Working Diagnosis:
Rupture of ureter at uretero-pelvic junction.

Treatment:
1. Stabilization and transport from field via EMS. Transported to Gettysburg Hospital >York Hospital > Johns Hopkins Urology (JHU)
2. JHU passed a nephroureteral stent Case Photo #4 through the affected area from the outside; no urostomy bag, instead change a dressing once a day and flush stent twice a day from external port; followed weekly at JHU.

Outcome:
10/21/14: fever and dysuria with 2+ LE, diagnosed with UTI but remote possibility of pyelonephritis and placed on ciprofloxacin; symptoms resolved by 10/27.
All stents/tubes removed early November, serial ultrasounds kidney/spleen OK, resumed soccer in spring! Followed with annual sono kidney/spleen. OK for contact sports.

Editor's Comments:
There aren't many case studies for review on ureteral injuries and they may up less than 1% of all urinary tract injuries. Neither CT nor IVP acutely has been found to be reliable in the detection of ureteral injuries. In a retrospective review of five patients with ureteral injuries secondary to blunt trauma, 80% of injuries were missed on initial CT and detected only on delayed CT 24 hours later[15]. One study suggests delaying spiral CT for five to eight minutes after contrast infusion to increase the sensitivity in detecting ureteropelvic junction disruption from blunt trauma[12].Another review of 12 ureteral injuries, the authors concluded that since ureteral injuries are infrequent and few surgeons have significant experience with their management, a high index of suspicion is required during celiotomy[17].

References:
Holevar, M et al. "Genitourinary Trauma, Diagnostic Evaluation of". Eastern Association for the Surgical of Trauma publication, 2003.

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