Alternative Procedures for Managing Ureteric Injuries
Alternative procedures, where the segment of damaged ureter is very long, include autotransplantation of the kidney into the pelvis and replacement of the ureter with ileum. Specialised surgical texts may be consulted for details on how to perform such procedures. Very occasionally ureteric injuries may be managed
5. TRAUMATIC UROLOGICAL EMERGENCIES 83
by a permanent cutaneous ureterostomy, where the patient's life expectancy is very limited.
When a ureter has been injured in a patient who has undergone a vascular graft procedure, e.g., an aortobifemoral graft, the traditional teaching advocated nephrectomy because of the potential for graft infection as a consequence of infection of urine which might leak from the site of a ureteric anastomosis. However, renal failure is a significant cause of death after aneurysm repair, particularly in the context of emergency (ruptured) aneurysm repair. Preservation of as much functioning renal tissue as possible, therefore, is clearly desirable in such patients, and this would tend to sway one away from nephrec-tomy. McAninch (2002) recommends repair of the ureteric injury, with nephrectomy being performed only in those cases where a urine leak develops postoperatively (as evidenced by continuing drainage of urine from the drain placed at the site of the ureteric anastomosis).
PELVIC FRACTURES AND INJURIES TO THE URINARY SYSTEM
Nowadays, pelvic fractures are usually due to run-over or crush injuries, where massive force is applied to the pelvis. Not supris-ingly, associated head, chest, intra-abdominal (spleen, liver, mesentery of bowel), pelvic (bladder, urethra, vagina, rectum), and genital injuries are common. These, along with massive blood loss from the pelvic fracture itself, account for the substantial (20%) mortality after pelvic fracture. Bleeding occurs from the fractured bone surfaces, tears in large pelvic veins and small pelvic arteries, as well as from chest and abdominal injuries. Injuries to large arteries are rare, but blood loss from small arterial and venous injury can be massive. A large pelvic haematoma is common and this may track up into the retroperitoneum.