Management of ureteric injury

1. Management of Ureteric
Injury
AUC Emergency Urology
Ngu Ing Soon
Year 3 (Parallel)
Sarawak General Hospital

2. Introduction
• Rare, accounting for 1% of urologic injuries
• Acute ureteral injury results from:
• Iatrogenic injury
• External violence from high-speed blunt mechanisms
• Penetrating stab and gunshot wounds
• Iatrogenic injury
• Procedures most commonly associated with iatrogenic ureteral injuries:
• Hysterectomy (54%)
• Colorectal surgery (14%)
• Ovarian tumor removal (8%)
• Transabdominal urethropexy (8%)
• Abdominal vascular surgery

3. Diagnosis and evaluation
• History and physical exam
• Hematuria is a non-specific indicator of urologic injury
• Post-operative signs and symptoms of missed ureteral injury:
• Flank pain
• Fever
• Leukocytosis
• Ileus
• Abdominal distention
• Urinary fistula

4. Diagnosis and evaluation
• Imaging (contrast enhanced CT with 10 minute delayed films)
• Indications
• Stable trauma patients with suspected ureteral injuries and not proceeding
directly to laparotomy
• Findings suggestive of ureteral injury:
• Contrast extravasation
• Lack of contrast in the ureter distal to the suspected injury
• Ipsilateral delayed pyelogram
• Ipsilateral hydronephrosis

5. AAST Grading

6. Management
• Based on hemodynamic stability
• If hemodynamically stable:
• Traumatic ureteral lacerations should be repaired immediately
• A longitudinal laceration is converted into a transverse one (Heineke-Mikulicz procedure)
• If hemodynamically unstable: temporary urinary drainage followed by delayed
definitive repair
• Options for temporary urinary drainage:
• Ureteral stent
• Short period of observation with a plan for reoperation when the patient is more stable
• Exteriorize the ureter
• Tie off the ureter and plan percutaneous nephrostomy
• Definitive repair of the injury should be performed when patient has
improved/stabilized

7. Special Occasion - Ureteral Contusion
• Options:
• Ureteral stenting
• In ureteral contusions that do not appear to require
excision/anastomosis
• Resection with primary repair
• Severe or large areas of contusion
• Gun-shot related ureteric contusions
• Only truly minor injuries can go untreated, but the patients
should be watched for signs of delayed urine leak.

8. Special Occasion - Delayed diagnosis
• Ureteral stent
• If ureteral stent placement unsuccessful or not possible, perform
percutaneous nephrostomy with delayed repair
• If nephrostomy alone does not adequately control the urine leak, options
then include placement of a periureteral drain or immediate open ureteral
repair
• Indications for immediate repair for delayed diagnosis
(within 1 week of injury)
• Injury located near a surgically closed viscus, such as bowel or vagina
• Patient is being re-explored for other reasons

9. Special Occasion - Endoscopic Injury
• Ureteral stent +/- percutaneous nephrostomy tube
• Ureteral perforation during ureteroscopy can be treated by ureteral
stenting,
• If endoscopic or percutaneous procedures are not possible or fail to
adequately divert the urine, open or laparoscopic repair may be
performed.

10. Special Occasion
• Ureterovaginal fistula: ureteral stent
• Success rates range from 64%-100%
• Patients who failed with ureteral stent insertion went on to undergo
ureteral reimplantation with or without Boari flap or psoas hitch, or
transureteroureterostomy with success rates approaching 100%
• Ligation of the ureter: removal ligature and observe the
ureter for viability
• If viability uncertain, perform ureteroureterostomy or ureteral
reimplantation

11. Principles of managing the injured ureter
• Mobilize the injured ureter
• Debride the ureter minimally but judiciously until edges bleed
• Repair ureters with spatulated, tension-free, stented, watertight
anastomosis, using fine absorbable monofilament such as 5-0
polydioxanone (PDS) and retroperitoneal drainage afterward.
• Retroperitonealize the ureteral repair by closing peritoneum over it if
possible
• Do not tunnel ureteroneocystostomies but rather create a widely
spatulated non-tunneled anastomosis

12. Surgical Management – Repair/reconstruction
• Choice depends on location and length of
injury
• Upper ureteral injuries (above iliac vessesls)
• Ureterocalycostomy
• Ureter-ureterostomy
• Trans-ureterostomy
• Ileal or other interposition (not recommended in acute
setting)
• Autotransplant (not recommended in acute setting)
• Rarely, acute nephrectomy is required to treat ureteral
injury after external violence
• Lower ureteral injuries (below iliac vessesls)
• Ureteroneocystostomy
• Psoas hitch
• Boari flap

13. Ureteroureterostomy
• Bridges ureteral defect of 2-3cm
• A surgical drain is placed, and a Foley catheter is usually left
indwelling for 1 to 2 days. The surgical drain may be removed if
there is minimal output for 24 to 48 hours.
• The double-J ureteral stent is usually removed 4-6 weeks
postoperatively
• The success rate for a tension-free, watertight
ureteroureterostomy is > 90%

14. Ureteroneocystostomy
• Bridges ureteral defect of 4-5cm
• A direct, non-tunneled anastomosis may be performed if
postoperative reflux is acceptable
• In a retrospective review, no significant difference in the
preservation of renal function or risk of stenosis was found
between refluxing versus anti-refluxing procedures.
• Principles:
• Long
• Non-tunneled
• Spatulated
• Stented anastomosis

15. Psoas hitch
• May be preferred over ureteroureterostomy in lower ureteral
injuries because the tenuous ureteral blood supply might not
survive transection.
• Femoral nerve is most likely to be injured during a psoas hitch
• Bridges ureteral defect of 6-10cm
• Contraindications: A small, contracted bladder with limited
mobility
• With traction, the ipsilateral dome of the bladder should be able
to reach the level proximal to the iliac vessels.

16. Boari flap
• A pedicle of bladder is swung cephalad
and tubularized to bridge a 10-
15cm gap to the injured ureter
• A small bladder capacity is likely to be
associated with difficult or inadequate
Boari flap creation
• The ratio of flap length to base width
should be ≤ 3:1 to help minimize flap
ischemia

17. Transureteroureterostomy
• Most often performed as a secondary or delayed procedure
• Absolute contraindications:
• Insufficient length of the donor ureter to reach the contralateral
recipient ureter
• Relative contraindications (5):
• History of nephrolithiasis
• Urothelial malignancy
• RPF
• Chronic pyelonephritis
• Abdominopelvic radiation

18. Transureteroureterostomy
• Problems:
• The injured ureter becomes subsequently difficult to intubate or image
with ureteroscopy through the bladder
• ureteral access needs to be provided by a nephrostomy placed on the
injured side.
• involves surgery on the uninjured, contralateral ureter
• Instead of transureteroureterostomy, ileal interposition or
ureteroureterostomy with renal mobilization, if necessary, are
preferred.

19. Ileal ureter substitution
• Delayed ureteral repairs, especially when a very long segment of ureter is
destroyed, can be performed by creation of a ureteral conduit out of
ileum
• Not recommended in the acute setting
• Contraindications:
• Baseline renal insufficiency (creatinine > 2 mg/dL)
• Inflammatory bowel disease
• Radiation enteritis
• Bladder dysfunction or outlet obstruction
• It is recommended that regular endoscopic examination be performed
starting at postoperative year 3 for early detection of malignancy

23. Follow-up after repair
• 6 weeks: remove stent
• At the time of stent removal, retrograde ureterogram can be perform to
document healing without leakage or stenosis.
• 10 weeks: furosemide (Lasix) renogram - document that the
system continues to be unobstructed.
• 4 months: renal US - document lack of hydronephrosis, which
itself might indicate late obstruction