra-abdominal organs in up to 90% of cases.
Stab wounds rarely cause ureteral injuries.
Ureteral injuries can occur iatrogenically during surgical procedures involving
the retroperitoneum as the ureters may be obscured by bleeding or fibrosis. While
these situations occur far less common in children than adults, a high suspicion
should be maintained in patients presenting with ongoing symptoms after
retroperitoneal surgery, most commonly gynecologic, colorectal, vascular, or
urologic procedures.
Clinical Considerations
Clinical Recognition
Trauma to the ureter should be suspected in patients presenting with fracture of
the transverse process of a lumbar vertebra. Pelvic fracture, hip fracture, lower rib
fracture, splenic laceration, liver laceration, and diaphragmatic rupture have also
been reported in association with ureteral injuries. Gunshot wounds with a bullet
course through the retroperitoneum should also prompt a high level of suspicion.
