A Rare Case Report of the Use of Allium Stent in Management of a Gunshot Injury with Incomplete Tear of the Proximal Part of the Right Ureter

Abstract

Background: Injuries to the ureter resulting from external trauma are uncommon. This type of injury is associated with a high mortality rate because of the involvement of concomitant multiorgan damage. Wound management depends primarily on the location and severity of the injury. In this study we present an example of Allium™ stent usage in a management of a rare type of injury with positive results.

Case Presentation: The case involves a Caucasian man, 46 years of age, the victim of multiple gunshot injury. One bullet struck the abdomen and caused a multiple organ injury. The first surgery revealed a perforation of the duodenum and two perforations of the small bowel. On the second surgery, urea and creatinine were found in the excretion of abdominal drains. A CT scan identified an incomplete tear of the proximal part of the right ureter. The lesion was temporarily managed by insertion of a percutaneous nephrostomy. We decided to use an Allium stent for definitive delayed repair, because it should be ideal for long-term ureteral stenting and easy to remove.

Conclusion: Because of the serious injuries and associated complications the patient had undergone three laparotomies and other surgical procedures. With the use of minimally invasive procedures we succeeded to repair the tear of the ureter. We demonstrate that the use of Allium stent is appropriate and safe in the management of ureteral injuries that result from penetrating trauma. The case also underlines the importance of careful examination for potential ureteral injuries after perforating external trauma.

Introduction and Background

In the majority of abdominal injuries, ureters are unlikely to suffer damage, as they are positioned retroperitoneally and are protected by muscles, the bony pelvis, and vertebrae. Most injuries arise from iatrogenic trauma (∼80%) and occur during surgical procedures.¹ Of the remaining causes, more injuries result from penetrating (<4% of all cases of penetrating trauma), and then from blunt trauma (<1% of all cases of blunt trauma).² In gunshot wounds the ureters are injured in 2%–3% of all cases.¹ Intraoperatively these injuries are often missed (11% miss rate), which accounts for significant complications (urinoma, abscess, fistula formation, ureteral strictures, or even nephrectomy).¹ In unstable trauma patients the ligation of the injured ureter is preferred, with urine diversion by a percutaneous nephrostomy (PNS) and a delayed definitive repair.³ Partial ureteral injuries can be managed with stenting or urine diversion by a nephrostomy. Allium™ ureteral stents are self-expanding large caliber stents for temporary use. The main indications are malignant or benign ureteral stenosis. They feature a polymeric coating that prevents tissue in-growth, encrustation, and calcification of the stent.

Presentation of Case

In October 2017, a Caucasian man, 46 years of age, was admitted to a regional hospital in Slovenia. Examination identified three gunshot entry wounds: one in the abdomen, one in the region of the left scapula, and one on the right knee, which were caused by handgun shots. The CT scan identified two bullets (one under the left acromion and one in the right lumbar region) in the height of L3, some blood and free air (intra- and retroperitoneal), and a suspected perforation of the duodenum. An exploratory laparotomy followed, which revealed a perforation of the duodenum and two perforations of the small bowel. On the first postoperative day, an unidentified fluid was observed to drain from the abdominal drains. On application of methylene blue through the nasogastric tube, the tracer also appeared in the abdominal drains. On the same day he was urgently transferred to the University Medical Centre in Ljubljana and reoperated. The relaparotomy revealed another injury of the duodenum and also an injury to the head of the pancreas.

On the fifth post-trauma day a drainage of unidentified fluid was identified from abdominal drains. Laboratory analysis suggested the fluid was positive for urea and creatinin. A CT scan showed that the right ureter ended 2 cm after the pelviureteric (PU) junction and was not traceable distally. There was also extravasation of the contrast in the retroperitoneal space. A urologist examined the patient and ordered an installation of a PNS in the right kidney.

On the eighth post-trauma day a cystoscopy was performed and a ureteral catheter was placed through the right ureter. An intravenous urography (IVU) showed extravasation of the contrast 3.5 cm after the right PU junction (Fig. 1). The ureteral catheter was, therefore, removed and replaced with a Double-J stent.

FIG. 1.

IVU showing extravasation of the contrast at the site of the ureter injury. IVU, intravenous urography.

On the 15th post-trauma day another CT scan was showing a small extravasation of the contrast on the site of the ureteral injury. There was also a 6 × 1.7 × 4.5 cm fluid collection mixed with free intraperitoneal air between the duodenum and the liver and extravasation of the contrast from the duodenum. The patient was again reoperated with a laparotomy. No evident site of bowel perforation was discovered.

On the 33th post-trauma day the lesion of the right ureter was endoscopically repaired. With a cystoscope the Double-J stent was partially pulled out through the penile meatus and a guiding wire was retrogradely inserted through it, but could not pass through the lesion. Therefore, it was inserted through the PNS, where it smoothly held down to the bladder. An Allium ureteral stent was placed on the guiding wire and inserted through the penile meatus retrogradely. Under the control of an X-ray intensifier it was then positioned correctly and activated. The PNS was then repositioned and a nephrostogram was recorded, where no extravasation of contrast was seen; also the ureter had an appropriate width of the lumen (Fig. 2).

FIG. 2.

Intraoperative nephrostogram showing the correct position of the Allium™ stent.

After 132 days with the stent inserted, he was admitted for its removal.

A rigid ureterorenoscope was introduced and advanced further to the proximal part of the right ureter, where the Allium stent was placed. It was seen that the stent was covered with some dirt particles. In an attempt to remove it with a rigid grasping forceps, traction was applied to the distal end of the stent, when it started to tear apart. The extraction was difficult and the stent was finally removed in two pieces. A retrograde pyelography showed no extravasation of contrast. The patient was discharged from the hospital after 2 days.

After 183 days post-trauma the patient was feeling well. An IVU and a plain abdominal X-ray were performed, where no calcinations in the urotract were seen, the renal pelvis was bilateral of normal size and was not dilated, the flow of the contrast was evenly distributed and arrived both sides timely to the bladder, the ureters were thin, and there was no extravasation (Fig. 3).

FIG. 3.

IVU after the removal of the Allium stent where no extravasation or dilation of the right ureter is seen.

Discussion and Literature Review

Sekhon and Suryavanshi used an interesting endourologic approach for the management of a similar type of injury to the proximal ureter also resulting from a gunshot, called the rendezvous technique. They used a ureteropelvic drainage catheter to bypass the lesion.⁴

In our case we retrogradely inserted a segmental self-expanding large caliber stent, which is made from a single Nitinol wire and embedded with a polymeric cover that prevents tissue ingrowth. This allowed us to effectively seal the ureteral wall, prevented extravasation and ultimately helped to restore the integrity of the ureter by tissue coaptation, without developing a stricture on the site of the injury.

Bahouth et al. performed a multicenter experience study with Allium stent for the treatment of ureteral stricture and fistula. The Allium stent was inserted into 107 ureters of 92 patients in 5 different centers worldwide. The results showed that the use of Allium stent for the treatment of ureteral strictures is feasible, safe, and effective. They concluded that the relative ease of its insertion could encourage its use in a wide range of other indications.⁵

So far this is our first experience with the use of the Allium stent for ureteral injuries resulting from external trauma. When reviewing the literature, we did not find any publications that described the use of the Allium stent in these instances. In our opinion this is a unique indication for the use of this stent, but further studies on more patients should be conducted for proper evaluation.

Conclusion

We demonstrated that the use of Allium stent for repair of incomplete proximal ureteral injuries is a safe and effective method in the hands of experienced surgeons and could represent a new indication for the use of it. A high index of suspicion should be maintained with the aim to identify potential lesions as soon as possible, so as to keep the complication rate low and begin with the treatment immediately.

Abbreviations Used

CT

computed tomography

IVU

intravenous urography

PNS

percutaneous nephrostomy

PU

pelviureteric

Disclosure Statement

No competing financial interests exist.

Cite this article as: Ditz I, Bizjak J (2019) A rare case report of the use of Allium stent in management of a gunshot injury with incomplete tear of the proximal part of the right ureter, Journal of Endourology Case Reports 5:4, 154–156, DOI: 10.1089/cren.2019.0044.