Most ureteral injuries occur during surgery. Procedures that most often injure the ureter include ureteroscopy, hysterectomy, low anterior colon resection, and open abdominal aneurysm repair. Mechanisms include ligation, transection, avulsion, crush, devascularization, kinking, and electrocoagulation.
Noniatrogenic ureteral injuries account for only about 1 to 3% of all genitourinary trauma. They usually result from gunshot wounds and rarely from stab wounds. In children, avulsion injuries are more common and occur at the ureteropelvic junction. Complications include peritoneal or retroperitoneal urinary leakage; perinephric abscess; fistula formation (eg, ureterovaginal, ureterocutaneous); and ureteral stricture, obstruction, or both.
Diagnosis of Ureteral Trauma
Imaging, exploratory surgery, or both
Diagnosis of ureteral injuries 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 Computed Tomography Imaging tests are often used to evaluate patients with renal and urologic disorders. Abdominal x-rays without radiopaque contrast agents may be done to check for positioning of ureteral stents... read more that includes delayed images, retrograde pyelography), exploratory surgery, or both. Fever, flank tenderness, prolonged ileus Ileus Ileus is a temporary arrest of intestinal peristalsis. It occurs most commonly after abdominal surgery, particularly when the intestines have been manipulated. Symptoms are nausea, vomiting... read more , urinary leakage, obstruction, and sepsis Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more are the most common delayed signs of otherwise occult injuries. Intraoperative findings suggestive of a ureteral injury include urinary leakage, ureteral bruising, or decreased peristalsis. The diagnosis can be further aided by injecting dye (eg, indigo carmine, methylene blue) intravenously or intraureterally.
Treatment of Ureteral Trauma
For minor injuries, percutaneous nephrostomy tube or ureteral stent
For major injuries, surgical repair
All ureteral injuries require intervention. A diverting percutaneous nephrostomy tube or placement of a ureteral stent (retrograde or antegrade) is often sufficient for minor injuries (eg, contusions or partial transections). Complete transection or avulsion injuries typically require reconstructive techniques, either open or laparoscopic. These techniques include ureteral reimplantation, primary ureteral anastomosis, anterior (Boari) bladder flap, transureteroureterostomy, ileal interposition, and, as a last resort, autotransplantation. In unstable patients a damage control approach is used whereby the ureter is temporarily drained with definitive management done later.
Most ureteral injuries occur during surgery.
For ureteral injuries from external trauma, maintain a high index of suspicion because findings are nonspecific and hematuria is commonly absent.