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Ureteral Injuries

by Noel A. Armenakas, MD

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.

If ureteral injuries are untreated, complications, such as formation of an abnormal connection to another abdominal structure (fistula), a collection of pus (abscess), narrowing of the ureter (stricture), blockage of urine flow, or persistent urinary leakage and infection, may result.

Symptoms and Diagnosis

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.

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 dye (contrast agent) or intravenous urography. Sometimes, retrograde pyelography (an x-ray taken after a radiopaque dye 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

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, usually 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.