Brad Figler, MD
Hunter Wessells, MD, FACS
BASICS
DESCRIPTION
• Owing to its mobility, narrow diameter, and protected location, ureteral injury from external trauma is rare.
• 75% of ureteral injuries are iatrogenic; 18% form blunt trauma and only 7% from penetrating trauma (1).
• Iatrogenic injury is discussed in detail elsewhere (see Section I: “Ureter, Intraoperative Injury”).
EPIDEMIOLOGY
Incidence
• Ureteral injuries represent <1% of all genitourinary injuries caused by violent trauma
• Typically result from gunshot wounds
• Blunt trauma and stab wounds responsible for <20% of ureteral injuries
• Typically occurs concomitant with other injuries (chest, retroperitoneal, intraperitoneal, pelvic)
Prevalence
Unknown
RISK FACTORS
• Penetrating injury to the abdomen and low chest/back
• Flexion/extension injuries (esp. children)
• Diagnosis requires high index of suspicion
Genetics
N/A
PATHOPHYSIOLOGY
• Direct injury from penetrating object
• Stretching of ureter as a result of hyperextension of the body
• Compression against transverse process as a result of rapid deceleration
• American Association for the Surgery of Trauma (AAST) Injury Scoring Scale for ureteral trauma (2)
ASSOCIATED CONDITIONS
• Small bowel injury
• Colon injury
• Liver injury
• Iliac vessel injury
• Bladder injury
GENERAL PREVENTION
• Avoid high-risk activity
• Seatbelt use
DIAGNOSIS
HISTORY
• Requires a high index of suspicion
• History of urologic condition or surgery
• Mechanism of injury
– Hyperextension
– Deceleration
– Fall from height
– Primary location of impact
• Presence of hematuria
– Onset
– Duration
• Flank pain
• Fever
• Nausea/vomiting
PHYSICAL EXAM
• Entrance/exit wounds
• Gross hematuria
• Flank or lower abdominal tenderness
• Flank bulge
• Abdominal distention
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Hematuria is unreliable; absent in 26% of cases (3)
• Creatinine may (rarely) be elevated due to extravasation and reabsorption of urine or obstruction.
ALERT
Absence of hematuria does not exclude ureteral injury. Clinical suspicion should guide investigation.
Imaging
• Demonstration of extravasation of contrast is the gold standard for the diagnosis of ureteral trauma.
– Retrograde pyelography is most reliable for diagnosing ureteral injury; often impractical in trauma patient.
– CT with IV contrast and delayed images is an acceptable alternative. Most trauma patients have CT scans before being taken to the OR emergently.
– On table “one-shot” IVP is sometimes performed in the operating room
Administration of 2 mg/kg IV contrast with on table x-ray plain film after 10 min
• Medial extravasation of contrast at the level of the UPJ, suggestive of UPJ or renal pelvis injury
• Ureters should opacify to the level of the bladder on delayed imaging to be diagnostic
• Assess for foreign bodies, fluid collection, and hydronephrosis
• Ultrasound is generally not useful, except in demonstrating a urinoma or hydronephrosis.
• MRI not used acutely in the trauma setting
Diagnostic Procedures/Surgery
• Retrograde pyelogram: Useful to verify presence or absence of suspected injury
• Ureteral exploration is highly sensitive
• Probe wounds to establish trajectory
Pathologic Findings
Microvascular injury from high-velocity missiles or thermal injury can extend up to 2 cm beyond evidence of gross injury
DIFFERENTIAL DIAGNOSIS
• Other urinary tract trauma
– Kidney
– Bladder
• Contusion
• Renal pelvis laceration
• Ureteropelvic junction avulsion
ALERT
Delay in diagnosis of ureteral injury is a major contributing factor to morbidity in a trauma patient.
TREATMENT
GENERAL MEASURES (1)
• Initial management of the trauma patient employs primary survey, resuscitation stabilization, and
• Minor ureteral injury:
– Ureteral stenting or
– Nephrostomy tube
• Some common options for complete ureteral injury
– Upper third: Uretero-ureterostomy
– Middle third: Uretero-ureterostomy or Boari flap and reimplantation; normally a staged procedure and not performed acutely.
– Lower third: Direct reimplantation or psoas hitch or Blandy cystoplasty.
– Complete ureteral loss: Ileal interposition or autotransplantation as a delayed procedure
ALERT
• With compete ureteral loss employ “Damage Control” first: tie off ureter, place percutaneous nephrostomy.
• Complete UPJ transections will not heal and need open repair
• Partial UPJ injury (laceration) may be successfully treated by primary repair or stent
• Ureteral contusions or proximity gunshot wounds can be treated successfully by stenting
MEDICATION
First Line
Methylene blue and indigo carmine may help identify the site of a ureteral perforation or transection (see Section I: “Ureter, Intraoperative Injury”).
Second Line
Furosemide (20–40 mg IV) can be administered to speed indigo carmine excretion.
SURGERY/OTHER PROCEDURES
• Principles of ureteral repair include:
– Careful mobilization
Preserve adventitia
Avoid electrocautery
– Debridement of nonviable tissue to bleeding
– Spatulated
– Tension-free
– Watertight
– Mucosa to mucosa
– Absorbable suture
– Ureteral stent
– Closed suction drain
• Blast effect from high-velocity gunshot wound (GSW) may require more extensive debridement.
• When concomitant injuries (particularly pancreatic) are present, consider omental flap to protect the repair.
• Successful methods for ureteric repair are based on injury location.
– Upper and middle third: Primary repair
– Lower third: Reimplantation
• Psoas hitch can reduce tension on repair
– Divide contralateral inferior pedicle
– Tack posterior bladder to psoas muscle
– Use multiple longitudinally placed sutures in psoas fascia to avoid femoral nerve injury
• Advanced techniques typically not appropriate in the acute trauma patient
– Bowel interposition
– Transureteroureterostomy
– Autotransplant
– Boari flap
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Delayed management (“damage control”) if patient unstable:
– Tie off ureter with long suture and place nephrostomy tubes post-operatively
– Externalize ureters
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
Long-term outcomes not reported in this population, but long-term results of ureteral surgery are excellent (4)
COMPLICATIONS
• Complication rate after repair of traumatic injuries of the ureter: 25%
– Prolonged leakage is most common
• Delayed complications include
– Ureteral stricture
– Retained ureteral stent
– Renal loss
– UTI
– Hydronephrosis
FOLLOW-UP
Patient Monitoring
• Check JP creatinine at least 2 days after abdominal closure. If consistent with serum, consider removing.
• Stent removal 4–6 wk
• Renal scintigraphy with Lasix 2–4 wk after stent removal to document function/drainage
Patient Resources
MedlinePlus: Injury-kidney and ureter http://www.nlm.nih.gov/medlineplus/ency/article/001065.htm
REFERENCES
1. Lynch TH, Martínez-Piñeiro L, Plas E, et al. ; European Association of Urology. EAU guidelines on urological trauma. Eur Urol. 2005;47(1):1–15. Review.
2. American Association for the Surgery of Trauma (AAST) Injury Scoring Scale. http://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx. Accessed January 19, 2014.
3. Elliott SP, McAninch JW. Ureteral injuries from external violence: The 25-year experience at San Francisco General Hospital. J Urol. 2003;170(4 Pt 1):1213–1216.
4. Ghali AM, El Malik EM, Ibrahim AI, et al. Ureteric injury: Diagnosis, management and outcome. J Trauma. 1999;46:150–158.
ADDITIONAL READING
• Brandes S, Coburn M, Armenakas N, et al. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int. 2004;94(3):277–289. Review.
• Figler BD, Master VA. Urologic trauma. In Chapple CR, Steers WD (eds.). Practical Urology: Essential Principles and Practicer. Springer; 2011.
• Morey AF, Brandes S, Dugi DD, et al. Urotrauma: AUA Guideline (https://www.auanet.org/common/pdf/education/clinical-guidance/Urotrauma.pdf Accessed August 21, 2014)
See Also (Topic, Algorithm, Media)
• Bladder Injury, Intraoperative
• Bladder Trauma
• Renal Trauma, Adult
• Ureter, Intraoperative Injury
• Ureter, Obstruction
• Ureter, Stricture
• Ureter Trauma Image 
CODES
ICD9
• 867.2 Injury to ureter, without mention of open wound into cavity
• 867.3 Injury to ureter, with open wound into cavity
• 997.5 Urinary complications, not elsewhere classified
ICD10
• N99.81 Other intraoperative complications of genitourinary system
• S37.10XA Unspecified injury of ureter, initial encounter
• S37.19XA Other injury of ureter, initial encounter
CLINICAL/SURGICAL PEARLS
• Diagnosis of ureteral injury requires a high index of suspicion.
• Absence of hematuria does not exclude ureteral injury. Hematuria absent in 25–45% of ureteral trauma.
• Ureteral injury is indicated by extravasation of contrast.
• Primary anastomosis and reimplant with psoas hitch are effective methods for repairing ureteral injuries. More complicated injuries can be managed in a delayed fashion.
• Unstable patients can be managed with temporary drainage followed by delayed management.