title: Delayed diagnosis of traumatic ureteral injuries.
abstract: OBJECTIVE
  We review our experience with traumatic ureteral injuries missed at exploration. We also conduct meta-analysis to define factors contributing to missed injury, comparing outcomes of early vs late diagnosis.
  
  
  METHODS
  Our genitourinary trauma database was retrospectively reviewed from 1995 through 2004. A total of 40 ureteral injuries were identified including 5 with delayed diagnosis. Previously published series of ureteral trauma were then analyzed for injuries with delayed diagnosis, with data extracted and collated for meta-analysis.
  
  
  RESULTS
  A total of 40 patients with traumatic ureteral injuries was identified, all of whom underwent laparotomy. Five (12.5%) injuries were discovered at a mean of 6.0 +/- 3.0 days after laparotomy. The number of associated injuries for early and delayed diagnosis was 3.2 and 2.6 (p = 0.25), respectively. Mean hospital stay was 19.2 vs 36.6 days (p = 0.18) for those with immediate vs delayed diagnosis, respectively. Only 2 of 5 (40%) patients achieved satisfactory results during initial hospitalization. Literature review revealed 48 missed ureteral injuries, representing 11.1% of all patients with ureteral injuries who underwent laparotomy. Rates of nephrectomy for early and late diagnosis were 2.4% and 18.4% (p = 0.0001). Mortality related to traumatic injuries occurred in 6.1% with early diagnosis and 13.2% with missed injuries (p = 0.089).
  
  
  CONCLUSIONS
  Despite preoperative studies and intraoperative inspection, ureteral injury may remain undiagnosed until after laparotomy. We report intraoperative exploration to have a sensitivity of 88.9% across multiple series for traumatic ureteral injuries. Delayed diagnosis of ureteral injuries produces an association with prolonged hospital stay, and meta-analysis reveals a statistically significant increase in the rate of nephrectomy when ureteral injury is missed at exploration.
authors.affiliation: Departments of Urology and Surgery, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA. dakunkle@yahoo.com
authors.forename: David A
authors.initials: DA
authors.lastname: Kunkle
authors.forename: Bryan T
authors.initials: BT
authors.lastname: Kansas
authors.forename: Abhijit
authors.initials: A
authors.lastname: Pathak
authors.forename: Amy J
authors.initials: AJ
authors.lastname: Goldberg
authors.forename: Jack H
authors.initials: JH
authors.lastname: Mydlo
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D012189:Retrospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014513:Ureter / Q000000981:diagnostic imaging / Q000293:injuries*; D053584:Urinoma / Q000000981:diagnostic imaging / Q000209:etiology; D014948:Wounds, Gunshot / Q000150:complications