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Ureteral Injuries

  1. Ureteral injuries are rare, and may be caused by penetrating injuries, Rapid deceleration (Causes avulsion of ureter at UPJ), Iatrogenic e.g. hysterectomy, endoscopic basket manipulation of ureteral stone, devascularization of ureter in pelvic nodes dissection).
  2. Clinical Finding:
    1. In cases of accidental ligation of ureter there is: flank pain, fever, paralytic ileus, with nausea and vomiting.
    2. Bilateral ligation presents as anuria.
    3. Ureterocutaneous, or ureteroveginal fistula may develop, usually within first 10 post op days.
    4. Mid ureter is most common site in penetrating injuries
    5. Acute peritonitis may develop if urine enters in peritoneal cavity.
  3. Laboratory Findings:
    1. Microscopic hematuria is present in 90% of cases.
    2. Serum creatinine level usually remains normal except in bilateral injuries.
  4. X-RAY:
    1. Diagnosis is made by IVP, showing extravasation.
    2. Plain film may show an area of increased density.
    3. In late cases there is hydronephrosis or non-functional kidney.
    4. Retrograde ureterography demonstrates the exact site of obstruction.
  5. Ultrasound:
    USG demonstrates hydroureter and collection due to extravasation.
  6. Treatment:
    1. Immediate exploration and repair is indicated.
    2. If the injury is recognized late, proximal diversion by PCN or formal nephrostomy should be done.
      1. For upper ureter, options available are:
        1. End to end primary uretero-ureteral anastomosis.
        2. Trans uretero-ureteral anastomosis.
        3. If there is extensive loss of ureteral tissue then: bowel interposition or auto transplantation.
      2. For mid ureter:
        Primary uretero-ureteral or trans uretero-ureteral anastomosis.
      3. For lower ureter:
        1. Reimplantation in bladder with psoas hitch (to decrease tension).
        2. Primary uretero-ureteral repair.
        3. A bladder tube flap can be used if the ureter is short (Boari flap).
        4. In the presence of extensive urinoma or pelvic infection trans uretero-ureteral anastomosis is preferred as this allows reconstruction in a clean area.  

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