URETERIC INJURY AND

THEIR MANAGEMENT
SPEAKER : DR. SAGNIK RAY
CHAIRPERSONS : PROF. D .KARMAKAR
PROF S S BHOJ
DR. A K SAHA
ANATOMY-COURSE & RELATION

• 25 cm
• Upper part over psoas
• Proximal part-lateral to
gonadal vessel
• Distal part- medial
COURSE & RELATION….CONTD.(ABOVE PELVIC
BRIM)

Rt ureter : Crossed by rt Left ureter :Crossed by left

colic & ileocolic vessels
Intimate relation-ascending
colon
Enters pelvic brim at
bifurcation of common iliac
colic vessels
Intimate relation-sigmoid
colon & mesocolon
Enters pelvis at bifurcation
of common iliac
 BELOW PELVIC BRIM

FEMALE MALE

• Ovarian vessels closely • Testicular vessels :-separate

related. and follow external iliac
vessel
• Uterine vessels :crosses
ureter • Ureter pass inferior to vas
and anterior to seminal
vescicle
PELVIC URETER-FEMALE
BLOOD SUPPLY
CONSTRICTIONS OF URETER & COMMON SITES OF
INJURY
URETRIC INJURY :SALIENT FEATURES

• Rare-----
Small size
Mobilility
Protected by vertebrae,bony pelvis & muscle
• 1-2.5%
 ETIOLOGY

• Commonest: Iatrogenic….. open, laparscopy, endoscopy

• Penetrating…….Gunshot injury

• Blunt trauma : Deceleration injury

 IATROGENIC INJURY------MECHANISM

• Ligation/kinking
• Crushing by a clamp
• Partial/incomplete transection
• Thermal injury
• Ischemia from devascularisation
INCIDENCE OF URETERAL INJURY IN VARIOUS
PROCEDURES
PROCEDURE PERCENTAGE(%)
1)GYNECOLOGICAL
Vaginal hysterectomy 0.02-0.5
Abdominal hysterectomy 0.03-2
Lap hysterectomy 0.2-6.0
Urogynecological procedure 1.7-3.0
2)Colorectal surgery 0.15-10.0
3)Ureteroscopy
Mucosal abrasion 0.3-4.1
Ureteral perforation 0.2-2.0
Intussucception/avulsion 0-0.3
 MANAGEMENT
1. History & physical examination
2. Investigation
3. Treatment
 HISTORY /PHYSICAL EXAM

• High degree of suspicion

• Hematuria :poor sensitivity…50-75%

• Iatrogenic :IV dye Indigo carmine intra op.

 CLINICAL FEATURES OF MISSED INJURY

1)URINOMA formation ……
Persistant low grade fever
Peritonitis
Flank pain
Paralytic ileas
CONTD…

• 2)ureterovaginal fistula
• 3)ureterovesicle fistula
 RADIOLOGICAL INVESTIGATIONS
IVP(WITH LATERAL FILMS)

1. IVP : Never one shot

Abnormal findings needs further investigation.
• Abnormal findings are :
I. Ureteral dilation/deviation
II. Incomplete deviation of total ureter
III. Delayed or no visualisation of renal unit
IV. Urinary/contrast extravasation
 CONTAST CT SCAN

• Delayed phase
• At 10 mins.
IF CT/IVP IS NON DIAGNOSTIC…….

• RETROGRADE /ANTEGRADE UROGRAPHY IS GOLD

STANDARD
 PRINCIPLES OF URETERIC INJURY
RECONSTRUCTION
1. Debridement of necrotic tissue.
2. Spatulation of ureteral ends
3. Watertight mucosa to mucosa with absorbable suture
4. Internal stenting
5. External drain
6. Isolation of injury with omentum/peritonium
TREATMENT DEPENDS UPON…….

1. Timing of diagnosis
2. Type of injury
3. Length of injury
4. Site of injury
5. Condition of patient
MANAGEMENT OF DELAYED (>2WKS) RECOGNISED
INJURY

• Stabilse the patient

• Proximal ureteric drainage with percutaneous
nephrostomy.
TECHNIQUES OF MANAGEMENT

URETERONEOCYSTOSTOMY
 LOWER THIRD

• Reimplantation of proximal end of ureter on bladder.

• Reimplantation done in an antireflux fashion…..prevent
long term kidney infection.
• PSOAS HITCH……Bladdar fixed to psoas.
• If ureter only ligated….primary ureteroureterostomy can
be done.
REIMPLANTATION
PSOAS HITCH
 UPPER & MIDDLE THIRD

• Primary uretero ureterostomy

• Transuretero ureterostomy (option in extensive ureteral

loss or when pelvic injuries preclude ureteral
reimplantation.)
PRIMARY URETEROURETEROSTOMY
TRANSURETEROURETEROSTOMY
URETERAL REIMPLANTATION WITH BOARIS FLAP

• In extensive mid-lower ureteral injury, the large gap can

be bridged with a tabularised L-shaped bladder flap. It is a
time-consuming operation and not usually suitable in the
acute setting.
BOARI FLAP
 ILEAL INTERPOSITION FLAP

• If it is necessary to replace the entire ureter or a long

ureteral segment, the ureter can be replaced using a
segment of the intestines, usually the ileum.
• This should be avoided in patients with impaired renal
function or known intestinal disease.
ILEAL TRANSPOSITION FLAP
• The ileal segment is placed in the isoperistaltic orientation
between the renal pelvis and the bladder.
• Follow up: Serum chemistry to diagnose hyperchloremic
metabolic acidosis.
• Long term complication: fistula(6%) and stricture(3%)
 PREVENTION OF IATROGENIC TRAUMA

• Proper identification during operation

• Pre op stenting
• Intra op cystoscopy
THANK YOU