Daniel D. Dugi III, MD
John M. Barry, MD, FACS
BASICS
DESCRIPTION
• Intra-operative injury to the ureter can ocurr during open, laparoscopic, or endoscopic surgery
• May be direct laceration, suture ligation, crush injury, thermal injury, or devascularization
• Lower 1/3 of ureter (within the pelvis) is most commonly injured
• Injury may cause obstruction of kidney if ureter is ligated or urinary extravasation if lacerated
• Due to the proximity to the vagina, some injuries may result in uretero-vaginal fistula
EPIDEMIOLOGY
Incidence
• Most series report 1–5% of pelvic surgeries; highest rates among radical hysterectomy cases (1)[B]
• 1–5% of ureteroscopic surgeries (1)[A]
• Approximately half of iatrogenic injuries occur during gynecologic surgery (2)[B]
Prevalence
N/A
RISK FACTORS
• Pelvic surgery, especially gynecologic, intestinal, urologic surgery, or aorto-iliac vascular surgery
• Laparoscopic surgery may have a higher incidence than open surgery (3)[B]
• Radiation therapy, cancer, prior pelvic surgery, aorto-iliac aneurysm, and inflammatory processes such as endometriosis, Crohn disease, and diverticulitis
Genetics
N/A
PATHOPHYSIOLOGY
• Ureters are anatomically close to the uterus, uterine and ovarian arteries, sigmoid colon and rectum, and iliac arteries, and they are at risk of injury during operations on these organs
• Although retroperitoneal organs, the ureters may become involved with inflammatory processes within the peritoneum
ASSOCIATED CONDITIONS
Any condition leading to pelvic, abdominal, or retroperitoneal surgery
GENERAL PREVENTION
• Awareness of risk of ureteral injury, especially during pelvic surgery
• Prospective identification of ureter during retroperitoneal or pelvic surgery
• Placement of ureteral catheters prior to complex pelvic surgery to aid in identifying ureters and increasing intraoperative recognition of ureteral injury (4)[C]
DIAGNOSIS
HISTORY
Most ureteral injuries are not recognized intraoperatively (3)[A]
PHYSICAL EXAM
• Intraoperative identification and inspection of ureters in cases where they are at risk for injury may help prevent or recognize an intraoperative injury
• Post-operatively, a patient with an unrecognized ureteral injury may develop fever, abdominal distention, flank or abdominal pain, or peritonitis and ileus from urinary extravasation
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Surgical drain fluid with elevated creatinine level confirms urinary extravasation
• Gross or microscopic hematuria may suggest urinary system injury but is non-specific, and its absence does not exclude injury
• Leukocytosis or elevated serum creatinine from renal obstruction or reabsorption of extravasated urine
Imaging
Contrast studies are critical for postoperative diagnosis. CT scan with IV contrast and excretory phase imaging may show urine extravasation or a urinoma
Diagnostic Procedures/Surgery
• Indigo carmine or methylene blue may help identify ureteral injury if dye is seen in the operative field after intravenous or intravesical administration
• Retrograde pyelography can definitively confirm or exclude ureteral injury. This also allows an attempt at placement of a ureteral stent
• Women with leakage of urine per vagina postoperatively may have ureteral or bladder injury. A tampon dye test may help differentiate between the two:
– Place a Foley catheter.
– Give oral phenazopyridine hydrochloride 200 mg orally.
– When the urine in the Foley catheter drainage is orange, place a tampon into the vagina
– Fill the bladder gently through the Foley with saline containing indigo carmine or methylene blue.
– Remove the tampon. If the tampon has only orange dye, there is likely a ureteral fistula and no bladder fistula. If there is also blue dye on the tampon, there is likely a bladder fistula.
– Further diagnostic imaging studies may still be necessary to guide therapy
Pathologic Findings
Diagnosis usually not made pathologically
DIFFERENTIAL DIAGNOSIS
• Unrecognized bladder injury
• Lymphocele
• Hematoma
TREATMENT
GENERAL MEASURES
Intraoperative recognition ensures best possible outcome and the fewest complications
MEDICATION
First Line
Indigo carmine or methylene blue may help identify ureteral injury if dye is seen in the operative field after intravenous or intravesical administration
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Injuries recognized intraoperatively:
– Ligation injures: Remove suture and inspect for devascularization
– Partial-thickness, clean lacerations may be closed with fine interrupted absorbable suture if the surrounding tissue has not be devascularized
– Injuries within the pelvis are usually best repaired by direct reimplantation into bladder, with psoas hitch, if necessary (3)[C]
– Injuries above the true pelvis (proximal ureter) may be repaired with direct anastomosis if proximal and distal mobilization allows tension-free repair of healthy, well-vascularized edges (3)[C]
– More complex repairs, such as Boari flap, trans-uretero-ureterostomy, or ileal ureter should be undertaken cautiously in the acute setting
– In unstable patients, the ureter may be left ligated and a percutaneous nephrostomy tube placed postoperatively to drain the kidney
– It is best to leave an indwelling ureteral stent
• Injuries recognized postoperatively:
– If recognized in the first few days to 1 week after initial injury, operative repair is recommended
– If recognized later, reoperation after resolution of surgical inflammation 6 weeks or more postoperatively is recommended (2)[C]
– Retrograde ureteropyelography is helpful in diagnosing ureteral injury and allows for attempt at ureteral stent placement in low-grade injuries (2)[C]
– Small lacerations or partial ligations may heal after a period of ureteral stenting
– Percutaneous nephrostomy drainage is recommended if ureteral stenting is not possible. This also allows attempt at antegrade ureteral stent placement
– Optimal duration of ureteral stenting is not known, but 6 wk is reasonable
– Percutaneous drainage of urinoma is necessary if the urinoma is infected, symptomatic, or does not decrease in size after reliable renal drainage is established
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Intraoperative recognition and repair usually prevents complication of urine extravasation or renal obstruction
• Ureteroneocystostomy for distal ureteral injuries has an excellent prognosis. Proximal ureteral repair have a higher risk of long-term complications because of compromised blood supply
• Patients who have delayed recognition of injuries have higher rates of complications and more procedures needed to resolve injury than those with injuries recognized intraoperatively (5)[B]
COMPLICATIONS
• Urine leakage from a ureteral injury may lead to urinoma formation and infection or abscess
• Extravasated urine may cause irritation of the intestines and peritoneum and result in pain and/or ileus
• Ureteral stricture and renal obstruction may cause loss of renal function
• Ureterovaginal fistula
• Complications of ureteral injury and repair may result in nephrectomy
FOLLOW-UP
Patient Monitoring
• Perform follow-up imaging of the kidney to assure no obstruction from ureteral stricture. Renal ultrasound can evaluate for hydronephrosis and urinoma and has no radiation.
– Excretory imaging (i.e., ExU, CT urography, radioisotope renography with furosemide washout) may be indicated in complex circumstances or when hydronephrosis is found by ultrasound.
Patient Resources
N/A
REFERENCES
1. Al-Awadi K, Kehinde EO, Al-Hunayan A, Al-Khayat A, et al. atrogenic ureteric injuries: incidence, aetiological factors and the effect of early management on subsequent outcome. Int J Urol Nephrol. 2005;37:235–241.
2. Brandes S, Coburn M, Armenakas N, et al. Diagnosis and management of ureteric injury: An evidence-based analysis. BJU Int. 2004;94:277–289.
3. Parpala-Spaman T, Paananen I, Santala M, et al. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. Scan J Urol Nephrol. 2008;48:422–427.
4. Da Silva G, Boutros M, Wexner SD, et al. Role of prophylactic ureteric stents in colorectal surgery. Asian J Endosc Surg. 2012;5:105–110.
5. Selzman A, Spirnak JP. Iatrogenic ureteral injuries: A 20-year experience in treating 165 injuries. J Urol. 1996;155:878–881.
ADDITIONAL READING
Abboudi H, Ahmed K, Royle J, et al. Ureteral injury: A challenging condition to diagnose and manage. Nat Rev Urol. 2013;10:108–115.
See Also (Topic, Algorithm, Media)
• Ureter, Stricture
• Ureter, Trauma
CODES
ICD9
• 867.2 Injury to ureter, without mention of open wound into cavity
• 997.5 Urinary complications, not elsewhere classified
• 998.2 Accidental puncture or laceration during a procedure, not elsewhere classified
ICD10
• N99.71 Acc pnctr & lac of a GU sys org during a GU sys procedure
• N99.81 Other intraoperative complications of genitourinary system
• S37.10XA Unspecified injury of ureter, initial encounter
CLINICAL/SURGICAL PEARLS
• During mobilization of the ureter, avoid “skeletonization” and include periureteral tissue to better preserve blood supply.
• Repair ureteral injuries and avoid nephrectomy unless the repair will place the patient at risk.
• A cystostomy allows easy access to the ureteral orifice to aid in stent placement during open surgery.