Most ureteral injuries occur during surgery. Procedures that most often injure the ureter include ureteroscopy, hysterectomy, low anterior colon resection, and open abdominal aneurysm repair. Mechanisms include inadvertent surgical ligation, transection, avulsion, crush, devascularization, kinking, and electrocoagulation.
Noniatrogenic ureteral injuries account for only approximately 1 to 3% of all genitourinary trauma (1). They usually result from gunshot wounds and rarely from stab wounds. In children, avulsion injuries are more common and occur at the ureteropelvic junction. Complications include peritoneal or retroperitoneal urinary leakage; perinephric abscess; fistula formation (eg, ureterovaginal, ureterocutaneous); and ureteral stricture, obstruction, or both.
General reference
1. Coccolini F, Moore EE, Kluger Y, et al. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:54. Published 2019 Dec 2. doi:10.1186/s13017-019-0274-x
Diagnosis of Ureteral Trauma
Imaging, exploratory surgery, or both
Diagnosis of ureteral injuries is suspected on the basis of history and requires a high index of suspicion, because symptoms are nonspecific and hematuria is absent in > 30% of patients. Diagnosis is confirmed by imaging (eg, CT with contrast that includes delayed images, retrograde urethrography), exploratory surgery, or both. Fever, flank tenderness, prolonged ileus, urinary leakage, obstruction, and sepsisare the most common delayed signs of otherwise occult injuries. Intraoperative findings suggestive of a ureteral injury include urinary leakage, ureteral bruising, or decreased peristalsis. The diagnosis can be further aided by injecting dye (eg, indigo carmine, methylene blue) intravenously or intraureterally and watching for it to come through the ureter or appear in the surgical field.
Treatment of Ureteral Trauma
For minor injuries, percutaneous nephrostomy tube or ureteral stent
For major injuries, surgical repair
All ureteral injuries require intervention. A diverting percutaneous nephrostomy tube and/or placement of a ureteral stent (retrograde or antegrade) is often sufficient for minor injuries (eg, contusions or partial transections) (1, 2). Minor iatrogenic intraoperative ureteral injuries such as a partial laceration can be managed with primary closure. In the case of unintended ligation with a suture, suture removal may be adequate. All repairs should be stented.
Major injuries (eg, complete transection or avulsion injuries) typically require reconstructive techniques, either open or minimally invasive using laparoscopic or robotic techniques, depending on their location and extent. These procedures include ureteral reimplantation, primary ureteral anastomosis, anterior (Boari) bladder flap creation, transureteroureterostomy, ileal interposition, and as a last resort, autotransplantation. In unstable patients, a damage control approach is used whereby the ureter is temporarily drained and definitive management is deferred.
Treatment references
1. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30-35. doi:10.1097/JU.0000000000001408
2. Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335. doi:10.1016/j.juro.2014.05.004
Key Points
Most ureteral injuries occur during surgery.
For ureteral injuries from external trauma, maintain a high index of suspicion because findings are nonspecific and hematuria is commonly absent.
Minor injuries can be treated with a ureteral stent or nephrostomy tube, and major injuries with surgical repair.
