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Diagnosis and Management of Ureteric Injury: An Evidence-Based Analysis
Diagnosis and Management of Ureteric Injury: An Evidence-Based Analysis
943
Review Article
DIAGNOSIS AND MANAGEMENT OF URETERIC INJURY
BRANDES
et al.
© 2 0 0 4 B J U I N T E R N A T I O N A L | 9 4 , 2 7 7 – 2 8 9 | doi:10.1111/j.1464-410X.2004.04978.x 277
B R A N D E S ET AL.
substantial and sizeable than for external external trauma and 66 iatrogenic trauma Although most civilian penetrating wounds
trauma, but the series are all retrospective, manuscripts were felt to have sufficient merit are of low velocity, occasionally a high-
generally cover long study periods, are to form the basis for the recommendations. velocity missile injury occurs. For this reason,
heterogeneous for type, and involve many Of the external trauma articles, 33 were six military and war-related articles from Iraq,
degrees and locations of injury, and many predominantly penetrating, 12 blunt and Northern Ireland, Croatia and Vietnam were
surgeons [13,53–117]. seven war-related. Of the iatrogenic trauma selected.
articles, most (21) were of gynaecological
Because of these inherent limitations and surgery; the remaining articles were
difficulties, evidence-based outcome predominantly urological, vascular or general CONSENSUS RECOMMENDATIONS
measures were used to develop surgery misadventures.
recommendations for consensus practice for
diagnosing and managing ureteric injuries, Each manuscript was then reviewed and PENETRATING URETERIC INJURIES
based on an integration and synthesis of classified as class 1–4 (see below) by a [1–33,46–52]
available reports, best current evidence and group of urologists, all whom subspecialized
expert opinion. in trauma and reconstructive urology. Each • Associated intra-abdominal visceral
article was read by at least two members injuries are common. (LOE 3);
SPECIFIC QUESTIONS of the panel to evaluate the design and • Deaths are predominantly from associated
method. This group collaborated to injuries, not the ureteric injury (LOE 3).
• What clinical signs and symptoms are produce the following recommendations
reliable indicators to prompt an evaluation for and evidentiary tables. All recommendations SIGNS AND SYMPTOMS
ureteric injury? Immediate vs delayed? were drafted, reviewed and accepted by
• What imaging studies or intraoperative consensus. Immediate: Haematuria is an unreliable sign
techniques are reliable to diagnose ureteric of penetrating ureteric injury. Absence of
injuries? Immediate vs delayed? QUALITY OF THE STUDIES haematuria does not exclude ureteric injury.
• How does timing (immediate vs delayed) of Any degree of haematuria warrants further
the diagnosis alter the treatment method? Articles were classified by their numerical investigation (LOE 3).
• What treatment methods are successful for level of evidence (LOE), as determined by the
each mechanism and location of ureteric following definitions: Delayed: Signs and symptoms of a possible
injury? Low vs high velocity missile? Blunt vs missed injury or delayed urinary leak that
penetrating trauma vs iatrogenic injury? • Class 1: Prospective randomized clinical should prompt further investigation are:
Upper, mid, or lower ureter? trial. prolonged ileus (LOE 3), urinary leakage (LOE
• What effect does contamination from • Class 2: Prospective noncomparative 3), prolonged high output from drains (LOE 3),
associated intra-abdominal injuries have on clinical study. fever/sepsis (LOE 4), persistent flank or
treatment and outcomes?. • Class 3: Retrospective case series, database abdominal pain (LOE 4), urinary obstruction
or registry review. (LOE 4), elevated creatinine or blood-urea
METHODS • Class 4: Case reports; nitrogen (LOE 5), and flank mass (LOE 4).
• Class 5: Expert opinion.
IDENTIFICATION OF REFERENCES DIAGNOSIS
No class 1 or class 2 articles were identified
The world publications were searched using or reviewed for this paper; this is a major • The early diagnosis of ureteric injury is
Medline and Embase search engines for the limitation of the available evidence and preferred. Delayed diagnosis results in higher
years 1966–2002. All English language thus weakens the strengths of our complication (fistula, urinoma, infection, etc.),
citations with the key words ‘ureter, PUJ, recommendations. In general, only a third renal unit loss and death rate (LOE 3).
wounds, trauma, injury, penetrating, blunt, of the external trauma and a fifth of the • A high index of suspicion and a low
crush, iatrogenic, surgery, gunshot wounds, iatrogenic trauma articles were of sufficient threshold for imaging or direct ureteric
stab wounds, urinoma, fistula, stricture, and merit for review. Of the selected iatrogenic exploration are needed to reliably diagnose
complications’ were identified. The abstract ureteric injury articles, 64 of 66 were class 3, ureteric injury (LOE 3).
for each of the 175 external trauma and 311 mostly covering long study periods. The • Explore all peri-ureteric gunshot wound
iatrogenic trauma citations was reviewed, and remaining two studies were class 4. Of the and associated retroperitoneal haematomas
all papers having any possible applicability to selected external trauma articles, 34 class noted at laparotomy (LOE 3).
the guideline topic were retrieved and 3 and two class 4 articles focused on • Surgical exploration is a reliable and
reviewed. Reference sections of the articles penetrating ureteric trauma, and four class accurate method to diagnose penetrating
and meta-analyses identified were then used 4 and six class 3 articles on blunt ureteric ureteric injury. Visual ureteric inspection with
to identify additional references not retrieved trauma. A further weakness is that nearly half or without intravenous or intra-ureteric dye
by the initial search engines. Review articles, of these external trauma articles included injection is reliable (LOE 3).
letters to the editor, single case reports, patients from the 1960s and 1970s, which • High-velocity gunshot wounds and
animal studies, and poorly written pre-dates the common use of CT or JJ ureteric shrapnel injuries to the ureter have a higher
retrospective studies with scant information stenting [1,4,6,9–11,14–18,21,22,26–28,34, complication (i.e. delayed urinary leak,
were excluded from the study. Thus, 52 37,39,42,44,47,49]. dehiscence after repair, urinoma, renal unit
loss, etc.) and delayed presentation rate (LOE watertight anastomosis over a ureteric • A high index of suspicion and low threshold
3). stent (LOE 3); (c) Isolate the ureteric repair for imaging and exploration are needed
from associated injuries and a place a (LOE 3).
IMAGING retroperitoneal drain (LOE 4); (d) Proximal • Blunt PUJ injury is rare and can often be
urinary diversion is typically unnecessary missed in the acute setting. Diagnosis is
• One-shot (high-dose) IVU is often not (LOE 4). commonly delayed (LOE 3).
diagnostic and thus unreliable at detecting • Associated injuries are common and often
penetrating ureteric injuries (LOE 3). SPECIFIC PROBLEMS multiple (LOE 3).
• Complete IVU is accurate in detecting • Delayed diagnosis results in higher
ureteric injury. Abnormal IVU findings warrant • Prompt repair of ureteric injuries is complication (i.e. urinoma, infection, leak,
further investigation (i.e. ureteric dilatation or preferred. However, trauma patients who etc.) and renal unit loss rate (LOE 3).
deviation, incomplete visualization of the are haemodynamically unstable, hypothermic,
entire ureter, delayed or no visualization of coagulopathic or acidotic, are best managed IMAGING
the renal unit, and extravasation) (LOE 3). by a planned staged repair, ‘damage control’
• For CT there are insufficient data for (i.e. ureteric exteriorization or ligation). • IVU (complete study): IVU is a reliable
a recommendation but it appears to be Definitive reconstruction is best delayed until and accurate test to diagnose PUJ injury
accurate when delayed images are obtained the patient is stable (LOE 4). in stable patients (particularly in the
(LOE 5). • Associated bowel injury or fecal delayed setting) (LOE 3); reliable signs
• Retrograde pyelography (RPG) is a sensitive contamination does not increase the of PUJ injury are medial contrast medium
and specific test in defining the presence, complication rate or compromise ureteric extravasation (LOE 3) and an unopacified
location and degree (i.e. partial vs complete) repair success (LOE 4). distal ureter (LOE 4).
of ureteric injury. Limitations: it difficult to • Delayed diagnosed ureteric injuries or • CT of the abdomen and pelvis is an
use in the acute trauma patient and better secondary leak after primary repair are best accurate tool to both screen and diagnose
reserved for the delayed setting (LOE 4). managed by percutaneous nephrostomy PUJ injury (LOE 3). Spiral CT scanners require
• Ultrasonography (US): there are (PCN, proximal diversion), and when possible, delayed (excretory) imaging with contrast
insufficient data for recommendation, and additional antegrade ureteric stenting. medium to reliably diagnose ureteric/PUJ
it is of limited use in the acute setting Retrograde ureteric stenting is often injury (LOE 4). CT findings of PUJ injury
(LOE 5). unsuccessful. A close follow-up is warranted include: predominant medial perirenal
(LOE 4). extravasation (LOE 3), intact renal
TREATMENT • Urinomas can be effectively managed by parenchyma (LOE 4), lack of perirenal
placing a percutaneous drain (LOE 4). haematoma (LOE 4), and an unopacified
• Early treatment is preferred (LOE 3). ureter, suggesting PUJ avulsion (LOE 4). The
• Minimal ureteric contusions or above suggests partial PUJ injury, yet contrast
proximity gunshot wounds can be BLUNT URETERIC INJURIES [34–45] medium is found in the ureter distal to the
treated successfully by ureteric stenting. PUJ (LOE 4).
Untreated contusions or proximity SIGNS AND SYMPTOMS • RPG is a sensitive and specific test for the
gunshot wounds are often complicated presence, location and degree (partial vs
by ureteric stricture or delayed necrosis Immediate: The possibility of a blunt ureteric complete) of ureteric injury; its role is limited
and urinary fistula (especially with high- injury should be considered in all patients in the acute setting (LOE 3).
velocity missiles) (LOE 4). Severe or large who are involved in accidents with • US has insufficient data for
ureteric contusions should be treated by hyperextension or deceleration mechanisms recommendation; it has a limited role in the
segmental excision and uretero-ureterostomy of injuries (especially a child in a pedestrian vs acute setting (LOE 5) but is accurate for
(UU) (LOE 4). motor vehicle accident or fall from height) diagnosing urinoma and hydronephrosis
• High-velocity gunshot wounds have higher (LOE 3). (LOE 3).
rates of delayed urinary leak, dehiscence after
repair, renal unit loss and overall death (LOE Lack of haematuria is an unreliable sign to TREATMENT
4). exclude injury. Any degree of haematuria
• Successful methods for ureteric repair should prompt further imaging or exploration • Blunt ureteric injury is typically to the PUJ
are based on injury location (Fig. 1): (a) upper, (LOE 3). Flank tenderness/ecchymosis should and secondarily to the proximal ureter (LOE 3).
UU or ureteropyelostomy (LOE 4); (b) middle, prompt further investigation (LOE 4). • Laceration (partial) PUJ injury can be
UU (LOE 3) or transuretero-ureterostomy successfully treated by primary repair or
(TUU) (LOE 4) or anterior wall bladder (Boari) Delayed: Signs and symptoms for delayed ureteric stenting with or without proximal
flap (LOE 5); (c) lower, ureteroneocystostomy ureteric leak are the same as for penetrating urinary diversion (LOE 4).
(UNC) with or without a psoas bladder hitch injuries (see above). • Complete transection (avulsion) injuries are
(LOE 3). successfully repaired by UU or
• Surgical principles for successful repair of DIAGNOSIS ureteropyelostomy (LOE 3).
acute ureteric transactions are: (a) adequate • The surgical principles for ureter repair are
ureteric debridement and careful mobilization • Early diagnosis of PUJ injury is preferred the same as detailed above for penetrating
(LOE 4); (b) Spatulated, tension-free, (LOE 3). ureteric injuries.
FIG. 1. The algorithm for external ureteric trauma. GSW, gunshot wound; Inj, injury; IV, intravenous; PE, physical examination; Sx, signs and symptoms; SW, stab
wound; Tx, treatment; UA, urine analysis; UP, ureteropyleostomy.
Stable
Stent
Complications of urinary leak
IVU or CT withdelayed – urinoma
Partial PUJ inj.
images – abscess
– fistula
Not diagnostic Normal – ureteric obstruction
Extrav.
Unstable Stable
GSW/SW
or blunt PUJ US and/orIVP and/or CT
avulsion Retrograde Abd/pelvis
– IV indigo Proximal UU or UP
– Retrograde indigo
– Direct inspect Ureter Injury Location
Viable Stable
Mid UU or TUU
Viable ??
Unstable
Stent Distal Reimplant ± Psoas hitch
Damage Control
• Delayed diagnosis or secondary leak is best IATROGENIC URETERIC INJURIES reduced ureteroscopic serious ureteric injury
managed by PCN urinary diversion. Add an [13,53–117] and morbidity (LOE 3).
antegrade ureteric stent when possible.
Retrograde ureteric stenting is usually • Injuries typically occur during SIGNS AND SYMPTOMS
unsuccessful. A staged reconstruction is gynaecological, urological, urogynaecological
typically needed (LOE 4). and other pelvic surgery (LOE 3). Signs and symptoms for delayed ureteric leak
• Urinoma formation is effectively • Iatrogenic injuries are predominantly to the that should prompt further investigation are
managed by placing a percutaneous drain distal one-third and pelvic ureter (LOE 3). the same as for penetrating injuries (see
(LOE 4). • Preoperative prophylactic stents do not above), in addition to anuria, flank or loin
• There are insufficient data for a assure preventing ureteric injury, yet assist in pain, incontinence, vaginal urinary leakage,
recommendation of the effect of associated intraoperative recognition (LOE 3). haematuria, fever, elevated serum blood urea
injuries (i.e. fecal contamination) on the • Contemporary, improved endoscope nitrogen and creatinine, or elevated creatinine
success of PUJ repair. design, technique and accessories have in fluid collections (urinomas) (LOE 3).
Intraoperative haemorrhage is a clear and Common signs and symptoms of a missed medial perirenal space is the most consistent
main risk factor for ureteric injury. Sudden ureteric injury are generally not specific. finding of blunt PUJ injury [36,39,41]. Absence
haemorrhage should never be treated with Suggestive of urinary leak are prolonged ileus, of contrast material in the distal ureter, on
blind cautery or suturing, but rather direct fever/sepsis, persistent flank or abdominal delayed CT images, is diagnostic of a complete
pressure, sharp dissection and exposure of the pain, palpable abdominal mass, elevated ureteric transection. Additional CT findings
bleeding vessels, followed by accurate and serum blood urea nitrogen, leukocytosis, and that distinguish PUJ injuries from renal
precise suturing [67,81,98]. Greater blood loss, prolonged drainage from the skin, vagina, parenchymal injuries are intact renal
long operative times, more transfusions, and operative drains or drain sites. Anuria can parenchyma and lack of perirenal haematoma
longer hospitalization are associated with be seen with bilateral injuries [13,70]. [36,39]. With rapid sequence spiral CT this
ureteric injury [67,98]. Occasionally, ureteric injury is not recognized cannot be assessed unless delayed (excretory)
until an obvious fistula is present. To avoid films are obtained [41,75]. CT also has a
In radical pelvic surgery (i.e. hysterectomy) such morbidity, reports clearly support that a reliable role in the delayed setting with signs
the ureter can be skeletonized when high index of suspicion be maintained (as of missed ureteric injury, being ascites,
dissecting out adjacent tumour, and so based on injury mechanism and location) and localized fluid collections (urinomas),
risk ischaemia and delayed necrosis is the key to prompt diagnosis of injury hydronephrosis, and contrast medium
[67,71,77,79,82,92,93,108,113]. Radical [1–4,22–25,29,47,51,87]. Essentially, all extravasation [75].
hysterectomy may also require en-bloc patients with penetrating abdominal trauma
resection of a segment of ureter [116]. or significant blunt deceleration injury should If the results of the IVU and CT are
Previous irradiation can compromise the be suspected of having a ureteric injury and inconclusive, RPG is indicated; this is the most
ureteric blood supply (by obliterative end appropriately evaluated. Similarly, children accurate ureteric imaging test to evaluate
arteritis) and increase the injury risk [116]. with significant blunt abdominal trauma, the location and degree of ureteric injury
However, these reports are from the 1960s significant deceleration or fall from height [6,13,52,108]. However, it is often too
and 1970s and there are no contemporary and multiple associated injuries should cumbersome and time-consuming for use in
series. Previous episodes of endometriosis or undergo radiographic ureteric assessment, the acute trauma setting. It is clearly a useful
pelvic inflammatory disease can lead to dense regardless of the absence of haematuria on tool for the delayed diagnosed of ureteric
ureteric adherence and so increase the urine analysis. Gross haematuria, flank injury. US is generally not useful, except in
chances for iatrogenic injury. Neoplasms can tenderness or flank ecchymosis may suggest showing a haematoma, urinoma, ascites,
directly invade and fix the ureter or distort its injury, and thus warrant further investigation absent ureteric jets or hydronephrosis, all
course. The ureter is thus at risk for injury [7,10,34,35,37,38,42–45]. which suggest a delayed ureteric injury (as
when any large retroperitoneal mass is supported in limited case series) [84].
resected. IMAGING However, there is little to no published
evidence to support the use of US in acute
Extravasation of contrast medium is the ureteric trauma.
DIAGNOSIS hallmark sign of a ureteric injury but in many
cases the findings are more subtle, including
Clinical: The prompt diagnosis of ureteric delayed function, or mild ureteric dilation or INTRAOPERATIVE
injury from external trauma is complicated deviation. Formal, complete IVU is a reliable
by the presence of multiple organ injuries and accurate study in the stable trauma Most penetrating ureteric injuries are
and the absence of clinical and laboratory patient for diagnosing ureteric injury diagnosed intraoperatively during the initial
findings specific for ureteric trauma. [4,6,14,23,28,34]. IVU findings suggestive of laparotomy for managing the associated
Published reports overwhelmingly show ureteric injury are delayed or no visualization abdominal injuries [3,17,19,20,24,25,27,30].
that haematuria is an unreliable indicator of the involved kidney, hydronephrosis, Blunt external and iatrogenic ureteric injuries
of ureteric trauma, and is absent in ≈ 30% urinary (contrast medium extravasation), or are often diagnosed after a delay
(up to 45%) [3–7,10,20,22,26,30,40,52]. These incomplete visualization of the entire ureter [13,34,35,37,40,42–45,53–117].
limitations frequently result in a delayed [6].
diagnosis. Most iatrogenic ureteric injuries If injury to the ureter is suspected
are not recognized intraoperatively and are Complete IVU is particularly useful for intraoperatively the ureter must be
diagnosed late and when symptomatic. diagnosing missed ureteric injuries. In meticulously examined in the area of interest.
the last decade there have been numerous Direct exploration and visual inspection
Of the six retrospective war-related reports, retrospective series showing that ‘one-shot’ (including the exploration of retroperitoneal
the injuries to the ureter were caused by high- IVU, for penetrating trauma or in the unstable and peri-ureteric haematomas) are the most
velocity missiles. Such missile injuries resulted patient, is inaccurate and unreliable common and reliable methods of assessing
in associated injuries, a high death rate [2–5,20,22,31]. ureteric integrity [3,19,20,22,30]. The bowel
[26,46,47,52] from associated injury, and high should be reflected sufficiently to expose the
rates of delayed diagnosis, delayed urinary With the contemporary widespread use of CT ureter(s) and an attempt made to trace
leak, repair dehiscence and nephrectomy. for evaluating the polytraumatized patient, surgical misadventure or missile path.
Typical symptoms of delayed leak were fever, blunt ureteric injuries are now more routinely
ileus, wound leakage (cutaneous fistula) and diagnosed by CT. Extravasation of contrast Intraoperative recognition of ureteric injury
flank mass. medium confined predominantly to the can be facilitated by intravenous or intra-
ureteric injection of indigo carmine or SUTURE LIGATION INJURY inferred. However, for minor injuries by a
methylene blue. Extravasation of blue-tinged small crushing instrument, the ureter should
urine helps to confirm the injury and location When the ureter has been inadvertently be stented and drained, as a minimum [74].
[3,5,25]. Even without extravasation, a visually ligated during surgery often all that is For severe contusions, or if ureteric viability is
appearing contused or bruised ureter necessary is to remove the suture or surgical in doubt, studies support the involved ureter
can have significant trauma, from blast clip and observe. Typically, ureteric damage is being segmentally resected, debrided and re-
injury, crush or ischaemic injury (from minimal, if recognized immediately, as these anastomosed over a JJ stent. The type of
excessive dissection). Signs of ureteric injuries most frequently include other tissue ureteric repair depends on the level (location)
devascularization are wall discoloration, in the ligature. Visual inspection is imperative and extent of the injury (see below for details).
absence of capillary refill, or lack of a bleeding to exclude significant ureteric injury. At a
edge [25]. minimum, ureteric stent placement is prudent DEVASCULARIZATION
in most circumstances [55,56]. When ureteric
viability is in question, UU should be Devascularization injuries are typically not
ASSOCIATED INJURIES performed [55]. When an absorbable suture is recognized until late and present within
determined after surgery to have entrapped several days to weeks after surgery, with
Concomitant intra-abdominal organ or the ureter, conservative management with complications from a urine leak or ureteric
vascular injuries should not preclude ureteric PCN tube drainage until the suture absorbs stricture [7,26,46,115]. When noted
reconstruction [107,112]. Overall success and has been reported to be successful. intraoperatively, extensive skeletonization
complication rates after primary ureteric or thermal injury of the ureter that results
repair for upper and mid ureteric injuries and Ureteric injuries during vaginal surgery are in an obviously nonviable ureter, should be
reimplantation for lower ureteric injuries are typically ligations and not detected until after segmentally excised until healthy tissue, and
unaffected by associated fecal contamination the operation [72,74,81,98,107]. Most injuries then repaired as detailed below. In most cases
or bowel injury [2,23,24]. As a general were associated with attempts to achieve the viability is difficult to assess, and it is
principle, tissue interposition (i.e. omental haemostasis without properly identifying the prudent to place a ureteric stent in any
flap) between the two injuries may help ureter [98]. In all vaginal hysterectomies, equivocal case. Delayed injury to the ureter
prevent secondary fistulae or repair Grade 4 cystocele repairs, enterocele repairs, can also be minimized by omental or
breakdown. and bladder neck suspensions, ureteric peritoneal coverage of the ureter.
integrity should be assessed with intravenous
The management of ureteric injuries during indigo carmine [57,58,60]. When no indigo is CONTUSIONS AND PROXIMITY INJURY
vascular graft surgery is controversial and cystoscopically observed from the ureteric
there is no clear consensus from the evidence orifice, a ureteric stent should be placed. If The conservative management of ureteric
[53,112]. Two decades ago nephrectomy was complete ureteric obstruction is noted during contusions or proximity injuries from a high-
the treatment of choice for all ureteric injuries cystocele, enterocele and bladder neck velocity missile leads to delayed leaks and
and concomitant vascular graft surgery suspension surgery, the offending sutures are stricture. Formal surgical resection and repair
(providing the contralateral kidney was typically removed. After vaginal hysterectomy for severe ureteric contusion is supported
normal) [106]. Spirnak et al. [111], in a case or vaginal vault reconstruction, sutures are [7,26,46]. With low-velocity gunshot wounds,
series of eight patients, showed that during typically not removed and the ureter Cass et al. [7] reported that ureteric proximity
vascular graft reconstruction, if the urine is reimplanted. injuries should be stented at least, to avoid
sterile, ureteric repair is indicated and does delayed complications. Obvious contusions
not unduly increase the vascular graft CRUSH INJURY require resection and surgical reconstruction.
infection or failure rate. Secondary renal unit
loss can be high, yet renal salvage can be There is little direct evidence based on PARTIAL AND COMPLETE TRANSECTIONS
enhanced by following standard urological retrospective data for conclusions, but rather (AVULSION) INJURY
principles, isolating the repair with an on case reports and expert opinion. If the
omental wrap and draining the repair away ureter has been crushed by a clamp, the Most partial transactions from surgical
from the graft. likelihood of a significant injury is high. misadventure or stab wounds can be
Generally, this occurs during an attempt to managed by primary sutured closure. Most of
control bleeding or on clamping/division of these injuries should also be stented and
TYPES OF INJURY pelvic vasculature. The ureteric adventitia drained. If more than half the diameter of the
must be carefully inspected as it often takes ureter is lacerated, an aggressive approach of
The common types of iatrogenic ureteric several days for the ischaemic injury to ureteric division and UU or reimplantation is
injuries, in descending order of frequency, manifest itself. The severity of the ureteric supported by published studies.
are ligation, kinking by suture, transection/ injury depends on the size of the clamp, the
avulsion, partial transection, crush, and time it was applied, and the amount of tissue Once the injured ureter is exposed, the general
devascularization (leading to delayed crushed. principles for ureteric reconstruction include:
necrosis/stricture) [13,53–117]. From (i) careful ureteric mobilization (with care to
external trauma, ureteric injuries are Study results are difficult to synthesise, as preserve the adventitia); (ii) debridement of
avulsion, partial transection and blast circumstances are so variable that a clear devitalized tissue, until there is a bleeding
injury devascularization. guideline for a crush injury cannot be edge [11]; (iii) mucosa to mucosa, spatulated,
tension-free, and watertight anastomosis injuries during laparoscopic surgery typically drainage or endoscopic ureteric stenting
[7,10,14,31]; (iv) ureteric drainage (usually occur during gynaecological laser ablation of [12,15,46,48]. Placing a PCN is usually safer
with an internal JJ stent) [16,17,21,48]; and (v) endometriosis or laparoscopically assisted and more universally applicable. Retrograde
isolation of the anastomosis from associated vaginal hysterectomy [78,84,100,104,112]. ureteric stenting is typically unsuccessful
injuries [25]. Minimal handling of the There are also case reports of ureteric injury (50–95%) and should be attempted
adventitia and careful peri-ureteric dissection during laparoscopic tubal ligation, only for certain low-grade injuries
are paramount in preserving ureteric adnexectomy, and laparoscopic uterosacral [13,15,46,49,69,72,100] Antegrade stenting is
vasculature. With the advent of the JJ stent, ligament ablation. Ureteric injuries range often successful, particularly after a few days
the common use in the 1960s and 1970s of T from a small partial tear to complete ureteric of proximal urinary diversion [49]. If a stent
tubes, nephrostomy tubes and ureterostomy avulsion, typically in patients with a history of can be placed an open repair is required only
fell into disfavour. Steers et al. [30] reported pelvic irradiation or previous extensive pelvic for persistent urinary leak or ureteric stricture
UU over a JJ stent, with no nephrostomy, to be surgery. Ureteric complications are often formation [69,72].
both reliable and effective. Reports from the related to surgical experience.
1970s showed that a watertight UU had fewer A PCN should also be placed into the urinoma
complications than one that was not. Partial ureteric lacerations or thermal injuries [90]; unless drained, the extravasated urine
However, before JJ stents were available that are diagnosed intraoperatively can be may lead to secondary retroperitoneal fibrosis
stents were used only selectively. Sieben et al. successfully managed by endoscopically and ureteric obstruction. At 2–3 weeks after
[109] showed that stented repairs were more placing a ureteric stent. Laparoscopic suturing surgery, re-exploration is typically difficult
successful and reliable than unstented. of the lacerated ureter has also been reported. and complex because of inflammation,
Selecting the appropriate management When ureteric transection is complete, an fibrosis, adhesions, haematoma and distorted
option depends on the patient’s physical immediate surgical approach is required. anatomy. The definitive repair should be
condition, the location and extent of injury, However, most laparoscopic ureteric injuries delayed or staged [46,107].
injury mechanism, and the time of diagnosis. are diagnosed after a delay
[78,84,100,104,112]. DAMAGE CONTROL
selected cases of a pelvic ureter where preferred here to UU because the pelvic ureter pelvic irradiation, retroperitoneal fibrosis,
dissection is not extensive and the vascular has a tenuous independent blood supply that chronic pyelonephritis, or anomalies of the
supply to the distal ureter is not may not survive transection or previous recipient ureter. The TUU involves bringing the
compromised. However, deep in the pelvis extensive dissection (i.e. abdominal injured (donor) ureter across the midline
UU can be technically challenging hysterectomy), and allows for a tension-free through a window in the colonic/sigmoid
[1–33,13,46–117]. and nonrefluxing anastomosis. The proximal mesentery, above the inferior mesenteric
ureteric end is debrided and spatulated, artery. The spatulated donor ureter is
Lacerations involving the middle or upper the bladder fundus mobilized and the anastomosed end-to-side to the contralateral
third of the ureter are often best managed contralateral superior vesical pedicle ligated. (recipient) ureter over a JJ stent. The main
by primary UU [4,9,11,12,14,46,47]. After After an anterior cystotomy is made, the disadvantage to the TUU is the potential
debriding nonviable ureter, each end is bladder dome is pulled cephalad and lateral, for damage to the recipient ureter, thus
spatulated on opposite sides and a watertight, and sutured to the psoas minor tendon (or to endangering both kidneys. However, reported
tension-free anastomosis made, over a the psoas major when the tendon is absent). success rates are excellent (up to 97%)
ureteric stent, using absorbable sutures. Care is taken to avoid entrapping the [83,99].
With concomitant intra-abdominal organ genitofemoral nerve. The ureter is then
injury, to prevent fistula formation, the reimplanted. For more extensive injuries involving the
omentum should be used mobilized to distal two-thirds of the ureter, there are
exclude the ureter and protect the repair ANTERIOR BLADDER WALL FLAP (BOARI FLAP) anecdotal reports of transureteropyelostomy
[34,35,37,38,40–45]. by anastomosing the involved ureter to the
Typically, injuries encompassing the lower medial aspect of the contralateral renal pelvis.
URETERIC REIMPLANTATION two-thirds of the ureter (too long to be Potentially, the integrity of the normal ureter
bridged by the psoas hitch procedure) are best or pelvis can be jeopardized and it is thus
Injuries to the distal third of the ureter managed with an anterior bladder wall flap, in indicated in highly selected cases.
that are close to the bladder or within the conjunction with a psoas hitch. In the acute
intramural tunnel usually can be successfully setting there are no reports of Boari flap use URETEROCALYCOSTOMY
and reliably managed by UNC (reimplantation for external trauma and only a few case
into the bladder) for repair. In general, reports for iatrogenic trauma. However, the There is little published evidence to
pelvic ureter viability distal to the ureteric evidence supports its use in planned, delayed support this method except in highly
injury is unreliable due to extensive prior ureteric reconstruction. Success and reliability selected anecdotal circumstances [13]. A
dissection or blast injury. Long defects rates are high, with reports for external ureterocalycostomy can be used for extensive
(usually >2 cm) typically require a trauma (mainly case series) and for iatrogenic injuries to the PUJ and proximal ureter.
Psoas hitch or Boari flap reconstruction trauma (a few large series) However, the lower pole of the involved
[3,4,22,26,32,48,50,51,54,59,94,95]. [55,59,73,86,97,114]. kidney must be amputated to expose the
infundibulum of the inferior calyx, for an end-
UNC alone is used to repair distal ureteric This procedure should not be used in patients to-end, spatulated anastomosis. The failure
injuries close enough to the bladder so that a with previous pelvic irradiation or neurogenic rate and anastomotic stricture rate are high
tension-free and tunnelled anastomosis can bladder disease. The bladder is mobilized and [13].
be made with no bladder mobilization. The fixed to the psoas tendon as described for a
proximal end of the ureter is debrided to psoas hitch [86]. A pedicle of bladder is ILEAL INTERPOSITION
viable tissue, spatulated, and then brought dissected, rotated cephalad, and tubularized
through a cystotomy in the posterior bladder to bridge the gap of missing ureter. The ureter For complete ureteric avulsion or loss, the
wall, medial to the original hiatus (not the is reimplanted submucosally into the flap and ureter can be reconstructed by interposing a
mobile lateral wall). Reflux is usually clinically the bladder closed. Using this technique, most segment of ileum. This cannot be done acutely
insignificant in the adult, but when it is a mid-ureteric defects can be easily bridged. as it requires a standard mechanical and
concern, a submucosal tunnel is created The gap can be further shortened a few antibiotic bowel preparation. Case reports
based on the standard ratio of tunnel length centimetres by caudal nephropexy [114]. to retrospective studies support its use,
to ureteric diameter. The repair is stented and with overall success rates of up to 81%
a prevesical drain placed. TUU [44,47,59,63,88]. Bacteriuria and vesico-ileal
reflux are common, but do not worsen renal
PSOAS HITCH When the defect to the lower ureter is function [63,88]. For extensive bilateral
extensive and/or the bladder is small, fibrotic, ureteric injuries, a segment of ileum can be
There are many retrospective studies or not easy to mobilize, a TUU is particularly tailored as a conduit for both kidneys. This can
reporting excellent success, few useful. The TUU is rarely used, with only a few be used alone or in conjunction with a psoas
complications and durability with the psoas large reported series, and is typically a hitch or anterior bladder wall flap to minimize
hitch [3,4,22,26,32,48,50,51,54,59,94,95]. secondary or delayed procedure [83,99]. the segment of ileum used. Reported
Injuries involving the lower third of the ureter complications of ileal interposition include
(caudal to the iliac vessels) are typically best Relative contraindications to a TUU are obstruction, prolonged mucus formation,
managed by a psoas hitch in conjunction with upper tract urothelial cancer, genitourinary stones, recurrent infections and metabolic
ureteric reimplantation. The psoas hitch is tuberculosis, recurrent nephrolithiasis, acidosis [59,63,88].
RENAL AUTOTRANSPLANTATION open segmental excision and repair is usually As to iatrogenic ureteric injuries, other
necessary [110]. potential studies are:
In patients with a solitary kidney or
compromised renal function, complete • A contemporary and prospective series on
ureteric loss or multiple failed repairs can be SUMMARY radical hysterectomy and ureteric injury.
managed by renal autotransplantation. The • Effects and outcomes of associated colonic
affected kidney is transplanted into the iliac A delay in diagnosis is the most important and pancreatic injuries on ureteric injury and
fossa with vascular anastomoses of the renal factor contributing to the morbidity of reconstruction.
to iliac vessels and urinary continuity restored ureteric injury. By maintaining a high index of • Prospective, multi-institutional study on
with a uretero- or pyelo-vesicostomy. suspicion and prompt use of appropriate vascular graft surgery and associated ureteric
Excellent long-term preservation of renal radiographic and intraoperative evaluations, injury and leak.
function has been reported in small case the difficulty in making the diagnosis can be
series and reports [46,59,61] but renal loss can minimized. The timing for definitive ureteric Evidentiary tables summarizing each of the
occur in up to 8% [61]. repair is based on the patient’s overall referenced articles are available from the
condition, promptness of injury recognition, author upon request.
and the location and degree of injury. When
DELAYED URETERIC COMPLICATIONS identified promptly ureteric injuries generally CONFLICT OF INTEREST
should be repaired immediately. However, if
FISTULA the patient is unstable or the diagnosis None declared.
delayed, temporizing measures are typically
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