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Introduction (1) Acute ureteral injury : external trauma, open surgery, laparoscopy, procedures (2) Uncommon : intraoperative energy) (3) external or suture ligation, energies sharp incision and or transection, vibratory and endoscopic

avulsion, devascularization, and heat (e.g., microwave, electrocautery, freezing (cryoablation)


from high-speed blunt mechanisms and penetrating stab and

gunshot wounds (4) An unrecognized or mismanaged ureteral injury : significant complications (including urinoma, abscess, ureteral stricture, urinary fistula, and potential loss of an ipsilateral renal unit) - Increased nephrectomy rates and a prolonged hospital stay are associated with a delayed or 2006). External Trauma (1) Ureteral injuries : < 1% of all genitourinary trauma Table 42-2 American association for the surgery of trauma organ injury severity scale for the ureter Grade I II III IV V Type Hematoma Laceration Laceration Laceration Laceration (2) Damage to Description Contusion or hematoma without devascularization <50% transection ≥50% transection Complete transection with <2cm devascularization Avulsion with >2cm devascularization the ureter after external violence : quite rare (<4% of all penetrating missed diagnosis from penetrating ureteral trauma (Kunkle et al,

and <1% of all cases of blunt trauma) (3) During wartime : 3% to 15% of urologic injuries – ureteral involvement (average of 5%) (4) Nonmilitary setting : 2% to 3% of ureteral injuries

an intraoperative shot‖ pyelogram (2 mL/kg intravenous flat plate abdomen radiograph) ―onecontrast material given 10 minutes before . more commonly. (10) Due to this ―blast third of these patients with UPJ injury have no evidence of hematuria (17) The rare entity of UPJ disruption consequent to blunt trauma is often missed because the patients do not always exhibit hematuria. and the injury is difficult to palpate during intraoperative manual examination -> recommend abdominal CT with contrast and delayed images whenever possible or if time does not permit.associated with such uncommon injuries as fractured lumbar processes and thoracolumbar spinal deceleration : found in 100% of patients with ureteropelvic junction (UPJ) injury in one small series .(5) Well-protected ureter (Located in the retroperitoneum between the spinal vertebra major muscle (6) Great violence groups) : an unlikely target must be inflicted for injury and for ureteral damage to occur (one third – significant concomitant injuries & devastating degree of mortality) (7) Associated visceral injury(common) : small (39% to 65%) and large (28% to 33%) bowel perforation (8) 10% to 28% of patients with ureteral injuries -> renal injuries. or significant associated (16) A history of rapid injuries from a height or a high-speed motor-vehicle accident) .‖ the full extent of ureteral loss : sometimes underestimated on initial exploration (11) Blunt trauma patients with ureteral injuries : subject to extreme force applied over the entire body (a fall dislocation (12) Rapid deceleration injuries : disrupt the ureter at fixed points along its course. namely the ureterovesical and. 5% -> bladder injuries (9) mechanism : direct transection but by disruption of the delicate intramural blood supply and subsequent necrosis. the ureteropelvic junction (13) Presence of massive force injuries in the blunt trauma patient : should always increase the level of suspicion for ureteral injury (14) Any degree of hematuria : possibility of genitourinary injury (15) Blunt trauma patients with gross hematuria or microhematuria plus hypotension : a history of significant deceleration.

risk factors for surgical that injury of the ureter : reoperation.7%) (6) Open urologic procedures : a significant number (21%) of reported ureteral injuries in one series (7) Intraoperative ureteral manipulation resulting in subsequent hydronephrosis : common after aortoiliac and aortofemoral bypass surgery (12% to 20%) (8) Surgical devascularization or inflammation : symptomatic ureteral stenosis. placement of a vascular graft anterior to the ureter and large can (10) The fever. and pregnancy (12) Currently. transabdominal urethropexy (8%).5% ~ 10% colorectal surgery (14%).3% to 5. and after abdominoperineal colon resection (0. infection. : 0. surgical. and abdominal vascular (4) Repeat C-section : a large number of ureteral injuries. (11) Ureteroarterial fistulas : should be diagnosed threatening hematuria. general (3) hysterectomy surgery (6%) ovarian tumor removal (8%). or (2) The overall urologic) incidence (54%).5%. dilated retroperitoneal inflammation involve the majority ileus. the reported rate of ureteral injury : 0. in this case up to 23% of the reported ureteral injuries at one hospital (5) The total incidence of ureteral injury after gynecologic surgery : between 0. and urinary intra-abdominal aneurysms that vascular cause surgery. radiation therapy. primary vascular disease.5% and 1. indwelling ureteral stents. other pelvic procedures like obstetric. Fistula (mostly between the ureter and ipsilateral iliac artery) previous pelvic surgery. often delayed in presentation by months (1-2%) (9) In patients undergoing arterial ureter. (up not recognized immediately .(18) UPJ disruption : associated with an unusual pattern of either medial contrast extravasation or a ―circumrenal‖ contrast extravasation Surgical Injury (1) Any difficult abdomino-pelvic surgical procedure(gynecologic.symptoms of ureteral abdominal distention.5% (experienced surgeons) . to 85%) of surgical injuries to the ureter after vascular procedures : injury (flank fistula) and treated immediately due to lifepain (36% to 90%).

and special care must be taken in this area. making ureteral visualization difficult . and leukocytosis. (17) Postoperatively. if those structures are going to be ligated. partially transected ureter or a complete ureteral transection . which herald the potential for missed ureteral injury. peritonitis. prior from their normal anatomic surgery. where at least one are recognized after for immediately.and 14% (inexperienced surgeons) after laparoscopic hysterectomy (13) A large percentage of ureteral injuries after gynecologic laparoscopy occur during electrosurgical or laser-assisted lysis of endometriosis .In 1999 a series of 118 patients reported a 3.the disease can deviate the ureters medially away position (14) A significant number of ureteral injuries also occur during tubal ligation . especially its relation to the uterine and ovarian arteries.a recent combined six larger series with a much greater number of patients and presumably more experienced surgeons demonstrated a more reasonable 1% rate (15) injury to the urinary tract during hysterectomy : malignancy.Absence of hematuria in ureteral injury may result from an adynamic. ureteral injury is required.4% incidence of ureteral injury after laparoscopic hysterectomy severe enough to cause obstruction . (18) Avoidance of ureteral injury is predicated on intimate knowledge of its location. . patients must be monitored for fever. endometriosis. and surgery for prolapse (16) In contradistinction to open operation.long-standing endometriosis can cause intraperitoneal adhesion.endometrioma can involve the ureter either extrinsically or intrinsically . fewer injuries to identified suspicion laparoscopy. Therefore during third of ureteral are high a injuries of the ureter immediately index laparoscopy. .Hematuria is a nonspecific indicator of urologic injury. as in a hysterectomy (19) Visualization of the ureter in the area of the ureterosacral ligaments is thought to be especially difficult. Diagnosis <Gunshot and Stab Wounds> (1) Incidence of Hematuria.

. .Liberal use of preoperative diagnostic tools (urinalysis. . wound location may be the only indicator for identifying ureteral injury in the acute setting (2) Intraoperative Recognition.often unhelpful. (3) Methylene Blue. proving nondiagnostic of the time) Computed Tomography . CT scan. . and 33% 100% intraoperative one-shot IVP. are difficult to to with array of diagnostic tools: preoperative urinalysis.The trajectory laparotomy. association prolonged increased rates of nephrectomy.Vigilance ureteral injury due diagnosis stay for at and statistically delayed to penetrating produces of ureteral exploration presentation an most important with means of trauma.If a ureteral or renal pelvis injury is suspected is also known that ureteral injuries often manifest with absence of contrast in the ureter . and ureteral exploration should be undertaken in all cases of potential injury. Fever.Ureteral detect injuries the after usual external violence. even if imperfect. 1 to 2 mL of methylene blue dye can be directly injected into the renal pelvis with a 27-gauge needle to confirm the diagnosis.CT is used increasingly in the evaluation of the trauma patient and. CT). IVP.If the urinary extravasation from the ureteral injury is contained by Gerota fascia. obscuring the diagnosis. . . injuries also allows detection of injuries missed on presentation. leukocytosis.With a 75% sensitivity for traumatic ureteral injury.delayed hospital . although it appears promising in detecting ureteral injuries.intraoperative inspection of the retroperitoneum : the diagnosing . the extent of medial leakage can be small. unlike renal injuries. (IVP . (4) Imaging Studies Excretory Urography . and local peritoneal irritation are the most common signs and symptoms of missed ureteral injury and should always prompt CT examination.93% of injuries of were the recognized promptly including 57% that were identified knife or missile must be carefully examined during intraoperatively. . there are few published data to assess its accuracy to date . is helpful.

or ureter . all patients with significant ureteropelvic laceration.This underscores the absolute necessity of tracing both ureters throughout their entire course on CT scans obtained to evaluate urogenital injuries. . .Ureteral contusions can heal with stricture or breakdown later if microvascular injury results in ureteral necrosis .to delineate the extent used of clinical .seldom used in the authors’ practice . renal pelvis.Because ureteral injuries are often detected late. periureteral urinoma seen on delayed CT scans may be diagnostic . . . the authors use anterograde ureterography and stent placement at the time of percutaneous nephrostomy placement Management External Trauma (1) Contusion Ureteroureterostomy. because modern helical CT scanners can obtain images before intravenous contrast dye is excreted in the urine. .Retrograde ureterograms (the most sensitive .on delayed images.In reported series.Following certain general principles of ureteral surgery increases the success rate of this delicate surgery. Repair of the ureter must be meticulous.most information commonly is necessary to diagnose missed ureteral injuries because it allows the radiographic seen on test CT for scan ureteral or IVP injury) if further ureteral injury simultaneous placement of a ureteral stent if possible.In addition. had either medial extravasation of contrast material or nonopacification of the ipsilateral ureter on CT Retrograde Ureterography. Antegrade Ureterography.Severe or large areas of contusion should be treated with excision of the damaged area and ureteroureterostomy. Ureteral blood supply is tenuous. delayed images must be obtained (5 to 20 minutes after contrast injection) to allow contrast material to extravasate from the injured collecting system. for instance. . .If retrograde stent placement is not possible (usually secondary to a large gap in the two ends of the transected ureter).

Principles of management of the injured ureter are as follows: patient debility. so as not to Debride the ureter liberally until the edges bleed. . using devascularize the ureter. postoperative drainage. With severely injured ureters. . use optical magnification and retroperitoneal drainage afterward. watertight anastomosis. 2. 3. or very proximal ureteral injury : reimplantation of the ureter directly into the renal pelvis. . Internal Stenting. Mobilize the injured ureter carefully. concomitant vascular surgery.Minor ureteral contusions can be treated with stent damage to When in the ureter) doubt.Complications after ureteroureterostomy(usually urine leakage) : 10% to 24% of the time . especially in high-velocity gunshot Repair ureters with spatulated. . and other complex cases. 5. wounds. the injured portion of the ureter should be debrided and placement (minor-appearing ureteral unappreciated microvascular contusions may stricture later or break down secondary to ureteroureterostomy used to repair the injury (2) Upper Ureteral Injuries Ureteroureterostomy. usually comprising ureteral stenosis : less common (5%-12%) .The principles of repair : spatulation.Management surprisingly dehiscence catheter placement for at least 6 weeks has been good success rate (83% to 88%).Ureteral avulsion from the renal pelvis. tension-free. sparing the adventitia widely. stenting. 4.required commonly (up to 32%) : success rate as high as 90%.Other . lack of tension.laparoscopic repair of ureteral injuries : increasingly common .and a sequela of imperfect repair can be urine leakage that can result in nephrectomy. stented. fine in rare cases even death. absorbable monofilament such as 5-0 polydioxanone. consider omental interposition to isolate the repair when possible. and 1.Chronic acute complications of include abscess and fistula. blast effect. with a complications. and a watertight anastomosis with fine nonreactive absorbable suture . Retroperitonealize the ureteral repair by closing peritoneum over it. by percutaneous nephrostomy placement and ureteral reported in small studies. . .Ureteroureterostomy (end-to-end repair) : used in injuries to the upper two thirds of the ureter .Laparoscopic pyeloplasty in the absence of trauma : quite common .

With technologic advances.Delayed ureteral repairs : creation of a ureteral conduit out of ileum. much in the same way that an ileal conduit is constructed to drain the urine after cystectomy .This involves bringing the injured ureter across the midline and anastomosing it end to side into the uninjured ureter and is most often performed as a secondary or delayed procedure.A new ureteral orifice is constructed with the use of interrupted 6-0 monofilament absorbable sutures in a watertight and nonobstructing fashion. and ureterocalicostomy Autotransplantation. . . ureteroureterostomy. .Autotransplantation of the kidney has been used after profound ureteral loss or after multiple attempts at ureteral repair have failed. (4) Lower Ureteral Injuries Ureteroneocystostomy. .transureteroureterostomy : some .The nephrectomy portion of the autotransplantation : can be performed with laparoscopic techniques Bowel Interposition.Success rates for ileal replacement of the ureter : 81% to 100% .repair distal ureteral injuries that occur so close to the bladder that the bladder does not need to be brought up to the ureteral stump with a psoas hitch or Boari procedure . robotics can also be successfully and safely used for a wide variety of delayed upper urinary tract reconstructions including dismembered pyeloplasty. . A rarely form used of but repair often (90% to 97%) successful technique in adults is transureteroureterostomy (pediatric series show a lower success rate of 70%) . .The through injured ureter the becomes bladder—ureteral vexing difficult access problems postoperatively to needs intubate to be or image with by ureteroscopy a nephrostomy provided placed on the injured side.significant clinical reflux stricture and 6% fistula rate is not a problem (3) Midureteral Injuries Ureteroureterostomy: Transureteroureterostomy.long-term complications : 3% anastomotic .Standard principles : creation of a submucosal tunnel for a nonrefluxing ureteral repair — usually a tunnel that is at least three times longer than the ureter is wide option before nephrectomy .

laparoscopic direct and robotic repair of distal ureteral injuries has emerged as psoas bladder hitch. watertight closure under optical magnification. .The ureteral injury : closed by converting a longitudinal laceration into a transverse one so as not to narrow the ureteral lumen (Heineke-Mikulicz procedure).the lower third of the ureter and has a high success postoperatively detected iatrogenic lower rate. The kidney is then . . Laparoscopic ureteroneocystostomy. .An internal stent and retroperitoneal drain are placed.The repair should be stented postoperatively. . Damage Control. up to 58% of the time in one large series : limited to low-velocity gunshot wounds or stab wounds. . it is sometimes necessary to treat the injured ureter by deferring definitive treatment until later. using long silk ties to aid the dissection of the ureteral stump during the second-stage repair. Psoas Bladder Hitch.In most cases of planned staged repair. reconstructions have all been described Partial Transection. . usually within 24 hours (2) place a ureteral stent and do nothing else (3) exteriorize the ureter (4) tie off the ureter and plan percutaneous nephrostomy . and Boari flap a viable alternative to open surgery.Principles of primary repair : spatulated.. . we tie off the damaged ureter. with interrupted or running 5-0 or 6-0 absorbable monofilament such as Maxon (polyglyconate) or Dexon (polyglycolic acid) .Injuries to the lower two thirds of the ureter with long ureteral defects (too bridged by bringing the bladder up in the psoas hitch procedure) long to be Minimally end-to-end repair may still be considered a realistic treatment option in ureteral injuries preservation identified on retrograde pyelography Boari Flap. This is usually because the patient is too unstable to tolerate the operative time required to complete the repair. . from 95% to 100% with distal stump .There are four options for damage control in ureteral injuries: (1) do nothing but plan a reoperation when the patient is more stable.Primary repair of a partial transection is used in the majority of ureteral injuries.More recently.In cases of ureteral injury after external violence.

ureteroureterostomy or ureteral reimplantation should be performed (2) Transection Immediate Recognition. Ligation of the ureter should be treated by removal of the ligature and observation of the ureter for viability. bilateral injury).Intraoperative recognition of ureteral injuries occurs in as low as 34% of patients undergoing open operation and as low as 0% of those undergoing laparoscopy. most with IVP.When stent placement success . rate as failure high to is a possible. . . functional Surgical Injury (1) Ligation.Nephrectomy must be performed aneurysm.Nephrectomy in cases of ureteral injury is controversial rate from renal failure in with a ruptured in patients .If possible. . either by the surgeon just postoperatively or later by interventional radiology specialists. hydronephrosis (1 of 35 patients).Usually. .We advocate percutaneous placement of a nephrostomy tube.We have found that intraoperative open nephrostomy placement can be too time consuming in these unstable patients. persistent pain or fever (3 .Patients present with a variety of signs and symptoms: by CT of 35 patients). and hematuria (1 of 35 patients). to complete obstruction of the ureter or too long a gap .drained percutaneously. If viability is in question. appropriate planned ureteric reconstruction should be done after and anatomic imaging is performed. urinary leakage from the wound (3 of 35 patients). urogenital fistula (4 of 35 patients). . . or retrograde ureterography anuria (5 of 35 patients.the risk of breakdown of ureteral repair after other surgeries : reported to be 8% to 40% with caution (the mortality routine aortic aneurysmectomy is 3% and climbs to 12% Delayed Recognition. .Intraoperative management of these injuries is debated .Delayed diagnosis of ureteral injury is most often (66% to 76%) achieved pyelography. stent is some the due authors have reported an ultimate as 73% place without need for open surgery. Other authors have advocated placing an 8-Fr feeding tube into the ureter and exteriorizing it until definitive repair can be completed .

practices : sound technique.Intraoperative recognition of ureteral injuries occurs in as low as 34% of patients undergoing open operation and as low as 0% of those undergoing laparoscopy. or retrograde ureterography anuria (5 of 35 patients. Successful repair of ureteral injuries. (8) Retroperitoneal surgery : constant attention to the location of the ureter. bilateral injury). urogenital fistula (4 of 35 patients). persistent pain or fever (3 . use CT scan and intraoperative one-shot IVP liberally. (5) Tenuously viable distal ureter is bypassed by sewing the bladder to the uninjured proximal ureteral stump.Delayed Recognition. and halting ureteroscopy immediately in the face of any . . limiting ureteroscopy times. scoping over guidewires. (4) Ureteral viability must be ensured by interval removal of nonviable segment before ureteroureterostomy. using safety wires. is predicated on the use of well-vascularized tissue. use retrograde pyelography aggressively. After penetrating injury. determine the course of the knife or bullet tract to ensure that the ureter is not at risk (3) If delayed recognition is suspected.Delayed diagnosis of ureteral injury is most often (66% to 76%) achieved pyelography. surgically expose and inspect the ureter when necessary: After penetrating injury. hydronephrosis (1 of 35 patients).Patients present with a variety of signs and symptoms: by CT of 35 patients).utmost importance. urinary leakage from the wound (3 of 35 patients). whether from external violence or surgical misadventure. most with IVP.) (7) Safe ureteroscopy ureteral injury. (Avoidance of iatrogenic ureteral injury . (6) Upper ureteral injuries can be removed and the ureter reimplanted into the renal pelvis after renal mobilization. and hematuria (1 of 35 patients). . Key Points: Ureteral Trauma (1) Ureteral injuries : carefully searched for them (2) Intraoperatively.