Overview
Definition:
Ureteral reimplantation after trauma refers to the surgical procedure to reattach a severed or damaged ureter to the bladder or a suitable segment of bowel, restoring continuity and ensuring adequate urine drainage
This is a critical reconstructive intervention often necessitated by blunt or penetrating injuries to the abdomen or flank.
Epidemiology:
Ureteral injuries are relatively uncommon, accounting for 1-2% of all major trauma cases
They can occur from blunt trauma (e.g., deceleration injuries, direct blows) or penetrating trauma (e.g., gunshot wounds, stab wounds)
The incidence varies with the mechanism of injury and is higher in severe trauma protocols.
Clinical Significance:
Untreated or inadequately managed ureteral trauma can lead to significant morbidity, including retroperitoneal fibrosis, urinoma formation, chronic infection, hydronephrosis, renal insufficiency, and even renal loss
Prompt and accurate surgical repair, such as ureteral reimplantation, is crucial for preserving renal function and preventing long-term complications.
Clinical Presentation
Symptoms:
Hematuria, gross or microscopic
Flank pain or abdominal pain
Decreased urine output or anuria
Signs of hypovolemic shock (tachycardia, hypotension) in severe cases
Fever or signs of infection if urinoma or abscess develops.
Signs:
Tenderness in the flank or abdomen
Palpable abdominal mass (urinoma)
Signs of peritonitis if associated bowel injury
Echymosis in the flank or abdominal wall
Absent or diminished bowel sounds in cases of ileus.
Diagnostic Approach
History Taking:
Detailed mechanism of injury (blunt vs
penetrating, location of impact)
Associated injuries sustained
Previous abdominal surgeries or renal pathology
Medications and allergies.
Physical Examination:
Comprehensive abdominal and flank examination, assessing for tenderness, rigidity, masses, and external signs of trauma
Assessment of vital signs for hemodynamic stability
Rectal and pelvic examination if indicated.
Investigations:
Urinalysis for hematuria
Complete Blood Count (CBC) for hemoglobin and white blood cell count
Serum electrolytes and renal function tests (BUN, creatinine)
Imaging: Intravenous Urography (IVU) or CT Urography (CTU) is the gold standard to delineate the extent of injury, location of the ureteral tear, and presence of extravasation
Retrograde pyelography can also be useful
Renal ultrasound to assess for hydronephrosis or urinoma
Arteriography may be indicated for associated vascular injuries.
Differential Diagnosis:
Renal contusion
Renal laceration without significant ureteral involvement
Ureteral avulsion
Bladder injury
Bowel perforation
Vascular injury
Retroperitoneal hematoma.
Management
Initial Management:
Resuscitation with intravenous fluids and blood products as needed to stabilize hemodynamics
Analgesia for pain control
Broad-spectrum antibiotics to cover potential infections, especially in cases of penetrating trauma or suspected urinoma
Early surgical exploration for hemodynamic instability or suspected life-threatening injuries.
Surgical Management:
Indications for ureteral reimplantation include significant ureteral transection, avulsion from the renal pelvis or bladder, or extensive contusion with devascularization
Techniques include: 1
Transureteroureterostomy: In cases of bilateral ureteral injury
2
Ureteroneocystostomy (e.g., Lich-Gregoir technique, Psoas hitch, Boari flap): Direct reimplantation into the bladder, often with anti-reflux measures
3
Ureteroenteric diversion: If reimplantation into the bladder is not feasible, using a segment of bowel (e.g., ileal conduit)
4
Ureteroureterostomy: Direct anastomosis of divided ureteral ends, typically with a stent
Surgical repair involves meticulous dissection, ensuring healthy ureteral edges, adequate mobilization, and watertight anastomosis with appropriate stenting and/or drainage
Drainage with a nephrostomy tube may be used pre-operatively or post-operatively for proximal diversion.
Supportive Care:
Close monitoring of vital signs and urine output
Pain management
Antibiotic prophylaxis
Nutritional support
Early mobilization as tolerated
Regular wound care and drain management.
Complications
Early Complications:
Bleeding from the surgical site
Infection (wound infection, urinary tract infection, urinoma, abscess)
Anastomotic leak with urine extravasation
Stricture formation at the anastomosis site.
Late Complications:
Ureteral stricture leading to hydronephrosis
Recurrent urinary tract infections
Chronic flank pain
Renal insufficiency or loss of renal function
Retroperitoneal fibrosis
Stone formation within the reimplanted segment.
Prevention Strategies:
Meticulous surgical technique
Ensuring healthy ureteral margins
Adequate ureteral mobilization
Judicious use of stents and drains
Prophylactic antibiotics
Careful postoperative monitoring for signs of leakage or infection
Early recognition and management of potential complications.
Prognosis
Factors Affecting Prognosis:
The extent and nature of the ureteral injury
The presence of associated injuries
Promptness of diagnosis and surgical intervention
The success of the reconstructive procedure
Patient's overall health status and comorbidities
Prevention of infection and stricture formation.
Outcomes:
With timely and appropriate surgical management, the prognosis is generally good, with preservation of renal function and restoration of normal urinary drainage
However, late complications like strictures can occur and may require further intervention
In severe cases with significant delay or extensive injury, loss of renal function is a possibility.
Follow Up:
Close follow-up is essential, including serial renal function tests (creatinine), urinalysis, and imaging (ultrasound, CTU) to monitor for signs of obstruction, infection, or recurrent injury
The duration of follow-up depends on the severity of the initial injury and the type of reconstruction performed, often extending for several months to a year or more.
Key Points
Exam Focus:
Recognize ureteral injury as a complication of trauma
Understand imaging modalities for diagnosis (CT Urography is key)
Differentiate management strategies based on the level and extent of ureteral damage
Key reconstructive options include ureteroneocystostomy, ureteroureterostomy, and ureteroenteric diversion.
Clinical Pearls:
Always consider ureteral injury in patients with significant flank or abdominal trauma and hematuria
Careful handling of the ureter during surgery is paramount to avoid devascularization
Ensure adequate drainage with stents and/or nephrostomy tubes as necessary
Adequate bladder mobilization is crucial for tension-free ureteroneocystostomy.
Common Mistakes:
Delayed diagnosis due to reliance on less sensitive imaging
Inadequate mobilization of the ureter leading to tension on the anastomosis
Failure to adequately stent or drain the ureteral repair
Overlooking associated injuries
Not considering anti-reflux techniques during ureteroneocystostomy.