ureteric injuries in practice

1. Ureteric injuries
Arul velusamy

2. Ureteric anatomy
•22-30cm
•Anterior edge of psoas
•Gonadal vessels anteriorly
•Anterior to iliac vessels

3. Ureter anatomy
Ureters enters the pelvis by
crossing the bifurcation of CI
from lateral to medial aspect
just medial to the ovarian
vessels
Thens it runs along the
greater sciatic notch to the
ischial spine
At the level of the ischial
spine it runs in the broad lig
and enters the ureteric canal
formed by the cardinal lig
,crossed anteriorly by the
uterine vessels,1.5cm lateral
to cervix
It then runs medially to
enter the bladder close to
anterior vaginal wall
At the base of the broad lig
it is closely related to
uterosacral lig

4. Ureter anatomy
•Utreine artery courses anterior to
ureter
•Lies in close proximity to the lig.
•10% females carry more supply
via uterine artery to distal ureter
•40%have decreased ureteral
blood supply after ligating uterine
artery

5. Ureteric injuries

6. Causes
• External trauma
• Open abdominopelvic surgeries
• Laparoscopic surgeries
• Endoscopic procedures

7. External trauma
• Rare
• 4% of penetrating
• 1% of blunt
• Associated renal injuries(10
-28%)
• Associated bladder
injuries(5%)
• Gun shot injury:vascular
disruption over 2cm

8. Surgical injuries(open)
• Abdominopelvic surgery overall incidence
0.5-10%
• Hysterectomy(54%)0.5 to 1.5 % incidence
• Colorectal surgery(14%)0.3 to 5.7% incidence
• Ovarian tumor removal(8%)
• Transabdominal urethropexy(8%)
• Abdominal vascular sx(8%)
aorto iliac/aortofemoral bypass12 to 20%

9. Surgical injuries (lap)
• Incidence of 0.5 to 14% for lap hysterectomy
• Most injuries are missed intra op(v/s 1/3rd in
open)
• Risk factors in hysterectomy being
malignancy
endometriosis
prior surgery
sx for prolapse

10. Endoscopic procedures
• Earlier rates were 0 to 28%
• Recent series : perforation rates 1 to 5 %
• Factors associated with higher risks :
longer surgery time
treatment of renal calculi
surgeon’s inexperience
previous irradiation
 Stone fragmentation:EHL>NdYAG>Ho YAG
 Protective
smaller scopes
flexible scopes
ureteral access sheath

11. Diagnosis trauma
• Hematuria :non specific25 to 45 % no hematuria
• Intraoperative recognitionduring exploration
wound location
methylene blue
• Imaging studiesexcretory urography non dx in 33 to 100%
CTdelayed imagescontrast extravasation
RGU most sensitive

12. Diagnosissurgical injuries
• Intraop recognition34% in open
less so in lap
• Delayed dx usually by CT,IVP,RGU may present with:
anuria(14%) in b/l cases
urogenital fistula(11%)
persistent fever/pain(9%)
urinary leakage from wound(9%)
hydronephrosis(3%)
hematuria(3%)
others :urinoma ,abscess,ureteral stricture,
• Triad of fever ,leucocytosis,generalised peritoneal signs

13. General principles of repair
1. Mobilize the injured ureter carefully sparing adventitia
2. Debride the ureter minimally ,judiciously,ends bleed
3. Repair ureters with spatulated, tension-free, stented , watertight
anastomosis, using fine absorbable monofilament and
retroperitoneal drainage afterward.
4. Retroperitonealize the ureteral repair
5. create a widely spatulated nontunneled anastomosis
6. With severely injured ureters, blast effect, concomitant vascular
surgery, and other complex cases, consider omental interposition
to isolate the repair when possible.
7. If immediate repair is not possible, tie off the ureter with long
silk sutures and plan to repair it later (damage control). Ipsilateral
drainage can be achieved by placing a single J stent brought out
cutaneously or a percutaneous nephrostomy tube placed later.

14. management
• Contusion:severe and large areas req excision
others stent
• Ligation :removal of ligature and observefor viability
• Timing of repair in surgical injuries:
intraop dx: immediate repair
dx <3 days:immediate repair
dx>3days :stent /pcndelayed repair at 6 weeks
• Damage control sx:1) do nothing,reoperation within 24hrs
2)internal or external stent
3)exteriorize the ureter
4)tie off ureter ,plan pcn

15. Management

16. Ureteroureterostomy
• Short defect of upper and
mid ureter
• Spatulated for 5 -6mm
• Spatulation at 180 degrees
apart
• Open or lap
• Success rate of 90%

17. Transuretero ureterostomy
•Rarely used
•Success rates in adults 90-97%,paeds 70%
•In cases where ureteroureterostomy or bladder flap/hitch is
impossible
•Usually ileal transposition or renal mobilisation is preferrred
•Absolute contraindication Relative contraindication
•Diseased recipient ureter
•Inadequate donor ureter length
•h/o nephrolithiasis
•RPF
•Urothelial malignancy
•Chronic pyelonephritis
•Abdominopelvic radiation

18. Ureteroneocystotomy
• Used for distal ureteric injuries
• Principles being long,nontunneled ,spatulated
,stented anastomosis
• Usually combined with psoas hitch or boari
flap

19. Psoas hitch
• Used for injuries in lower third of ureter
• High success rate of 95 to 100%•Small ,contracted badder is c/I
•Ipsilateral dome should reach proximal
to iliac vessels
•Divide vas deferens/round lig
•Divide c/l superior vesical a.
•i/l dome secured to psoas minor
tendon or psoas major
•Avoid injury to genitofemoral n. and
femoral n.

20. Boari flap
•Distal ureter 10-15 cm defect
•c/l bladder pedicle is divided
•A postero lateral bladder flap based on i/l
superior vesical a. or its
branches,continuing anteriorly
•Base atleast 4 cm,tip atleast 3cm
•Flap length:ureteral defect + 3-4cm
•Flap length:base<3:1
•Distal end of flap pexed to psoas
•Ureter deliverd in the posterior flap
•Flap tubularised anteriorly
•Mc complication is stricture formation

21. Ileal transposition
Isoperistaltic ileal segment ,
Segment 15 cm away from ic valve
Success rate of 81 to 100%
c/I in:baseline creatinine >2mg/dl
bladder dysfunction/BOO
Inflammatory bladder disease
radiation enteritis
Malignancy chances:endoscopic
examination 3yrs post op

22. Autotransplantation/renal descensus
• Hardy first performed it for proximal ureter injury
• Last resort in :
c/l kidney absent or poorly functioning
other methods have failed or not feasible
• Kidney is harvested with maximum vessel length
• Vessel anastomosed to iliac vessels
• Kidney is completely mobilised
• Renal vein limit the extent to which kidney can be
mobilised

23. Omental flaps
Ureteral injuries with:
vascular graft surgeries
vascular compromise
bullet injuries

24. Partial transection
• Primary repair
• Closed by converting a longitudinal laveration
into a transverse one

25. Management flowcart

26. Management flowchart

27. Management flowchart