Trauma: Ureter Trauma

Ureter Trauma

General

  • Most Common from Penetrating Trauma (95%)

AAST Ureter Injury Scale

Diagnosis

  • Sx: Hematuria & Flank Pain
    • Hematuria Unreliable (Absent in 67% of Blunt and 45% of Penetrating Wounds)
    • Delayed Sx: Pain, Fever, Sepsis, Fistula or Ileus
  • Dx: IV Pyelogram or Contrast CT (Need Delayed Excretory Phase)
    • Consider Cystoscopy with Retrograde Pyelography if Needed

Proximal Ureter Injury with Extravasation (Left); Delayed Imaging (Right) 1

Treatment

  • Ureteral Contusion
    • Can Evolve, Narrow & Scar
    • Minor: Stent
    • Severe: Segmental Resection & Anastomosis Over Stent
  • Stable:
    • Upper 2/3 (Over Pelvic Brim)
      • Small (< 2 cm): Primary Ureteroureterostomy Over Stent
      • Large (> 2 cm): Nephropexy (Decrease Tension) & Ureteroureterostomy
        • Ureteroureterostomy – Spatulating and Anastomosis Over Stent
    • Lower 1/3 (Below Pelvic Brim)
      • Ureteroneocystostomy (Re-Implant in Bladder)
      • If Large: May Need to Decrease Tension
        • Psoas Hitch (Mobilize Bladder and Anchor to Psoas)
          • Preferred Method
        • Transureteroureterostomy (Implant into Contralateral Ureter)
        • Boari Bladder Flap (Bladder is Tubularized)
        • Ileal Interposition
        • Autotransplantation in Pelvis
  • Unstable: Damage Control & Delayed Repair
    • Options:
      • Ligation (Proximal & Distal) with Percutaneous Nephrostomy
      • Cutaneous Ureterostomy
  • Considerations:
    • Always Use Absorbable Sutures (Avoid Stricture/Stones)
    • If Dissecting, Save ≥ 1 cm For Blood Supply
    • Methylene Blue: Check for Leak at End
    • Always Leave Drains
  • Intraoperative Injury

Ureteroureterostomy 2

Psoas Hitch 2

Transureteral Ureterostomy 2

Boari Bladder Flap 2

References

  1. Ortega SJ, Netto FS, Hamilton P, Chu P, Tien HC. CT scanning for diagnosing blunt ureteral and ureteropelvic junction injuries. BMC Urol. 2008 Feb 7;8:3. (License: CC BY-2.0)
  2. Pereira BM, Ogilvie MP, Gomez-Rodriguez JC, Ryan ML, Peña D, Marttos AC, Pizano LR, McKenney MG. A review of ureteral injuries after external trauma. Scand J Trauma Resusc Emerg Med. 2010 Feb 3;18:6. (License: CC BY-2.0)