Ureteral injury

Urology د. نعمان هادي سعيدأستاذ مساعد – فرع الجراحة M.B.Ch.B., M.R.C.S., Ph.D.(Uro), C.A.B.(Uro), F.J.M.C.(Uro).

URETERAL INJURIES

Rare Etiology 1. Iatrogenic: most common cause Surgical Injury: Difficult pelvic surgery, gynecological, (hysterectomy & CS), or vascular surgery. Endoscopic: ureteroscopy, TUR, & Dormia basket stone extraction.

.
2. External Trauma Ureteric injuries after external violence are rare, occurring in less than 4% of cases of penetrating trauma (Gun shot, bullet and shells) and less than 1% of cases of blunt trauma Those patients often have significant associated other organs injuries and a devastating degree of mortality that approaches one third 3. Hyperextension injury of the spine

Types: ligation, perforation, or division

Ligation: 1- Asymptomatic resulting in renal atrophy. 2- Ureteric colic or pain post operatively with or without fever of UTI, and tender renal angle. 3- In single kidney: unuria Ligation of both ureters also result in uremia (obstructive uremia).

Division & perforation:

Result in urine collection (urinoma) then super added by infection resulting in abscess formation, fever, rigor and abdominal pain. More commonly urine leak from the wound or vagina (ureterocutaneous or ureterovaginal fistula) about 10th post operative day.

Staging ( Scale ) of Ureteric Injury

Grade Type Description I Hematoma Contusion or hematoma without devascularization. II Laceration <50% transection III Laceration ≥50% transection IV Laceration Complete transection with <2 cm devascularization V Laceration Avulsion with >2 cm devascularization

Clinical presentation

- Hematuria : sometimes - Delayed presentation of ureteral injuries Fever, leukocytosis, and local peritoneal irritation (Signs of internal abscess formation (infected urinoma)) are the most common signs and symptoms of missed ureteral injury and should always prompt CT scan examination. - Post operative colic. - Post operative urine leak (urinary fistula). - Post operative uremia. - Asymptomatic


Diagnosis
A high index of suspicion is required in cases of potential ureteral injury Laboratory investigations GUE : hematuria ? Renal function tests: normal, and elevated in uremia. CBC : leukocytosis

Imaging Studies

U/S: hydronephrosis in ligation and urinoma in division. IVU: contrast leak in division, hydronephrosis or poor function in ligation. CT scan with contrast: diagnostic Retrograde pyelography: obstruction in ligation and contrast leak in division.


IVU demonstrating extravasation in the upper right ureter consequent to stab wound. Note lack of contrast below the site of injury indicating complete ureteral transection.


Ureteroscopy with a rigid ureteroscope to attempt retrieval of a calculus from the midureter resulted in perforation

Ureteral avulsion: blunt trauma. A, CT shows normal function of both kidneys and an Extrarenal collection of densely opacified urine (arrow). B and C, Water-density fluid extends retroperitoneally along the course of the ureter. No opacification of the distal right ureter is apparent. D, Retrograde urogram confirms avulsion and extravasation at the ureteropelvic junction (arrow)

Management of ureteric injury

Prevention is better than treatment. Proper identification of the ureter before uterine artery ligation in gynecological operations or pre-operative stenting in pelvic surgeries. The aim is to regain the continuity of the ureter, preserving renal function and decreasing the morbidity.

Management (Surgical options )

Perforation: ureteric stenting using DJ stent ( double J or JJ stent ). If it is possible to insert a stent endoscopically past a partial ureteric obstruction, an open repair may be avoidable. Ligation: excision of the ischemic segment with end to end anastamosis. Division or Transection: refreshment of the ends with end to end anastamosis.


Methods for repairing a damaged ureter
If there is no loss of length: Spatulation and end-to-end anastomosis without tension If there is little loss of length: Mobilize kidney, Psoas hitch of bladder, Boari operation If there is marked loss of length: Transureteroureterostomy, Interposition of isolated bowel loop, or mobilized appendix, or Nephrectomy

Upper Ureteral Injuries

Mid Ureteral Injuries
Uretero ureterostomy Transuretero ureterostomy Lower Ureteral Injuries Uretero neocystostomy (ureteric reimplantation) with Psoas Bladder Hitch Boari Flap

Boari operation

Suggested management options for ureteral injuries at different levels.

Technique of ureteroureterostomy after traumatic disruption