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Ureteral Injuries

By Noel A. Armenakas, MD, Clinical Professor of Urology;Attending Surgeon, Weill Cornell Medical School;New York Presbyterian Hospital and Lenox Hill Hospital

The ureters are the tubes that carry urine from the kidneys to the bladder.

Organs of the Urinary Tract

The urinary tract consists of the kidneys, ureters (tubes that carry urine from the kidneys to the bladder), bladder, and urethra. These organs may be injured by blunt force (as occurs in a motor vehicle crash or a fall) or by penetrating force (as results from a gunshot or stabbing). Injuries may also occur unintentionally during surgery.

Most injuries to the ureter occur during pelvic or abdominal operations, such as removal of the uterus (hysterectomy) or the colon (colectomy), cesarean delivery, or repair of an abdominal aortic aneurysm, or during ureteroscopy (an examination of the ureter with a rigid or flexible viewing tube). Another rare cause of ureteral injury is penetration by either a gunshot or stab wound. Rarely, blunt injuries, particularly those that cause the trunk to bend backward, can separate the upper part of the ureter from the kidney; such injuries are more common in children and young adolescents.

Complications

If ureteral injuries are untreated, complications may result, such as

  • Formation of a collection of pus (abscess)

  • Blockage of urine flow

  • Persistent urinary leakage and infection

  • Narrowing of the ureter (stricture)

  • Formation of an abnormal connection to another abdominal structure (fistula)

Symptoms

People may complain simply of pain in the abdomen or the area between the ribs and the hip (flank), or they may notice urine leaking from their wound. Fever may accompany an infection caused by persistent urinary leakage. Blood may appear in the urine.

Diagnosis

  • Imaging tests, exploratory surgery, or both

Because ureteral injury is rarely the most likely cause of such symptoms, an injury to the ureter may not be recognized promptly. Usually, doctors suspect an injury when a person who has symptoms has had a recent surgical procedure or when a person has a wound that has penetrated the abdomen.

When a ureteral injury is suspected, imaging tests are needed. The initial test is often computed tomography (CT) with radiopaque contrast agent. Sometimes, retrograde urography (an x-ray taken after a radiopaque contrast agent is instilled directly into the end of the ureter) is done, usually during cystoscopy (passing a flexible viewing tube through the urethra into the bladder). Sometimes, ureteral injuries are identified during surgery.

Treatment

  • For minor injuries, ureteral stent or urine drainage tube

  • For major injuries, surgery

Some minor ureteral injuries can be treated by placing a flexible tube (stent) in the ureter either through the bladder or through the kidney via a needle inserted into the person's side (percutaneous nephrostomy). These treatments divert urine from flowing through the ureter and are usually left in place for 2 to 6 weeks, allowing the ureter to heal. If the ureteral injury does not heal despite the use of a stent, additional surgery may be needed. In people with more severe injuries, surgery may be required to reconstruct the ureter.

Treatment helps to prevent complications of ureteral injuries. If complications occur despite efforts to prevent them, they must be treated.

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