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Etiology andMechanisms ofUreteral
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Trauma
The ureter is relatively well protected from external trauma by many factors: vermiform shape, small diameter, mobility, retroperitoneal location with an anterior
bowel cushion, and a posterior psoas muscle shield. The other side of the coin is that
the ureter travels in close proximity to uterine, iliac, inferior mesenteric, and sigmoid vessels, as well as the cervix, the colon, and the rectum exposing it to the risk
for iatrogenic injuries during gynecological or colorectal surgeries [1].
For the sake of clarity, it is important to divide the etiology into two categories:
iatrogenic and non-iatrogenic trauma.
13.1 Iatrogenic Injuries
13
This is the most common cause of ureteral injury and may occur during endourological procedures, open or laparoscopic gynecological, colorectal, and vascular
surgeries, and to a lesser degree as a delayed complication of chemoradiation
therapy.
The iatrogenic ureteric injury may occur either after direct physical trauma, i.e.,
abrasion, perforation, section, ligation, crush, or coagulation, or indirectly due to
secondary ischemia provoked by large-caliber endourological instruments, extrinsic
devascularization, or thermal injury during open or laparoscopic surgery [1]. The
mechanism of injury comprises four types: laceration, ligation (stitches or clips),
devascularization, and energy-induced (monopolar cautery bears more risks) [2]
(Fig.13.1a, b).
In general, iatrogenic agents most commonly injure the pelvic ureter while noniatrogenic and especially penetrating trauma mostly damage the proximal ureter [3].
Indeed, iatrogenic injuries involve the distal, the middle, and the proximal third
of the ureter in 91%, 7%, and 2%, respectively [4].
The iatrogenic causes may be further subdivided as follows:
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_13
105
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13 Etiology andMechanisms ofUreteral Trauma
a b
Fig. 13.1 (a, b) Antegrade nephrostogram in a 54-year woman with a history of radical abdomi-
nal hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer followed by chemotherapy. She developed partial obstruction of right kidney caused by a metallic clip (C) inadvertently
applied on the distal right ureter during the hysterectomy
13.1.1 Endourological Procedures
They were reported to be the most frequent cause of iatrogenic ureteral injuries
accounting for 42% in a series of 156 cases, followed by gynecological surgeries
with 34% [4]. However, most of the endourological complications are minor, diagnosed intraoperatively, and timely managed with a better prognosis. In addition, a
large number of them have a low clinical signicance and remain underreported,
thus leaving gynecological causes to take the lion’s part in iatrogenic causes according to recent studies [1].
A prospective study of 437 patients who underwent ureteroscopy for stones
revealed the occurrence of ureteral wall injury of various grades in 30.4% [5]. Here
again, it is important to notice that many of these injuries consisted of mucosal abrasions and perforations which are self-limited and well-managed with a good prognosis. The most catastrophic complication of endourology is ureteral avulsion, but
this is a very rare event, being reported in less than 1% of procedures only [6].
During a ureteroscopy performed for calculi, the injury might be caused by the
insertion of a guidewire, the push of the semi-rigid ureteroscope, the in-situ lithotripsy with whatever energy (Swiss Lithoclast, Holmium-Laser, etc..), the retrieval
of a stone that scratches the ureteral wall during its descent, or the insertion of a
ureteral access sheath.
A recent review has shown the following incidence of ureteroscopic complications: mucosal erosions and false passages (0.13–9.5%), perforations (0.3–7.4%),
and avulsion (0.04–0.9%) [7]. Ureteral avulsion occurs mostly during an attempt to
retrieve a stone that is too large to pass through the ureteral lumen, or during the
13.1 Iatrogenic Injuries
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Fig. 13.2 Complete
avulsion of the right ureter
with preexisting strictures
during a rigid ureteroscopy
performed for an upper
ureteric stone in a
75-year-old man.
(Courtesy Kurian George,
Retiree from the Urology
Department, The Royal
Hospital, Muscat, Oman)
107
insertion of a semi-rigid ureteroscope that is too large to be safely negotiated through
the ureter. Sometimes even a small ureteroscope might avulse the ureter if forcibly
pushed against a diseased brotic and strictured ureter (Fig.13.2).
Ureteral wall injury by ureteral access sheath may consist of supercial lesions
(39.9%), deeper lesions (17.6%), or circumferential perforation (4.7%) [7].
13.1.2 Gynecological Procedures (Cesarean
Section, Hysterectomy)
Here the risk factors for ureteric injury are obesity, previous laparotomic pelvic
surgery, pelvic adhesions, large pelvic tumors, and unexpected intra-operative
bleeding [8] (Fig.13.3a–c). Most ureteral injuries during gynecological procedures
are diagnosed only after discharge from the hospital (70%) resulting in litigation in
45% of the cases [8].
A systematic review recruiting 140,444 gynecologic laparoscopic surgeries for
benign indications showed 0.08% of ureteral injury, and these were more often
unrecognized intraoperatively [9]. A more specic study showed incidences of 1.3
ureteric injuries per 1000 cases of total abdominal hysterectomy and 0.2 injuries per
1000 cases of vaginal hysterectomy, with or without bilateral salpingo- oophorectomy
[10]. In this review, laparoscopic hysterectomy was associated with the highest incidence of ureteral injury reaching 7.8 per 1000 procedures.
There is also a correlation between the types of gynecological interventions and
the location of ureteral injury [11] (Fig.13.4).
In developing countries, obstetrical injuries are frequent causes of vesicovaginal
stulas. The alarm was recently sounded about the surge of uterovaginal stulas
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13 Etiology andMechanisms ofUreteral Trauma
a
b
c
Fig. 13.3 Pan-ureteral injury with devitalization of the left ureter in a 36-year woman during
cesarean section complicated with severe bleeding that prompted a hysterectomy and packing in a
regional hospital. She later underwent repeated laparotomies for recurrent bleeding, as well as
embolization and ligation of the left internal iliac artery. The ureteral injury was initially managed
with ligation at the remaining viable stump and nephrostomy. (a) Coronal CT showing the nephrostomy tube in situ with dilated proximal ureter ending abruptly at the level of ligation (arrow)
and a urinoma (U). (b) Antegrade nephrostogram demonstrating the left pelvicalyceal system and
the short ureteral stump. (c) Four months after the injury, the left kidney was harvested after a
tedious open approach through a ank incision. A short ureter (5.5cm) is seen during the backtable preparation of the graft for autotransplantation in the right iliac fossa. (Courtesy Feroz Amir
Zafar, Urology, the Royal Hospital, Muscat, Oman)
secondary to emergency cesarean sections for prolonged labors, abdominal hysterectomies, and vaginal hysterectomies [12].
Colpopexy also carries a potential risk to the ureter, as shown by a cadaveric
study [13].
13.1 Iatrogenic Injuries
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Fig. 13.4 The common
sites of ureteral injuries.
(From Ade-Ojo IP etal.
[11]. International Journal
of Women’s Health 2021,
13, 895–902. Originally
published by and used with
permission from Dove
Medical Press Ltd.)
109
13.1.3 Colorectal Procedures
A nationwide retrospective study in the United States conducted over a decade and
recruiting 2,165,848 colorectal surgical procedures showed a total of 6027 ureteral injuries equivalent to 0.28%. It was also noticed that this rate was higher in the
second half of the decade than in the rst decade, with respective rates of 0.31% vs.
0.25%, probably because of the trend to operate on more complex cases, such as
sigmoidectomy for complicated diverticulitis with adhesions, or surgery on cancer
after neoadjuvant chemoradiotherapy [14]. It is estimated that colorectal procedures
(such as low anterior resection and abdominoperineal resection) account for 9% of
iatrogenic ureteral injuries [15].
The risk factors associated with colorectal surgery are rectal cancer diagnosis,
presence of intra-operative adhesions, metastatic cancer, malnutrition or weight
loss, and teaching institutions [14]. On the contrary, some factors such as laparoscopic procedures, as opposed to the open counterpart, surgery on the transverse
and right colons, as opposed to left colon and recto-sigmoid segments, didn’t appear
to be associated with ureteral injuries [14].
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13 Etiology andMechanisms ofUreteral Trauma
13.1.4 Other Procedures
The ureter can also be injured in pelvic vascular surgery. Nonetheless, this complication is extremely rare, and an old review documented only 23 cases in English
Literature over a period of 25years [16]. Moreover, a 20-year retrospective multicentric review showed only ten cases of ureteral injury in relation to vascular surgery, namely abdominal aortic aneurysm repair and aorto-femoral bypass,
representing 6% of a total of 165 iatrogenic ureteric injuries in the same period [4].
In this series, urological interventions were the rst causes, followed by Gynae and
colorectal surgeries with 42%, 34%, and 26%.
Exceptional cases of ureteral injuries have also been reported in routine general
surgery such as inguinal hernia repair in patients with a congenital abnormality or
sliding hernia [17, 18].
Chemoradiation of locally advanced pelvic malignancies is also known to potentially cause delayed ureteric brosis and stricture. An EMBRACE collaborative
group1 review of 1860 patients who received either External beam radiation therapy
combined with Cisplatin, or brachytherapy, for locally advanced cervix cancer,
showed that actuarial 3- and 5-year risk for ureteral stricture was 1.7% and 2.1%
respectively. Advanced disease stage T3–4 along with the presence of hydronephrosis at diagnosis were the only independent risk factors for ureteral stricture, and
patients uniting these two conditions had a 3-year risk of 11.5%, which remained
unchanged at 5years [19].
13.2 Non-iatrogenic or External Trauma
As already mentioned above, penetrating injuries are more frequent than blunt
trauma among non-iatrogenic causes.
A series of 20 patients with penetrating ureteric injuries showed that 18 of them
were due to gunshot (90%) and only two were caused by stabbing (10%), and none
was diagnosed before an emergency laparotomy that was performed for associated
injuries [20].
Abdomen gunshot wound has been estimated to involve the ureter in 2–5% of the
time, through two mechanisms: either by a direct transection of the ureter in the
pathway of the projectile, or disruption of its blood supply in blast injury, resulting
in necrosis [21]. This combined mechanism results in extensive damage to the ureter. By contrast, stab wounds account for only 5% of ureteral injuries in the United
States and cause only short-segment damage to the ureter [21] (Table13.1).
1
EMBRACE: Image-guided intensity modulated External beam radiochemotherapy and MRI-
based adaptive BRAchytherapy in Locally advanced CErvical cancer.
References
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Table 13.1
ureteral trauma
Mechanism of
n (total
Mechanism of ureteral injuries
Blunt trauma 224 38
Motor vehicle collision 110 19
Pedestrian 25 4
Motorcyclist 18 3
High fall 15 3
Low fall 8 1
Cyclist 3 <1
Other 45 8
Penetrating trauma 358 62
Gunshot wound 316 54
Stab 29 5
Other 13 2
From Siram SM [21], with permission from Elsevier
582)
Percentage
13.3 “Spontaneous Ureteral Rupture”
At rst glance, this entity seems off-topic in this book. But the concept of spontaneous rupture remains a subject of controversy, raising some interest here. Despite
having been described for nearly one century [22], there are still extremely rare
cases of spontaneous ureteral rupture in the literature. No clear underlying causes
have been found. Attempts to explain their mechanism include stone impaction,
malignancy, old neglected trauma, extracorporeal shockwave lithotripsy, idiopathic
retroperitoneal brosis, and other factors proceeding through obstruction and/or
dilatation [23–25]. Some cases of spontaneous ureteral rupture of the ureter have
been described after an uncomplicated vaginal delivery, and the authors hypothesized that the downward pressure exerted on the bladder during active labor creates
traction on the ureter [26]. Nonetheless, despite all the attempted explanations, there
are cases of spontaneous ureteral rupture which are not associated with none of the
above factors (tumor, stone, history of trauma, obstruction, etc.), validating therefore the concept of “spontaneous rupture” [27].
References
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injury and stricture-incidence and treatment strategies. Asian J Urol. 2018;5(2):101–6. https://
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2. Delacroix SE Jr, Winters JC.Urinary tract injures: recognition and management. Clin Colon
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3. Engelsgjerd JS, LaGrange CA.Ureteral injury 2021. In: StatPearls [Internet]. Treasure Island
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5. Karakan T, Kilinc M, Demirbas A, Hascicek A, Doluoglu O, Yucel M, Resorlu B.Evaluating
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6. Burks FN, Santucci RA. Management of iatrogenic ureteral injury. Ther Adv Urol.
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7. De Coninck V, Keller EX, Somani B, Giusti G, Proietti S, Rodriguez-Socarras M, RodríguezMonsalve M, Doizi S, Ventimiglia E, Traxer O.Complications of ureteroscopy: a complete
overview. World J Urol. 2020;38(9):2147–66. https://doi.org/10.1007/s00345- 019- 03012- 1.
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8. Jacob GP, Vilos GA, Al Turki F, etal. Ureteric injury during gynaecological surgery—lessons
from 20 cases in Canada. Facts Views Vis Obgyn. 2020;12(1):31–42. Published 2020 May 7
9. Wong JMK, Bortoletto P, Tolentino J, Jung MJ, Milad MP.Urinary tract injury in gynecologic
laparoscopy for benign indication: a systematic review. Obstet Gynecol. 2018;131(1):100–8.
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the role of intraoperative cystoscopy. Obstet Gynecol. 2006;92:1366–77.
11. Ade-Ojo IP, Tijani O. A review on the etiology, prevention, and management of ureteral
injuries during obstetric and gynecologic surgeries. Int J Womens Health. 2021;13:895–902.
https://doi.org/10.2147/IJWH.S330060. PMID: 34621135; PMCID: PMC8491787
12. Lawal O, Bello O, Morhason-Bello I, Abdus-Salam R, Ojengbede O.Our experience with
iatrogenic ureteric injuries among women presenting to University College Hospital, Ibadan:
a call to action on trigger factors. Obstet Gynecol Int. 2019;2019:6456141. https://doi.
org/10.1155/2019/6456141. PMID: 30881457; PMCID: PMC6387707
13. Siff LN, Jallad K, Hickman LC, Walters MD.Surgical anatomy of the uterosacral ligament colpopexy. Urogynecology. 2018;24(5):380–2. https://doi.org/10.1097/SPV.0000000000000461.
14. Halabi WJ, Jafari MD, Nguyen VQ, Carmichael JC, Mills S, Pigazzi A, Stamos MJ.Ureteral
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period in the United States. Dis Colon Rectum. 2014;57(2):179–86. https://doi.org/10.1097/
DCR.0000000000000033.
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16. Dalsing MC, Bihrle R, Lalka SG, Cikrit DF, Sawchuk AP.Vascular surgery-associated ureteral
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IM, Segedin B, Tan LT, Hoskin P, Mahantshetty U, Bruheim K, Rai B, Kirisits C, Lindegaard
JC, EMBRACE Collaborative Group. Risk factors for ureteral stricture after radiochemotherapy including image guided adaptive brachytherapy in cervical cancer: results from
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org/10.1016/j.ijrobp.2018.11.006. Epub 2018 Nov 10
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s1677- 55382007000200003.
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13 Etiology andMechanisms ofUreteral Trauma
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24. Liu S, Lin J, Huang C, Tsai I.Spontaneous rupture of the ureter mimicking acute appendicitis:
two case reports. JACME. 2011;1:61–3.
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Presentation, Symptoms, Imaging,
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Grading, andComplications ofUreteral
14
Injuries
14.1 Presentation andSymptoms
The urologist is often called to the operating theater by gynecologists or colorectal
surgeons suspecting a ureteral injury. More rarely the call comes from an endocrinological surgeon performing adrenalectomy and para-aortic lymphadenectomy, or
a vascular surgeon. The patient may also be referred to the urologist 1 or 2days after
a surgical procedure because of severe localized loin and ank pain and tenderness,
with or without signs of peritoneal irritation, that have prompted an ultrasonographic study revealing ipsilateral hydronephrosis.
However, as a urologist, you are likely to end your career without being involved
in the emergency department for suspected ureteral injury after blunt or penetrating
trauma. Not surprisingly and very logically, priority is given there by the trauma
team to other life-threatening injured organs, and the ureteric trauma will become
obvious only when imaging investigations will show urinary leak or signs of
obstruction and hydronephrosis.
Depending on the delay in the presentation, the patient may develop fever and
sometimes abscess formation in infected urinoma. A female patient may also present with a vaginal urinary leak. Hematuria (microscopic and macroscopic) occurs in
only 44–53% of the cases of ureteral injury [1, 2].
14.2 Imaging
Historically intravenous urography (IVU) was the imaging modality of choice to
evaluate the ureters. Now like in kidney trauma, it has been superseded by comput-
erized-tomography urography (CTU). However, the choice of the best imaging
modality practically depends on the scenarios [3–5]:
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_14
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