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Etiology

Introduction (1) Acute ureteral injury : external trauma, open surgery, laparoscopy, procedures (2) Uncommon : intraoperative energy) (3) external or suture ligation, energies sharp incision and or transection, vibratory and endoscopic

avulsion, devascularization, and heat (e.g., microwave, electrocautery, freezing (cryoablation)

violence

from high-speed blunt mechanisms and penetrating stab and

gunshot wounds (4) An unrecognized or mismanaged ureteral injury : significant complications (including urinoma, abscess, ureteral stricture, urinary fistula, and potential loss of an ipsilateral renal unit) - Increased nephrectomy rates and a prolonged hospital stay are associated with a delayed or 2006). External Trauma (1) Ureteral injuries : < 1% of all genitourinary trauma Table 42-2 American association for the surgery of trauma organ injury severity scale for the ureter Grade I II III IV V Type Hematoma Laceration Laceration Laceration Laceration (2) Damage to Description Contusion or hematoma without devascularization <50% transection 50% transection Complete transection with <2cm devascularization Avulsion with >2cm devascularization the ureter after external violence : quite rare (<4% of all penetrating missed diagnosis from penetrating ureteral trauma (Kunkle et al,

and <1% of all cases of blunt trauma) (3) During wartime : 3% to 15% of urologic injuries ureteral involvement (average of 5%) (4) Nonmilitary setting : 2% to 3% of ureteral injuries

(5) Well-protected ureter (Located in the retroperitoneum between the spinal vertebra major muscle (6) Great violence groups) : an unlikely target must be inflicted for injury

and

for ureteral damage to occur (one third

significant concomitant injuries & devastating degree of mortality) (7) Associated visceral injury(common) : small (39% to 65%) and large (28% to 33%) bowel perforation (8) 10% to 28% of patients with ureteral injuries -> renal injuries, 5% -> bladder injuries

(9) mechanism : direct transection but by disruption of the delicate intramural blood supply and subsequent necrosis. (10) Due to this blast effect, the full extent of ureteral loss : sometimes underestimated on initial exploration (11) Blunt trauma patients with ureteral injuries : subject to extreme force applied over the entire body (a fall dislocation (12) Rapid deceleration injuries : disrupt the ureter at fixed points along its course, namely the ureterovesical and, more commonly, the ureteropelvic junction (13) Presence of massive force injuries in the blunt trauma patient : should always increase the level of suspicion for ureteral injury (14) Any degree of hematuria : possibility of genitourinary injury (15) Blunt trauma patients with gross hematuria or microhematuria plus hypotension : a history of significant deceleration, or significant associated (16) A history of rapid injuries from a height or a high-speed motor-vehicle accident) - associated with such uncommon injuries as fractured lumbar processes and thoracolumbar spinal

deceleration : found in 100% of patients with ureteropelvic

junction (UPJ) injury in one small series - one third of these patients with UPJ injury have no evidence of hematuria (17) The rare entity of UPJ disruption consequent to blunt trauma is often missed because the patients do not always exhibit hematuria, and the injury is difficult to palpate during intraoperative manual examination -> recommend abdominal CT with contrast and delayed images whenever possible or if time does not permit, an intraoperative shot pyelogram (2 mL/kg intravenous flat plate abdomen radiograph) onecontrast material given 10 minutes before

(18) UPJ disruption : associated with an unusual pattern of either medial contrast extravasation or a circumrenal contrast extravasation Surgical Injury (1) Any difficult abdomino-pelvic surgical procedure(gynecologic, surgical, or (2) The overall urologic) incidence (54%), : 0.5% ~ 10% colorectal surgery (14%), other pelvic procedures like obstetric, general

(3) hysterectomy surgery (6%)

ovarian tumor removal (8%), transabdominal urethropexy (8%), and abdominal vascular

(4) Repeat C-section : a large number of ureteral injuries, in this case up to 23% of the reported ureteral injuries at one hospital (5) The total incidence of ureteral injury after gynecologic surgery : between 0.5% and 1.5%, and after abdominoperineal colon resection (0.3% to 5.7%) (6) Open urologic procedures : a significant number (21%) of reported ureteral injuries in one series (7) Intraoperative ureteral manipulation resulting in subsequent hydronephrosis : common after aortoiliac and aortofemoral bypass surgery (12% to 20%)

(8) Surgical devascularization or inflammation : symptomatic ureteral stenosis, often delayed in presentation by months (1-2%) (9) In patients undergoing arterial ureter. to 85%) of surgical injuries to the ureter after vascular procedures : injury (flank fistula) and treated immediately due to lifepain (36% to 90%), and urinary intra-abdominal aneurysms that vascular cause surgery, risk factors for surgical that

injury of the ureter : reoperation, placement of a vascular graft anterior to the ureter and large can (10) The fever, dilated retroperitoneal inflammation involve the majority ileus,

(up

not recognized immediately - symptoms of ureteral abdominal distention,

(11) Ureteroarterial fistulas

: should be diagnosed

threatening hematuria. Fistula (mostly between the ureter and ipsilateral iliac artery) previous pelvic surgery, radiation therapy, indwelling ureteral stents, infection, primary vascular disease, and pregnancy (12) Currently, the reported rate of ureteral injury : 0.5% (experienced surgeons)

and 14% (inexperienced surgeons) after laparoscopic hysterectomy (13) A large percentage of ureteral injuries after gynecologic laparoscopy occur during electrosurgical or laser-assisted lysis of endometriosis - endometrioma can involve the ureter either extrinsically or intrinsically - long-standing endometriosis can cause intraperitoneal adhesion, making ureteral visualization difficult - the disease can deviate the ureters medially away position (14) A significant number of ureteral injuries also occur during tubal ligation - In 1999 a series of 118 patients reported a 3.4% incidence of ureteral injury after laparoscopic hysterectomy severe enough to cause obstruction - a recent combined six larger series with a much greater number of patients and presumably more experienced surgeons demonstrated a more reasonable 1% rate (15) injury to the urinary tract during hysterectomy : malignancy, endometriosis, prior from their normal anatomic

surgery, and surgery for prolapse (16) In contradistinction to open operation, where at least one are recognized after for immediately, fewer injuries to identified suspicion laparoscopy. Therefore during third of ureteral are high a injuries of

the ureter

immediately index

laparoscopy,

ureteral injury is required.

(17) Postoperatively, patients must be monitored for fever, peritonitis, and leukocytosis, which herald the potential for missed ureteral injury.

(18) Avoidance of ureteral injury is predicated on intimate knowledge of its location, especially its relation to the uterine and ovarian arteries, if those structures are going to be ligated, as in a hysterectomy (19) Visualization of the ureter in the area of the ureterosacral ligaments is thought to be especially difficult, and special care must be taken in this area.

Diagnosis
<Gunshot and Stab Wounds> (1) Incidence of Hematuria. - Hematuria is a nonspecific indicator of urologic injury. - Absence of hematuria in ureteral injury may result from an adynamic, partially transected ureter or a complete ureteral transection

- With a 75% sensitivity for traumatic ureteral injury, wound location may be the only indicator for identifying ureteral injury in the acute setting (2) Intraoperative Recognition. - 93% of injuries of were the recognized promptly including 57% that were identified knife or missile must be carefully examined during intraoperatively. - The trajectory laparotomy, and ureteral exploration should be undertaken in all cases of potential injury. - Liberal use of preoperative diagnostic tools (urinalysis, IVP, CT), even if imperfect, is helpful. - intraoperative inspection of the retroperitoneum : the diagnosing - delayed hospital - Vigilance ureteral injury due diagnosis stay for at and statistically delayed to penetrating produces of ureteral exploration presentation an most important with means of trauma. association prolonged

increased rates of nephrectomy. injuries also allows detection of

injuries missed on presentation. Fever, leukocytosis, and local peritoneal irritation are the most common signs and symptoms of missed ureteral injury and should always prompt CT examination. (3) Methylene Blue. - If a ureteral or renal pelvis injury is suspected intraoperatively, 1 to 2 mL of methylene blue dye can be directly injected into the renal pelvis with a 27-gauge needle to confirm the diagnosis. (4) Imaging Studies

Excretory Urography
- Ureteral detect injuries the after usual external violence, unlike renal injuries, are difficult to to with array of diagnostic tools: preoperative urinalysis, CT scan, and 33% 100%

intraoperative one-shot IVP. (IVP - often unhelpful, proving nondiagnostic of the time)

Computed Tomography
- CT is used increasingly in the evaluation of the trauma patient and, although it appears promising in detecting ureteral injuries, there are few published data to assess its accuracy to date - If the urinary extravasation from the ureteral injury is contained by Gerota fascia, the extent of medial leakage can be small, obscuring the diagnosis. - it is also known that ureteral injuries often manifest with absence of contrast in the ureter

on delayed images. - This underscores the absolute necessity of tracing both ureters throughout their entire course on CT scans obtained to evaluate urogenital injuries. - In addition, because modern helical CT scanners can obtain images before intravenous contrast dye is excreted in the urine, delayed images must be obtained (5 to 20 minutes after contrast injection) to allow contrast material to extravasate from the injured collecting system, renal pelvis, or ureter - Because ureteral injuries are often detected late, periureteral urinoma seen on delayed CT scans may be diagnostic - In reported series, all patients with significant ureteropelvic laceration, for instance, had either medial extravasation of contrast material or nonopacification of the ipsilateral ureter on CT

Retrograde Ureterography.
- Retrograde ureterograms (the most sensitive - to delineate the extent used of clinical - most information commonly is necessary to diagnose missed ureteral injuries because it allows the radiographic seen on test CT for scan ureteral or IVP injury) if further ureteral injury

simultaneous placement of a ureteral stent if possible.

Antegrade Ureterography.
- seldom used in the authors practice - If retrograde stent placement is not possible (usually secondary to a large gap in the two ends of the transected ureter), the authors use anterograde ureterography and stent placement at the time of percutaneous nephrostomy placement

Management
External Trauma (1) Contusion

Ureteroureterostomy.
- Ureteral contusions can heal with stricture or breakdown later if microvascular injury results in ureteral necrosis - Severe or large areas of contusion should be treated with excision of the damaged area and ureteroureterostomy. - Following certain general principles of ureteral surgery increases the success rate of this delicate surgery. Repair of the ureter must be meticulous. Ureteral blood supply is tenuous,

and a sequela of imperfect repair can be urine leakage that can result in nephrectomy, and 1. 2. 3. fine in rare cases even death. - Principles of management of the injured ureter are as follows:

patient

debility,

Mobilize the injured ureter carefully, sparing the adventitia widely, so as not to Debride the ureter liberally until the edges bleed, especially in high-velocity gunshot Repair ureters with spatulated, tension-free, stented, watertight anastomosis; using

devascularize the ureter. wounds. absorbable monofilament such as 5-0 polydioxanone; use optical magnification and

retroperitoneal drainage afterward. 4. Retroperitonealize the ureteral repair by closing peritoneum over it. 5. With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition to isolate the repair when possible.

- Ureteroureterostomy (end-to-end repair) : used in injuries to the upper two thirds of the ureter - required commonly (up to 32%) : success rate as high as 90%. - Complications after ureteroureterostomy(usually urine leakage) : 10% to 24% of the time - Other - Chronic acute complications of include abscess and fistula. by percutaneous nephrostomy placement and ureteral reported in small studies, with a complications, usually comprising ureteral stenosis : less common (5%-12%)

- Management surprisingly

dehiscence

catheter placement for at least 6 weeks has been good success rate (83% to 88%).

Internal Stenting.
- Minor ureteral contusions can be treated with stent damage to When in the ureter) doubt, the injured portion of the ureter should be debrided and placement (minor-appearing ureteral unappreciated microvascular contusions may stricture later or break down secondary to

ureteroureterostomy used to repair the injury (2) Upper Ureteral Injuries

Ureteroureterostomy.
- Ureteral avulsion from the renal pelvis, or very proximal ureteral injury : reimplantation of the ureter directly into the renal pelvis. - The principles of repair : spatulation, lack of tension, stenting, postoperative drainage, and a watertight anastomosis with fine nonreactive absorbable suture - laparoscopic repair of ureteral injuries : increasingly common - Laparoscopic pyeloplasty in the absence of trauma : quite common

- With technologic advances, robotics can also be successfully and safely used for a wide variety of delayed upper urinary tract reconstructions including dismembered pyeloplasty, ureteroureterostomy, and ureterocalicostomy

Autotransplantation.
- Autotransplantation of the kidney has been used after profound ureteral loss or after multiple attempts at ureteral repair have failed. - final option before nephrectomy - The nephrectomy portion of the autotransplantation : can be performed with laparoscopic techniques

Bowel Interposition.
- Delayed ureteral repairs : creation of a ureteral conduit out of ileum, much in the same way that an ileal conduit is constructed to drain the urine after cystectomy - Success rates for ileal replacement of the ureter : 81% to 100% - long-term complications : 3% anastomotic - significant clinical reflux stricture and 6% fistula rate is not a problem

(3) Midureteral Injuries

Ureteroureterostomy: Transureteroureterostomy.
A rarely form used of but repair often (90% to 97%) successful technique in adults is transureteroureterostomy (pediatric series show a lower success rate of 70%) - This involves bringing the injured ureter across the midline and anastomosing it end to side into the uninjured ureter and is most often performed as a secondary or delayed procedure. - transureteroureterostomy : some - The through injured ureter the becomes bladderureteral vexing difficult access problems postoperatively to needs intubate to be or image with by ureteroscopy a nephrostomy provided

placed on the injured side. (4) Lower Ureteral Injuries

Ureteroneocystostomy.
- repair distal ureteral injuries that occur so close to the bladder that the bladder does not need to be brought up to the ureteral stump with a psoas hitch or Boari procedure - Standard principles : creation of a submucosal tunnel for a nonrefluxing ureteral repair usually a tunnel that is at least three times longer than the ureter is wide - A new ureteral orifice is constructed with the use of interrupted 6-0 monofilament absorbable sutures in a watertight and nonobstructing fashion.

- The repair should be stented postoperatively.

Psoas Bladder Hitch.


- the lower third of the ureter and has a high success postoperatively detected iatrogenic lower rate, from 95% to 100% with distal stump - open end-to-end repair may still be considered a realistic treatment option in ureteral injuries preservation identified on retrograde pyelography

Boari Flap.
- Injuries to the lower two thirds of the ureter with long ureteral defects (too bridged by bringing the bladder up in the psoas hitch procedure) long to be

Minimally Invasive.
- More recently, laparoscopic direct and robotic repair of distal ureteral injuries has emerged as psoas bladder hitch, and Boari flap a viable alternative to open surgery. Laparoscopic ureteroneocystostomy, reconstructions have all been described

Partial Transection.
- Primary repair of a partial transection is used in the majority of ureteral injuries, up to 58% of the time in one large series : limited to low-velocity gunshot wounds or stab wounds. - Principles of primary repair : spatulated, watertight closure under optical magnification, with interrupted or running 5-0 or 6-0 absorbable monofilament such as Maxon (polyglyconate) or Dexon (polyglycolic acid) - The ureteral injury : closed by converting a longitudinal laceration into a transverse one so as not to narrow the ureteral lumen (Heineke-Mikulicz procedure). - An internal stent and retroperitoneal drain are placed.

Damage Control.
- In cases of ureteral injury after external violence, it is sometimes necessary to treat the injured ureter by deferring definitive treatment until later. This is usually because the patient is too unstable to tolerate the operative time required to complete the repair. - There are four options for damage control in ureteral injuries: (1) do nothing but plan a reoperation when the patient is more stable, usually within 24 hours (2) place a ureteral stent and do nothing else (3) exteriorize the ureter (4) tie off the ureter and plan percutaneous nephrostomy - In most cases of planned staged repair, we tie off the damaged ureter, using long silk ties to aid the dissection of the ureteral stump during the second-stage repair. The kidney is then

drained

percutaneously.

- We advocate percutaneous placement of a nephrostomy tube, either by the surgeon just postoperatively or later by interventional radiology specialists. - We have found that intraoperative open nephrostomy placement can be too time consuming in these unstable patients. Other authors have advocated placing an 8-Fr feeding tube into the ureter and exteriorizing it until definitive repair can be completed - If possible, appropriate planned ureteric reconstruction should be done after and anatomic imaging is performed. functional

Surgical Injury
(1) Ligation. Ligation of the ureter should be treated by removal of the ligature

and observation of the ureter for viability. If viability is in question, ureteroureterostomy or ureteral reimplantation should be performed (2) Transection

Immediate Recognition.
- Intraoperative management of these injuries is debated - Nephrectomy in cases of ureteral injury is controversial rate from renal failure in with a ruptured in patients - Nephrectomy must be performed aneurysm. - the risk of breakdown of ureteral repair after other surgeries : reported to be 8% to 40% with caution (the mortality

routine aortic aneurysmectomy is 3% and climbs to 12%

Delayed Recognition.
- Intraoperative recognition of ureteral injuries occurs in as low as 34% of patients undergoing open operation and as low as 0% of those undergoing laparoscopy. - Delayed diagnosis of ureteral injury is most often (66% to 76%) achieved pyelography, most with IVP, or retrograde ureterography anuria (5 of 35 patients, bilateral injury), urogenital fistula (4 of 35 patients), persistent pain or fever (3 - Patients present with a variety of signs and symptoms: by CT

of 35 patients), urinary leakage from the wound (3 of 35 patients), hydronephrosis (1 of 35 patients), and hematuria (1 of 35 patients). - When stent placement success - Usually, rate as failure high to is a possible, stent is some the due authors have reported an ultimate as 73% place without need for open surgery. to complete obstruction of the ureter or

too long a gap

Delayed Recognition.
- Intraoperative recognition of ureteral injuries occurs in as low as 34% of patients undergoing open operation and as low as 0% of those undergoing laparoscopy. - Delayed diagnosis of ureteral injury is most often (66% to 76%) achieved pyelography, most with IVP, or retrograde ureterography anuria (5 of 35 patients, bilateral injury), urogenital fistula (4 of 35 patients), persistent pain or fever (3 - Patients present with a variety of signs and symptoms: by CT

of 35 patients), urinary leakage from the wound (3 of 35 patients), hydronephrosis (1 of 35 patients), and hematuria (1 of 35 patients). Key Points: Ureteral Trauma

(1) Ureteral injuries : carefully searched for them (2) Intraoperatively, surgically expose and inspect the ureter when necessary: After penetrating injury, use CT scan and intraoperative one-shot IVP liberally. After penetrating injury, determine the course of the knife or bullet tract to ensure that the ureter is not at risk (3) If delayed recognition is suspected, use retrograde pyelography aggressively. Successful repair of ureteral injuries, whether from external violence or surgical misadventure, is predicated on the use of well-vascularized tissue. (4) Ureteral viability must be ensured by interval removal of nonviable segment before ureteroureterostomy. (5) Tenuously viable distal ureter is bypassed by sewing the bladder to the uninjured proximal ureteral stump. (6) Upper ureteral injuries can be removed and the ureter reimplanted into the renal pelvis after renal mobilization. (Avoidance of iatrogenic ureteral injury - utmost importance.) (7) Safe ureteroscopy ureteral injury. (8) Retroperitoneal surgery : constant attention to the location of the ureter. practices : sound technique, limiting ureteroscopy times, using safety

wires, scoping over guidewires, and halting ureteroscopy immediately in the face of any

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