Complete transection of the pelvi-ureteric junction in an adult

Abstract

A 41-year-old man was transferred by ambulance to the emergency department following a road traffic accident. The patient left his home to walk his dog when his wife heard a crash from inside the house and arrived outside to find him 2 m from the roadside and semi-conscious.On arrival at hospital, the patient was talking, had a GCS of 14 (E3, M6, V5) and was haemodynamically stable. On examination, he had severe generalised abdominal tenderness. Other injuries of note included open left tibial and fibula fractures and a left hip abrasion.The patient was stabilised and sent for a computed tomography (CT) scan of his head, neck, chest, abdomen, and pelvis. The CT showed a right renal haematoma with some extravasation of contrast at the level of the pelviureteric junction (Fig. 1). Bone views also showed a fracture through L3 transverse process on the right side (Fig. 2). Other injuries of note on CT scan were right superior and inferior pubic rami fractures and pulmonary contusions.Initially, he maintained good urine output with no haematuria and his renal function was normal. In accordance with local protocol, his open lower limb fractures were fixed on the day of injury. An ultrasound scan the following day, demonstrated no evidence of a perirenal collection/urinoma; therefore, a conservative approach for his urological injury as initially adopted. A follow-up CT scan was performed 2 days' post-injury due to worsening right-sided abdominal pain, tachycardia and hypertension. This showed a larger right pelvicalyceal system leak and likely urinoma (Fig. 3).Retrograde ureteric studies were performed on day 3 post-injury; however, attempts to pass the guide wire into Complete transection of the pelvi-ureteric junction in an adult DT WALKER, F MASSOUH, NJ BARBER Departments of General Surgery and Urology, Frimley Park Hospital, Frimley, UK ABSTRACTWe present a unique case report of a 41-year-old man involved in a hit-and-run accident. The patient suffered a complete disruption of the pelvi-ureteric junction along with a fracture of the L3 transverse process. Occasionally seen in children, we believe this to be the first reported adult case. The report details the presentation and symptoms, with subsequent radiology. This case also demonstrates how using an effective multidisciplinary team approach and the ATLS principles, uncommon injuries can be identified and managed successfully. We revisit the classification of ureteric trauma and the accepted best surgical management.

Case report of ureteric transection of lower moiety in high-speed road traffic collision

“…We hypothesise the fracture of the right L2 transverse process may indicate the area of maximum impact. This could be due to the rapid deceleration from the lap seatbelt acting as a fulcrum, which led to the ureteric injury [ 3 ]. This was classified as a Grade 4 ureteric injury as per the American Association for the Surgery of Trauma [ 1 ].…”

“…The diagnosis and prompt management of these injuries is paramount to reduce long-term complications and morbidity. To our knowledge there has only been one case report of a complete transection of the ureter at the pelvi-ureteric junction in an adult (41-year-old man) following blunt trauma in a road traffic collision, which was successfully repaired via laparotomy [ 3 ].…”