This document discusses ureteric injury and its management. It begins with the anatomy of the ureters and their course and relations. It then discusses the etiology of ureteric injuries, which are most commonly iatrogenic from open, laparoscopic or endoscopic procedures. Radiological investigations like IVU and CT scans are used to diagnose injuries. Principles of repair include debridement, spatulation and mucosa-to-mucosa anastomosis with stenting. Management depends on factors like timing, length and site of injury. Techniques include ureteroneocystostomy, ureteroureterostomy and transureteroureterostomy. Prevention involves

1. URETERIC INJURY AND
THEIR MANAGEMENT
SPEAKER : DR. SAGNIK RAY
CHAIRPERSONS : PROF. D .KARMAKAR
PROF S S BHOJ
DR. A K SAHA

2. ANATOMY-COURSE & RELATION
• 25 cm
• Upper part over psoas
• Proximal part-lateral to
gonadal vessel
• Distal part- medial

3. COURSE & RELATION….CONTD.(ABOVE PELVIC
BRIM)
Left ureter :Crossed by left
colic vessels
Intimate relation-sigmoid
colon & mesocolon
Enters pelvis at bifurcation
of common iliac
Rt ureter : Crossed by rt
colic & ileocolic vessels
Intimate relation-ascending
colon
Enters pelvic brim at
bifurcation of common iliac

4. BELOW PELVIC BRIM
FEMALE
• Ovarian vessels closely
related.
• Uterine vessels :crosses
ureter
MALE
• Testicular vessels :-separate
and follow external iliac
vessel
• Ureter pass inferior to vas
and anterior to seminal
vescicle

5. PELVIC URETER-FEMALE

6. BLOOD SUPPLY

7. CONSTRICTIONS OF URETER & COMMON SITES OF
INJURY

8. URETRIC INJURY :SALIENT FEATURES
• Rare-----
Small size
Mobilility
Protected by vertebrae,bony pelvis & muscle
• 1-2.5%

9. ETIOLOGY
• Commonest: Iatrogenic….. open, laparscopy, endoscopy
• Penetrating…….Gunshot injury
• Blunt trauma : Deceleration injury

10. IATROGENIC INJURY------MECHANISM
• Ligation/kinking
• Crushing by a clamp
• Partial/incomplete transection
• Thermal injury
• Ischemia from devascularisation

11. INCIDENCE OF URETERAL INJURY IN VARIOUS
PROCEDURES
PROCEDURE PERCENTAGE(%)
1)GYNECOLOGICAL
Vaginal hysterectomy 0.02-0.5
Abdominal hysterectomy 0.03-2
Lap hysterectomy 0.2-6.0
Urogynecological procedure 1.7-3.0
2)Colorectal surgery 0.15-10.0
3)Ureteroscopy
Mucosal abrasion 0.3-4.1
Ureteral perforation 0.2-2.0
Intussucception/avulsion 0-0.3

12. MANAGEMENT
1. History & physical examination
2. Investigation
3. Treatment

13. HISTORY /PHYSICAL EXAM
• High degree of suspicion
• Hematuria :poor sensitivity…50-75%
• Iatrogenic :IV dye Indigo carmine intra op.

14. CLINICAL FEATURES OF MISSED INJURY
1)URINOMA formation ……
Persistant low grade fever
Peritonitis
Flank pain
Paralytic ileas

15. CONTD…
• 2)ureterovaginal fistula
• 3)ureterovesicle fistula

16. RADIOLOGICAL INVESTIGATIONS
IVP(WITH LATERAL FILMS)
1. IVP : Never one shot
Abnormal findings needs further investigation.
• Abnormal findings are :
I. Ureteral dilation/deviation
II. Incomplete deviation of total ureter
III. Delayed or no visualisation of renal unit
IV. Urinary/contrast extravasation

17. CONTAST CT SCAN
• Delayed phase
• At 10 mins.

18. IF CT/IVP IS NON DIAGNOSTIC…….
• RETROGRADE /ANTEGRADE UROGRAPHY IS GOLD
STANDARD

19. PRINCIPLES OF URETERIC INJURY
RECONSTRUCTION
1. Debridement of necrotic tissue.
2. Spatulation of ureteral ends
3. Watertight mucosa to mucosa with absorbable suture
4. Internal stenting
5. External drain
6. Isolation of injury with omentum/peritonium

20. TREATMENT DEPENDS UPON…….
1. Timing of diagnosis
2. Type of injury
3. Length of injury
4. Site of injury
5. Condition of patient

21. MANAGEMENT OF DELAYED (>2WKS) RECOGNISED
INJURY
• Stabilse the patient
• Proximal ureteric drainage with percutaneous
nephrostomy.

22. TECHNIQUES OF MANAGEMENT
URETERONEOCYSTOSTOMY

23. LOWER THIRD
• Reimplantation of proximal end of ureter on bladder.
• Reimplantation done in an antireflux fashion…..prevent
long term kidney infection.
• PSOAS HITCH……Bladdar fixed to psoas.
• If ureter only ligated….primary ureteroureterostomy can
be done.

24. REIMPLANTATION

25. PSOAS HITCH

26. UPPER & MIDDLE THIRD
• Primary uretero ureterostomy
• Transuretero ureterostomy (option in extensive ureteral
loss or when pelvic injuries preclude ureteral
reimplantation.)

27. PRIMARY URETEROURETEROSTOMY

28. TRANSURETEROURETEROSTOMY

29. URETERAL REIMPLANTATION WITH BOARIS 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.

30. BOARI FLAP

31. 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.

32. ILEAL TRANSPOSITION FLAP

33. • 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%)

34. PREVENTION OF IATROGENIC TRAUMA
• Proper identification during operation
• Pre op stenting
• Intra op cystoscopy

35. THANK YOU