Most ureteral injuries are iatrogenic. Procedures that most often injure a ureter include ureteroscopy, hysterectomy, low anterior colon resection, and abdominal aneurysm repair. 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 ureteral stricture, obstruction, or both; peritoneal or retroperitoneal urinary leakage; and fistula (eg, ureterovaginal, ureterocutaneous) formation.

Diagnosis

• Imaging, exploratory surgery, 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, IVU), exploratory surgery, or both. Flank pain and fever are the main symptoms of otherwise occult injuries.

Treatment

• For minor injuries, nephrostomy tube or ureteral stent
• For major injuries, surgical repair

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 bladder flap, ileal interposition, and, as a last resort, autotransplantation.

Last full review/revision February 2007 by Noel A. Armenakas, MD