Overview
Definition:
Ureteral injury refers to damage or transection of one or both ureters, leading to urine extravasation, potential infection, and compromised renal function
It can be iatrogenic, traumatic, or due to intrinsic ureteral disease.
Epidemiology:
Iatrogenic injuries are the most common, with reported incidence rates ranging from 0.03% to 3% depending on the surgical procedure
Gynecological and urological surgeries account for the majority of iatrogenic injuries
Trauma-related injuries are less common but can be severe.
Clinical Significance:
Untreated ureteral injuries can lead to severe morbidity including sepsis, urinoma, hydronephrosis, renal insufficiency, and even renal loss
Prompt recognition and appropriate management are crucial to preserve renal function and prevent long-term complications.
Clinical Presentation
Symptoms:
Often nonspecific and can be delayed
May include flank pain radiating to the groin
Hematuria (gross or microscopic)
Fever and chills suggesting infection or sepsis
Abdominal pain or distension if urinoma forms
Decreased urine output or anuria in severe cases.
Signs:
Tenderness in the flank or abdomen
Palpable abdominal mass (urinoma)
Signs of infection: fever, tachycardia, hypotension
Signs of peritonitis if urine leakage is significant
Vital sign instability in severe cases.
Diagnostic Criteria:
Diagnosis is often made intraoperatively or postoperatively based on clinical suspicion, imaging findings, and urine output
A high index of suspicion is key, especially after pelvic or abdominal surgery
No specific established diagnostic criteria, but a combination of symptoms, physical findings, and imaging is used.
Diagnostic Approach
History Taking:
Detailed surgical history is paramount: type of surgery, operative findings, any intraoperative concerns regarding the ureters, duration of surgery, energy sources used
History of trauma: mechanism, severity
Prior ureteral manipulation or instrumentation.
Physical Examination:
Thorough abdominal examination for tenderness, masses, or signs of peritonitis
Assess for flank tenderness
Evaluate vital signs for instability
Rectal and pelvic examination may reveal associated injuries.
Investigations:
Urinalysis: microscopic hematuria is common
Urine culture: to rule out infection
Complete Blood Count (CBC): leukocytosis may indicate infection
Serum Creatinine and BUN: to assess renal function
Imaging: Intravenous Urography (IVU) or CT Urography (CTU) are gold standards for identifying ureteral injury, demonstrating extravasation, hydronephrosis, and filling defects
Retrograde Pyelography: can confirm injury and assist in planning repair
Renal Ultrasound: may show hydronephrosis but is less sensitive for detecting extravasation.
Differential Diagnosis:
Renal colic from stones
Pyelonephritis
Appendicitis
Diverticulitis
Bowel obstruction
Pelvic inflammatory disease
Ovarian pathology
Other intra-abdominal injuries.
Management
Initial Management:
Fluid resuscitation if hemodynamically unstable
Broad-spectrum antibiotics if infection or sepsis is suspected
Analgesia for pain control
Nasogastric tube decompression if bowel obstruction is present
Consultation with urology and/or general surgery specialists.
Surgical Management:
Depends on the location, extent, and timing of diagnosis
Options include: Ureteral reimplantation (for distal injuries)
Ureteroureterostomy (for mid-ureteral injuries)
Ureteroneocystostomy with psoas hitch or Boari flap (for distal injuries involving the bladder
Ureterocalicostomy (rarely)
Ureteral stent placement (temporary or permanent)
Nephrectomy (if irreparable damage or severe sepsis).
Non Surgical Management:
Limited role, mainly for very minor, contained leaks or in patients with prohibitive surgical risks
Typically involves percutaneous drainage of urinoma and ureteral stenting.
Supportive Care:
Close monitoring of urine output and vital signs
Pain management
Nutritional support
Regular laboratory monitoring of renal function and electrolytes
Antibiotic therapy tailored to culture results.
Complications
Early Complications:
Urinoma formation
Sepsis
Hemorrhage
Anastomotic leak
Stricture formation.
Late Complications:
Ureteral stricture
Chronic hydronephrosis
Renal insufficiency or failure
Recurrent urinary tract infections
Ureteral fistula
Stone formation in retained debris.
Prevention Strategies:
Meticulous surgical technique, especially during procedures near the ureters
Careful dissection and identification of ureteral anatomy
Use of intraoperative ureteral stenting or identification techniques (e.g., indigo carmine injection, ureteroscopy) when indicated
Adequate visualization and hemostasis
Judicious use of electrocautery and energy devices
Prompt recognition and management of any suspected intraoperative injury.
Prognosis
Factors Affecting Prognosis:
Timeliness of diagnosis and repair
Extent and location of injury
Presence of infection or sepsis
Patient's overall health status
Technical success of the repair
Degree of peri-ureteral inflammation and fibrosis.
Outcomes:
Early diagnosis and successful repair generally lead to good outcomes with preservation of renal function
Late diagnosis or complicated injuries may result in long-term renal dysfunction or the need for nephrectomy
Stricture formation is a significant late complication that may require further intervention.
Follow Up:
Regular clinical assessment and imaging (e.g., CTU, ultrasound) are necessary to monitor for complications such as stricture formation, hydronephrosis, or renal function decline
Ureteral stent, if placed, will require periodic assessment and eventual removal or exchange
Follow-up duration can extend for months to years depending on the injury and repair.
Key Points
Exam Focus:
Common causes of iatrogenic ureteral injury (gynecological, urological, GI surgeries)
Key imaging modalities for diagnosis (CTU is gold standard)
Principles of ureteral repair: tension-free, watertight anastomosis
Management options for distal vs
proximal injuries
Role of ureteral stenting
Immediate recognition and management are crucial for renal preservation.
Clinical Pearls:
Maintain a high index of suspicion in patients presenting with flank pain, hematuria, or fever post-abdominal/pelvic surgery
Intraoperative fluoroscopy or retrograde pyelography can be invaluable for definitive diagnosis and planning repair
Consider a psoas hitch or Boari flap for distal ureteral defects when primary anastomosis is not feasible.
Common Mistakes:
Delayed diagnosis leading to significant renal damage
Inadequate visualization of the ureters during surgery
Attempting primary repair of large or tension-filled defects
Forgetting to stent a repair or inadequately stenting
Overlooking associated injuries in trauma patients.