Mianné D, Brunet C, Andreu J M, Jourdan P, Alliot P
Service d'Urologie, Hôpital d'Instruction Laveran, MARSEILLE.
Ann Chir. 1996;50(2):146-58.
The increased incidence of gunshot injuries of the ureter (GIU) can be explained by increased of armed violence in some large cities and by the performance of intensive care teams, both in civilian practice and in a context of war. The discovery of a GIU, during salvage laparotomy for vascular or visceral lesions is no longer exceptional. We report 5 cases of abdomen gunshot wounds with ureteric trauma treated between 1987 and 1994 by three surgical teams. The data in the literature and the principles of ballistic wounds are analysed. Theses lesions are initially misdiagnosed diagnosis in 10 to 20% of cases, as there are no specific clinical signs, radiological opacification of urinary tract is rarely performed, and septic nature of associated lesions and the ballistic context of the trauma guide the treatment of GIU. When the ureteric lesion is short and associated lesions are limited, the continuity of the urinary tract can be restored after debridement of the extremities by end-to-end anastomosis for the upper 2/3 and direct vesical reimplantation or into a psoas bladder for the lower 1/3. Drainage is ensured either by a bladder catheter or by a double J stent, for a minimal duration of 3 weeks. When there is a defect of the upper two-thirds of the ureter, mobilization of the kidney and its pedicle or transureteroureterostomy may be required. Urinary diversion by nephrostomy or in situ ureterostomy is indicated when the haemodynamic state is unstable and the associated lesions are very septic or in the presence of multiple lesions. Extensive contusion of the ureteric wall must be intubated to prevent fistula formation due to necrosis. Nephrectomy should be avoided in these patients with a mean age of 27 years.
输尿管枪伤（GIU）发病率增加的原因可以归结为一些大城市武装暴力事件增多，以及重症监护团队在平民医疗实践和战争环境中的救治工作。在因血管或内脏损伤而进行的挽救性剖腹手术中发现输尿管枪伤已不再罕见。我们报告了1987年至1994年间由三个外科团队治疗的5例腹部枪伤合并输尿管创伤的病例。同时分析了文献数据和弹道伤的处理原则。这些损伤在最初10%至20%的病例中会被误诊，因为没有特异性临床体征，很少进行尿路造影，且相关损伤的感染性质和创伤的弹道背景主导了输尿管枪伤的治疗。当输尿管损伤较短且相关损伤有限时，对于上2/3段，经清创后可通过端端吻合恢复尿路连续性；对于下1/3段，则可直接行膀胱再植术或植入腰大肌膀胱。通过膀胱导管或双J支架确保引流，最短持续3周。当上2/3段输尿管存在缺损时，可能需要游离肾脏及其蒂部或行输尿管输尿管吻合术。当血流动力学状态不稳定、相关损伤严重感染或存在多处损伤时，应行肾造瘘或原位输尿管造口术进行尿流改道。输尿管壁广泛挫伤必须插管，以防止因坏死形成瘘管。对于这些平均年龄为27岁的患者，应避免行肾切除术。
