1. Injury to the ureter is a serious complication that can result in high morbidity and potential loss of renal function. 2. The ureter is most commonly injured during gynecological or abdominal surgeries, though trauma from blunt force or penetrating injuries can also cause damage. 3. Diagnosis of ureteral injury relies on imaging like CT scans and retrograde ureterography to identify signs of extravasation or deviation, though hematuria alone is a poor indicator.

1. URETERIC INJURY
Presented by:
Rojan Adhikari

2. Introduction
• Injury to ureter is a serious operative complication
• High morbidity
• Potential loss of renal function
• Renal > Ureteric > Bladder injury

3. INTRODUCTION
• The ureter is a narrow, thick- walled,
expansile muscular tube.
• 25 cm length and 3 mm internal diameter.
• Conveys urine from the kidney to the urinary
bladder.
• The urine is propelled by the peristaltic
contractions of the smooth muscle of the wall
of the ureter.

4. COURSE IN ABDOMEN
• begins as a downward continuation of a funnel
shaped renal pelvis at the medial margin of the
lower end of the kidney.
• passes downward and slight medially on the
psoas major, which separates it from the
transverse processes of the lumbar vertebrae.
• Enters the pelvic cavity by crossing in front of
the bifurcation of the common iliac artery at the
pelvic brim in front of the sacroiliac joint.

5. COURSE IN PELVIS
• In the pelvis, the ureter first runs downward,
backward, and laterally along the anterior margin
of the greater sciatic notch.
• Opposite to the ischial spine, it turns forward and
medially to reach the base of the urinary bladder.
• Enters the bladder wall obliquely.

6. COURSE IN PELVIS
• Within the bladder wall, it narrows down, takes a
sinuous course, and opens into the cavity of the
bladder at the lateral angle of its trigone as
ureteric orifice.

8. Posterior relation

9. CONSTRICTIONSOFURETER

10. BLOODSUPPLY

11. VENOUS DRAINAGE
• The venous blood from the ureter is drained into the veins
corresponding to the arteries.
LYMPHATIC DRAINAGE
• The lymph from the ureter is drained into lateral aortic and iliac
nodes.

12. NERVE SUPPLY
• The sympathetic supply of the ureter is derived from T12–L1
spinal segments through renal, aortic, and hypogastric plexuses.
• The parasympathetic supply of ureter is derived from S2–S4
spinal segments through pelvic splanchnic nerves.
• The afferent fibres travel with both sympathetic and
parasympathetic nerves.

13. URETERIC INJURY
• Small size
• Mobilility
• Protected by vertebrae,bony pelvis & muscle
• 1-2.5%

14. ETIOLOGY
1. Iatrogenic : open (Gynaecological pelvic surgeries,
oncological ,uro surgeries)
2. Penetrating- Gunshot injury, stab
3. Blunt trauma :Deceleration injury, external injury

15. IATROGENIC INJURY
• Intraoperative suture ligation
• sharp incision
• transection
• Avulsion
• Devascularization
• Heat(microwave,electrocautery,vibratory)
• freezing(cryoablation)

16. IATROGENIC INJURY MECHANISM
1. Ligation/kinking
2. Crushing by a clamp
3. Partial/incomplete transection
4. Thermal injury
5. Ischemia from devascularisation
EAU Guidelines 2020

17. EXTERNAL TRAUMA
associated with uncommon injuries
• fracture lumbar processes
• thoracolumbar spine dislocation
Acceleration & deceleration injury is common at fixed point
• ureteropelvic junction
• ureterovesical junction

19. Iatrogenic injury: Incidence
procedure percentage
hysterectomy 54%
Colorectal surgery 14%
Transabdominal urethropexy 8%
Abdominal vascular surgery 8%
Pelvic surgery(ovarian tumor) 8%
Cesarean section and others 8%

20. Incidence
EAU Guidelines 2020

21. • In open surgeries, most ureteric injury are recognized immediately and
very few during laparoscopy are identified.
• Intimate knowledge of its location, especially its relation to the uterine
and ovarian arteries is necessary .

22. Ureteroscopic injury
• most common cause of iatrogenic ureteral trauma in modern series
• perforation 1-5%, of which 0.2% requires open surgery
Causes
1. persistence of stone basket attempts after recognition of ureteral
tear.
2. longer surgery time
3. inexperience surgeon
4. previous irradiation

23. Ureteric injury following Stone fragmentation:
Electro hydraulic lithotripsy > neodymium:YAG(Nd:YAG) > Ho:YAG
After suspect injury, halt the procedure and keep ureteral stent .
Prevention
I. smaller ureteroscope
II. flexible ureterosope

24. MANAGEMENT
1. History & physicalexamination
2. Investigation
3. Treatment

25. HISTORY/PHYSICAL EXAM
•High degree of suspicion
•Hematuria :poor sensitivity, presents in about 50-75% patients
C/F of missed injury
1)URINOMA formation-Persistant low grade fever, Peritonitis, Flank pain,
Paralytic ileas, hydronephrotic kidney
2)ureterovaginal fistula
3)ureterovesiclar fistula
4)anuria
EAU Guidelines 2020

26. INTRAOPERATIVE RECOGNITION
Penetrating injury
-Intraoperative inspection of the retroperitonium
- High index of suspicion
• methylene blue- 1-2ml directly injected into renal pelvis with 27g needle
and see the spillage.
• Iatrogenic injury may be noticed during the primary procedure, when
intravenous dye (e.g. indigo carmine) is injected to exclude ureteral
injury.
Campbell and Walsh Urology 111h edition

27. RADIOLOGICAL INVESTIGATIONS
• Multi-phase CT is the mainstay imaging technique for
trauma patients
• IVP/ Excretoryurography
• Never one shot - unreliable in diagnosis, as it is negative in up
to 60% of patients
Abnormal findings needs further investigation.
I. Ureteral dilation/deviation
II. Incomplete deviation of total ureter
III. Delayed or no visualisation of renal unit
IV. Urinary/contrast extravasation

29. CONTASTCT SCAN
• Delayed phase
• At 10 mins.
• Extravasation of
contrast medium in
the delayed phase
is the hallmark sign
of ureteral trauma

30. Retrograde ureterography
• most sensitive test
• Used to diagnose missed injuries
• simultaneous placement of ureteric stent

31. Uncommon condition

32. Antegrade ureterography
• Seldom used
• if retrograde ureterography is not possible (usually secondary to a
large gap in the two ends of the transected ureter) then anterograde
ureterography is performed
• at the time of percutaneous nephrostomy placement

33. TREATMENT DEPENDS UPON
• Timing of diagnosis
• Type of injury
• Length of injury
• Site of injury
• Condition of patient

34. EAU Guidelines 2020

35. TECHNIQUESOFMANAGEMENT
Campbell and Walsh Urology 111h edition

36. Time of repair
• generally the best time to repair is as soon as the injury has been
diagnoses
• Delayed definitive repair
1. patient is unable to tolerate a prolonged procedure under GA
2. active infection at the site of proposed ureteric repair
PCN(per cutaneous nephrostomy) tube is placed until definitive repair
Campbell and Walsh Urology 111h edition

37. PRINCIPLESOF REPAIRURETERICINJURY
1. Mobilize the injured ureter carefully, sparing the adventitia widely, so as
not to devascularize the ureter further.
2. Debride the ureter minimally but judiciously until edges bleed,
especially in high-velocity gunshot wounds.
3. Repair ureters with spatulated, tension-free, stented, watertight
anastomosis, using fine absorbable monofilament such as 5-0
polydioxanone and retroperitoneal drainage afterward. Use optical
magnification if necessary.
(Palmer et al, 1983) & Campbell and Walsh Urology 111h edition

38. 4. Retroperitonealize the ureteral repair by closing peritoneum over it if
possible
5. Do not tunnel ureteroneocystostomies but rather create a widely spatulated
nontunneled anastomosis.
Campbell and Walsh Urology 111h edition

39. 6. With severely injured ureters, blast effect, concomitant vascular surgery,
and other complex cases, consider omental interposition to isolate the
repair when possible.
7. If immediate repair is not possible, tie off the ureter with long silk
sutures and plan to repair it later (damage control). Ipsilateral drainage
can be achieved by placing a single J stent brought out cutaneously or a
percutaneous nephrostomy tube placed later.
Campbell and Walsh Urology 111h edition

40. EAU Guidelines 2020

42. URETERAL CONTUSION
• Mild- treat conservatively
• Severe or large areas of contusion should be treated with excision of
the damaged area and ureteroureterostomy.
• If not repaired they heal with stricture or ureteral leak.

43. URETERO-URETEROSTOMY
• end to end repair
• upper 2/3rd injury.
• if avulsion in renal pelvis or proximal ureter injury; reimplantation of
ureter directly into renal pelvis.
• done by open, laparoscopic or robotics

45. COMPLICATIONS
• Urinoma
• Abscess
• Ureteral stricture
• Urinary fistula
• Potential loss of ipsilateral renal unit.

46. Auto-transplantation
- profound ureteral loss
- After multiple attempts of ureteral implantation has been failed

47. Bowel interposition
- Delayed or staged repair
- Most common ileum is used
- appendix can also be used

48. ILEAL INTERPOSITION FLAP
•If it is necessary to replace the entire ureter or a long
ureteral segment, the ureter can be replaced using a
segment of the intestines, usually the ileum.
•This should be avoided in patients with impaired renal
function or known intestinal disease.

49. •The ileal segment is placed in the isoperistaltic orientation
between the renal pelvis and the bladder.
•Follow up: Serum chemistry to diagnose hyperchloremic
metabolic acidosis.
•Long term complication: fistula(6%) and stricture(3%)

50. ILEAL TRANSPOSITION FLAP

51. TRANS-URETERO-URETEROSTOMY
• end to side anastomosis

52. • The injured ureter becomes difficult to intubate or image with ureteroscopy
through the bladder
• allows anastomosis and reconstruction in an area away from pathologic
process
• done when extensive urinoma and pelvic infection have developed.
CONTRAINDICATION:
History of urothelial cancer
Caution- surgery on the uninjured ureter, may be iatrogenic injury

53. Uretero-neo-cystostomy
• Reimplantation of proximal end of ureter on bladder.
• antireflux procedure done whenever possible
• PSOAS HITCH -- Bladdar fixed to psoas to mimimize tension on
ureteral anastomosis

54. REIMPLANTATON

55. PSOAS HITCH

56. URETERAL REIMPLANTATION WITH BOARI FLAP
• In extensive mid-lower ureteral injury, the large gap can be
bridged with a tabularised L-shaped bladder flap.
• It is a time-consuming operation and not usually suitable in
the acute setting.

57. BOARI FLAP

58. Partial Transection
• Making a complete transection and repair
• primary closure

59. DAMAGE CONTROL
• it is sometimes necessary to treat the injured ureter by deferring
definitive treatment until later, when the patient is too unstable to
tolerate the operative time required to complete the repair.
• Eg.hemorrhagic shock, uncontrollable intraoperative bleeding, severe
colon injury
• ureteral repair should be avoided in favor of nephrectomy or staged
repair.

60. 5 options for damage control
1. do nothing plan a reoperation
2. place a ureteral stent
3. exteriorize the ureter
4. tie off the ureter and plan percutaneous nephrostomy
5. permanent cutaneous uretostomy

61. Surgical injury
Ligation
-removal of the ligature and observation of the ureter for viability
-if viability is in question, ureteroureterostomy or ureteral
reimplantation should not be performed.
- Ureteral stent placement either by opening the bladder or cystoscopic
guidance.

62. Delayed recognition
• Placement of retrograde ureteric stent. If achived , open repair only in
patient with ureteral stricture or persistent leakage.
• If stenting can’t be done then, nephrostomy tube and make an anterograde
attempt for stenting.
If can’t done then attempt after 7-14 days.
• If ureter cannot be stented then allow for 6 weeks for complete healing
and open repair.

63. EAU Guidelines 2020

64. Summary of evidence
• Iatrogenic ureteral trauma is the most common cause of ureteral injury.
• Gunshot wounds account for the majority of penetrating ureteral injuries,
while MVAs account for most blunt injuries.
• Haematuria is an unreliable and poor indicator of ureteral injury.
• Pre-operative prophylactic stents do not prevent ureteral injury; however,
they may assist in its detection.
• Endo-urological treatment of small ureteral fistulae and strictures is safe
and effective.
• Major ureteral injury requires ureteral reconstruction following temporary
urinary diversion

65. References
• Oxford-handbook of urology 4rd Edition
• Smith’s General Urology 17th Edition
• Campbell-Walsh urology 11th Edition
• EAU guidelines 2020
• UpToDate

66. THANK YOU