Urology: Ureter Injury

Iatrogenic/Intraoperative Ureter Injury

Responsible Procedures

  • Urologic: 43%
  • Gynecologic: 34%
    • Risk After Hysterectomy: 0.02-0.78%
  • General Surgery: 24%
    • Risk After Right Hemicolectomy: 0.8%
    • Risk After Sigmoidectomy: 3.3%
    • Risk After LAR/APR: 0.3-5.7%

Risk Factors

  • Rectal Cancer
  • Adhesions
  • Metastatic Cancer
  • Weight Loss/Malnutrition

Diagnosis

  • Intraoperative Evaluation:
    • Preoperative Ureteral Stents Help Identify Injury
      • It is Debated if Stents Help to Actually Prevent Injury
    • IV Methylene Blue or Indigo Carmine
  • Postoperative Evaluation:
    • CT Urogram (CT with IV Contrast & Delayed Images)
    • Retrograde Pyelogram is Most Accurate Test

Timing of Repair

  • Recognized Intraoperatively or Early: Immediate Repair
  • Delayed Diagnosis: Debated Immediate Repair vs Stent with Delayed Repair
    • Consider Percutaneous Nephrostomy with Delayed Repair if Injury Identified Late with Complications (UTI, Abscess, or Urinary Fistula) – Impede Healing

Repair

  • Partial Transection: Primary Repair Over a Stent
  • Complete Transection:
    • Proximal 2/3: Primary Ureteroureterostomy Over a Stent
    • Distal 1/3: Ureteroneocystostomy (Reimplant in the Bladder)
    • *Endourologic Procedures are Evolving & Realignment/Stenting May Be Possible for Complete Transection in Some Cases

Adjuncts to Decrease Tension

  • Psoas Hitch (Mobilize Bladder and Anchor to Psoas)
    • Preferred Method
  • Transureteroureterostomy (Implant into Contralateral Ureter)
  • Boari Bladder Flap (Bladder is Tubularized)
  • Ileal Interposition
  • Autotransplantation in Pelvis

Proximal Ureter Injury with Extravasation (Left); Delayed Imaging (Right) 1

Ureteroureterostomy 2

Psoas Hitch 2

Transureteral Ureterostomy 2

Boari Bladder Flap 2

Traumatic Ureter Injury

Traumatic Injury

References

  1. Ortega SJ, Netto FS, Hamilton P, Chu P, Tien HC. CT scanning for diagnosing blunt ureteral and ureteropelvic junction injuries. BMC Urol. 2008 Feb 7;8:3. (License: CC BY-2.0)
  2. Pereira BM, Ogilvie MP, Gomez-Rodriguez JC, Ryan ML, Peña D, Marttos AC, Pizano LR, McKenney MG. A review of ureteral injuries after external trauma. Scand J Trauma Resusc Emerg Med. 2010 Feb 3;18:6. (License: CC BY-2.0)