This document discusses ureteral injuries, including their etiology, types, anatomy, risk factors, diagnosis, and management. It notes that ureteral injuries most commonly occur during gynecologic surgeries like hysterectomy. Diagnosis involves imaging like IVU, CT scan, or retrograde ureterography. Management depends on the location and severity of injury, and may include ureteroureterostomy, bowel or bladder flaps, nephrectomy, or autotransplantation. Prevention involves identifying anatomical landmarks and avoiding thermal or electrosurgical injuries during surgery.

1. URETERAL INJURIES
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai 1

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2

3. ETIOLOGY
 External trauma
 Penetrating -4%
 Blunt- 1%
 Gunshot injuries-2 %
 Open surgical injury
 Hysterectomy-54%
 Repeat Cesearean section-23%
 Colorectal surgery-14%
 Pelvic Vascular surgeries-6%
 34% identified per operatively
Dept Of Urology, KMC and GRH, Chennai 3

4. Laparoscopic Injury
Hysterectomy
Tubal ligation
Ovarian surgeries
Electrosurgical or Laser assisted lysis of
endometriosis
Dept Of Urology, KMC and GRH, Chennai 4

5.  Laparoscopic hysterectomy - 0.2 – 6.0 %
 Abdominal hysterectomy - 0.03 -2.0 %
 Vaginal hysterectomy - 0.02 – 0.5 %
 Anti incontinence procedure - 1.7 -3.0 %
 Colorectal - 0.15 – 10 %
Dept Of Urology, KMC and GRH, Chennai 5

6. American Association for the Surgery of
Trauma Organ Injury Severity Scale for the Ureter
Dept Of Urology, KMC and GRH, Chennai 6

7. TYPES OF INJURIES
 Ligation with sutures
 Crushing
 Transection (complete or partial)
 Angulation (kinking)
 Diathermy related injuries
 Resection
 Ischemia
Dept Of Urology, KMC and GRH, Chennai 7

8. Abdominal part
 Renal pelvis to pelvic brim
 Enters the pelvis
 behind the ovarian vessels
 crossing over
 - rt -ext illiac artery
 - lt side common iliac artery.
Liable to injury during
para aortic LN dissection
Dept Of Urology, KMC and GRH, Chennai 8

9. Blood supply
 Abdominal part
-from medial side
 Pelvic part
– from lateral side
Dept Of Urology, KMC and GRH, Chennai 9

10. Pelvic part
Pelvic brim to bladder
 Passes in loose areolar tissue
- lateral pelvic wall
 In close contact with
peritoneum medially
int iliac artery posteriorly
over the si joint
Passes downwards up to
ischial spine
Dept Of Urology, KMC and GRH, Chennai 10

11. Uterine artery
 Crossed by uterine artery
antero-superiorly
1.5 cm away from
internal cervical os
bridge over the river
Water under the bridge
Dept Of Urology, KMC and GRH, Chennai 11

12.  Tunnel of meckendrodt’s ligament / tunnel of
wertheim.
 ureter lies medially and anteriorly over the ant vaginal
fornix.
 Enters the bladder in the supero lateral part of trigone
Dept Of Urology, KMC and GRH, Chennai 12

13. Dept Of Urology, KMC and GRH, Chennai 13

14. Anatomical landmark
 At the pelvic brim – dorsal to infundibulo pelvic
ligament (parallel to ovarian vessels)
 Lateral pelvic wall – just above uterosacral ligament
 Base of the broad ligament – crossed by uterine artery
 Tunnel of meckenrodts lig – over ant vaginal fornix
 Intra mural portion – inside the bladder.
Dept Of Urology, KMC and GRH, Chennai 14

15. Identification
 Peristalsis
 Pale glistening
appearance
 Longitudinal vessel on
the surface..
Dept Of Urology, KMC and GRH, Chennai 15

16. Risk Factors for Ureteral Injury
 Most cases do NOT have an identifiable risk factor
 Disruption of normal anatomy
 Endometriosis, ovarian masses, Inflammation
(Diverticulitis, PID)
 Congenital ureteral anomaly
 Previous pelvic surgery, Malignancy.
 Pelvic radiation
Dept Of Urology, KMC and GRH, Chennai 16

17. ENDOMETRIOSIS
(1) Involve the ureter either extrinsically or intrinsically;
(2) Intraperitoneal adhesion, making ureteral visualization
difficult .
(3) Deviate the ureters medially .
Dept Of Urology, KMC and GRH, Chennai 17

18. Avoiding and Detecting Ureteral Injury.
 LOCATION - relation to the uterine and ovarian arteries.
 Ureterosacral ligaments .
Dept Of Urology, KMC and GRH, Chennai 18

19.  uncontrolled bleeding,
Adequate intraoperative hemostasis and surgical
exposure .
 Intraoperative hydration or diuretic
administration
Enhance ureteral visualization and potentially decrease
the risk for injury.
Dept Of Urology, KMC and GRH, Chennai 19

20. Preoperative ureteral stenting
 Not actually decrease ureteral injuries .
 Not recommended nowadays
Dept Of Urology, KMC and GRH, Chennai 20

21. Intra operative diagnosis
Methylene blue dye test
 RGP
 Single shot IVU
 Intra venous administration of 10 ml indigo carmine or
methylene blue with 20 mg of furosemide may help to
localize the ureteral injury.
 Under fluroscopic guidance retrograde uretero pyelogram
Dept Of Urology, KMC and GRH, Chennai 21

22. Immediate Presentation
Hematuria- upto 75%
25%-45% No hematuria
Loin pain
Decreased urine output
Persistent fever
Dept Of Urology, KMC and GRH, Chennai 22

23. Immediate Presentation Contd.
Urine leak from operation site
Peritonitis
Uremia- bilateral injuries
Anuria in bilateral injury
Urinary ascites
Dept Of Urology, KMC and GRH, Chennai 23

24. USG-Pre op normal /post HUN
Dept Of Urology, KMC and GRH, Chennai 24

25. IMAGING-IVU
Ext injuries – Preop IVU
Iatrogenic injuries – Intraoperative single shot IVU
Post operative pt - IVU
Findings often subtle & non specific
 Delayed function
 Ureteral dilatation.
Dept Of Urology, KMC and GRH, Chennai 25

26. Dept Of Urology, KMC and GRH, Chennai 26

27. CONTRAST CT
Medial opacification,
non opacification of ipsilateral ureter in PUJ injury
Periureteral urinoma
Delayed film (5 to 20 mins after contrast) in helical
CT – more informative
 Absence of contrast in ureter
 Contrast extravasation
Dept Of Urology, KMC and GRH, Chennai 27

28. Dept Of Urology, KMC and GRH, Chennai 28

29. Dept Of Urology, KMC and GRH, Chennai 29

30. Retrograde Ureterography
IVU , CT – Non diagnostic
To delineate extent of injury seen on CT/IVU
 if more information needed
Dept Of Urology, KMC and GRH, Chennai 30

31. Retrograde Ureterography.
 Most sensitive
 But invasive.
 Most commonly used to diagnose initially missed ureteral
injuries
 it allows the simultaneous placement of a ureteral stent if
possible.
Dept Of Urology, KMC and GRH, Chennai 31

32. Principles of management
 1. Mobilize the ureter carefully, spare the adventitia.
 2. Debride the ureter minimally but until edges bleed.
 3. spatulated , tension-free,
 4. stented
 5.watertight anastomosis, using fine absorbable
 6. Retroperitonealize the ureteral
 7. severely injured ureters – omental interposition.
Dept Of Urology, KMC and GRH, Chennai 32

33. Dept Of Urology, KMC and GRH, Chennai 33

34. Ureteric injuries management
 Upper- ureteroureterostomy
trans ureteroureterostomy
bowel interposition,
auto transplantation,
Nephrectomy
 Middle- ureteroureterostomy
transureteroureterostomy
Boari flap
 Lower -
ureteric reimplantation
psoas hitch,
Dept Of Urology, KMC and GRH, Chennai 34

35. Surgical Injury
Ligation
 Removal of the ligature and observation of the
ureter for viability.
 Contusion-major or minor.
 Stenting.
 viability doubtful- ureteroureterostomy or ureteral
reimplantation .
Dept Of Urology, KMC and GRH, Chennai 35

36. Upper ureter
Ureteroureterostomy.
 Ureteral avulsion from the renal pelvis, or even very
proximal ureteral injury - reimplantation of the ureter
directly into the renal pelvis (open, laparoscopically, or
robotically )
Complications
 urine leakage (10 – 24 % )
 Abscess and fistula.
 Chronic complications, usually ureteral stenosis,
involving approximately 5% to 12%.
Dept Of Urology, KMC and GRH, Chennai 36

37. Dept Of Urology, KMC and GRH, Chennai 37

38.  Rarely, ureterocalycostomy,
In which the ureteral stump is sewn end-to-side into an
exposed renal calyx.
(where there is profound damage to the renal pelvis and
UPJ)
Dept Of Urology, KMC and GRH, Chennai 38

39. Bowel Interposition.
 very long segment of ureter is
destroyed.
 Success rates for
ileal replacement of the ureter
( 81% to 100 %).
 3% anastomotic stricture
 6% fistula rate .
Dept Of Urology, KMC and GRH, Chennai 39

40.  Laparoscopic-assisted ureteral interposition by ileum .
 The use of appendix in open and laparoscopic ureteral
substitution has also been reported.
 Most practitioners create a wide-open, refluxing, ileal
replacement of the ureter .
Dept Of Urology, KMC and GRH, Chennai 40

41. Autotransplantation.
 profound ureteral loss
 After multiple attempts at ureteral repair have failed.
 Final option before nephrectomy.
 Despite great efforts, renal units are sometimes lost after
autotransplantation.
Dept Of Urology, KMC and GRH, Chennai 41

42. Nephrectomy.
 Rarely, required to treat ureteral injury after external
violence.
Reason for nephrectomy
 severe associated injury to the ipsilateral kidney when
renal repair is not possible .
 persistent ureteral fistula (especially vascular
fistula).
Dept Of Urology, KMC and GRH, Chennai 42

43. Mid ureter - Ureteroureterostomy
Adequate mobilisation
Resect the edges
Spatulate ureter
Anastamosis with 4-0 vicryl
Stenting done
Dept Of Urology, KMC and GRH, Chennai 43

44. Dept Of Urology, KMC and GRH, Chennai 44

45. Mid ureter
Trans ureteroureterostomy
Mobilising donor ureter and anastamosing end to side to
reciepient ureter.
-INDICATIONS
severe bladder scarring,
congenitally small bladder,
very long segment of missing ureter.
Problems
Difficult to intubate or image
with ureteroscopy
unilateral ureteral injury into bilateral ureteral injury
Dept Of Urology, KMC and GRH, Chennai 45

46.  Absolute contraindications
-Insufficient length of the donor ureter
-Diseased recipient ureter or a donor ureter
Relative contraindications
history of nephrolithiasis, retroperitoneal fibrosis,
urothelial malignancy, chronic pyelonephritis, and
abdominopelvic radiation,Reflux to the recipient ureter.
Dept Of Urology, KMC and GRH, Chennai 46

47. Dept Of Urology, KMC and GRH, Chennai 47

48. BOARI FLAP
 spiraled bladder flap
 10- to 15-cm ureteral defect, can reach the renal pelvis.
 Contralateral bladder pedicle ligated
 Ipsilateral superior vesical artery based posterolateral
bladder flap
 The flap length -ureteral defect plus 3 to 4 cm if
nonrefluxing anastomosis is planned.
 Ratio of flap length to base width should not be greater
than 3:1 to help minimize flap ischemia.
Dept Of Urology, KMC and GRH, Chennai 48

49. Dept Of Urology, KMC and GRH, Chennai 49

50. Distal ureter - Ureteroneocystostomy
Nonrefluxing
Submucosal tunnel at least three times longer than
the ureter
Refluxing
ureteral length is insufficient for tunneling tunneling
increase the risk of ureteral stenosis
Dept Of Urology, KMC and GRH, Chennai 50

51. Psoas hitch
 If primary repair cannot be done tension free
 Bladder mobilised on both sides
 Ipsilateral dome - proximal to the iliac vessel
 Additional mobility -contralateral superior vesical artery
divided
 Cystotomy in anterior wall away from dome
 Anchoring stitch in psoas minor tendon or major muscle
 Avoid genitofemoral nerve
Indications -distal ureteral stricture, injury, and failed
ureteroneocystostomy .
C/I-small, contracted bladder with limited mobility
Dept Of Urology, KMC and GRH, Chennai 51

52. Dept Of Urology, KMC and GRH, Chennai 52

53. LATE PRESENTATION
Features of Hydronephrosis & its complications
Genitourinary fistulae
Ureteric strictures
Abscess
Loss of ipsilateral renal unit (silent atrophy)
Dept Of Urology, KMC and GRH, Chennai 53

54. URETERIC INJURY
 Intra operative post operative
clinical symptoms &signs
Minor injury - major injury diagnostic workups
Stenting LOCATION IVP
Follow up with IVP upper CT CONTRAST
At 6 weeks middle RGP
lower minor injury - stenting
Dept Of Urology, KMC and GRH, Chennai 54

55. Urological cause
Dept Of Urology, KMC and GRH, Chennai 55

56. Ureteroscopic injuries
Rigid & Semi rigid
Ureteroscope-7%
During basketing
Dept Of Urology, KMC and GRH, Chennai 56

57. Ureteroscopy
 Mucosal abrasion
- 0.3 – 4.1 %
 Ureteral perforation
- 0.2 – 2.0 %
 Intussusception/avulsion
- 0-0.3 %
Dept Of Urology, KMC and GRH, Chennai 57

58. Dept Of Urology, KMC and GRH, Chennai 58

59. Dept Of Urology, KMC and GRH, Chennai 59