AUTHOR AND EDITOR INFORMATION

Section 1 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

INTRODUCTION

Section 2 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Ureteral injuries due to external trauma are rare. The ureter is well-protected in the retroperitoneum by the bony pelvis, psoas muscle, and vertebrae. As a result, any damage to the ureter must come from a significant traumatic event that almost always occurs with collateral injury to other abdominal structures. Much of the presentation and management of ureteral injuries are dictated by the severity and management of the associated injuries. This article discusses the etiology, presentation, evaluation, and management of ureteral injuries due to external causes.

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Blood in the Urine and Intravenous Pyelogram.

Etiology

Injury to the ureter can occur from either iatrogenic causes or external trauma. Iatrogenic causes are more common and may occur during abdominopelvic surgery or ureteroscopy. Such injuries may result from ligation, transection, electrocautery, avulsion, or secondary involvement from a fibrotic or inflammatory reaction. These injuries are usually isolated and present differently from those associated with external violence.

External Trauma

Fortunately, fewer than 3% of gunshot injuries involve the ureters. The incidence of ureteral injury is even less common with stab wounds. Nevertheless, stab wounds to the abdomen with long-bladed weapons or stab-wounds entry point posterior to the midaxillary line should always raise suspicion for possible ureteral involvement.
 
Blunt trauma may result in ureteral injury from several mechanisms. These mostly involve deceleration or acceleration mechanisms with sufficient force to disrupt the ureter from either the ureteropelvic or ureterovesical junctions. Such injuries may be secondary to a high-speed motor-vehicle collision, a fall from a significant height, or a direct blow to L2-3 vertebrae. 

Iatrogenic Causes

Gynecologic surgery

The abdominal hysterectomy was once the most common cause of iatrogenic ureteral injury. However, ureteral injuries can occur during any abdominopelvic surgery. Risk factors for ureteral injury during open surgery include previous operations, bulky tumors, retroperitoneal fibrosis, previous radiation, inflammatory processes, ureteral duplication, and ectopic kidneys. These all have the potential to alter the expected course of the ureter. Iatrogenic injury may occur as a result of crushing, suture ligation, devascularization, electrocautery, cryoablation, avulsion, or transection of the ureter.

Approximately 52-82% of surgical ureteral injuries occur during gynecologic procedures. Hysterectomy accounts for most of these cases. However, the modality used plays a role; ureteral injury occurs 1.3-2.2% of abdominal hysterectomies and in only 1.3% and 0.03% of laparoscopic and vaginal hysterectomies, respectively.^{2, 3, 4, 5, 6} The risk factors for ureteral injury include a large uterus, pelvic organ prolapse, and prior pelvic surgery. The injury typically occurs in the distal ureter in the region of the infundibulopelvic ligament or as a ureter crosses inferior to the uterine artery, often from blind clamping and ligature placement to control hemorrhage. The ureter may also be injured during laparoscopic gynecologic procedures, most commonly by cauterization or clipping. Interestingly, 33-87% of ureteral injuries caused during laparoscopic surgery are not recognized at the time.^{7, 8, 9, 6}

Colorectal surgery

After gynecologic procedures, colorectal surgery causes the most iatrogenic ureteral injuries. Together, low anterior resection (LAR) and abdominal perineal resection (APR) account for 9% of all such incidences in a combined series and 67% of all general surgical injuries. The incidence of ureteral injury during LAR or APR is 0.3-5.7%.¹⁰ The left ureter is involved more commonly than the right, as it may be elevated with the sigmoid mesentery and mistaken for a mesenteric vessel.

Vascular surgery

Iatrogenic injury to the ureter during vascular surgery is more common than previously thought. The overall incidence has been reported as 2-4%. Ureteral injury may result from direct injury during the procedure or may present as a fistula or hydronephrosis postoperatively. Patients undergoing repeat aortoiliac surgery appear to be at the greatest risk for ureteral injury.

The incidence of asymptomatic hydronephrosis after abdominal vascular surgery has been estimated to be as high as 20%, while only 2% of cases are symptomatic. Of those who are symptomatic, 35% present within 2 months, 50% within 12 months, and 18% after 5 years.¹¹ Risk factors include ureteral devascularization, retroperitoneal fibrosis, radiation exposure, graft infections, graft dilations, false aneurysms, and anterior graft placement. In patients with early obstruction (<6 mo), it tends to resolve spontaneously.

Another condition related to vascular surgery is the development of an aortoureteric or graft-ureteric fistula, which can lead to massive hematuria and vascular collapse. The risk factors for the development of the fistulae include anterior graft placement, prolonged use of a ureteral stent, compression, and obstruction.

Urologic procedures

Ureteral injuries that occur during urologic procedures are becoming increasingly common. In a recent series, they comprised 42% of all iatrogenic injuries.¹² The increased incidence of ureteral injuries during urologic procedures is directly related to the increased use of ureteroscopic equipment. Endoscopic procedures accounted for 79% of injuries, while open surgery accounted for 21%. Most of these injuries occurred in the distal ureter (87%).¹² The injuries include perforation, stricture, avulsion, false passage, intussusception, and prolapse into the bladder. Risk factors for these injuries include radiation, tumor, inflammation, and impacted stones. Injury also may be related to the equipment used, such as wires, baskets, and lithotriptors (eg, electrohydraulic lithotriptor [EHL]).

The increasing use of thermoablation and cryoablation for renal tumors have placed the ureter is at risk for injury. This risk is theoretically higher for lower pole and medially located tumors.

Other iatrogenic causes

Other surgical procedures that may injure the ureters include spinal surgery for disc disease, vaginal surgery for pelvic prolapse, and appendectomy.

Radiation injury to the ureter is rare. The ureter is more resistant to the effects of radiation than the bladder. The incidence of ureteral obstruction due to radiation is 0.04%, while the incidence of obstruction due to recurrent tumor is 95%.

Clinical

The key to managing any ureteral injury, regardless of its etiology, is maintaining a high index of suspicion.

Most iatrogenic injuries (70-80%) are diagnosed postoperatively. The presenting signs and symptoms may include flank pain (36-90%), fever and sepsis (10%), fistula (ureterovaginal and/or ureterocutaneous), urinoma, prolonged ileus, and renal failure due to bilateral obstruction (10%).⁵ The presenting sign of an aortoureteric or graft-ureteric fistula may be mild-to-massive gross hematuria. In addition, silent obstruction may present later as hypertension and nephrotic syndrome. A careful physical examination may reveal a mass, costovertebral angle tenderness, peritoneal signs, or fluid drainage from the wound or vagina.

Ureteral involvement associated with external trauma may not be obvious. Patients with such injuries are usually critically ill and have multiple associated injuries. Therefore, the diagnosis of a ureteral injury may be delayed as other critical injuries are addressed. Nevertheless, as discussed above, a high index of suspicion for ureteral involvement must be maintained.

INDICATIONS

Section 3 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

The choice of treatment is based on the location, type, extent, and timing of presentation, as well as the patient's medical history, overall condition, and survival prognosis (see Surgical therapy).

RELEVANT ANATOMY

Section 4 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

The ureters are peristaltic tubular structures that course from the kidney to the bladder in the retroperitoneum. Histologically, they are composed of an outer serous layer, a smooth muscle layer, and an inner mucosal layer. The smooth muscle layer consists of 2 circular layers separated by a longitudinal layer. The ureters can be divided into 3 segments. The proximal ureter is the segment that extends from the ureteropelvic junction to the area where the ureter crosses the sacroiliac joint, the middle ureter courses over the bony pelvis and iliac vessels, and the pelvic or distal ureter extends from the iliac vessels to the bladder. The terminal portion of the ureter may be subdivided further into the juxtavesical, intramural, and submucosal portions.

The ureters are at risk during open surgery because of their proximity to many abdominal and pelvic structures. They lie anterior to the psoas muscles and adhere to the posterior peritoneum. The left ureteropelvic junction is posterior to the pancreas and duodenal-jejunal junction. On the right, it lies posterior to the duodenum and just lateral to the inferior vena cava (IVC). The left ureter is crossed anteriorly by the inferior mesenteric artery and sigmoidal vessels. The right ureter is crossed by the right colic and ileocolic vessels. As they descend into the pelvis, the ureters course anterior to the iliac vessels but posterior to the gonadal vessels.

In males, the ureter is crossed anteriorly by the medial umbilical ligament, and, before entering the bladder, it passes under the vas deferens. In females, the ureter courses posterior to the ovary, lateral to the infundibulopelvic ligament, and medial to the ovarian vessels. It then passes posterior to the broad ligament and lateral to the uterus. As the ureter approaches the bladder, it is about 2 cm lateral to the cervix. The uterine vessels run just anterior to the ureter near the ureterovesical junction. Most commonly, the ureter is injured in the ovarian fossa near the infundibulopelvic ligament and where the ureter courses posterior to the uterine vessels.

The ureteric arteries course in the adventitia longitudinally. They are supplied by branches from the renal, aortic, gonadal, iliac, and vesical arteries. The ureteric arteries are continuous in 80% of cases. In the abdominal portion, the blood supply is derived medially, and, in the pelvis, the blood supply comes from the lateral aspect. The richest blood supply is to the pelvic ureter.

Lymphatic drainage from the ureter drains to regional lymph nodes. No continuous lymph channels extend from the kidney to the bladder. The regional nodes that serve as drainage include the common iliac, external iliac, and hypogastric lymph nodes.

CONTRAINDICATIONS

Section 5 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

• Relative contraindications to a vesicopsoas hitch include small-capacity bladders (eg, neurogenic bladder, irradiated bladders) and evidence of significant bladder outlet obstruction.
• Relative contraindications to a Boari bladder flap include small, contracted, irradiated, and neuropathic bladders; transitional cell carcinoma; and previous bladder mobilization that threatens the blood supply to the pedicle.
• The absolute contraindications to transureteroureterostomy (TUU) include a short donor ureter or a diseased recipient ureter. Relative contraindications include a urothelial tumor, nephrolithiasis, pelvic or abdominal irradiation, retroperitoneal fibrosis, and ureteral injury caused during aortoiliac bypass surgery.
• Autotransplantation is contraindicated in patients who are older than 60 years and in those with underlying aortoiliac atherosclerosis or renal disease. The presence of retroperitoneal fibrosis is a relative contraindication because of the potential of venous obstruction.
• Contraindications to ileal ureteral substitution include a serum creatinine level of greater than 2 mg/dL, neurogenic bladder, bladder outlet obstruction, inflammatory disease, radiation enteritis, and hepatic dysfunction.
• Surgical treatments of injured ureters are discussed in Surgical therapy.

WORKUP

Section 6 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Lab Studies

• Laboratory evaluation should include urinalysis, urine culture, complete blood count, and creatinine determination from the serum and drainage. 
• Hematuria is not a reliable finding in ureteral injuries. Only 74% of cases involve gross or microscopic hematuria.¹ The reasons for a lack of hematuria may be secondary to a completely transected ureter or partial transection of an adynamic segment.

Imaging Studies

Imaging studies to evaluate for potential ureteral injuries should be performed in patients who are hypotensive on presentation (56%). In stable patients with penetrating injuries and in those with blunt trauma due to rapid deceleration, radiographic studies provide information on the ureter and on associated injuries to other organs. 

• CT scanning: This modality is already the criterion standard for evaluating abdominal injuries due to blunt trauma. Contrast-enhanced CT scanning is highly sensitive in detecting urine extravasation. Because CT scanning is useful in detecting other abdominal injuries, it can be considered the primary imaging study to evaluate for ureteral trauma in stable patients. However, delayed imaging at least 10-15 minutes after contrast injection must be performed to adequately evaluate for urine extravasation.
• Excretory urography or intravenous pyelography
• • Formal intravenous pyelography (IVP) is not appropriate in the acute setting. However, in patients who must undergo immediate exploratory laparotomy for a penetrating injury to the abdomen, the ureters may be evaluated with a one-shot IVP. This is performed by obtaining a single anterior-posterior abdominal film on the gurney or operating-room table 10 minutes after the intravenous injection of a 2 mL/kg (maximum of 150 mL) bolus of contrast material. The advantage of this study is that, when performed correctly, surgical intervention is not delayed, allowing for concurrent assessment of renal function and staging of upper urinary tract injuries.
  • Findings that suggest injury include delayed renal function, ureteral dilatation or deviation, extravasation of contrast, and nonvisualization of the ureter.
  • Unfortunately, this study may provide suboptimal visualization of the upper urinary tract; accordingly, the sensitivity of this study ranges from 0% to 100% (average, 61%).¹ As a result, negative findings do not preclude the surgical exploration of the ureter if damage is suspected, but completely normal findings indicate that significant ureteral injury is unlikely.
• Retrograde pyelography (RPG): This is the most sensitive radiographic study for the diagnosis of ureteral injury. It is not always appropriate for use in the acute setting but may be used in the stable patient as an adjunct to other imaging modalities when other clinical information is needed. It also has the added advantage of facilitating the placement of a ureteral stent in the same session, if indicated.
• Antegrade ureterography: Antegrade ureterography is not routinely used in diagnosing ureteral injuries. It is useful in conjunction with percutaneous nephrostomy tube placement or placement of an antegrade ureteral stent.

Missed injuries

Delayed presentation of ureter injuries or those missed on initial presentation may be suggested by signs such as fever, leukocytosis, local peritoneal irritation, and leakage of urine from the wound. These should be evaluated with CT scanning, but RPG may ultimately be necessary.

Diagnostic Procedures

• Surgical exploration of the retroperitoneum with direct visualization of the ureter is the best method of diagnosing ureteral injury.
• • An average of 89.3% of ureteral injuries are detected with intraoperative inspection.¹³
  • Inspection of the ureter involves mobilization of the ureter and visualization of the entire wall for evidence of contusion, hemorrhage, or disruption. Neither blind palpation nor observation of ureteral peristalsis is a reliable indicator of a healthy ureter.
  • An adjunct in this diagnostic method is the use of intravenous indigo carmine or methylene blue injection with simultaneous inspection for ureteral dye leakage. Alternately, 1-2 mL can be injected directly in the renal pelvis with a 27-gauge needle and the ureter examined for leakage. This is particularly helpful in patients with hypotension in whom intravenous dye may not be excreted efficiently. The lack of dye extravasation is only guardedly reassuring; as a damaged ureteral wall may not leak immediately but may leak or extravasate later. This indicates the importance of visualization of the entire ureteral segment in question. In some cases, the dye itself may hinder diagnosis by staining local tissues, impeding visualization of the specific leakage points. 
• Gunshot wounds near the ureter warrant careful inspection of the entire ureteral wall for continuity, hemorrhage, and contusion. Indigo carmine or methylene blue may be given intravenously or injected directly into the renal pelvis in patients with hypotension while the ureters are inspected for the leakage of dye. If the bladder is already open, the dye may be injected in a retrograde fashion; otherwise, ureteral catheters may be passed up the ureter. If the catheter passes easily and no obvious defect in the continuity of the ureter is observed, a ureter injury is unlikely.
• Cystoscopy with RPG is a sensitive test to diagnose ureteral injuries. It has the advantage of allowing the stenting of the ureter at the same time if minor injuries are identified. However, its practicality as a diagnostic tool is limited by the patient's hemodynamic stability and/or position on the operating table.

TREATMENT

Section 7 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Management of ureteral injuries is dictated by the location, type, extent, timing of presentation, medical history, overall status of the patient, including associated injuries, and prognosis.

Surgical therapy

From a surgical standpoint, knowledge of the vascular supply to the ureter is crucial to any manipulation and subsequent repair. The ureteric arteries and arterioles travel longitudinally in the adventitia, with the abdominal ureter receiving branches medially from the renal, aortic, gonadal, and lumbar arteries, while the pelvic ureter is perfused by branches laterally from the iliac artery and its branches. Ureteral blood supply is tenuous; therefore, strict adherence to the principles of ureteral repair can prevent complications such as urinary leakage leading to patient debility, nephrectomy, and, in, rare cases, death.

The choice of repair also is influenced by the presence of cancer, previous radiation, infection, retroperitoneal fibrosis, and associated injuries. Most importantly, the function of the contralateral kidney must be considered. Regardless of the procedure performed, the principles of optimal ureteral repair are the same.

• Carefully mobilize the ureter to preserve the adventitia (blood supply).
• Judiciously débride the nonviable tissue until the edges bleed.
• Spatulate the edges and repair with 5-0 absorbable suture under magnification.
• Anastomosis should be watertight and tension-free over an internal stent.
• The repair must be isolated from infection, retroperitoneal fibrosis, and cancer.
• The omentum or retroperitoneal fat can be used to cover the repair; this decreases the risk of fibrosis and increases the blood supply to the repair region. (Wrapping the repair reportedly also allows the ureter to remain unscarred and to resume normal peristalsis).
• The retroperitoneum should be drained with a gravity drain.

Most ureteral injuries are short and can be repaired with debridement and either ureteroneocystostomy in the distal ureter or ureteroureterostomy in the mid and proximal ureter. Partial transection of the ureteral wall after blunt injury or stab wound may be managed with primary closure. However, gunshot injuries require wide debridement, as the associated microvascular injuries extend up to 2 cm beyond the areas of gross injury.

Prudent management of profound ureteral loss is to ligate the ureter and drain the ipsilateral kidney with a percutaneous nephrostomy tube. This allows enough time for the patient to recover from acute injuries before any extensive ureteral repair is performed.

Nephrectomy may be performed when the conservation of renal function is not paramount or when the extent of the injury and the patient's overall medical condition do not allow for a reconstructive procedure.

Urinary diversion

Urinary diversion in the form of a stent and/or nephrostomy tube should be considered. A stent aligns the area of anastomosis, prevents extravasation, prevents obstruction from edema, and provides a scaffolding around which the ureter may heal. Studies of ureteral healing have demonstrated that the mucosa has healed by 3 weeks and muscular continuity is established by 7 weeks.¹⁴ Thus, many recommend that a stent remain in place for 6-8 weeks after a repair. Stents come in various diameters (4-8F) and lengths. The size of stent chosen depends on the diameter and length of the ureter. The height of the patient is often used to estimate the ureteral length, although this is not always accurate. A stent should fit in the ureter smoothly, without compressing the ureteral wall, which would compromise ureteral blood supply. 

The appropriate stent length can be gauged from an IVP or RPG (length corrected for 10% magnification plus 1 cm) or from the patient's height and sex. The average male usually requires a 26-cm stent, while the average female requires a 24-cm stent. The type of stent must also be considered. Stents are made of different materials that have different effects on the ureter and differing biocompatibility. All stents cause epithelial erosion and ulceration. Experimental studies have shown that C-Flex (Concept Polymer Technologies; Clearwater, FL), which is a proprietary styrene/ethylene/butylene copolymer, causes less epithelial reaction and has excellent biocompatibility. Firm or hard stents may be more appropriate in patients in whom fibrosis and extrinsic compression may become an issue.

Percutaneous nephrostomy may be used for more proximal diversion if the repair is tenuous or if healing may be delayed. However, complete proximal diversion should be avoided because the flow of urine down the ureter often is needed to help promote ureteral healing. Prolonged diversion may result in a dry anastomosis that may scar. The advantage of a percutaneous nephrostomy is that it can be clamped prior to removal to assess for symptoms of persistent obstruction, and antegrade nephrostography can be performed to assess the integrity of the repair. If persistent extravasation or poor healing is evident, the nephrostomy tract that has already been created can be used to place an indwelling ureteral stent if it has not been placed previously. In the author's institution, antegrade nephrostography is routinely performed to assess the integrity of the repair. Then, the tube is clamped for several hours to ensure the patient does not develop flank pain. It is then removed.

Retrograde ureteral stent placement

An endoscopic approach with retrograde ureteral stent placement may be effective in certain iatrogenic injuries and injuries secondary to external violence. If the patient is stable, this is often the first line of treatment. If retrograde placement is unsuccessful, a percutaneous nephrostomy tube may be placed to acutely decompress the system and to potentially attempt antegrade placement of a stent.

Unstable patients

Ureteral injury in patients who are too unstable to tolerate surgery should be repaired in a staged fashion or, extremely rarely, with nephrectomy. If a staged repair is chosen, the damaged ureter is initially tied off with long silk ties to aid in visualization of the ureter during the second stage of the repair. The kidney is drained percutaneously, preferably in the immediate postoperative period by the surgeon or later by the interventional radiologist. Some surgeons have placed an 8F feeding tube into the ureter and exteriorized it until the repair can be completed.

Although nephrectomy is rarely necessary, it may be indicated in cases of severe collateral and irreparable injury to the ipsilateral kidney or a severe panureteral injury, although even the most devastating ureteral injuries can usually be repaired with reconstruction.

Contusion

Although a contusion may be considered a minor injury, it can result in a stricture if left untreated. Extensive areas of contusion may even result in ureteral necrosis secondary to microvascular damage. Minor injuries can be treated with internal ureteral stenting, while severe or large areas of contusion should be excised and ureteroureterostomy performed.

Upper Ureteral Injuries

In the event of a ureteral avulsion from the renal pelvis or a very proximal ureteral injury, the ureter may be anastomosed directly into the renal pelvis. The principles of this repair include spatulation of the ureter, stenting, tension-free and water-tight anastomosis using 5-0 absorbable suture, and postoperative drainage.

Ureterocalicostomy

If the renal pelvis or ureteropelvic junction is damaged beyond repair, ureterocalicostomy may be performed. In this procedure, the ureteral stump is sewn end-to-side into an exposed renal calyx while adhering to the principles used during ureteropyelostomy. 

Whether the repair is antirefluxing depends on the age of the patient and the severity of associated injuries. In adults, antirefluxing and refluxing procedures are associated with the same rates of renal function preservation and risk of stenosis. In adults with normal bladders, unobstructed infravesical pathways, and no urinary tract infection, reflux does not impair renal function. Various types of reimplantation procedures have been described; such a discussion is beyond the scope of this review. The reimplant may be intravesical or extravesical, depending on surgeon preference.

For injuries too long to be bridged with the psoas hitch procedure alone, a Boari flap can be created to provide an additional 12-15 cm of length (see Image 2). In this procedure, a pedicle of bladder is swung cephalad and tubularized to bridge the gap to the injured ureter. The base of the flap should be at least 4 cm to avoid ischemia. It can be developed obliquely across the anterior bladder or as a spiral flap to help gain additional length. The flap can be fixed to the psoas tendon superiorly with the ureter anastomosed to the flap, which is then rolled anteriorly into a tube and closed in 2 layers. The procedure is time-consuming and is likely not useful in the acute setting. 

Complications include bladder pedicle ischemia with resultant necrosis, possible stricture formation, and urinary leakage. Relative contraindications include small contracted bladders, neurogenic bladder, and transitional cell carcinoma.

Partial Transection

Partial transections can be repaired with primary closure. This procedure should rarely be performed in victims of gunshot wounds; instead, resection of the injured segment and primary anastomosis should be performed. Principles of repair include a spatulated watertight closure over a stent under optical magnification with interrupted or running 5–0 or 6–0 absorbable monofilament suture. The defect is closed by converting a longitudinal laceration into a transverse one to avoid narrowing the ureteral lumen, and a retroperitoneal drain is placed. 

Elective Procedures

Damage Control

Patients with ureteral injury secondary to external violence often have multiple associated injuries, and the patient is often critically ill. In patients with acidosis (pH <7.25), hypothermia (35°C), and coagulopathy, avoiding a prolonged reconstructive procedure is often prudent.

Patients who are in shock and/or have peritoneal contamination may be at a higher risk for complications following repair. Tissue hypoxia and gross contamination play an important role in the pathogenesis of strictures, urinomas, fistulas, and even death.

An abbreviated laparotomy and planned reoperation is becoming a preferred form of management in hemodynamically unstable patients with trauma. The damage-control approach involves evaluating the extent of the ureteral injury and expeditiously performing a stented cutaneous ureterostomy. The patient can then be taken to the intensive care unit for resuscitation and definitive repair can be planned for the second-look laparotomy.

An alternative technique is to ligate the ureter and place a percutaneous nephrostomy intraoperatively or in the interventional suite postoperatively. This damage-control approach also allows the ureter to be reexamined at the planned reoperation.

Delayed Diagnosis

The interval from injury to recognition is important and should guide management. If the injury is diagnosed within the first 7 days without a concomitant significant infection, surgical exploration and repair may be performed. Attempting repair after 10-14 days may be difficult secondary to a marked inflammatory response. In addition, the presence of an abscess, urinoma, or fistula should delay any attempt at a definitive operative repair.

In patients in whom recognition of a ureteral injury is delayed, an initial endourologic approach may be appropriate. Patients with sepsis may benefit from urinary diversion via a percutaneous nephrostomy tube or retrograde ureteral catheter. Associated fluid collections can also be drained percutaneously.

Occasionally, diversion of the urine stream with a nephrostomy or stent is the only intervention needed. Ureters without strictures heal in most patients. However, if a stricture does develop, it can be managed endoscopically with balloon dilation or endoureterotomy. Open ureteral repair can be deferred for 1-3 months while infection and inflammation subside. Despite concerns of inflammation that may be encountered during early exploration, several studies have reported early open repair with low morbidity, a low complication rate, and equally good results.⁵

Managing a ureteral injury during a vascular graft procedure is controversial and can be approached via nephrectomy (if the patient has a functioning contralateral kidney) or a primary ureteroureterostomy with isolation of the repair with omentum. While a nephrectomy may be advocated to prevent postoperative urine leakage around the prosthetic vascular graft, it may come at a cost. The mortality rate associated with renal failure during routine aortic aneurysmectomy is 3% (and up to 12% in patients with a ruptured aneurysm). Conversely, if the risk associated with ureteral repair is minimal, the vascular surgeon should complete the graft anastomosis before addressing the ureteral injury. Studies have demonstrated that primary ureteral repair without nephrectomy is feasible and does not unduly jeopardize the vascular graft if the urine is not infected preoperatively.¹⁵

Follow-up

The repair should be observed regularly for the first year to evaluate for signs of obstruction or loss of renal function. This may include IVP to delineate the anatomy and serial renal ultrasonography to evaluate for hydronephrosis.

To evaluate renal function more objectively, nuclear scanning may be helpful. 

In patients with an ileal ureter, serum chemistry studies are helpful to monitor serum creatinine and metabolic derangements.

Clearly, the frequency and duration of follow-up depends on the clinical setting and the long-term stricture rates associated with each procedure.

COMPLICATIONS

Section 8 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Procedures used to repair traumatically injured ureters carry a complication rate of 25%, and the specific types of complications possible depend on the type of reconstruction performed.

The most common acute complication is prolonged urinary leakage from the anastomosis. This can manifest as urinoma, abscess, or peritonitis and can be prevented by intraoperative placement of a drain in the retroperitoneum, thereby allowing both the drainage of urine and early recognition of urinary leakage from the anastomosis. If a high volume of fluid drains, the fluid should be checked for creatinine. The delayed recognition of undrained urinary leakage has been associated with sepsis, a more complicated reconstruction, and increased hospital stay.

Other complications common to all repairs may include stricture, hydronephrosis, abscess, fistula formation, and infection. The key is to diagnose the problem early and to treat accordingly.

Hydronephrosis that develops following injury repair may be managed by simply replacing a stent or dilating the strictured segment. However, management of each complication depends on the time of diagnosis and presentation. Most complications can be managed with endoscopy or reoperation.

Ileal ureter substitution may be complicated by stone formation, renal failure, infection, stricture, calculi, pyelonephritis, and associated metabolic derangements.

After ureteral repair during aortic surgery, vascular grafts can become infected, requiring vascular and urinary diversion to eradicate. The best method of treating this dreaded complication is prevention, which usually means performing a ureteral repair with omental interposition. Nephrectomy may still need to be performed if initial repairs are unsuccessful.

Complications related to prolonged stent placement and nephrostomy tubes include migration, infection, encrustation, pain, and loss of renal function.

OUTCOME AND PROGNOSIS

Section 9 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

See Surgical therapy for detailed discussions of the outcomes of each procedure.

FUTURE AND CONTROVERSIES

Section 10 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Prevention

Ureters tend to be injured during difficult open surgery or endoscopic procedures. Some injuries may be unavoidable, and the goal is to minimize such injuries. Preoperative imaging is not indicated in all cases but may be of benefit in high-risk patients. Careful identification of the ureters and their course helps avoid injury. Lasix and hydration facilitate visualization of the ureter. The ureter is often injured during attempts at bleeding control. Adequate exposure and hemostasis, when possible, also help prevent injury.

Some have advocated the prophylactic placement of ureteral catheters. Advocates of this practice argue that they help the surgeon palpate the ureter and may be of particular help in laparoscopic procedures. The stents may help in recognizing an injury intraoperatively. Of particular use in laparoscopy are lighted stents, which illuminate and help identify the ureter. They also can be used in open cases when the ureters cannot be palpated.

Opponents of this practice argue that, in the presence of inflammation, the stents still may not be palpable and that the presence of the stent actually may alter the course of the ureter, placing it at risk. Complication rates associated with ureteral stent placement are 1%. Anuria secondary to ureteral edema may occur. Some also argue that ureteral stimulation may cause renal cortical vasoconstriction, leading to decreased filtration and anuria. Additionally, placement of ureteral catheters significantly adds to the cost of the procedure.

However, the prophylactic placement of stents is useful in many surgeries. Placement is safe and associated with few complications. It does not prevent injury but aids in the diagnosis and treatment of an injury.

FURTHER READING

Section 11 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

For more information, see Medscape's Trauma Resource Center.

MULTIMEDIA

Section 12 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Media file 1:  Psoas hitch in ureteral trauma.
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Media file 2:  Boari flap procedure in ureteral trauma.
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Media file 3:  Ureteroureterostomy in ureteral trauma.
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Media file 4:  Transureteroureterostomy in ureteral trauma.
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Media file 5:  Complete ureteral replacement utilizing ileum in ureteral trauma.
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REFERENCES

Section 13 of 13

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

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