al-Ali M, Haddad L F
Department of Urology, Al-Rasheed Military Hospital, Baghdad, Iraq.
J Urol. 1996 Dec;156(6):1918-21.
Nephrostomy was emphasized as an initial treatment for ureteral fistulas, internal leakage (urinoma or urinary ascites) or ureteral obstruction due to a high velocity missile injury that was overlooked during the acute phase of management or manifested after primary surgery. Autotransplantation is introduced as an option for treatment of such late sequelae. We report a large series of complicated penetrating ureteral injuries of war.
A series of 63 patients with war related ureteral injuries secondary to high velocity missile wounds presented with external fistulas, internal leakage or ureteral obstruction. No patient presented in the acute phase of injury, and they were referred from frontline hospitals or other departments at our hospital. The ureteral injury was missed during exploratory laparotomy in 47 patients (75%), while 16 (25%) had undergone a primary ureteral procedure elsewhere. A total of 59 patients (94%) had associated injuries elsewhere in the body. Nephrostomy was performed initially in 51 patients (81%) and various reconstructions were done in 39, including autotransplantation in 2.
Leakage, internal or external, ceased in all 46 patients who underwent nephrostomy, of whom 20 (44%) had a patent ureter after 3 to 8 weeks and no further reconstruction was needed. Patients were followed for 13 to 24 months (average 15), after which they had a normal excretory urogram or mild residual dilatation of the pelvicaliceal system with sterile urine. Two kidneys (3.2% of cases) were removed due to chronic sepsis. One patient (1.6%) died of septicemia related to the ureteral injury and 3 (5%) died of associated injuries although leakage had ceased. Both autotransplanted kidneys were normal.
When treating fistulas, urinomas, urinary ascites and obstruction due to a missed ureteral injury or a complication of the primary operation, the best results are achieved with initial nephrostomy followed by reconstruction when needed. Nephrostomy was a definitive treatment in 44% of our cases with leakage and it protected any required reconstruction. The option of autotransplantation for an otherwise unsalvagable kidney is emphasized.
肾造瘘术被强调为输尿管瘘、内漏（尿瘤或尿腹水）或因高速导弹伤导致的输尿管梗阻的初始治疗方法，这些损伤在急性期处理时被忽视或在初次手术后出现。自体肾移植被作为治疗此类晚期后遗症的一种选择引入。我们报告了一系列战争中复杂的穿透性输尿管损伤病例。
一系列63例因高速导弹伤继发输尿管损伤的战争相关患者，表现为外瘘、内漏或输尿管梗阻。无患者在损伤急性期就诊，他们是从一线医院或我院其他科室转诊而来。47例患者（75%）在剖腹探查术中漏诊输尿管损伤，而16例（25%）在其他地方接受了初次输尿管手术。共有59例患者（94%）身体其他部位有合并伤。51例患者（81%）最初进行了肾造瘘术，39例进行了各种重建手术，其中2例进行了自体肾移植。
所有46例接受肾造瘘术的患者的内漏或外漏均停止，其中20例（44%）在3至8周后输尿管通畅，无需进一步重建。患者随访13至24个月（平均15个月），之后排泄性尿路造影正常或肾盂肾盏系统有轻度残余扩张且尿液无菌。2例肾脏（3.2%的病例）因慢性脓毒症被切除。1例患者（1.6%）死于与输尿管损伤相关的败血症，3例（5%）死于合并伤，尽管漏已停止。2例自体移植肾均正常。
在治疗因输尿管损伤漏诊或初次手术并发症导致的瘘、尿瘤、尿腹水和梗阻时，最初进行肾造瘘术，必要时再进行重建，可取得最佳效果。在我们44%的漏诊病例中，肾造瘘术是一种确定性治疗方法，它为任何必要的重建提供了保障。强调了对于其他无法挽救的肾脏进行自体肾移植的选择。
