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15 Management of Ureteral Injuries: Prevention, Conservative, and Minimally…
2. Endoureterotomy and endoscopic realignment: Laser endoureterotomy and
balloon dilatation are frequently used for short strictures with incomplete
obstruction, but the risk of recurrence is very high. Scanty articles report successful results of this technique which is contraindicated in active infection, in
strictures longer than 2cm, and failure of endoureterotomy [14].
Endoscopic realignment of the ureter has seldom been reported. A small
series of eight patients with totally transected ureters showed successful results
in six of them (75%) at a mean follow-up of 21.5months. Larger series and longer follow-ups are required to validate this approach [15].
References
1. Chou MT, Wang CJ, Lien RC.Prophylactic ureteral catheterization in gynecologic surgery:
a 12-year randomized trial in a community hospital. Int Urogynecol J Pelvic Floor Dysfunct.
2009;20(6):689–93. https://doi.org/10.1007/s00192- 008- 0788- 3.
2. Croghan SM, Zaborowski A, Mohan HM, Mulvin D, McGuire BB, Murphy M, Galvin DJ,
Lennon G, Quinlan D, Winter DC.The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections. Int J Color Dis. 2019;34(7):1161–78.
https://doi.org/10.1007/s00384- 019- 03314- 1.
3. Douissard J, Meyer J, Ris F, Liot E, Morel P, Buchs NC. Iatrogenic ureteral injuries
and their prevention in colorectal surgery: results from a nationwide survey. Color Dis.
2019;21(5):595–602. https://doi.org/10.1111/codi.14552.
4. EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam. 2022. https://
d56bochluxqnz.cloudfront.net/documents/full- guideline/EAU- Guidelines- on- Urological- Tra
uma- 2022_2022- 03- 24- 104100_fwda.pdf.
5. Senagore AJ, Luchtefeld M. An initial experience with lighted ureteral catheters during
laparoscopic colectomy. J Laparoendosc Surg. 1994;4(6):399–403. https://doi.org/10.1089/
lps.1994.4.399.
6. Burks FN, Santucci RA. Management of iatrogenic ureteral injury. Ther Adv Urol.
2014;6(3):115–24. https://doi.org/10.1177/1756287214526767.
7. Barberio M, Al-Taher M, Felli E, etal. Intraoperative ureter identication with a novel uorescent catheter. Sci Rep. 2021;11:4501. https://doi.org/10.1038/s41598- 021- 84121- z.
8. Dip FD, Nahmod M, Anzorena FS, Moreira A, Sarotto L, Ampudia C, Kalaskar SN, Ferraina
P, Rosenthal RJ, Wexner SD.Novel technique for identication of ureters using sodium uorescein. Surg Endosc. 2014;28(9):2730–3. https://doi.org/10.1007/s00464- 014- 3519- 5.
9. Delacroix SE Jr, Winters JC.Urinary tract injures: recognition and management. Clin Colon
Rectal Surg. 2010;23(2):104–12. https://doi.org/10.1055/s- 0030- 1254297.
10. 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.
11. Abboudi H, Ahmed K, Royle J, Khan MS, Dasgupta P, N'Dow J.Ureteric injury: a challenging
condition to diagnose and manage. Nat Rev Urol. 2013;10:108–15.
12. Coccolini F, Moore EE, Kluger Y, et al. Kidney and uro-trauma: WSES-AAST guidelines.
World J Emerg Surg. 2019;14:54. https://doi.org/10.1186/s13017- 019- 0274- x.
13. Morrow J, Curry D, Dooher M, Woolsey S.Minimally invasive management of delayed recognition iatrogenic ureteric injury. Ulster Med J. 2017;86(3):181–4.
14. Isogai M, Hamamoto S, Hasebe K, Iida K, Taguchi K, Ando R, Okada A, Yasui T.Dual ureteral
stent placement after redo laser endoureterotomy to manage persistent ureteral stricture. IJU
Case Rep. 2020;3(3):93–5. https://doi.org/10.1002/iju5.12152.
15. Liu C, Zhang X, Xue D, Liu Y, Wang P.Endoscopic realignment in the management of complete transected ureter. Int Urol Nephrol. 2014;46:335–40.
Reconstructive Techniques forUreteral
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Injuries: Using Urinary Tract Tissues
Generally, patients presenting with penetrating wounds have associated injuries
prompting urgent exploration without pre-diagnosis of any ureteral injury.
For blunt trauma, experience-based experts’ opinion recommends managing
severe blunt traumatic ureteral injuries rst with minimally invasive methods such
as PCN insertion and antegrade DJ stenting. Early ureteral reconstructive surgery is
advised only when the patient must undergo laparotomy for associated injuries [1],
and the use of ureteral stents is universally recommended after all surgical repairs
[2–4] because it reduces leaks and prevents strictures.
As a general rule of thumb, injuries to the distal ureter (caudal to the iliac ves-
sels) are better treated by reimplantation of the ureter into the bladder, the so-called
uretero-neocystostomy because of the risk of impaired blood supply to the distal
end, and injuries above this level are better addressed with an end-to-end anastomosis [2, 4].
If the ureteric injury is iatrogenic, its management further depends on whether it
is diagnosed intraoperatively or not. When the injury is diagnosed intraoperatively,
the management can be summarized as follows, depending on the anatomic location
and the mechanism [5]:
16
– Laceration or transection: the two ends should be spatulated, then anastomosed
without tension using 4/0 absorbable sutures in a watertight technique, and a DJ
stent should be left for 4–6weeks. This end-to-end ureteric anastomosis is tech-
nically called ureteroureterostomy.
– Ligation: The tying material should be removed, and a DJ stent left for
4–6weeks. However, the ligated segment may suffer irreversible focal damage
due to ischemia and develop a secondary stricture that should be ruled out with
a follow-up imaging study (CT-urography), and treated to prevent ipsilateral
renal atrophy.
© 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_16
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Radiation therapy should not be forgotten among iatrogenic causes of ureteral
injury. Either external beam radiation therapy (EBRT) or brachytherapy (for cervix
cancer, for example) can cause ureteral ischemia, brosis, and stricture in a slow
process that can only be diagnosed months or years after the treatment [6]. Hence,
when one bears in mind this possible complication, imaging of the kidneys should
be obtained for early detection of kidney and upper tract changes.
There are controversies about the timing for surgical correction of a ureteral
injury discovered post-operatively. The debate is about operating immediately or
placing a nephrostomy tube and waiting 6 weeks–3 months or even more until
edema and inammation subside. Some authors plead for the rst attitude and others for the second [7, 8]. The debate is still on the table, and for most iatrogenic
injuries, it has been suggested that the delay depends on the type and location of the
ureteral injury and the general condition of the patients, the extent of the damage,
and the pathologies for which the rst surgery was performed (benign condition,
malignancy, post-radiation, inammatory disease). Some patients might need to be
explored for immediate repair, while others might need to be kept on kidney drainage (nephrostomy), and the denitive management of the ureteral injury be deferred
until optimal conditions prevail [8, 9].
Further techniques depend on the location and the extent of tissue loss.
16 Reconstructive Techniques forUreteral Injuries: Using Urinary Tract Tissues
16.1 Antegrade DJ Stenting
This is a very common procedure that should always be attempted for a short segment ureteric stricture and may be all that is needed for the treatment of the injury.
16.2 Endoureterotomy and Endoscopic Realignment
As mentioned in the previous chapter, this is seldom reported in the literature [10].
16.3 Ureteroneocystostomy
This is the technique of choice for damage to a small segment of the distal ureter,
ideally 2–3cm. It consists of a dissection of the ureter up to the injury site, then a
section of the healthy ureter just proximal to the brotic segment which is ligated
and left in situ. The healthy ureter is then spatulated and reimplanted into a different
site of the bladder without tension, using a 4/0 absorbable suture material (Monocryl,
Vicryl). The anastomosis should be performed in an anti-reux way (see the techniques below) and stented for 3–6weeks. This procedure has been successfully
performed for decades using an open approach [11]. After a transient period of
16.3 Ureteroneocystostomy
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laparoscopic surgery which is a very challenging approach for the ureteroneocystostomy, there are now increasing reports of robotic-assisted procedures with excellent
results after over a 20-month follow-up [12].
Many techniques of ureteroneocystostomy have been described in the 50s and
60s, and the main indication was then to treat patients with vesicoureteral reux
[13–18]. These techniques were further developed in the subsequent decades
with the generalization of renal transplantations [19, 20], and they are generally
eponymously referred to their inventors’ or the rst authors’ names who published them. They all aim at creating a non-reuxing mechanism and can be
roughly divided into two groups:
(a) Intra-vesical technique: Here the most famous are the Hutch technique
(1952) [13] (Fig. 16.1), the Nipple or valve technique (1956) [14], the
Ledbetter- Politano technique (1958) [15] (Fig. 16.2a–g), and the Taguchi
technique (1971) [19] (Fig.16.3a–d).
(b) Extravesical technique: The Lich-Gregoir technique (published by Lich
etal. in 1961 [17] and by Gregoir etal. and 1964 [18]). The eponym “de
Campos Freire” also applies to this technique since the publication of a
successful Brazilian series of renal transplantation in 1974 [20] (Fig.16.4a–i).
abc
Fig. 16.1 (a) Course of normal ureter passing through a normal bladder. (b) Saccule above the
ureteral orice. Note how the course of the intramural ureter is altered. The saccule must have
resulted from weakness of the detrusor muscle which normally lies under the intramural ureter. (c)
Postoperative position of the ureter. The attachment at trigone has been preserved. A long intravesical ureter has been created. The defect in the bladder under the ureter has been rmly sutured.
X marks indicate the position of the sutures. (From Hutch JA [13], with permission from Wolters
Kluwer Health)
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16 Reconstructive Techniques forUreteral Injuries: Using Urinary Tract Tissues
ab
cd
Fig. 16.2 (a–d) Step 1: ureteral orice is circumscribed and intramural ureter dissected free. Step
2: submucosal tunnel is made by gentle spreading of clamp beneath mucosa. Step 3: bladder is
perforated. Clamp is passed behind bladder grasping traction suture placed through ureter. Step 4:
withdrawal of clamp pulls ureter into bladder at new site. Original muscular defect is closed with
interrupted sutures. From Politano VA, Leadbetter WF [15], with permission from Wolters Kluwer
Health. (e–g) Step 5: distal end of ureter is pulled through submucosal tunnel. Step 6: ureter has
been pulled through tunnel and is ready for mucosa-to-mucosa anastomosis. Step 7: anastomosis
completed by using several interrupted ne chromic sutures. (From Politano VA, Leadbetter WF
[15], with permission from Wolters Kluwer Health)
16.3 Ureteroneocystostomy
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ef g
Fig. 16.2 (continued)
ab
131
cd
Fig. 16.3 (a–d) Technique for ureteral implantation. (From Taguchi Y etal. [19], with permission
from Wolters Kluwer Health)
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16 Reconstructive Techniques forUreteral Injuries: Using Urinary Tract Tissues
abc
de f
gh i
Fig. 16.4 (a–c) Spatulation of distal end of ureter and placement of sutures at each end of spatu-
lated opening. (d–f) Preparation of muscular tunnel in the bladder. (g–i) Ureterovesical anastomosis and closure of muscular tunnel. (From Campos Freire Júnior etal. [20], with permission from
Elsevier)
16.5 Uretero-Ureterostomy
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a
bcd
Fig. 16.5 (a) Mobilization of bladder dome, transection of urachus. Psoas muscles exposed.
Ilioinguinal nerve identied. Oblique incision in order to spare blood vessels. (b) Atretic and
obstructing part of ureter removed, xation of the bladder to psoas muscles and to the tendon of the
psoas muscle. (c) Creation of a submucosal tunnel, xation of the ureter into the bladder wall. (d)
Leaving a double J stent in situ. (From Groen VH etal. [25], Creative Commons License)
16.4 Psoas Hitch Associated withtheUreteroneocystostomy
This technique is reported to exist in the urology armamentarium for more than one
century, having been described for the rst time by Witzel in 1896 [21]. However, the
name “Psoas hitch” was coined by Turner Warwick and Peter Worth in 1969 [22]. It
helps to approximate the bladder to the ureter and to support the anastomosis. It is
indicated when the anastomosis appears under tension and can be utilized to palliate
up to a 10-cm defect of the distal ureter [23]. To be successful, this technique must
ensure a tension-free anastomosis, an antireux ureteral implantation through a long
submucosal tunnel, and a straight non-kinking course of the implanted ureter at the
entry point into the bladder [24]. In expert hands, the success rate of a psoas-hitch
ureteroneocystostomy has been estimated to be 92–96.7% [24, 25] (Fig.16.5a–d).
16.5 Uretero-Ureterostomy
This procedure applies to any level of the ureter provided the damaged segment is short
to allow tension-free anastomosis of both ends. It also proceeds through a spatulation
of both ends, the use of 4/0 absorbable suture materials, and stenting [26] (Fig.16.6).
It has traditionally been performed through an open approach. Nowadays many centers
are publishing successful results using laparoscopic and robotic approaches. It is a
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Fig. 16.6 Spatulated,
end-to-end anastomosis of
the ureter using interrupted
absorbable, synthetic
suture. (From Shah NL and
Fred Muhletaler M [26],
with permission from
Springer Nature)
16 Reconstructive Techniques forUreteral Injuries: Using Urinary Tract Tissues
valuable approach for various indications (malignancy, trauma) provided the defect
doesn’t exceed 5cm and was recently shown to have a high success rate (95%) in terms
of kidney protection after a median follow-up time of 62months [27].
16.6 Ureterocalycostomy
This technique can be understood as the proximal counterpart of a ureteroneocytostomy. However, it is a far rarer and more complex procedure. Its traditional indica-
tion is a congenital pelvi-ureteric obstruction with an intra-renal pelvis. Yet, it
can also be helpful in injured PUJ and proximal ureter where there is no possibility
of an end-to-end anastomosis (uretero-ureterostomy) with the distal healthy ureter.
The latter is then anastomosed to the lower calyx using a 4/0 absorbable suture. A
73–90% success rate was published in various series [28, 29].
16.7 Boari Flap
This eponym has been given after Achille Boari, an Italian Urological surgeon in
Ferrara (North Italy) who dedicated his career to surgery. He rst described the
technique of bladder ap on a dog to palliate a large loss of the lower ureter in 1894
[30, 31]. It took nearly 40years more until this canine experience was revived by
Spies etal. in 1933 at the Yale Institute [32]. The rst human experience is attrib-
uted to Nelse Ockerblad who performed this technique on a 44-year-old woman in
1936 in Kansas City (Missouri). Hereafter is the encouraging message left by
N. Ockerblad to posterity while publishing his case in 1947 after the successful
completion of his surgery and an uneventful 10-year follow-up [33]:
16.7 Boari Flap
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I believe I was the rst to make use of this ingenious ap method of performing a ureteral
implantation into the bladder in a human being. It is a method which is practical and can
be used whenever the ureter is too short to be implanted by any of the better-known procedures. It does not seem to matter how the bladder aps are made, nor just where the base
of the ap is located, nor yet the direction the ap may take. The ap should not be too
narrow as it will shrink. There seems to be ample blood supply.
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While paying tribute to Dr. N.Ockerblad for this great and exceptional surgical
and artistic achievement and saluting his optimism, his positive attitude, and his
inspiring message, we should at the same time temper his exaltation because the
size and position of the base to achieve a good length and the direction of the ap
are important aspects in the nal success of the reconstruction (see further discussion below).
The ap is indicated for defects of around 5–10cm and is traditionally utilized
for distal or mid-ureteric damage [34] (Figs.16.7, 16.8a–c). However, cases have
been published of extended Boari aps reaching the upper ureter and even replacing
a panureteric stricture up to the renal pelvis [35–37] (Figs.16.9, 16.10, and 16.11).
The advantage of the bladder ap is to avoid bowel-related complications. A mini-
mum of 4cm of the ap base breadth is required to maintain a good blood supply
of the ap and the ratio length/base should not exceed 3. If a greater length of the
ap is desired, a useful artice consists of fashioning an oblique or “S” shaped ap
[36]. Also, a good bladder capacity is a prerequisite for Boari ap as the subtraction of
abc
Fig. 16.7 Boari ap. (From Pereira BM etal. [34]. Creative Commons Attribution License)
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