Blackwell Science, LtdOxford, UKBJUBJU International1464-410XBJU InternationalAugust 2004

943

Review Article
DIAGNOSIS AND MANAGEMENT OF URETERIC INJURY
BRANDES
et al.

The Consensus on Genitourinary

Trauma continues this month
Diagnosis and management of
with an evidence-based analysis, ureteric injury: an evidence-based
by a team of experts under the
chairmanship of Dr Jack McAninch,
analysis
of current reports on the diagnosis STEVEN BRANDES, MICHAEL COBURN*, NOEL ARMENAKAS† and
and management of ureteric JACK McANINCH‡
Department of Surgery (Urology), Washington University School of Medicine, St. Louis, MO,
trauma. This is quite a unique Departments of Urology, *University of Texas, South-western, Houston, TX, †Cornell University,
document, and of interest to all New York, NY and ‡University of California School of Medicine, San Francisco, USA
urologists; not only as a consensus Accepted for publication 15 April 2004
on how this condition should be
managed, but also as a model of
how to review current publications. KEYWORDS
ureter, trauma, injury, external, iatrogenic
INTRODUCTION
Ureteric injuries from external trauma are
rare; the ureter’s mobility, narrow diameter,
retroperitoneal location (between the spine
and major muscle groups) and overlying
peritoneal contents all protect it and make it
an unlikely target for injury. Furthermore, the
presenting signs of ureteric injury are often
not specific, and diagnostic tests often
specific but not sensitive.
Even in the busiest of trauma centres, external
ureteric injuries are rare, typically with <10
injuries per year [1–45] There are only a few
series [4,6,13,14,18,22] with a sizeable
experience, and they are all retrospective,
cover long study periods (10–40 years) and
are mostly treated by heterogeneous groups
of physicians. Most external ureteric injuries
occur from gunshot wounds [1–52]. The
missile path even close to the ureter can
cause significant delayed tissue destruction.
Such injuries can be difficult to identify
initially and often present after a delay
[3,7,18,47,51]. Penetrating ureteric injuries are
almost always associated with multiple intra-
abdominal organ injuries (e.g. small bowel,
colon, liver and iliac vessels [1–33,46–52]).
Associated injuries are often more obvious
and overshadow the ureteric injury. Ureteric
injuries from blunt trauma are equally rare.
They usually occur in children during
rapid deceleration, causing excessive
hyperextension and disruption at the PUJ
[34,35,37,40,42,45]. Such patients are usually
poly-traumatized and have associated
multiple organ injuries (mostly liver, spleen
and skeletal system).
In the acute trauma setting therefore the
diagnosis of ureteric injury can be difficult.
When the ureteric injury is missed and not
diagnosed until late, or the primary repair
fails, the complication rate increases
considerably, including renal loss and even
death [1,11,13,15,16,18,25–30,45–48,51,52].
Immediate diagnosis and proper management
at the time of ureteric injury is essential to
reduce potential morbidity and mortality.
The incidence of iatrogenic ureteric injury is
0.05–30%, depending on the experience of
the surgeon and the technical difficulty of the
procedure [29]. As for external trauma
ureteric injuries, iatrogenic injuries are
relatively rare and often difficult to diagnose
acutely, and typically recognized after delay.
Again, delayed diagnosis results in more
significant complications. Published reports
for iatrogenic injuries are somewhat more

© 2 0 0 4 B J U I N T E R N A T I O N A L | 9 4 , 2 7 7 – 2 8 9 | doi:10.1111/j.1464-410X.2004.04978.x 277
B R A N D E S ET AL.
substantial and sizeable than for external
trauma, but the series are all retrospective,
generally cover long study periods, are
heterogeneous for type, and involve many
degrees and locations of injury, and many
surgeons [13,53–117].
Because of these inherent limitations and
difficulties, evidence-based outcome
measures were used to develop
recommendations for consensus practice for
diagnosing and managing ureteric injuries,
based on an integration and synthesis of
available reports, best current evidence and
expert opinion.
SPECIFIC QUESTIONS
• What clinical signs and symptoms are
reliable indicators to prompt an evaluation for
ureteric injury? Immediate vs delayed?
• What imaging studies or intraoperative
techniques are reliable to diagnose ureteric
injuries? Immediate vs delayed?
• How does timing (immediate vs delayed) of
the diagnosis alter the treatment method?
• What treatment methods are successful for
each mechanism and location of ureteric
injury? Low vs high velocity missile? Blunt vs
penetrating trauma vs iatrogenic injury?
Upper, mid, or lower ureter?
• What effect does contamination from
associated intra-abdominal injuries have on
treatment and outcomes?.
METHODS
IDENTIFICATION OF REFERENCES
The world publications were searched using
Medline and Embase search engines for the
years 1966–2002. All English language
citations with the key words ‘ureter, PUJ,
wounds, trauma, injury, penetrating, blunt,
crush, iatrogenic, surgery, gunshot wounds,
stab wounds, urinoma, fistula, stricture, and
complications’ were identified. The abstract
for each of the 175 external trauma and 311
iatrogenic trauma citations was reviewed, and
all papers having any possible applicability to
the guideline topic were retrieved and
reviewed. Reference sections of the articles
and meta-analyses identified were then used
to identify additional references not retrieved
by the initial search engines. Review articles,
letters to the editor, single case reports,
animal studies, and poorly written
retrospective studies with scant information
were excluded from the study. Thus, 52
278
external trauma and 66 iatrogenic trauma
manuscripts were felt to have sufficient merit
to form the basis for the recommendations.
Of the external trauma articles, 33 were
predominantly penetrating, 12 blunt and
seven war-related. Of the iatrogenic trauma
articles, most (21) were of gynaecological
surgery; the remaining articles were
predominantly urological, vascular or general
surgery misadventures.
Each manuscript was then reviewed and
classified as class 1–4 (see below) by a
group of urologists, all whom subspecialized
in trauma and reconstructive urology. Each
article was read by at least two members
of the panel to evaluate the design and
method. This group collaborated to
produce the following recommendations
and evidentiary tables. All recommendations
were drafted, reviewed and accepted by
consensus.
QUALITY OF THE STUDIES
Articles were classified by their numerical
level of evidence (LOE), as determined by the
following definitions:
• Class 1: Prospective randomized clinical
trial.
• Class 2: Prospective noncomparative
clinical study.
• Class 3: Retrospective case series, database
or registry review.
• Class 4: Case reports;
• Class 5: Expert opinion.
No class 1 or class 2 articles were identified
or reviewed for this paper; this is a major
limitation of the available evidence and
thus weakens the strengths of our
recommendations. In general, only a third
of the external trauma and a fifth of the
iatrogenic trauma articles were of sufficient
merit for review. Of the selected iatrogenic
ureteric injury articles, 64 of 66 were class 3,
mostly covering long study periods. The
remaining two studies were class 4. Of the
selected external trauma articles, 34 class
3 and two class 4 articles focused on
penetrating ureteric trauma, and four class
4 and six class 3 articles on blunt ureteric
trauma. A further weakness is that nearly half
of these external trauma articles included
patients from the 1960s and 1970s, which
pre-dates the common use of CT or JJ ureteric
stenting [1,4,6,9–11,14–18,21,22,26–28,34,
37,39,42,44,47,49].
Although most civilian penetrating wounds
are of low velocity, occasionally a high-
velocity missile injury occurs. For this reason,
six military and war-related articles from Iraq,
Northern Ireland, Croatia and Vietnam were
selected.
CONSENSUS RECOMMENDATIONS
PENETRATING URETERIC INJURIES
[1–33,46–52]
• Associated intra-abdominal visceral
injuries are common. (LOE 3);
• Deaths are predominantly from associated
injuries, not the ureteric injury (LOE 3).
SIGNS AND SYMPTOMS
Immediate: Haematuria is an unreliable sign
of penetrating ureteric injury. Absence of
haematuria does not exclude ureteric injury.
Any degree of haematuria warrants further
investigation (LOE 3).
Delayed: Signs and symptoms of a possible
missed injury or delayed urinary leak that
should prompt further investigation are:
prolonged ileus (LOE 3), urinary leakage (LOE
3), prolonged high output from drains (LOE 3),
fever/sepsis (LOE 4), persistent flank or
abdominal pain (LOE 4), urinary obstruction
(LOE 4), elevated creatinine or blood-urea
nitrogen (LOE 5), and flank mass (LOE 4).
DIAGNOSIS
• The early diagnosis of ureteric injury is
preferred. Delayed diagnosis results in higher
complication (fistula, urinoma, infection, etc.),
renal unit loss and death rate (LOE 3).
• A high index of suspicion and a low
threshold for imaging or direct ureteric
exploration are needed to reliably diagnose
ureteric injury (LOE 3).
• Explore all peri-ureteric gunshot wound
and associated retroperitoneal haematomas
noted at laparotomy (LOE 3).
• Surgical exploration is a reliable and
accurate method to diagnose penetrating
ureteric injury. Visual ureteric inspection with
or without intravenous or intra-ureteric dye
injection is reliable (LOE 3).
• High-velocity gunshot wounds and
shrapnel injuries to the ureter have a higher
complication (i.e. delayed urinary leak,
dehiscence after repair, urinoma, renal unit
© 2004 BJU INTERNATIONAL

loss, etc.) and delayed presentation rate (LOE
3).
IMAGING
• One-shot (high-dose) IVU is often not
diagnostic and thus unreliable at detecting
penetrating ureteric injuries (LOE 3).
• Complete IVU is accurate in detecting
ureteric injury. Abnormal IVU findings warrant
further investigation (i.e. ureteric dilatation or
deviation, incomplete visualization of the
entire ureter, delayed or no visualization of
the renal unit, and extravasation) (LOE 3).
• For CT there are insufficient data for
a recommendation but it appears to be
accurate when delayed images are obtained
(LOE 5).
• Retrograde pyelography (RPG) is a sensitive
and specific test in defining the presence,
location and degree (i.e. partial vs complete)
of ureteric injury. Limitations: it difficult to
use in the acute trauma patient and better
reserved for the delayed setting (LOE 4).
• Ultrasonography (US): there are
insufficient data for recommendation, and
it is of limited use in the acute setting
(LOE 5).
TREATMENT
• Early treatment is preferred (LOE 3).
• Minimal ureteric contusions or
proximity gunshot wounds can be
treated successfully by ureteric stenting.
Untreated contusions or proximity
gunshot wounds are often complicated
by ureteric stricture or delayed necrosis
and urinary fistula (especially with high-
velocity missiles) (LOE 4). Severe or large
ureteric contusions should be treated by
segmental excision and uretero-ureterostomy
(UU) (LOE 4).
• High-velocity gunshot wounds have higher
rates of delayed urinary leak, dehiscence after
repair, renal unit loss and overall death (LOE
4).
• Successful methods for ureteric repair
are based on injury location (Fig. 1): (a) upper,
UU or ureteropyelostomy (LOE 4); (b) middle,
UU (LOE 3) or transuretero-ureterostomy
(TUU) (LOE 4) or anterior wall bladder (Boari)
flap (LOE 5); (c) lower, ureteroneocystostomy
(UNC) with or without a psoas bladder hitch
(LOE 3).
• Surgical principles for successful repair of
acute ureteric transactions are: (a) adequate
ureteric debridement and careful mobilization
(LOE 4); (b) Spatulated, tension-free,
© 2004 BJU INTERNATIONAL
DIAGNOSIS AND MANAGEMENT OF URETERIC INJURY
watertight anastomosis over a ureteric
stent (LOE 3); (c) Isolate the ureteric repair
from associated injuries and a place a
retroperitoneal drain (LOE 4); (d) Proximal
urinary diversion is typically unnecessary
(LOE 4).
SPECIFIC PROBLEMS
• Prompt repair of ureteric injuries is
preferred. However, trauma patients who
are haemodynamically unstable, hypothermic,
coagulopathic or acidotic, are best managed
by a planned staged repair, ‘damage control’
(i.e. ureteric exteriorization or ligation).
Definitive reconstruction is best delayed until
the patient is stable (LOE 4).
• Associated bowel injury or fecal
contamination does not increase the
complication rate or compromise ureteric
repair success (LOE 4).
• Delayed diagnosed ureteric injuries or
secondary leak after primary repair are best
managed by percutaneous nephrostomy
(PCN, proximal diversion), and when possible,
additional antegrade ureteric stenting.
Retrograde ureteric stenting is often
unsuccessful. A close follow-up is warranted
(LOE 4).
• Urinomas can be effectively managed by
placing a percutaneous drain (LOE 4).
BLUNT URETERIC INJURIES [34–45]
SIGNS AND SYMPTOMS
Immediate: The possibility of a blunt ureteric
injury should be considered in all patients
who are involved in accidents with
hyperextension or deceleration mechanisms
of injuries (especially a child in a pedestrian vs
motor vehicle accident or fall from height)
(LOE 3).
Lack of haematuria is an unreliable sign to
exclude injury. Any degree of haematuria
should prompt further imaging or exploration
(LOE 3). Flank tenderness/ecchymosis should
prompt further investigation (LOE 4).
Delayed: Signs and symptoms for delayed
ureteric leak are the same as for penetrating
injuries (see above).
DIAGNOSIS
• Early diagnosis of PUJ injury is preferred
(LOE 3).
• A high index of suspicion and low threshold
for imaging and exploration are needed
(LOE 3).
• Blunt PUJ injury is rare and can often be
missed in the acute setting. Diagnosis is
commonly delayed (LOE 3).
• Associated injuries are common and often
multiple (LOE 3).
• Delayed diagnosis results in higher
complication (i.e. urinoma, infection, leak,
etc.) and renal unit loss rate (LOE 3).
IMAGING
• IVU (complete study): IVU is a reliable
and accurate test to diagnose PUJ injury
in stable patients (particularly in the
delayed setting) (LOE 3); reliable signs
of PUJ injury are medial contrast medium
extravasation (LOE 3) and an unopacified
distal ureter (LOE 4).
• CT of the abdomen and pelvis is an
accurate tool to both screen and diagnose
PUJ injury (LOE 3). Spiral CT scanners require
delayed (excretory) imaging with contrast
medium to reliably diagnose ureteric/PUJ
injury (LOE 4). CT findings of PUJ injury
include: predominant medial perirenal
extravasation (LOE 3), intact renal
parenchyma (LOE 4), lack of perirenal
haematoma (LOE 4), and an unopacified
ureter, suggesting PUJ avulsion (LOE 4). The
above suggests partial PUJ injury, yet contrast
medium is found in the ureter distal to the
PUJ (LOE 4).
• RPG is a sensitive and specific test for the
presence, location and degree (partial vs
complete) of ureteric injury; its role is limited
in the acute setting (LOE 3).
• US has insufficient data for
recommendation; it has a limited role in the
acute setting (LOE 5) but is accurate for
diagnosing urinoma and hydronephrosis
(LOE 3).
TREATMENT
• Blunt ureteric injury is typically to the PUJ
and secondarily to the proximal ureter (LOE 3).
• Laceration (partial) PUJ injury can be
successfully treated by primary repair or
ureteric stenting with or without proximal
urinary diversion (LOE 4).
• Complete transection (avulsion) injuries are
successfully repaired by UU or
ureteropyelostomy (LOE 3).
• The surgical principles for ureter repair are
the same as detailed above for penetrating
ureteric injuries.
279
B R A N D E S ET AL.

FIG. 1. The algorithm for external ureteric trauma. GSW, gunshot wound; Inj, injury; IV, intravenous; PE, physical examination; Sx, signs and symptoms; SW, stab
wound; Tx, treatment; UA, urine analysis; UP, ureteropyleostomy.

Suspected Ureteric Injury

Not detected initially, Delayed

Unstable or Planned History, PE, Mechanism of Injury, UA
diagnosis
laparotomy

Stable
Stent
Complications of urinary leak
IVU or CT withdelayed – urinoma
Partial PUJ inj.
images – abscess
– fistula
Not diagnostic Normal – ureteric obstruction
Extrav.

Unstable Stable
GSW/SW
or blunt PUJ US and/orIVP and/or CT
avulsion Retrograde Abd/pelvis

Normal – Urinoma Drainage

Extrav. and/or
– Urinary diversion
Surgical Exploration by stent or PCN
Blunt partial PUJ injury No TX.

Stent Surgical exploration if

Sx. persist
– Ureteral contusion
– Proximity GSW Normal

– IV indigo Proximal UU or UP
– Retrograde indigo
– Direct inspect Ureter Injury Location
Viable Stable
Mid UU or TUU

Viable ??
Unstable
Stent Distal Reimplant ± Psoas hitch
Damage Control

• Delayed diagnosis or secondary leak is best
managed by PCN urinary diversion. Add an
antegrade ureteric stent when possible.
Retrograde ureteric stenting is usually
unsuccessful. A staged reconstruction is
typically needed (LOE 4).
• Urinoma formation is effectively
managed by placing a percutaneous drain
(LOE 4).
• There are insufficient data for a
recommendation of the effect of associated
injuries (i.e. fecal contamination) on the
success of PUJ repair.
IATROGENIC URETERIC INJURIES
[13,53–117]
• Injuries typically occur during
gynaecological, urological, urogynaecological
and other pelvic surgery (LOE 3).
• Iatrogenic injuries are predominantly to the
distal one-third and pelvic ureter (LOE 3).
• Preoperative prophylactic stents do not
assure preventing ureteric injury, yet assist in
intraoperative recognition (LOE 3).
• Contemporary, improved endoscope
design, technique and accessories have
reduced ureteroscopic serious ureteric injury
and morbidity (LOE 3).
SIGNS AND SYMPTOMS
Signs and symptoms for delayed ureteric leak
that should prompt further investigation are
the same as for penetrating injuries (see
above), in addition to anuria, flank or loin
pain, incontinence, vaginal urinary leakage,
haematuria, fever, elevated serum blood urea
nitrogen and creatinine, or elevated creatinine
in fluid collections (urinomas) (LOE 3).

280 © 2004 BJU INTERNATIONAL


DIAGNOSIS
• Immediate/intraoperative diagnosis of
ureteric injury is preferred (LOE 3).
• Diagnosis is typically delayed (LOE 3).
• Delayed diagnosis of ureteric injuries
results in more common and serious
complications (i.e. urinoma, infection, leak,
etc.), and renal unit loss rate (LOE 3).
IMAGING
• IVU is accurate in the delayed diagnosis of
ureteric injury. Abnormal or nondiagnostic
findings warrant further investigation (LOE 3).
• CT is accurate for the delayed diagnosis of
ureteric injury with signs of contrast medium
extravasation, ascites, hydronephrosis and
urinoma (LOE 3).
• RPG is a sensitive and specific test for the
presence, location and degree (partial vs
complete) of ureteric injury (LOE 3). There are
insufficient data for a recommendation in the
acute setting.
• US; there are insufficient data for a
recommendation in acute setting. Accurate
for delayed diagnosis with signs suggesting
injury of ascites, hydronephrosis and absent
ureteric jets (LOE 4). Abnormal findings
warrant further investigation (LOE 4).
TREATMENT
• The best method for ureteric repair
depends on the location, nature, extent and
mechanism of injury (LOE 3).
• Surgical principles for the successful
ureteric repair (i.e. acute ureteric transactions)
are the same as listed above for external
penetrating injuries (LOE 3).
• Successful methods for ureteric repair as
based on location of the ureteric injury are as
listed above for external penetrating injuries
(LOE 3).
• Adequate renal and bladder mobilization
will allow for ureteric reconstruction despite
long defects (LOE 3).
IMMEDIATE
• Ligation injury; manage by de-ligation and
depending on the degree of ureteric damage,
stent placement and/or UU (LOE 3).
• Crush injury; conditions are very variable
but depending on ureteric viability, are
managed by stent or/and UU (LOE 4).
© 2004 BJU INTERNATIONAL
DIAGNOSIS AND MANAGEMENT OF URETERIC INJURY
DELAYED
• Retrograde stenting of the ureter is
typically unsuccessful for the delayed
diagnosed ureteric injury (LOE 3).
Nephrostomy with or without antegrade
stenting is successful in managing missed
ureteric injuries (LOE 3).
• Devascularization injuries are typically
diagnosed late; they are managed by stent
placement or surgical repair (depending on
the location and degree of injury; LOE 3).
• Ligation injury; a nephrostomy is an
effective means for urinary diversion. Manage
by stent placement or staged surgical repair
(LOE 3).
• Endourological treatment of small ureteric
fistulae and strictures can be safe and
effective (LOE 3).
• Temporizing urinary diversion, followed by
staged ureteric reconstruction, is successful
and effective in selected patients (LOE 3).
SPECIFIC PROBLEMS
Ureteric injuries noted during vascular graft
surgery, with sterile urine, can be effectively
managed by immediate repair and tissue
interposition, without unduly jeopardizing the
vascular graft (LOE 3).
SCIENTIFIC FOUNDATION
Ureteric trauma is classified based on the
mechanism, location and extent of injury.
The cause of the trauma is apparent from
the patient’s history. The mechanism is
penetrating, blunt or iatrogenic trauma. The
location is to the proximal, mid or distal
ureter, and extent is determined by the length
and severity of the ureteric injury.
Iatrogenic trauma is the leading cause of
ureteric injuries [13,65,74,98,107]. Iatrogenic
ureteric injuries are a potential complication
of any open or endoscopic pelvic operation. A
review of published studies shows that during
open abdominal and pelvic surgery, iatrogenic
injury to the ureter typically occurs during
the following operations: abdominal
hysterectomy (ligation of the ovarian vessels,
ligation of the uterine vessels), radical
hysterectomy, ligation of the inferior
mesenteric artery, abdominal perineal
resection (division of the lateral ligaments of
the rectum), mobilization of the ureter,
peritonealization of the pelvic floor, and
attempting to control profuse pelvic bleeding
[13,53–117].
Gynaecological surgery accounts for over half
of all iatrogenic ureteric injuries, with the
remainder occurring during urological,
colorectal, general, and vascular surgery
[13,53–107]. The ureter is injured in 0.5–2% of
all hysterectomies and routine gynaecological
pelvic operations and in 10 (5–30)% of radical
hysterectomies [56–60,67,70–74,77–79,
87,91–93,98–104,112,115]. Ureteric
complications from radical hysterectomy
have declined over the years because of
improved patient selection, surgery limited to
mostly low-stage disease, the decreased use
of preoperative radiation, and modifications
in surgical technique that limit extreme
skeletonization of the ureter [107,115]. During
vaginal surgery most ureteric injuries occur
during vaginal vault reconstruction or vaginal
cuff closure, where sutures can ligate or kink
the ureter. Gynaecological ureteric injuries
typically occur to the distal third of the ureter
[67,71,77,87,95,98,102,108].
RISK FACTORS/PREVENTION
The most reliable method to avoid iatrogenic
ureteric injury are generous surgical exposure,
meticulous surgical technique, and to clearly
identify the ureter throughout the operative
field. For anticipated difficult pelvic
operations, or patients with large pelvic
masses, previous pelvic surgery, infection, or
irradiation, the use of preoperative ureteric
radiographic imaging by IVU or CT has been
widely advocated. Others report that
preoperative imaging did not help to prevent
ureteric damage [91,92]. However, neither
ureteric stent placement nor pelvic imaging is
recommended routinely. Most reported
ureteric injuries occurred in patients with no
identifiable risk factors. Indeed, most ureteric
injuries resulting from gynaecological surgery
occur during procedures that surgeons
described as uncomplicated and routine, and
where pelvic anatomy was normal [81].
However, stent placement clearly helps to
identify a ureteric injury when it does occur
[109]. When a pelvic tumour is large or
ureteric anatomy distorted on preoperative
imaging, preoperative stents may increase the
ability to palpate the ureters, minimize the
need for ureteric dissection, and minimize
ureteric kinking by adjacent suturing [62].
However, prophylactic stenting does not
ensure the prevention of injury [62,91].
281
B R A N D E S ET AL.
Intraoperative haemorrhage is a clear and
main risk factor for ureteric injury. Sudden
haemorrhage should never be treated with
blind cautery or suturing, but rather direct
pressure, sharp dissection and exposure of the
bleeding vessels, followed by accurate and
precise suturing [67,81,98]. Greater blood loss,
long operative times, more transfusions, and
longer hospitalization are associated with
ureteric injury [67,98].
In radical pelvic surgery (i.e. hysterectomy)
the ureter can be skeletonized when
dissecting out adjacent tumour, and so
risk ischaemia and delayed necrosis
[67,71,77,79,82,92,93,108,113]. Radical
hysterectomy may also require en-bloc
resection of a segment of ureter [116].
Previous irradiation can compromise the
ureteric blood supply (by obliterative end
arteritis) and increase the injury risk [116].
However, these reports are from the 1960s
and 1970s and there are no contemporary
series. Previous episodes of endometriosis or
pelvic inflammatory disease can lead to dense
ureteric adherence and so increase the
chances for iatrogenic injury. Neoplasms can
directly invade and fix the ureter or distort its
course. The ureter is thus at risk for injury
when any large retroperitoneal mass is
resected.
DIAGNOSIS
Clinical: The prompt diagnosis of ureteric
injury from external trauma is complicated
by the presence of multiple organ injuries
and the absence of clinical and laboratory
findings specific for ureteric trauma.
Published reports overwhelmingly show
that haematuria is an unreliable indicator
of ureteric trauma, and is absent in ≈ 30%
(up to 45%) [3–7,10,20,22,26,30,40,52]. These
limitations frequently result in a delayed
diagnosis. Most iatrogenic ureteric injuries
are not recognized intraoperatively and are
diagnosed late and when symptomatic.
Of the six retrospective war-related reports,
the injuries to the ureter were caused by high-
velocity missiles. Such missile injuries resulted
in associated injuries, a high death rate
[26,46,47,52] from associated injury, and high
rates of delayed diagnosis, delayed urinary
leak, repair dehiscence and nephrectomy.
Typical symptoms of delayed leak were fever,
ileus, wound leakage (cutaneous fistula) and
flank mass.
282
Common signs and symptoms of a missed
ureteric injury are generally not specific.
Suggestive of urinary leak are prolonged ileus,
fever/sepsis, persistent flank or abdominal
pain, palpable abdominal mass, elevated
serum blood urea nitrogen, leukocytosis, and
prolonged drainage from the skin, vagina,
operative drains or drain sites. Anuria can
be seen with bilateral injuries [13,70].
Occasionally, ureteric injury is not recognized
until an obvious fistula is present. To avoid
such morbidity, reports clearly support that a
high index of suspicion be maintained (as
based on injury mechanism and location) and
is the key to prompt diagnosis of injury
[1–4,22–25,29,47,51,87]. Essentially, all
patients with penetrating abdominal trauma
or significant blunt deceleration injury should
be suspected of having a ureteric injury and
appropriately evaluated. Similarly, children
with significant blunt abdominal trauma,
significant deceleration or fall from height
and multiple associated injuries should
undergo radiographic ureteric assessment,
regardless of the absence of haematuria on
urine analysis. Gross haematuria, flank
tenderness or flank ecchymosis may suggest
injury, and thus warrant further investigation
[7,10,34,35,37,38,42–45].
IMAGING
Extravasation of contrast medium is the
hallmark sign of a ureteric injury but in many
cases the findings are more subtle, including
delayed function, or mild ureteric dilation or
deviation. Formal, complete IVU is a reliable
and accurate study in the stable trauma
patient for diagnosing ureteric injury
[4,6,14,23,28,34]. IVU findings suggestive of
ureteric injury are delayed or no visualization
of the involved kidney, hydronephrosis,
urinary (contrast medium extravasation), or
incomplete visualization of the entire ureter
[6].
Complete IVU is particularly useful for
diagnosing missed ureteric injuries. In
the last decade there have been numerous
retrospective series showing that ‘one-shot’
IVU, for penetrating trauma or in the unstable
patient, is inaccurate and unreliable
[2–5,20,22,31].
With the contemporary widespread use of CT
for evaluating the polytraumatized patient,
blunt ureteric injuries are now more routinely
diagnosed by CT. Extravasation of contrast
medium confined predominantly to the
medial perirenal space is the most consistent
finding of blunt PUJ injury [36,39,41]. Absence
of contrast material in the distal ureter, on
delayed CT images, is diagnostic of a complete
ureteric transection. Additional CT findings
that distinguish PUJ injuries from renal
parenchymal injuries are intact renal
parenchyma and lack of perirenal haematoma
[36,39]. With rapid sequence spiral CT this
cannot be assessed unless delayed (excretory)
films are obtained [41,75]. CT also has a
reliable role in the delayed setting with signs
of missed ureteric injury, being ascites,
localized fluid collections (urinomas),
hydronephrosis, and contrast medium
extravasation [75].
If the results of the IVU and CT are
inconclusive, RPG is indicated; this is the most
accurate ureteric imaging test to evaluate
the location and degree of ureteric injury
[6,13,52,108]. However, it is often too
cumbersome and time-consuming for use in
the acute trauma setting. It is clearly a useful
tool for the delayed diagnosed of ureteric
injury. US is generally not useful, except in
showing a haematoma, urinoma, ascites,
absent ureteric jets or hydronephrosis, all
which suggest a delayed ureteric injury (as
supported in limited case series) [84].
However, there is little to no published
evidence to support the use of US in acute
ureteric trauma.
INTRAOPERATIVE
Most penetrating ureteric injuries are
diagnosed intraoperatively during the initial
laparotomy for managing the associated
abdominal injuries [3,17,19,20,24,25,27,30].
Blunt external and iatrogenic ureteric injuries
are often diagnosed after a delay
[13,34,35,37,40,42–45,53–117].
If injury to the ureter is suspected
intraoperatively the ureter must be
meticulously examined in the area of interest.
Direct exploration and visual inspection
(including the exploration of retroperitoneal
and peri-ureteric haematomas) are the most
common and reliable methods of assessing
ureteric integrity [3,19,20,22,30]. The bowel
should be reflected sufficiently to expose the
ureter(s) and an attempt made to trace
surgical misadventure or missile path.
Intraoperative recognition of ureteric injury
can be facilitated by intravenous or intra-
© 2004 BJU INTERNATIONAL

ureteric injection of indigo carmine or
methylene blue. Extravasation of blue-tinged
urine helps to confirm the injury and location
[3,5,25]. Even without extravasation, a visually
appearing contused or bruised ureter
can have significant trauma, from blast
injury, crush or ischaemic injury (from
excessive dissection). Signs of ureteric
devascularization are wall discoloration,
absence of capillary refill, or lack of a bleeding
edge [25].
ASSOCIATED INJURIES
Concomitant intra-abdominal organ or
vascular injuries should not preclude ureteric
reconstruction [107,112]. Overall success and
complication rates after primary ureteric
repair for upper and mid ureteric injuries and
reimplantation for lower ureteric injuries are
unaffected by associated fecal contamination
or bowel injury [2,23,24]. As a general
principle, tissue interposition (i.e. omental
flap) between the two injuries may help
prevent secondary fistulae or repair
breakdown.
The management of ureteric injuries during
vascular graft surgery is controversial and
there is no clear consensus from the evidence
[53,112]. Two decades ago nephrectomy was
the treatment of choice for all ureteric injuries
and concomitant vascular graft surgery
(providing the contralateral kidney was
normal) [106]. Spirnak et al. [111], in a case
series of eight patients, showed that during
vascular graft reconstruction, if the urine is
sterile, ureteric repair is indicated and does
not unduly increase the vascular graft
infection or failure rate. Secondary renal unit
loss can be high, yet renal salvage can be
enhanced by following standard urological
principles, isolating the repair with an
omental wrap and draining the repair away
from the graft.
TYPES OF INJURY
The common types of iatrogenic ureteric
injuries, in descending order of frequency,
are ligation, kinking by suture, transection/
avulsion, partial transection, crush, and
devascularization (leading to delayed
necrosis/stricture) [13,53–117]. From
external trauma, ureteric injuries are
avulsion, partial transection and blast
injury devascularization.
© 2004 BJU INTERNATIONAL
DIAGNOSIS AND MANAGEMENT OF URETERIC INJURY
SUTURE LIGATION INJURY
When the ureter has been inadvertently
ligated during surgery often all that is
necessary is to remove the suture or surgical
clip and observe. Typically, ureteric damage is
minimal, if recognized immediately, as these
injuries most frequently include other tissue
in the ligature. Visual inspection is imperative
to exclude significant ureteric injury. At a
minimum, ureteric stent placement is prudent
in most circumstances [55,56]. When ureteric
viability is in question, UU should be
performed [55]. When an absorbable suture is
determined after surgery to have entrapped
the ureter, conservative management with
PCN tube drainage until the suture absorbs
has been reported to be successful.
Ureteric injuries during vaginal surgery are
typically ligations and not detected until after
the operation [72,74,81,98,107]. Most injuries
were associated with attempts to achieve
haemostasis without properly identifying the
ureter [98]. In all vaginal hysterectomies,
Grade 4 cystocele repairs, enterocele repairs,
and bladder neck suspensions, ureteric
integrity should be assessed with intravenous
indigo carmine [57,58,60]. When no indigo is
cystoscopically observed from the ureteric
orifice, a ureteric stent should be placed. If
complete ureteric obstruction is noted during
cystocele, enterocele and bladder neck
suspension surgery, the offending sutures are
typically removed. After vaginal hysterectomy
or vaginal vault reconstruction, sutures are
typically not removed and the ureter
reimplanted.
CRUSH INJURY
There is little direct evidence based on
retrospective data for conclusions, but rather
on case reports and expert opinion. If the
ureter has been crushed by a clamp, the
likelihood of a significant injury is high.
Generally, this occurs during an attempt to
control bleeding or on clamping/division of
pelvic vasculature. The ureteric adventitia
must be carefully inspected as it often takes
several days for the ischaemic injury to
manifest itself. The severity of the ureteric
injury depends on the size of the clamp, the
time it was applied, and the amount of tissue
crushed.
Study results are difficult to synthesise, as
circumstances are so variable that a clear
guideline for a crush injury cannot be
inferred. However, for minor injuries by a
small crushing instrument, the ureter should
be stented and drained, as a minimum [74].
For severe contusions, or if ureteric viability is
in doubt, studies support the involved ureter
being segmentally resected, debrided and re-
anastomosed over a JJ stent. The type of
ureteric repair depends on the level (location)
and extent of the injury (see below for details).
DEVASCULARIZATION
Devascularization injuries are typically not
recognized until late and present within
several days to weeks after surgery, with
complications from a urine leak or ureteric
stricture [7,26,46,115]. When noted
intraoperatively, extensive skeletonization
or thermal injury of the ureter that results
in an obviously nonviable ureter, should be
segmentally excised until healthy tissue, and
then repaired as detailed below. In most cases
the viability is difficult to assess, and it is
prudent to place a ureteric stent in any
equivocal case. Delayed injury to the ureter
can also be minimized by omental or
peritoneal coverage of the ureter.
CONTUSIONS AND PROXIMITY INJURY
The conservative management of ureteric
contusions or proximity injuries from a high-
velocity missile leads to delayed leaks and
stricture. Formal surgical resection and repair
for severe ureteric contusion is supported
[7,26,46]. With low-velocity gunshot wounds,
Cass et al. [7] reported that ureteric proximity
injuries should be stented at least, to avoid
delayed complications. Obvious contusions
require resection and surgical reconstruction.
PARTIAL AND COMPLETE TRANSECTIONS
(AVULSION) INJURY
Most partial transactions from surgical
misadventure or stab wounds can be
managed by primary sutured closure. Most of
these injuries should also be stented and
drained. If more than half the diameter of the
ureter is lacerated, an aggressive approach of
ureteric division and UU or reimplantation is
supported by published studies.
Once the injured ureter is exposed, the general
principles for ureteric reconstruction include:
(i) careful ureteric mobilization (with care to
preserve the adventitia); (ii) debridement of
devitalized tissue, until there is a bleeding
edge [11]; (iii) mucosa to mucosa, spatulated,
283
B R A N D E S ET AL.
tension-free, and watertight anastomosis
[7,10,14,31]; (iv) ureteric drainage (usually
with an internal JJ stent) [16,17,21,48]; and (v)
isolation of the anastomosis from associated
injuries [25]. Minimal handling of the
adventitia and careful peri-ureteric dissection
are paramount in preserving ureteric
vasculature. With the advent of the JJ stent,
the common use in the 1960s and 1970s of T
tubes, nephrostomy tubes and ureterostomy
fell into disfavour. Steers et al. [30] reported
UU over a JJ stent, with no nephrostomy, to be
both reliable and effective. Reports from the
1970s showed that a watertight UU had fewer
complications than one that was not.
However, before JJ stents were available
stents were used only selectively. Sieben et al.
[109] showed that stented repairs were more
successful and reliable than unstented.
Selecting the appropriate management
option depends on the patient’s physical
condition, the location and extent of injury,
injury mechanism, and the time of diagnosis.
SPECIAL MECHANISMS
URETEROSCOPIC INJURY
With the introduction of the rigid
ureteroscope there were numerous reports in
the 1980s of ureteric injuries [55,68,89].
Injuries ranged from perforations to complete
avulsions, with relatively high rates of delayed
ureteric stricture (up to 5%) [68,80,89,105].
Ureteric injury is also associated with
surgeons’ inexperience and longer operative
time [105]. Ureteric avulsion injuries that
occur during ureteroscopy are treated in
the same manner as other immediately
recognized transection injuries. Ureteric
perforations can typically be treated
successfully by ureteric stenting. However,
over the last two decades ureteroscopes have
become smaller and more flexible, surgeons’
experience has matured, placing safety
guidewires is routine and visual optics have
improved. Reports of avulsion injuries, and
other complications, have thus decreased over
the years [80,89,105].
LAPAROSCOPIC INJURY
Since the early 1970s ureteric injuries during
laparoscopic surgery have been reported.
Laparoscopy was initially only for
gynaecological indications, but with its
expanded use to all disciplines the incidence
of ureteric injury has increased [55]. Ureteric
284
injuries during laparoscopic surgery typically
occur during gynaecological laser ablation of
endometriosis or laparoscopically assisted
vaginal hysterectomy [78,84,100,104,112].
There are also case reports of ureteric injury
during laparoscopic tubal ligation,
adnexectomy, and laparoscopic uterosacral
ligament ablation. Ureteric injuries range
from a small partial tear to complete ureteric
avulsion, typically in patients with a history of
pelvic irradiation or previous extensive pelvic
surgery. Ureteric complications are often
related to surgical experience.
Partial ureteric lacerations or thermal injuries
that are diagnosed intraoperatively can be
successfully managed by endoscopically
placing a ureteric stent. Laparoscopic suturing
of the lacerated ureter has also been reported.
When ureteric transection is complete, an
immediate surgical approach is required.
However, most laparoscopic ureteric injuries
are diagnosed after a delay
[78,84,100,104,112].
MANAGEMENT
The method of ureteric repair is determined by
many factors, including the location and
length of ureteric injury, the time of diagnosis
(during or soon after surgery, or delayed), the
type of injury, the mechanism of injury, and
the presence of associated medical or surgical
illnesses.
The optimum time for repair of a ureteric
injury is during surgery when it initially
occurs. At the time of injury the tissues are
typically in their best condition, where the
options and likelihood for success are
greatest. Immediate recognition and repair
allow for better results and fewer
complications than after a delay.
Unfortunately most (>65%) iatrogenic
ureteric injuries and most (75–93%) blunt
PUJ injuries are discovered after a delay
[41–45,65,71,74,82,85,92,109,111,117].
Injuries that are detected after surgery or
delayed tend to be more complex, require
more complex repairs, require multiple
procedures, and have higher rates of
nephrectomy and death
[7,13,15,34,41,45,74,117].
URINARY DIVERSION
Ureteric injuries with a significant delay in
diagnosis are best managed initially by PCN
drainage or endoscopic ureteric stenting
[12,15,46,48]. Placing a PCN is usually safer
and more universally applicable. Retrograde
ureteric stenting is typically unsuccessful
(50–95%) and should be attempted
only for certain low-grade injuries
[13,15,46,49,69,72,100] Antegrade stenting is
often successful, particularly after a few days
of proximal urinary diversion [49]. If a stent
can be placed an open repair is required only
for persistent urinary leak or ureteric stricture
formation [69,72].
A PCN should also be placed into the urinoma
[90]; unless drained, the extravasated urine
may lead to secondary retroperitoneal fibrosis
and ureteric obstruction. At 2–3 weeks after
surgery, re-exploration is typically difficult
and complex because of inflammation,
fibrosis, adhesions, haematoma and distorted
anatomy. The definitive repair should be
delayed or staged [46,107].
DAMAGE CONTROL
In an intraoperative situation where a high-
grade ureteric injury is identified but the
patient is unstable, cold, coagulopathic or
acidotic, immediate ureteric reconstruction
can potentially compromise survival, and thus
it is often best delayed until the patient is
resuscitated and stable. Ureteric exterioration
or ureteric ligation with a PCN tube followed
by a staged and planned definitive repair can
at times be the best option. Such a ‘damage
control’ method of management is supported
only by anecdotal case reports [32,51]. The
appropriate ureteric reconstruction is planned
only after obtaining functional and anatomic
radiographs.
URETERIC RECONSTRUCTION
PRIMARY CLOSURE
This technique occasionally can be considered
in the management of low-grade lacerations;
it should not be used for gunshot wounds.
Such injuries require careful debridement
to avoid delayed tissue breakdown as a
consequence of underestimated ischaemia
created by the missile’s cavitation [37].
UU
Most reported repairs with UU are with the
abdominal ureter (above the iliac artery
bifurcation). UU can be appropriate in very
© 2004 BJU INTERNATIONAL

selected cases of a pelvic ureter where
dissection is not extensive and the vascular
supply to the distal ureter is not
compromised. However, deep in the pelvis
UU can be technically challenging
[1–33,13,46–117].
Lacerations involving the middle or upper
third of the ureter are often best managed
by primary UU [4,9,11,12,14,46,47]. After
debriding nonviable ureter, each end is
spatulated on opposite sides and a watertight,
tension-free anastomosis made, over a
ureteric stent, using absorbable sutures.
With concomitant intra-abdominal organ
injury, to prevent fistula formation, the
omentum should be used mobilized to
exclude the ureter and protect the repair
[34,35,37,38,40–45].
URETERIC REIMPLANTATION
Injuries to the distal third of the ureter
that are close to the bladder or within the
intramural tunnel usually can be successfully
and reliably managed by UNC (reimplantation
into the bladder) for repair. In general,
pelvic ureter viability distal to the ureteric
injury is unreliable due to extensive prior
dissection or blast injury. Long defects
(usually >2 cm) typically require a
Psoas hitch or Boari flap reconstruction
[3,4,22,26,32,48,50,51,54,59,94,95].
UNC alone is used to repair distal ureteric
injuries close enough to the bladder so that a
tension-free and tunnelled anastomosis can
be made with no bladder mobilization. The
proximal end of the ureter is debrided to
viable tissue, spatulated, and then brought
through a cystotomy in the posterior bladder
wall, medial to the original hiatus (not the
mobile lateral wall). Reflux is usually clinically
insignificant in the adult, but when it is a
concern, a submucosal tunnel is created
based on the standard ratio of tunnel length
to ureteric diameter. The repair is stented and
a prevesical drain placed.
PSOAS HITCH
There are many retrospective studies
reporting excellent success, few
complications and durability with the psoas
hitch [3,4,22,26,32,48,50,51,54,59,94,95].
Injuries involving the lower third of the ureter
(caudal to the iliac vessels) are typically best
managed by a psoas hitch in conjunction with
ureteric reimplantation. The psoas hitch is
© 2004 BJU INTERNATIONAL
DIAGNOSIS AND MANAGEMENT OF URETERIC INJURY
preferred here to UU because the pelvic ureter
has a tenuous independent blood supply that
may not survive transection or previous
extensive dissection (i.e. abdominal
hysterectomy), and allows for a tension-free
and nonrefluxing anastomosis. The proximal
ureteric end is debrided and spatulated,
the bladder fundus mobilized and the
contralateral superior vesical pedicle ligated.
After an anterior cystotomy is made, the
bladder dome is pulled cephalad and lateral,
and sutured to the psoas minor tendon (or to
the psoas major when the tendon is absent).
Care is taken to avoid entrapping the
genitofemoral nerve. The ureter is then
reimplanted.
ANTERIOR BLADDER WALL FLAP (BOARI FLAP)
Typically, injuries encompassing the lower
two-thirds of the ureter (too long to be
bridged by the psoas hitch procedure) are best
managed with an anterior bladder wall flap, in
conjunction with a psoas hitch. In the acute
setting there are no reports of Boari flap use
for external trauma and only a few case
reports for iatrogenic trauma. However, the
evidence supports its use in planned, delayed
ureteric reconstruction. Success and reliability
rates are high, with reports for external
trauma (mainly case series) and for iatrogenic
trauma (a few large series)
[55,59,73,86,97,114].
This procedure should not be used in patients
with previous pelvic irradiation or neurogenic
bladder disease. The bladder is mobilized and
fixed to the psoas tendon as described for a
psoas hitch [86]. A pedicle of bladder is
dissected, rotated cephalad, and tubularized
to bridge the gap of missing ureter. The ureter
is reimplanted submucosally into the flap and
the bladder closed. Using this technique, most
mid-ureteric defects can be easily bridged.
The gap can be further shortened a few
centimetres by caudal nephropexy [114].
TUU
When the defect to the lower ureter is
extensive and/or the bladder is small, fibrotic,
or not easy to mobilize, a TUU is particularly
useful. The TUU is rarely used, with only a few
large reported series, and is typically a
secondary or delayed procedure [83,99].
Relative contraindications to a TUU are
upper tract urothelial cancer, genitourinary
tuberculosis, recurrent nephrolithiasis,
pelvic irradiation, retroperitoneal fibrosis,
chronic pyelonephritis, or anomalies of the
recipient ureter. The TUU involves bringing the
injured (donor) ureter across the midline
through a window in the colonic/sigmoid
mesentery, above the inferior mesenteric
artery. The spatulated donor ureter is
anastomosed end-to-side to the contralateral
(recipient) ureter over a JJ stent. The main
disadvantage to the TUU is the potential
for damage to the recipient ureter, thus
endangering both kidneys. However, reported
success rates are excellent (up to 97%)
[83,99].
For more extensive injuries involving the
distal two-thirds of the ureter, there are
anecdotal reports of transureteropyelostomy
by anastomosing the involved ureter to the
medial aspect of the contralateral renal pelvis.
Potentially, the integrity of the normal ureter
or pelvis can be jeopardized and it is thus
indicated in highly selected cases.
URETEROCALYCOSTOMY
There is little published evidence to
support this method except in highly
selected anecdotal circumstances [13]. A
ureterocalycostomy can be used for extensive
injuries to the PUJ and proximal ureter.
However, the lower pole of the involved
kidney must be amputated to expose the
infundibulum of the inferior calyx, for an end-
to-end, spatulated anastomosis. The failure
rate and anastomotic stricture rate are high
[13].
ILEAL INTERPOSITION
For complete ureteric avulsion or loss, the
ureter can be reconstructed by interposing a
segment of ileum. This cannot be done acutely
as it requires a standard mechanical and
antibiotic bowel preparation. Case reports
to retrospective studies support its use,
with overall success rates of up to 81%
[44,47,59,63,88]. Bacteriuria and vesico-ileal
reflux are common, but do not worsen renal
function [63,88]. For extensive bilateral
ureteric injuries, a segment of ileum can be
tailored as a conduit for both kidneys. This can
be used alone or in conjunction with a psoas
hitch or anterior bladder wall flap to minimize
the segment of ileum used. Reported
complications of ileal interposition include
obstruction, prolonged mucus formation,
stones, recurrent infections and metabolic
acidosis [59,63,88].
285
B R A N D E S ET AL.
RENAL AUTOTRANSPLANTATION
In patients with a solitary kidney or
compromised renal function, complete
ureteric loss or multiple failed repairs can be
managed by renal autotransplantation. The
affected kidney is transplanted into the iliac
fossa with vascular anastomoses of the renal
to iliac vessels and urinary continuity restored
with a uretero- or pyelo-vesicostomy.
Excellent long-term preservation of renal
function has been reported in small case
series and reports [46,59,61] but renal loss can
occur in up to 8% [61].
DELAYED URETERIC COMPLICATIONS
FISTULA
Fistulae (mainly ureterovaginal and
secondarily uretero-uterine) are rare after
ureteric repair [93,115]. They usually develop
when the ureteric injury is undiagnosed
intraoperatively, and the ureter undergoes
a delayed necrosis and/or stricture
(obstruction). Other factors that contribute to
fistula formation are infection (abscess,
peritonitis), inflammation, a foreign body and
neoplasia [93]. With external trauma fistulae
are caused by missed or proximity injuries
[1,13,21,26,46,52]. A history of previous pelvic
irradiation is another independent risk factor,
increasing the risk for fistula formation after
pelvic surgery, and complicating the difficulty
of fistula repair. Ureteric fistulae usually do
not require an open operation, and typically
close spontaneously with proper drainage and
ureteric stenting [93]. When the repair is
unsuccessful by urinary diversion and
stenting, UU or ureteric reimplantation has
been reportedly successful
[1,13,21,26,46,52,93,115].
STRICTURE
Strictures develop when an ischaemic ureter,
often from extensive adventitial dissection,
radiation or blast injury, heals by scar tissue
[11,13,16,22,31,40,46,49,110]. Flank or
abdominal pain and UTI/pyelonephritis is a
common presentation. Ureteric strictures that
are diagnosed early, distal and are relatively
short (<2 cm) can be managed successfully (in
50–80% of cases) by endourological
procedures, i.e. dilatation (antegrade) or
endoscopic incision and stenting [110]. For
endoscopic failures, late stricture discovery,
overly dense or long, or radiation induced,
286
open segmental excision and repair is usually
necessary [110].
SUMMARY
A delay in diagnosis is the most important
factor contributing to the morbidity of
ureteric injury. By maintaining a high index of
suspicion and prompt use of appropriate
radiographic and intraoperative evaluations,
the difficulty in making the diagnosis can be
minimized. The timing for definitive ureteric
repair is based on the patient’s overall
condition, promptness of injury recognition,
and the location and degree of injury. When
identified promptly ureteric injuries generally
should be repaired immediately. However, if
the patient is unstable or the diagnosis
delayed, temporizing measures are typically
used to divert the urine. With minimally
invasive techniques to manage urinary leak,
ureteric reconstruction can be safely staged
to later in the recovery period. Successful
surgical management requires familiarity
with the broad reconstructive options and
attention to the mechanism, extent and
location of the injury. As founded on this
evidence-based analysis and review of
published studies, adherence to the diagnostic
and therapeutic principles outlined minimizes
complications and maximizes successful
outcomes and renal preservation.
FUTURE INVESTIGATIONS
Studies of prospective design are clearly
lacking for urological trauma. Class 1
(prospective randomized) and class 2
(prospective noncomparative) studies are
desperately needed. A consortium of active
trauma centres is needed to consolidate
their experiences by conducting multi-
institutional, randomized prospective studies
on varying issues in traumatic injuries to the
ureter. Potential issues for investigation are:
• The role of ‘damage control’ in managing
external ureteric injuries; an outcomes
analysis study.
• The sensitivity and specificity (i.e. predictive
value) of haematuria, and other physical signs
in diagnosing ureteric injuries.
• The sensitivity and specificity of ureteric
imaging for penetrating abdominal trauma.
• The role, sensitivity and specificity of US
and other imaging methods for ureteric
trauma.
As to iatrogenic ureteric injuries, other
potential studies are:
• A contemporary and prospective series on
radical hysterectomy and ureteric injury.
• Effects and outcomes of associated colonic
and pancreatic injuries on ureteric injury and
reconstruction.
• Prospective, multi-institutional study on
vascular graft surgery and associated ureteric
injury and leak.
Evidentiary tables summarizing each of the
referenced articles are available from the
author upon request.
CONFLICT OF INTEREST
None declared.
REFERENCES
1 Albert DJ, Banks DE Jr, Persky L.
Civilian ureteral gunshot injuries. Ohio
State Med J 1970; 66: 479–84
2 Azimuddin K, Milanesa D, Ivantury R,
Porter J, Ehrenpreis M, Allman DB.
Penetrating ureteric injuries. Injury 1998;
29: 363
3 Brandes SB, Chelsky MJ, Buckman RF,
Hanno PM. Ureteral injuries from
penetrating trauma. J Trauma 1994; 36:
766
4 Bright TC, Peters PC. Ureteral injuries
due to external violence: 10 years
experience with 59 cases. J Trauma 1977;
17: 616–20
5 Campbell EW, Filderman PS, Jacobs
SC. Ureteral injury due to blunt and
penetrating trauma. Urology 1992; 40:
216
6 Carlton CE, Scott R Jr, Guthrie AG. The
initial management of ureteral injuries: a
case report of 78 cases. Urol 1971; 105:
340–55
7 Cass AS. Ureteral contusion with gunshot
wounds. J Trauma 1984; 24: 59–60
8 Digiacomo JC, Frankel H, Rotondo MF,
Schwab CW, Shaftan GW. Preoperative
radiographic staging for ureteral injuries
is not warranted in patients undergoing
celiotomy for trauma. Am Surg 2001; 67:
969–73
9 Eickenberg HU, Amin M. Gunshot
wounds to the ureter. J Trauma 1976; 16:
562–5
10 Evans RA, Smith JV. Violent injuries to
the upper ureter. J Trauma 1976; 16:
558
© 2004 BJU INTERNATIONAL

11 Fisher S, Young DA, Malin JM Jr,
Pierce JM Jr. Ureteral gunshot wounds.
J Urol 1972; 108: 238
12 Franko I, Eshghi M, Schutte H et al.
Value of proximal diversion and ureteral
stenting in management of penetrating
ureteral trauma. Urology 1988; 32: 99–
102
13 Ghali AM, El Malik EM, Ibrahim AI,
Ismail G, Rashid M. Ureteric injuries.
diagnosis, management, and outcome.
J Trauma 1999; 46: 150–8
14 Holden S, Hicks CC, O’Brien DP III,
Stoine HH, Walker JA, Walton KN.
Gunshot wounds of the ureter; A 15-year
review of 63 consecutive cases. J Urol
1976; 116: 562
15 Khashu BL, Seery WH, Smulewicz JJ,
Rothfeld SH. Gunshot injuries to the
ureter. Urology 1975; 6: 182
16 Lankford R, Block VM, Politano VA.
Gunshot wounds of the ureter; A review
of 10 cases. J Trauma 1974; 14: 848–52
17 Liroff SA, Pontes JES, Pierce JM Jr.
Gunshot wounds of the ureter: 5 years of
experience. J Urol 1977; 118: 551
18 McGinty DM, Mendez R. Traumatic
ureteral injuries with delayed recognition.
Urology 1977; 10: 115
19 Medina D, Lavery R, Ross SE et al.
Ureteral trauma: preoperative studies
neither predict injury nor prevent missed
injuries. J Am Coll Surg 1998; 186: 641
20 Palmer LS, Rosenbaum RR, Gershbaum
MD, Kreutzer ER. Penetrating ureteral
trauma at an urban trauma center: 10
year experience. Urology 1999; 54:
34–6
21 Parker JM. Re-emphasizing the
importance of urinary tract diversion and
splinting in injuries of the upper third of
the ureter. J Urol, 1971; 106: 368
22 Perez-Brayfield MR, Keane TE, Krishnan
A, Lafontaine P, Feliciano DV, Clarke
HS. Gunshot wounds to the ureter; A 40
year experience at Grady Memorial
Jospital. J Urol 2001; 166: 119–21
23 Peterson N, Pitts J. Penetrating injuries
of the ureter. J Urol 1981; 126: 587–90
24 Pitts JC, Peterson NE. Penetrating
injuries of the ureter. J Trauma 1981; 21:
978–82
25 Presti JC, Carroll PR, McAninch JW.
Ureteral and renal pelvic injuries from
external trauma: Diagnosis and
management. J Trauma 1989; 29: 370–4
26 Rohner TJ Jr. Delayed ureteral fistula
from high velocity missiles; report of 3
cases. J Urol 1971; 105: 63
© 2004 BJU INTERNATIONAL
DIAGNOSIS AND MANAGEMENT OF URETERIC INJURY
27 Rober PE, Smith JB, Pierce JM. Gunshot
injuries to the ureter. J Trauma 1990; 30:
83
28 Salvatierra O Jr, Bucklew B. Penetrating
ureteral injuries. Surg Gynecol Obstet
1969; 128: 591
29 Spirnak JP, Persky L, Resnick MI. The
management of civilian ureteral gunshot
wounds: a review of 8 patients. J Urol
1985; 134: 733
30 Steers WD, Corriere JN, Benson GS,
Boileau M. The use of indwelling ureteral
stents in managing ureteral injuries due
to external violence. J Trauma 1985; 25:
1001
31 Velhamos GC, Degiannis E, Wells M,
Souter I. Penetrating ureteral injuries.
The impact of associated injuries on
management. Am Surg 1996; 62: 461–7
32 Velmahos GC, Degiannis E. The
management of urinary tract injuries
after gunshot wounds of the anterior and
posterior abdomen. Injury 1997; 28: 535–
8 management of ureteral injuries from
33 Walker JA. Injuries of the ureter due
to external violence. J Urol 1969; 102:
410–3
34 Ambiavagar R, Nambiar R. Traumatic
closed avulsion of the upper ureter. Injury
1979; 11: 71
35 Boone TB, Gilling PJ, Husman DA.
Ureteropelvic junction disruption
following blunt abdominal trauma. J Urol
1993; 150: 33
36 Brown SL, Hoffman DM, Spirnak JP.
Limitations of Routine Spiral CT in the
evaluation of blunt renal trauma. J Urol
1998; 160: 1979
37 Cass AS. Blunt renal pelvic and ureteral
injury in multiple-injured patients.
Urology 1983; 23: 268
38 Kawashima A, Sandler CM, Corriere JN
Jr, Rodgers BM, Goldman SM.
Ureteropelvic junction injuries secondary
to blunt abdominal trauma. Radiology
1997; 205: 487
39 Kenney PJ, Panicek DM, Witanowski LS.
Computed tomography of ureteral
disruption. J Comput Assist Tomogr 1987;
11: 480
40 Laberge I, Homsy YL, Dadour G, Beland
G. Avulsion of ureter by blunt trauma.
Urology 1979; 13: 172
41 Mulligan JM, Cagiannos I, Collins JP,
Millward SF. Ureteropelvic junction
disruption secondary to blunt trauma:
excretory phase imaging (delayed films)
should help prevent a missed diagnosis.
J Urol 1998; 159: 67
42 Palmer JM, Drago JR. Ureteral avulsion
from nonpenetrating trauma. J Urol 1981;
125: 108
43 Powell MA, Nicholas JM, Davis JW.
Blunt ureteropelvic junction disruption.
J Trauma 1999; 47: 186
44 Reznichek RC, Brosman SA, Rhodes DB.
Ureteral avulsion from blunt trauma.
J Urol 1973; 109: 812
45 Starinsky R, Melzer M, Modai D
et al. Blunt abdominal trauma with
unrecognized urinary tract injury. Israel J
Med Sci 1984; 20: 401
46 Al-ali M, Haddad LF. The late
treatment of 63 overlooked or
complicated ureteral missile injuries:
the promise of nephrostomy and role of
autotransplantation. J Urol 1996; 156:
1918–21
47 Archbold JAA, Barros-D’Sa AAB,
Morrison E. Genito-urinary injuries of
civil hostilities. Br J Surg 1981; 68: 625
48 Stutzmann RE. Ballistics and the
high velocity missiles. J Urol 1977; 118:
947
49 Toporoff B, Sclafani S, Scalea T et al.
Percutaneous antegrade ureteral stenting
as an adjunct for treatment of
complicated ureteral injuries. J Trauma
1992; 32: 534–8
50 Townsend M, Defalco AJ. Absence of
ureteral opacification below ureteral
disruption: a sentinel CT finding. Am J
Roentgenol 1995; 164: 253–4
51 Tucak A, Peter Z, Kuvezdic H. War
injuries of the ureter. Mil Med 1997; 162:
344–5
52 Vuckovic I, Tucak A, Gotovac J et al.
Croatian experience in the treatment of
629 urogenital war injuries. J Trauma
1995; 39: 733
53 Adams JR Jr, Mata JA, Culkin DJ,
Venable DD. Ureteral injury in abdominal
vascular reconstructive surgery. Urology
1992; 39: 77–81
54 Ahn M, Loughlin KR. Psoas hitch
ureteral reimplantation in adults-analysis
of a modified technique and timing of
repair. Urology 2001; 58: 184–7
55 Assimos DG, Patterson LC, Taylor CL.
Changing incidence and etiology of
iatrogenic ureteral injuries. J Urol 1994;
152: 2240–6
56 Aslan P, Brooks A, Drummond M, Woo
H. Incidence and management of
gynecological related ureteric injuries.
Aust N Z J Obstet Gynacol 1999; 39: 178–
81
287
B R A N D E S ET AL.
57 Badenoch DF, Tiptaft RC, Thakar DR
et al. Early repair of accidental injury
to the ureter or bladder following
gynecological survey. Br J Urol 1987;
59: 516
58 Beland G. Early treatment of ureteral
injuries found after gynecological surgery.
J Urol 1977; 188: 25–7
59 Benson MC, Ring KS, Olsson CA.
Ureteral reconstruction and bypass:
Experience with ileal interposition, the
Boari flap-psoas hitch and renal
autotransplantation. J Urol 1990; 43:
202–23
60 Blandy JP, Badenoch DF, Fowler CG,
Jenkins BJ, Thomas NW. Early repair of
iatrogenic injury to the ureter or bladder
after gynecological surgery. J Urol 1991;
146: 761–5
61 Bodie B, Novick AC, Rose M, Staffron
RA. Long results with renal
autotransplantation for ureteral
replacement. J Urol 1986; 136: 1187–9
62 Bothwell WN, Bleicher RJ, Dent TL.
Prophylactic ureteral catheterization in
colon surgery. A five year review. Dis
Colon Rectum 1994; 37: 330–4
63 Boxer RJ, Fritzsche P, Skinner DG et al.
Replacement of the ureter by small
intestine: Clinical application and results
of the ileal ureter in 89 Patients. J Urol
1979; 121: 728–31
64 Bowsher WG, Shah PJ, Costello AJ,
Tiptaft RC, Paris AN, Blandy JP. A
critical appraisal of the boari flap. Br J Urol
1982; 54: 682–5
65 Bright TC, Peters PC. Ureteral injuries
secondary to operative procedures.
Report of 24 cases. Urology 1977; 9:
22–6
66 Brown RB. Surgical and external ureteric
trauma. Aust NZ J Surg 1977; 47: 471–6
67 Carley ME, McIntire D, Carley JM,
Scaffer J. Incidence, risk factors and
morbidity of unintended bladder or ureter
injury during hysterectomy. Int J Pelvic F
Dys 2002; 13: 18–21
68 Chang R, Marshall FF. Management of
ureteroscopic injuries. J Urol 1987; 137:
1132–5
69 Cormio L, Battaglia M, Traficante A,
Selvaggi FP. Endourological treatment
of ureteric injuries. Br J Urol 1993; 72:
165–8
70 Cormio L, Ruutu M, Traficante A,
Battaglia M, Selvaggi FP. Management
of bilateral ureteric injuries after
gynecological and obstetric procedures.
Int Urol Nephrol 1993; 25: 551–5
288
71 Daly JW, Higgins KA. Injury to the ureter
during gynecologic surgical procedures.
Surg Gynecol Obstet 1988; 167: 19–22
72 Dowling RA, Corriere JN Jr, Sandler
CM. Iatrogenic ureteral injury. J Urol
1986; 135: 912–5
73 Flynn JT, Tiptaft RC, Woodhouse CR,
Paris AM, Blandy JP. The early and
aggressive repair of iatrogenic ureteric
injuries. Br J Urol 1979; 51: 454–7
74 Fry DE, Milholen L, Harbrecht PJ.
Iatrogenic ureteral injury. Options
Manage Arch Surg 1983; 118: 454–7
75 Gayer G, Zissin R, Apter S et al. Urinomas
caused by ureteral injuries. CT
appearance. Abdom Imaging 2002; 27:
88–92
76 Gangai MP, Agee RE, Spence CR.
Surgical injury to the ureter. Urology
1976; 8: 22–7
77 Goodno JA Jr, Powers TW, Harris VD.
Ureteral injury in gynecologic surgery. A
ten year review in a community hospital.
Am J Obstet Gynecol 1995; 172: 1817–20
78 Grainger DA, Soderstrom RM, Schiff SF,
Glickman MG, DeCherney AH, Diamond
MP. Ureteral injuries at laparoscopy:
Insights into diagnosis, management, and
prevention. Obstet Gynecol 1990; 75: 839
79 Hakki-Siren P, Sjoberg J, Tiitnen A.
Urinary tract in juries after hysterectomy.
Obstet Gynecol 1998; 92: 113–8
80 Harmon WJ, Sershon PD, Blute ML,
Patterson DE, Segu JW. Ureteroscopy;
Current practice and long-term
complications. J Urol 1997; 157: 28–32
81 Higgins CC. Ureteral injuries during
surgery. A review of 87 cases. JAMA 1967;
199: 118
82 Hoch WH, Kursh ED, Persky L. Early,
aggressive management of intraoperative
ureteral injuries. J Urol 1975; 114: 530–2
83 Hodges CV, Barry JM, Fuchs EF et al.
Transureteroureterostomy: 25 year
experience with 100 patients. J Urol 1980;
123: 834–8
84 Hung MJ, Huang CH, Chou MM, Liu FS,
Ho ES. Ultrasonic diagnosis of ureteral
injury after laparoscopically assisted
vaginal hysterectomy. Ultasound Ob
Gynecol 2000; 16: 279–83
85 Ihse I, Arnesjo B, Jonsson G. Surgical
injuries of the ureter: a review of 42 cases.
Scand J Urol Nephrol 1975; 9: 39–44
86 Kishev SV. Indications for combined
psoas-bladder hitch procedure with Boari
vesical flap. Urology 1975; 6: 447–52
87 Kostakopoulos A, Deliveliotis C, Louras
G, Giftopoulos S, Skolaricos A. Early
repair of the ureter or bladder after
hysterectomy. Int Urol Nephrol 1998; 30:
445–50
88 Kochakarn W, Tirapanich W,
Kositchaiwat S. Ileal interposition for the
treatment of a long gap ureteral loss.
J Med Assoc Thai 2000; 83: 37–41
89 Kramolowsky EV. Ureteral perforation
during ureterorenoscopy. Treatment and
management. J Urol 1987; 138: 36–8
90 Lask D, Abarbanel J, Luttwak Z, Manes
A, Makamelm E. Changing trends in the
management of iatrogenic ureteral
injuries. J Urol 1995; 154: 1693–5
91 Mann WJ. Intentional and unintentional
ureteral surgical treatment in gynecologic
procedures. SGO 1991; 172: 453–6
92 Mann WJ, Arato M, Pastner B, Stone
ML. Ureteral injuries in an obstetrics and
gynecology training program. Etiology
and management. Obstet Gynecol 1988;
72: 82–5
93 Mandal AK, Sharma SK, Vaidyanathan
S, Dwani AK. Ureterovaginal fistula.
Summary of 18 years experience. Br J Urol
1993; 65: 453
94 Mathews R, Marshall FF. Versatility
of the adult psoas hitch ureteral
reimplantation. J Urol 1997; 158: 2078–
82
95 Meirow D, Moriel EZ, Zilberman M,
Frakas A. Evaluation and treatment of
iatrogenic ureteral injuries during
obstetric and gynecologic operations for
nonmalignant conditions. J Am Coll Surg
1994; 178: 144–8
96 Mendez R, McGinty DM. The
management of delayed recognized
ureteral injuries. J Urol 1978; 119: 192–3
97 Motiwala HG, Shah SA, Patel SM.
Ureteric substitution with boari bladder
flap. Br J Urol 1990; 66: 369–71
98 Neuman M, Eidelman A, Langer R,
Golan A, Bukovsky I, Caspi E. Iatrogenic
injuries to the ureter during gynecologic
and obstetric operations. SGO 1991; 173:
268–72
99 Noble I, Lee K, Mundy A.
Transureteroureterostomy – a review of
253 cases. Br J Urol 1997; 79: 20–3
100 Oh BR, Kwon DD, Park KS, Ryu SB,
Park YI, Presti JC Jr. Late presentation
of ureteral injury after laparoscopic
surgery. Obstet Gynecol 2000; 95: 337–9
101 Polat O, Gul O, Aksoy Y, Ozbey I,
Demirel A, Bayraktar Y. Iatrogenic
injuries to ureter, bladder, and urethra. Int
Urol Nephrol 1997; 29: 13–8
102 Rafique M, Arif MH. Management of
© 2004 BJU INTERNATIONAL

iatrogenic ureteric injuries associated
with gynecological surgery. Int Urol
Nephrol 2002; 34: 31–5
103 Rajasekar D, Hall M. Urinary tract
injuries during obstetric intervention. Br J
Obstet Gyn 1997; 104: 731–4
104 Saidi MH, Sadler RK, Vancaillie TG,
Akright BD, Farhart SA, White AJ.
Diagnosis and management of serious
urinary complications after operative
laparoscopy. Obstet Gynecol 1996; 87:
272–6
105 Schuster TG, Hollenbeck BK, Faerber
GJ, Wolf JS Jr. Complications of
ureteroscopy: Analysis of predictive
factors. J Urol 2001; 166: 538–40
106 Schapira HE, Li R, Gribetz M et al.
Ureteral injuries during vascular surgery.
J Urol 1981; 125: 293
107 Selzman AA, Spirnak JP. Iatrogenic
ureteral injuries: a 20 year experience in
treating 165 injuries. J Urol 1996; 155:
878–81
108 Sharfi AR, Ibrahim F. Ureteric injuries
© 2004 BJU INTERNATIONAL
DIAGNOSIS AND MANAGEMENT OF URETERIC INJURY
during gynecological surgery. Aint Urol
Nephrol 1994; 26: 277–81
109 Sieben DM, Howerton L, Amin M, Hotl
H, Lich R Jr. The role of ureteral stenting
in the management of surgical injury of
the ureter. J Urol 1978; 119: 330–1
110 Smith AD. Management of iatrogenic
ureteral strictures after urological
procedures. J Urol 1988; 140: 1372–4
111 Spirnak JP, Hampel N, Resnick MI.
Ureteral injuries complicating vascular
surgery: Is repair indicated. J Urol 1989;
141: 13–4
112 Tamussino KF, Lang PF, Breinl E.
Ureteral complications with operative
gynecologic laparoscopy. Am J Obstet
Gynecol 1998; 178: 967–70
113 Tarkington MA, Dejter SW Jr,
Bresette JF. Early surgical management
of extensive gynecologic ureteral injuries.
SGO 1991; 173: 17–21
114 Thompson IM, Ross G Jr. Long-term
results of bladder flap repair of ureteral
injuries. J Urol 1974; 111: 483–7
115 Underwood PB Jr, Wilson WC,
Kreutner A, Miller MC III, Murphy E.
Radical hysterectomy. A critical review of
twenty-two years experience. Am J Obstet
Gynecol 1979; 134: 889
116 Witters S, Cornelissen M, Vereecken R.
Iatrogenic ureteral injuries: Aggressive or
conservative treatment. Am J Obstet
Gynecol 1986; 155: 582–4.
117 Zinman LM, Libertino JA, Roth RA.
Management of operative ureteral injury.
Urology 1978; 12: 290–303
Correspondence: Steven Brandes, Washington
University Medical Center, Division of
Urologic Surgery, Campus Box 8242, 4960
Children’s Place, St. Louis, MO 63110, USA.
e-mail: brandess@msnotes.wustl.edu
Abbreviations: LOE, level of evidence; RPG,
retrograde pyelography; US, ultrasonography;
PCN, percutaneous nephrostomy; TUU,
transuretero-ureterostomy; UU, uretero-
ureterostomy; UCN, ureteroneocystostomy.
289