Most ureteral injuries occur during surgery. Procedures that most often injure a ureter include ureteroscopy, hysterectomy, low anterior colon resection, and abdominal aneurysm repair; mechanisms include ligation, transection, avulsion, crush, devascularization, kinking, and electrocoagulation.
Noniatrogenic ureteral injury accounts for only about 1 to 3% of all GU trauma. It usually results from gunshot wounds and rarely from stab wounds. In children, avulsion injuries are more common. Complications include peritoneal or retroperitoneal urinary leakage; perinephric abscess; fistula (eg, ureterovaginal, ureterocutaneous) formation; and ureteral stricture, obstruction, or both.
Diagnosis is suspected on the basis of history and requires a high index of suspicion, because symptoms are nonspecific and hematuria is absent in > 30% of patients. Diagnosis is confirmed by imaging (eg, CT with contrast that includes delayed images, retrograde pyelography), exploratory surgery, or both. Fever, flank tenderness, prolonged ileus, urinary leakage, obstruction, and sepsis are the most common delayed signs of otherwise occult injuries.
All injuries require intervention. A diverting percutaneous nephrostomy tube or cystoscopic placement of a ureteral stent is often sufficient for minor injuries (eg, contusions or partial transections). Complete transection or avulsion injuries typically require reconstructive techniques, including ureteral reimplantation, primary ureteral anastomosis, anterior (Boari) bladder flap, ileal interposition, and, as a last resort, autotransplantation.