GUNSHOT INJURIES OF THE URETER

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 laparotom y for vascular or visceral lesions is no longer exceptional. We report 5 cases of abdomen gunshot wounds with ureteric trauma treated betwee n 1987 and 1994 by three surgical teams. The data in the literature an d the principles of ballistic wounds are analysed Theses lesions are i nitially mis-diagnosed diagnosis in 10 to 20% of cases, as there are n o specific clinical signs, radiological opacification of urinary tract is rarely performed, and associated lesions are always predominant. T he severity and septic nature of associated lesions and the ballistic context of the trauma guide the treatment of GIU. When the ureteric le sion is short and associated lesions are limited, the continuity of th e urinary tract can be restored after debridement of the extremities b y end-to-end anastomosis for the upper 2/3 and direct vesica reimplant ation or into a psoas bladder for the lower 1/3. Drainage is ensured e ither by a bladder catheter or by a double J stent, for a minimal dura tion of 3 weeks. When there is a defect of the upper two-thirds of the ureter, mobilization of the kidney and its pedicle or transureteroure terostomy 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 t o prevent fistula formation due to necrosis. Nephrectomy should be avo ided in these patients with a mean age of 27 years.