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14 Presentation, Symptoms, Imaging, Grading, andComplications ofUreteral Injuries
1. Intra-operative suspicion of ureteric injury: The patient is already in the Operating
theater and is under general or spinal anesthesia, retrograde urography is the
best choice, and is indeed the most sensitive imaging means for the detection
of ureteral trauma.
2. Post-operative suspicion of ureteric injury suggested by specic complaints and
complications (pain, tenderness, raised creatinine, fever, inammatory markers,
etc.): Ultrasonography is the most rapid test to orient the diagnosis but has
limited sensitivity and specicity. If the suspicion of ureteral injury is strengthened by the ultrasonographic ndings (ipsilateral hydronephrosis, free uid in
the retroperitoneal or intraperitoneal cavity), a CTU will be the best imaging
modality to ascertain the diagnosis, harboring high specicity and
sensitivity.
3. In a patient presenting with a history of trauma, either penetrating or blunt, the
rst imaging modality is an abdominal and pelvic multi-detector CT (MDCT)
images or a contrast-enhanced CT (CECT) scan of the abdomen which will
provide a view of the whole post-trauma damage. If the CECT-scan raised suspicion of ureteral injury but provides unclear images of the anatomy, delayedphase images, namely a CTU should be requested [4, 5].
4. Sometimes the patient might have an obvious obstruction or leak in the ureter
suggestive of ligation or transection, respectively, for which a percutaneous
nephrostomy (PCN) has already been performed. When a further denition of
the lesion is necessary, the ideal modality here is an antegrade urography or
pyelography performed through the PCN tube, technically known as antegrade nephrostogram (ANG).
After an initial non-contrast phase, CTU comprises three phases following
IV-contrast injection [5] (Fig.14.1):
– Vascular (angiographic or corticomedullary) phase: at 25–40s after IV-contrast
injection.
– Nephrographic (parenchymal) phase: at 75–90s after IV-contrast injection,
– Urographic (excretory) phase: at 3–5min after IV-contrast injection.
MR urography has a limited value in the evaluation of a suspected injured ureter
because it doesn’t add much information compared to a CT scan, is not widely distributed, is not cost-effective, and is time-consuming and therefore not suitable in an
emergency setting. However, being radiation-free, it can be useful for selected cases
such as pregnant women and children, with a reservation for the latter category who
would require general anesthesia for the completion of the investigation.
As mentioned above, ultrasonography is only useful in the primary assessment
of the kidney for any hydronephrosis suggestive of ureteric obstruction, and for the
visualization of a free uid collection compatible with a urinoma. However, it has
no value in the direct identication of a ureteric injury.
ac
14.3 Grading
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d
b
Fig. 14.1 A 50-year-old woman presents with pain and fever after transabdominal hysterectomy.
Excretory-phase CTU image shows right hydronephrosis (arrow, a) and a leak of contrast from the
right distal ureter (arrow, b). (c) Retrograde pyelography conrmed right ureteral transection with
a leak of contrast (arrow) (grade 3 injury). (d) Antegrade pyelography after percutaneous drainage
of right hydronephrosis was performed for the management of the ureteral injury. (From Alabousi
A. etal. [5], with permission from Springer)
14.3 Grading
The ureteral injuries are commonly described as per their anatomic location, being
at the ureteropelvic junction, abdominal, or pelvic, or according to the timing of
their diagnosis, being immediate (at the time of, or shortly after, the injury), or
delayed [6]. The American Association for the Surgery of Trauma (AAST) classication is very widely used for kidney injury but is seldom utilized for ureteral
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14 Presentation, Symptoms, Imaging, Grading, andComplications ofUreteral Injuries
Table 14.1 AAST ureter injury scale
Injury type Description of injury
Grade
I Hematoma Contusion or hematoma without devascularization 2
II Laceration Less than 50% transection 2
III Laceration 50% or greater transection 3
IV Laceration Complete transection with less than 2cm of devascularization 3
V Laceration Avulsion with greater than 2cm of devascularization 3
Advance one grade for bilateral lesions up to grade III
From Moore etal. [7], with permission from Elsevier
AIS 90
Fig. 14.2 (a) Left arteriogram showing contrast extravasating through the stula tract in a
65-year-old male patient who underwent radical cystectomy with ureterocutaneostomy 15months
earlier. (b) The catheter entering the ureter through the stula of the iliac artery. (From Jiang Z
etal. [11]. Creative Commons Attribution 4.0 International License)
injuries and many Urologists are unfamiliar with it. It comprises the following
grades [7] (Table14.1):
Contrary to kidney trauma, the majority of reported ureteric injuries are intermediate and high grade (III and IV), but this might probably be due to underdiagnosis
and underreporting of minor cases [8].
14.4 Complications ofUreteral Injury
Mild to moderate injuries caused by endourology might progress insidiously and
give rise to delayed strictures with chronic hydronephrosis and progressive loss of
kidney function. Serious ureteral injuries are associated with increased morbidity,
hospital stay, and costs. Those subsequent to blunt or penetrating trauma are associated with higher mortality because of associated injuries to other organs. Regardless
of other associated injuries, ureteral perforation alone causes anuria (if solitary
References
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kidney), uremia, urinoma, and ascites. In more severe cases, there might be abdominal compartment syndrome and death [9].
The presence of an indwelling DJ stent, major pelvic vascular or visceral surgeries may trigger an intense inammatory response around the ureters ending in an
arterio-ureteral stula (AUF) [10, 11], a potentially life-threatening complication
(Fig.14.2). When considering all possible causes, hundreds of cases of AUF stulae
have been reported in the literature [12, 13]. A very recent comprehensive review
included up to 445 patients with AUF and showed that the most common associated
factors are chronic indwelling ureteral stents (80%) and a history of pelvic cancer
(70%), the best diagnostic mean is angiography with 62% sensitivity, and the most
predominant location is the common iliac artery ureteral crossing [14].
References
1. Medina D, Lavery R, Ross SE, Livingston DH.Ureteral trauma: preoperative studies neither
predict injury nor prevent missed injuries. J Am Coll Surg. 1998;186(6):641–4. https://doi.
org/10.1016/s1072- 7515(98)00108- 2.
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;18:6. https://doi.org/10.1186/1757- 7241- 18- 6. PMID: 20128905; PMCID:
PMC2830948
3. EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam March 2022. ISBN
978-94-92671-16-5. https://d56bochluxqnz.cloudfront.net/documents/full- guideline/EAU-
Guidelines- on- Urological- Trauma- 2022_2022- 03- 24- 104100_fwda.pdf.
4. Ramchandani P, Buckler PM. Imaging of genitourinary trauma. AJR Am J Roentgenol.
2009;192(6):1514–23. https://doi.org/10.2214/AJR.09.2470.
5. Alabousi A, Patlas MN, Menias CO, Dreizin D, Bhalla S, Hon M, O'Brien A, Katz DS.Multimodality imaging of the leaking ureter: why does detection of traumatic and iatrogenic ureteral injuries remain a challenge? Emerg Radiol. 2017;24(4):417–22. https://doi.org/10.1007/
s10140- 017- 1507- 5. Epub 2017 Apr 27
6. Engelsgjerd JS, LaGrange CA.Ureteral injury 2021. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022.
7. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, Flint LM,
Gennarelli TA, Malangoni MA, Ramenofsky ML, etal. Organ injury scaling: spleen, liver,
and kidney. J Trauma. 1989;29(12):1664–6. https://doi.org/10.1016/S0039- 6109(16)46589- 8.
8. Best CD, Petrone P, Buscarini M, Demiray S, Kuncir E, Kimbrell B, Asensio JA. Traumatic
ureteral injuries: a single institution experience validating the American Association for the
Surgery of Trauma-Organ Injury Scale grading scale. J Urol. 2005;173(4):1202–5. https://doi.
org/10.1097/01.ju.0000155526.37963.ef.
9. Katz R, Meretyk S, Gimmon Z.Abdominal compartment syndrome due to delayed identication of a ureteral perforation following abdomino-perineal resection for rectal carcinoma. Int J
Urol. 1997;4(6):615–7. https://doi.org/10.1111/j.1442- 2042.1997.tb00320.x.
10. Burks FN, Santucci RA. Management of iatrogenic ureteral injury. Ther Adv Urol.
2014;6(3):115–24. https://doi.org/10.1177/1756287214526767.
11. Jiang Z, Wang J, Cui J, etal. Arterioureteral stula after radical cystectomy and ureterocutaneostomy: two case reports and a systematic literature review. BMC Urol. 2022;22:117. https://
doi.org/10.1186/s12894- 022- 01071- y.
12. van den Bergh RC, Moll FL, de Vries JP, Lock TM.Arterioureteral stulas: unusual suspectssystematic review of 139 cases. Urology. 2009;74(2):251–5. https://doi.org/10.1016/j.urol-
ogy.2008.12.011. Epub 2009 Apr 10
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14 Presentation, Symptoms, Imaging, Grading, andComplications ofUreteral Injuries
13. Turo R, Hadome E, Somov P, Hamid B, Gulur DM, Pettersson BA, Awsare NS. Ureteroarterial stula—not so rare? Curr Urol. 2018;12(1):54–6. https://doi.org/10.1159/000489419.
Epub 2018 Jun 30. PMID: 30374282; PMCID: PMC6198778
14. Kamphorst K, Lock TMTW, van den Bergh RCN, Moll FL, de Vries JPM, Lo RTH, de Kort GAP,
Bruijnen RCG, Dik P, Horenblas S, de Kort LMO.Arterio-ureteral stula: systematic review
of 445 patients. J Urol. 2022;207(1):35–43. https://doi.org/10.1097/JU.0000000000002241.
Management ofUreteral Injuries:
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Prevention, Conservative, andMinimally
15
Invasive Management
The management of ureteral injuries depends on the causes, either iatrogenic, blunt,
or penetrating trauma.
15.1 Prevention andEarly Detection
This applies to iatrogenic ureteric injuries.
Obviously, in order to avoid ureteric damage during any open or laparoscopic
surgery, the rst critical point is to identify and clearly visualize the ureters and
many techniques and tricks help achieve this goal:
1. Pre-operative urteral catheter placement: There is a controversy on whether the
ureteric catheter prevents ureteric injury or just helps diagnose it once it has happened, or is not effective in none [1].
A systematic review of the role of prophylactic ureteral catheters recruiting a
total of 102,370 patients with ureteric stents/catheters versus 767,233 controls,
without randomization, paradoxically showed a higher rate of ureteric inju-
ries in stented patients than in the controls, which may retrospectively be
attributed to a selection bias where the stented patients were selected based on a
higher risk of ureteral injuries and more complex surgeries [2].
A nationwide survey conducted among Swiss surgeons showed that 93.5% of
them considered that ureteral stenting was useful in complex procedures, 56.9%
of them admitted the use of stents at least once in the past year, and 54.5% of the
participants considered only noninvasive techniques for identifying ureters in
their regular daily practice [3].
Anyway, to date, there is insufcient data to conclude about the effectiveness of the stents to decrease ureteric injury or increase intraoperative
detection of ureteral injuries.
© 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_15
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15 Management of Ureteral Injuries: Prevention, Conservative, and Minimally…
However, the European Association Of Urology (EAU) recommends the
pre-operative prophylactic use of stents in high-risk cases (major procedures,
large pelvic tumors, or history of previous surgery with distorted anatomy) [4].
Technology to enhance ureteric detection: Early clinical experience of
lighted ureteral catheters was published in the mid-90s; however, they are still
not widely distributed [5, 6].
A novel technology was recently introduced using stents coated with biocompatible uorescent material (NICE: near-infrared coating of equipment) with
conclusive results in pigs and human cadavers [7] (Figs.15.1 and 15.2).
Fig. 15.1 (a, b) NICE-
coated catheter
demonstration under white
light (a) and near-infrared
light (b). (From Barberio
etal. [7] Commons
Creative License)
a
b
ab
15.1 Prevention andEarly Detection
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Fig. 15.2 Demonstration of a NICE-coated catheter under white light (a) and near-infrared mode
(b). The arrow highlights the uorescence reference card. Contrary to humans, the ureter is easily
visible under white light in pigs due to the thin overlying tissues. (From Barberio et al. [7]
Commons Creative License)
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2. No-stent tricks and technique: Where no ureteric tube is used, the ureter may be
identied through its characteristic vermiculations (peristalsis). If sluggish or at
prolonged intervals, these reptations can be stimulated by gentle manual pressure, the so-called “Kelly’s sign”. There is also a promising rat model that
showed perfect visualization of the ureters and their vasculatures after intravenous administration of sodium uorescein and activation with a 530-nm light
transmitter, with no stent use [8].
3. Finally, once a ureteric injury is suspected, on-table IVP or an retrograde
pyelography (RGP) or retrograde injection of methylene blue are easy and
effective diagnostic methods [9].
Regarding ureteral injuries in endourological procedures, the following rec-
ommendations should be considered [10]
– Use of small-sized instruments, i.e., to adapt the instruments to the patient’s
anatomy and not vice-versa.
– When the ureter is deemed narrow, leave a ureteral stent and retry the interven-
tion after a few weeks, to allow time for passive ureteral dilatation.
– Use baskets with utmost care under direct vision.
– Fragment the ureteral stones from the center, far from the mucosa.
Abboudi etal. have suggested a practical algorithm to manage an intra- operatively
suspected ureteric injury [11] (Fig.15.3).
Notwithstanding the above recommendations of clearly visualizing the ureter to
prevent injury and proceeding to its immediate repair or stenting if diagnosed intraoperatively, the situation may sometimes dictate priority to the patient survival in
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15 Management of Ureteral Injuries: Prevention, Conservative, and Minimally…
Suspected ureteric injury
Cystoscopy and retrograde pyelography and/or ureteroscopy
Injury
Ureteric stent and/or ureteral catheter
Successful
Close monitoring
of urine output and
renal function and
postoperative CT
Reassess extent of ureteric injury with CT and/or
ureteroscopy and decide on definitive management
Nonsurgical management Surgical management
Open or laparoscopic ureteroneocystostomy.
psoas hitch, and/or Baori flap
Unsuccessful
Percutaneous nephrostomy
and antegrade stent
Successful
output and renal function plus
Laparoscopic
exploration
and repair
No injury
Ureteric stent is possible,
but not mandatory
Close monitoring of urine
postoperative intravenous
or CT urogram
Unsuccessful
Open
exploration
and repair
Open or laparoscopi
ureteroureterostomy
Fig. 15.3 A suggested schematic for the clinical management of an intraoperatively suspected
ureteric injury. (From Abboudi H etal. [11], with permission from Springer Nature)
cases with severe bleeding and therefore a so-called “damage-control strategy”
should be preferred, consisting of ligation of the damaged ureter and urinary diversion with a temporary nephrostomy, and a repair to be considered later [12].
15.2 Minimally Invasive Techniques inUreteral Injury
1. Percutaneous nephrostomy, antegrade or retrograde DJ stenting with or
without balloon dilatation: A review of post-open hysterectomy ureteral injury
showed a successful rst attempt stenting of 52.4% within a median time of
25days. However, out of those who had successful stenting, only 27.3% had a
resolution of the ureteral injury requiring no further intervention, and others
required open delayed reconstruction [13] (Fig.15.4a–d).
15.2 Minimally Invasive Techniques inUreteral Injury
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a
c
d
b
Fig. 15.4 (a–d) 38-year-old man with a history of right iatrogenic lower ureteric injury sustained
during an endourological procedure. (a) Antegrade nephrostogram showing severely strictured
distal right ureter (prone position). (b) Successful negotiation of a guidewire through the stricture.
(c) Balloon dilatation of the stricture. (d) Successful antegrade insertion of the DJ stent. (Courtesy
Mahmood Al Hajri, Interventional Radiologist, The Royal Hospital, Muscat, Sultanate of Oman)
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