Missed ureteral injury in stab injury: BMJ case report
An 18-year-old man was referred from the department of emergency surgery for management of his ureteric injury. The patient underwent exploratory laparotomy for bowel injury that he had sustained due to a stab wound to his left flank 1 month ago. At that time his ureteric injury was missed. Two weeks after being discharged he developed fever and his ultrasonogram was suggestive of a large left retroperitoneal collection with mild left hydronephrosis.

A contrast-enhanced CT (CECT) scan was done that demonstrated leak of contrast from left ureter into the collection (figure 1A). The patient then underwent insertion of a percutaneous nephrostomy tube into the left kidney along with placement of a drain into the retroperitoneal collection. The drain placed into the collection had purulent output suggesting an infected urinoma.

Two weeks later another CECT scan was done, which showed persistent retroperitoneal urinoma, and ureter distal to the injury was not visualised (figures 1B and 2A). We did a combined antegrade and retrograde pyelography that demonstrated complete transection of the left ureter (figure 2B).

The drain placed into the collection was blocked so we flushed and slightly manipulated it following which it drained the residual purulent collection. Three months after his initial injury the patient was posted for definitive surgery, and a ureteroureterostomy could be easily performed over a 6F JJ-stent. The JJ-stent was removed after 8 weeks. Four months postsurgery the patient is doing fine.

Learning points
• Ureteral injuries are less common than other urological injuries because the ureters are anatomically well protected by the vertebrae, psoas muscle and bony pelvis.

• A high index of suspicion is required to diagnose ureteral injuries because there are no specific signs and symptoms.

• The imaging modalities useful in diagnosis include ultrasound, contrast-enhanced CT, intraoperative single shot intra venous pyelography and retrograde pyelography, and the management of ureteral injuries depends on the anatomical location in the ureter.

Source: http://casereports.bmj.com/content/2018/bcr-2018-226261.full