This document summarizes the evaluation and management of upper urinary tract trauma. Initial evaluation involves resuscitation according to ABCDE priorities. Renal injuries are most commonly caused by blunt trauma and present with flank pain and hematuria. CT is the gold standard for diagnosis and staging injuries according to the American Association for the Surgery of Trauma Organ Injury Scale. Most grade I-III injuries can be managed non-operatively with observation, while higher grade injuries often require surgery. The document outlines surgical techniques for renal exploration and reconstruction.

1. UPPER URINARY TRACT
TRAUMA

3. INTRODUCTION
• Traumatic injury:-
– A leading national and international health problem.
• Trauma:-
– leading cause of death
– for persons between 1 and 44 years of age.
• In the United States:-
• 1 of every 14 deaths.
• more than 150,000 per year.

4. • INITIAL EVALUATION AND RESUSCITATION
– Done By:-
• emergency department physician and
• trauma surgeon
• Best care to polytrauma patients comes from
– a well-organized team of specialists,
– most often led by a surgeon experienced in trauma care.
• Urologists are a valued team member
– approximately 10% of injuries involve the genitourinary
tract.
– kidney being the most commonly injured.

5. • First hour of care after major injury:-
– Extremely important and
– Requires rapid assessment of the injuries and
– resuscitation
• Based on priorities established by the
American College of Surgeons’ Acute Trauma
Life Support Program.

6. • Mnemonic “ABCDE” defines these priorities in
order of importance:
– A, airway with cervical spine protection;
– B, breathing;
– C, circulation and control of external bleeding;
– D, disability or neurologic status; and
– E, exposure (undress) and environment (temperature
control)

7. RENAL INJURIES
• Most common genitourinary organs injured from
external trauma.
• 10% of abdominal trauma cases,
• Divided into:-
– Blunt Renal Trauma
– Penetrating Renal Injuries

8. • Blunt Renal Trauma:-
– Motor vehicle accidents,
– falls from heights, and
– Assaults
• MECHANISM:-
– Direct transmission of kinetic energy and
– rapid deceleration forces

9. Mechanism of Renal Injuries

10. • SITE:-
– major renovascular injuries occur at
retroperitoneal points of fixation such as
• renal hilum or
• ureteropelvic junction,
– resulting in renal artery thrombosis, renal vein
disruption, and renal pedicle avulsion.

11. • Penetrating renal injuries
– gunshot and
– stab wounds.
• Gunshot wounds comprise the great majority
of penetrating trauma with stab wounds a
distant second (86% vs. 14%).

12. • Stab wounds
– cause both renovascular and parenchymal
injuries.
– Common entry sites
• upper abdomen,
• flank, and
• lower chest

13. • Trauma to the anterior axillary line is
– more prone to damage renal hilum and pedicle,
• Trauma to the posterior axillary line
– More often resulting in parenchymal injury.
• Indicators of possible renal injury:-
– flank hematoma,
– abdominal or flank tenderness,
– rib fractures, and
– penetrating injuries to the low thorax or flank

15. • Evaluation and Management of renal injuries:-
– evolved over past 2 decades.
• DUE TO:-
– Advances in radiographic staging,
– improvements in hemodynamic monitoring,
– validated renal injury scoring systems,
• Allow successful nonoperative management
strategies for renal preservation.

17. HEMATURIA
• The best indicators of significant urinary
system injury include:-
– presence of microscopic (>5 [RBCs/HPF] or
positive dipstick finding) OR
– gross hematuria and hypotension (systolic blood
pressure <90 mm Hg).

18. • Degree of hematuria and severity of renal
injury do not correlate consistently.
• Gross hematuria has been observed in minor
renal contusions and
• Microscopic hematuria has been associated
with severe renal injuries.

19. • For example:-
– hematuria was absent in 7% of 420 grade IV renal
injuries in a recent analysis (Shariat et al, 2008a)
– and 36% of renal vascular injuries from blunt trauma
demonstrated no blood in the urine (Cass, 1989).
• Approximately 50% of injuries to the
ureteropelvic junction have no microscopic or
gross hematuria.

20. URINE SAMPLE
• The first aliquot of urine obtained either by
catheterization or by voiding should be used
to determine the presence of hematuria.
• Later urine samples are often diluted by
diuresis from resuscitation fluids, resulting in
an underestimation or absence of hematuria.

21. • Any degree of visible blood in the urine is
regarded as Gross Hematuria.
• Microscopic Hematuria detected by dipstick
analysis or microanalysis.
• The dipstick method
– rapid and
– sensitivity and specificity for detection of
microhematuria of more than 97%.

22. CLASSIFICATION
• Developed by The American Association for
the Surgery of Trauma.
• Based on contrast-enhanced computed
tomography (CT)
• valid predictive tool for clinical outcomes in
patients with renal trauma.

23. American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Kidney

24. RADIOLOGIC IMAGING
• Criteria for radiologic imaging include
– (1) all penetrating trauma patients with a
likelihood of renal injury (abdomen, flank, or low
chest) who are hemodynamically stable;
– (2) all blunt trauma with significant mechanism of
injury, specifically rapid deceleration as would
occur in a motor vehicle accident or a fall from
heights;

25. – (3) all blunt trauma with gross hematuria;
– (4) all blunt trauma with hypotension defined as a
systolic pressure of less than 90 mm Hg at any time
during evaluation and resuscitation;
– (5) all pediatric patients with greater than 5 red blood
cells (RBCs)/HPF.
• Patients who are hemodynamically unstable after
initial resuscitation require surgical intervention.

26. Algorithm demonstrating the results of the authors’
study on radiographic assessment of renal injuries.

27. • Patients with microscopic hematuria
without shock can be observed clinically
without imaging studies.
• All blunt trauma patients with gross hematuria
and patients with microscopic hematuria
and shock (systolic BP<90 mm Hg any time
during evaluation and resuscitation) should
undergo renal imaging, usually with CT using IV
contrast.

28. • Penetrating injuries with any degree of
hematuria should be imaged.
• Children are known to be at a greater risk for
renal trauma than adults after blunt
abdominal injury

29. • Pediatric patients sustaining blunt renal
trauma must be carefully evaluated.
• Children have a high catecholamine output
after trauma, which maintains blood pressure
until approximately 50% of blood volume has
been lost

30. IMAGING STUDIES
• Contrast-enhanced computed tomography
(CT)
– gold standard for genitourinary imaging in renal
trauma
– Highly sensitive and specific,
– Provides most definitive staging information:
– Parenchymal lacerations are clearly defined;

31. – extravasation of contrast-enhanced urine can easily be
detected;
– associated injuries to other organs can be identified;
and
– the degree of retroperitoneal bleeding can be
assessed by the size and dimensions of the
retroperitoneal hematoma.
– Lack of uptake of contrast material in the parenchyma
suggests arterial injury.

32. • Arteriovenous scanning
– 80 seconds after contrast administration
– provides visualization of the kidneys in the
nephrogenic phase of contrast excretion
– necessary to detect arterial extravasation.

33. • Injury to the renal collecting system may be
missed; contrast material has not had time to
be excreted into the parenchyma and
collecting system adequately.
• Repeated/delayed scanning
– 10 minutes after injection of contrast
– identifies parenchymal lacerations and urinary
extravasation

34. CT findings suggestive of major injury
– (1) medial hematoma
– suggesting vascular injury;
– (2) medial urinary extravasation
– suggesting renal pelvis or ureteropelvic junction avulsion
– (3) lack of contrast enhancement of the
parenchyma,
– suggesting arterial injury.

35. VENOUS INJURY
• major limitation of CT
– inability to define a renal venous injury
adequately.
• Medial hematoma accompanied by following
findings strongly suggests a venous injury.
– normal arterial perfusion,
– normal parenchyma and
– contrast material in the collecting system.

36. Excretory Urography & “Single-shot” IVP
• Excretory Urography:-
– most commonly used modality to evaluate
genitourinary injuries historically.
• “Single-shot” IVP:-
– limited but important role intraoperatively.

37. “Single-shot” IVP
• INDICATIONS:-
– unexpected retroperitoneal hematoma
surrounding kidney during abdominal exploration
• PURPOSE:-
– to assess presence of a functioning contralateral
kidney and
– to radiographically stage the injured side.

38. • TECHNIQUE:-
– gain important information and
– minimize the time involved.
• PROCEDURE:-
– only a single film is taken
– 10 minutes after intravenous injection (IV push) of 2 mL/kg
of contrast material.
– If findings are not normal or near normal, the kidney
should be explored to complete the staging of the injury
and reconstruct any abnormality found.

39. OTHER IMAGING MODALITIES
• limited role in the evaluation of genitourinary
trauma.
• Sonography:-
– Facilitate rapid diagnosis of intra abdominal injuries
(i.e., hemoperitoneum).
– If necessary, sonography can confirm the presence of
two kidneys and
– can define a retroperitoneal hematoma.

40. • RENAL ARTERIOGRAPHY
– both diagnostic as well as therapeutic.
– used to define arterial injuries suspected on CT or
– to localize and control arterial bleeding (Fig. 42–4).
– useful in the primary setting with persistent bleeding
in a hemodynamically stable patient.

41. • Pseudoaneurysms and AV fistula are treated
by angiographic embolization to stop
secondary hemorrhage.
• Superselective embolization therapy:-
– Effective minimally invasive technique
– avoid unnecessary exploration that could
otherwise result in a nephrectomy.

42. NONOPERATIVE MANAGEMENT
• Has become the standard of care in
– hemodynamically stable,
– well-staged patients with American Association for
the Surgery of Trauma (AAST) grade I to III renal
injuries
• grade IV and V injuries
– more often require surgical exploration,
– but even these high-grade injuries can be managed
without renal operation if carefully staged and
selected

44. A Guide For Decision Making

45. • Patients with high-grade injuries (grades III to
V) selected for nonoperative management are
closely observed with
– serial hematocrit readings
– strict bed rest is mandatory until gross hematuria
resolves.

46. FOLLOW UP
• The risk of complications in patients who have been
treated conservatively increases with injury grade.
Repeat imaging 2-4 days after trauma minimises the
risk of missed complications, especially in grade 3-5
blunt injuries.
• The usefulness of frequent CT scanning after injury has
never been satisfactorily proved.
• Repeat imaging can be safely omitted for patients with
grade 1-4 injuries as long as they remain clinically well.
• Nuclear scans are useful for documenting and tracking
functional recovery following renal reconstruction.

47. • A decline in renal function correlates directly with
injury grade; this is independent of the mechanism of
injury and the method of management.
• Follow-up examinations should continue until healing
is documented and laboratory findings have stabilised,
although checking for latent renovascular hypertension
may need to continue for years.
• In general, the literature is inadequate on the subject
of the long-term consequences of renal tissue trauma.

49. DELAYED RENAL BLEEDING
• Most grades II to IV injuries resolve
uneventfully
• Delayed renal bleeding can occur in up to
25%
• Angiography with selective embolization of
bleeding vessels.

50. OPERATIVE MANAGEMENT
• Indications for renal exploration after trauma:-
– absolute and
– Relative
• Absolute indications:-
– (1) hemodynamic instability with shock;
– (2) expanding /pulsatile renal hematoma (usually
indicating renal artery avulsion);
– (3) suspected renal pedicle avulsion (grade 5); and
– (4) ureteropelvic junction disruption.

51. • Relative indications:-
– urinary extravasation together with nonviable
tissue,
– renal injury together with colon/pancreatic injury,
– a delayed diagnosis of arterial injury (which most
likely will need delayed nephrectomy).

52. MANAGEMENT OF SPECIAL CONDITIONS
• Intraoperative presence of a nonexpanding
retroperitoneal hematoma:-
– Nonoperative therapy is recommended,
• Urinary extravasation alone from a grade IV
parenchymal laceration or forniceal rupture:-
– managed nonoperatively
– with an expectation of spontaneous resolution of
more than 90%.

53. • Nonviable tissue constitute more than 25% in
association with a parenchymal laceration or
urinary extravasation or both,
– potential for complications greatly increases
– and operative management is recommended

54. • CRITICAL PATIENTS:-
– patient’s critical condition necessitates surgical
intervention before appropriate imaging studies and
– renal injury is obvious (manifested by perirenal
hematoma or hematuria),
– single-shot intraoperative IVP should be done.
– If findings are not normal,
• renal exploration
• reconstruction of injury.

55. RENAL EXPLORATION
• Best done by a transabdominal approach,
• Allows complete inspection of intra-abdominal
organs and bowel.
• Injuries to the great vessels, liver, spleen,
pancreas, or bowel can be identified and
stabilized if necessary before renal
exploration.

56. Renal Exploration
Surgical exploration of the
acutely injured kidney is best done by
Transabdominal approach
allows complete inspection of
intra-abdominal organs and bowel
ส

57. Surgical Approach to
the renal vessels and kidney

58. SURGICAL APPROACH TO RENAL EXPLORATION
• The renal vessels are
isolated before
exploration to provide
the immediate
capability to occlude
them if massive
bleeding ensue when
Gerota’s fascia is
opened

59. • The transverse colon is lifted
superiorly onto the chest,
• and the small bowel is lifted
superiorly and to the right.
• This exposes the mid
retroperitoneum.
• An incision is made over the
aorta in the retroperitoneum
just superior to the inferior
mesenteric artery.

60. • The incision is extended superiorly to the
ligament of Treitz.
• Exposure of the anterior surface of the aorta is
accomplished and followed superiorly to the
left renal vein, which crosses the aorta
anteriorly.

61. • With a vessel loop controlling the vein, the
anatomic relationships of the right and left renal
arteries as they leave the aorta provide the ability
to isolate and secure these structures with vessel
loops.
• The right renal vein can be secured through this
incision;
– if this proves difficult, reflecting the second portion of
the duodenum provides excellent exposure to the
vein.

62. • Large hematomas:-
– may extend over the aorta and
– obscure the landmarks for the planned initial
retroperitoneal incision.
– inferior mesenteric vein used as an anatomic guide for
an appropriate incision.
– By making the retroperitoneal incision just medial to
the inferior mesenteric vein and dissecting through
the hematoma, the anterior surface of the aorta can
be identified and followed superiorly to the crossing
left renal vein.

63. • The kidney is exposed by incising the peritoneum lateral to the
colon,
• followed by mobilization off Gerota fascia.
• This maneuver often requires release of the splenic (left) or hepatic
(right) attachments of the colon.
• Gerota fascia is then opened and the kidney with injury is
completely dissected from the surrounding hematoma.
• Should troublesome bleeding develop, the previously isolated
vessels can be temporarily occluded with a vascular clamp or a
vessel loop tourniquet.

64. • Is Early Vessel Isolation Necessary?
– Renal bleeding a major cause of nephrectomy in renal
trauma.
– Obtaining early vascular control before opening Gerota
fascia can decrease renal loss.
– McAninch and Carroll, 1982:-
• the total nephrectomy rate was reduced from 56% to 18% .
– McAninch and colleagues (1991):-
• In a series of 133 renal units in which early vessel isolation and
control before opening Gerota fascia was achieved,
• the reported renal salvage rate of 88.7%.

65. RENAL RECONSTRUCTION
• Principles of renal reconstruction after trauma:-
– complete renal exposure,
– measures for temporary vascular control,
– debridement of nonviable tissue,
– hemostasis by individual suture ligation of bleeding
vessels,
– watertight closure of the collecting system if possible,
– coverage or reapproximation of the parenchymal
defect, and
– judicious use of drains

66. RENORRHAPHY
• Involves
– exposure of the kidney,
– debridement of nonviable tissue,
– hemostasis obtained with absorbable 4-0 chromic
sutures on bleeding vessels
– closure of the collecting system,
– and approximation of the margins of the laceration (3-0
absorbable suture) with the use of renal capsule and an
absorbable hemostatic agent bolster such as Gelfoam

67. RENORRHAPHY

68. PARTIAL NEPHRECTOMY
• When polar injuries cannot be reconstructed,
• a partial nephrectomy should be done and all
nonviable tissue removed,
• hemostasis obtained, and the collecting
system closed.

69. PARTIAL NEPHRECTOMY
• The open parenchyma should then be covered
when possible by a pedicle flap of omentum
• With its rich vascular and lymphatic supply,
omentum promotes wound healing and
decreases the risk of delayed bleeding and
urinary extravasation.
• Should it not be available, the use of absorbable
mesh, peritoneal graft, or retroperitoneal fat has
been successful

70. PARTIAL NEPHRECTOMY

71. RENOVASCULAR INJURIES
• Uncommon
• often have associated injuries
• requires operative intervention.
• For major renovascular injuries, nephrectomy
is advocated.

72. • Rare instances
– where repair is possible,
– renal salvage rates are low,
– 33% renal salvage rate for main renal artery
reconstruction
– Vascular repair requires occlusion of the involved
vessel with vascular clamps.
– The lacerated main renal vessels injured by
penetrating trauma can be repaired with 5-0 non
absorbable vascular suture

73. VASCULAR INJURIES

74. RENAL ARTERY THROMBOSIS
• occurs secondary to
deceleration injuries.
• The mobility of the kidney
results in stretch on the
renal artery,
• which in turn causes the
arterial intima to disrupt.
• The consequent thrombus
occludes the vessel,
rendering the kidney
ischemic (Fig. 42–10).

75. • Diagnosis
– CT or angiography
– immediate renal exploration in the appropriate
candidate in an attempt to salvage the kidney,
• outcomes
– for salvage remain dismally low and
– nephrectomy is almost always required.
• With delayed diagnosis (>8 hours), the kidney
typically cannot be salvaged

76. DAMAGE CONTROL
• Coburn (2002):-
– Noted benefit of damage control
– improve renal salvage.
• The wound and area around the injured kidney are packed
with laparotomy pads to control bleeding
• with a planned return in 24 hours to explore and evaluate
the extent of injury.
• useful in patients with extensive injuries along with
complex renal injuries to avoid total nephrectomy.

77. INDICATIONS FOR NEPHRECTOMY
• Davis et al, 2006:-
– The unstable patient, with low body temperature and
poor coagulation, cannot risk an attempt at renal
repair if a normal contralateral kidney is present
• Total nephrectomy would be indicated
immediately in extensive renal injuries when the
patient’s life would be threatened by attempted
renal repair.

78. • Nash and colleagues (1995):-
– 77% required removal because of the extent of
parenchymal, vascular, or combined injury and
– 23% required nephrectomy in otherwise
reconstructable kidneys because of hemodynamic
instability.

79. COMPLICATIONS
• Persistent urinary extravasation can result in
– urinoma,
– perinephric infection,
– and even renal loss.
• MANAGEMENT:-
– initially administered systemic antibiotics and
– carefully observed with appropriate antibiotics.
• In a high percentage, the extravasation resolves spontaneously
(Matthews et al, 1997).
• Should it persist, placement of an internal ureteral stent often
corrects the problem.

80. COMPLICATIONS
• Delayed renal bleeding
– can occur up to several weeks after injury but
– usually occurs within 21 days.
• Management
– bed rest and hydration.
• Persistent bleeding – angiography localize the
bleeding vessel - embolization

81. COMPLICATIONS
• Perinephric abscess
– Rare
– persistent urinary extravasation and urinoma are
the precursors.
• Management
– Percutaneous drainage
– followed by surgical drainage if necessary.

82. COMPLICATIONS
• Hypertension
• seldom noted in the early post injury period
– The basic mechanisms
• (1) renal vascular injury,
– leading to stenosis or occlusion of the main renal artery or one of
its branches (Goldblatt kidney);
• (2) compression of the renal parenchyma with
extravasated blood or urine (Page kidney); and

83. • (3) post-trauma arteriovenous fistula.
– In these instances, the reninangiotensin axis is
stimulated by partial renal ischemia, resulting in
hypertension

84. URETERAL INJURIES
• "The venial sin is
injury to the ureter;
the mortal sin is
failure of
recognition" -Higgins

85. ETIOLOGY
• Acute ureteral injury results from:-
– external trauma,
– open surgery,
– laparoscopy, and
– endoscopic procedures.
• Uncommon:-
– intraoperative suture ligation,
– sharp incision and transection,
– avulsion,
– Devascularization
• Additionally:-
– external violence from high-speed blunt mechanisms and
– penetrating stab and gunshot wounds contributes to the overall incidence.

87. • COMPLICATIONS associated with
unrecognized or mismanaged ureteral injury:-
– urinoma,
– abscess,
– ureteral stricture,
– urinary fistula, and
– potential loss of an ipsilateral renal unit.

88. EXTERNAL TRAUMA
• ureteral damage after external violence is
quite rare,
• represent less than 1% of all GU trauma.
• penetrating injury - less than 4% and
• blunt trauma - less than 1%

89. • Located in the retroperitoneum between the spinal vertebra and
major muscle groups, the well-protected ureter is an unlikely target
for injury.
• Great violence must be inflicted for ureteral damage to occur.
• These patients often have significant concomitant injuries and a
devastating degree of mortality that approaches one third (Medina
et al, 1998).
• Associated visceral injury is common, predominantly
– small (39% to 65%) and
– large (28% to 33%) bowel perforation.
– 10% to 28% also have associated renal injuries.
– 5% has associated bladder injuries

91. BULLET INJURY
• The mechanism of bullet injury to ureter:-
– direct transection
– disruption of the delicate intramural blood supply and
subsequent necrosis.
• Due to this “blast effect,” full extent of ureteral loss is
sometimes underestimated on initial exploration.
• The ureter may appear entirely normal despite the
cavitation injury.
• Ureteric debridement should be done back to a
bleeding edge after bullet injury to remove tissue that
may have invisible microvascular damage.

92. BLUNT TRAUMA
• Blunt trauma associated with extreme forces
causes disruption of ureter at fixed points
along its course:-
– ureterovesical and,
– ureteropelvic junction – m/c
• UPJ disruption shows a typical pattern on contrast
CT:-
– Medial contrast extravasation or
– Circumrenal contrast extravasation

93. CT showing right medial extravasation of contrast
material in a patient with a renal pelvis laceration

94. SURGICAL INJURY
• Any difficult abdomino - pelvic surgical procedure
can potentially injure the ureter.
• Incidence varies between 0.5% and 10%
• procedures contributing to iatrogenic ureteral
injuries:
– hysterectomy (54%),
– colorectal surgery (14%),
– ovarian tumor removal (8%),
– transabdominal urethropexy (8%), and
– abdominal vascular surgery (6%)

95. RISK FACTORS FOR URETERIC
INJURIES
1. ANATOMICAL RISK FACTORS.
2. PATHOLOGICAL RISK FACTORS.
3. TECHNICAL RISK FACTORS

96. 1.ANATOMICAL RISK FACTORS:
A)THE URETER:
• Has close attachment to the peritoneum.
• Closely related to female genital tract.
• Has variable course.
• Not easily seen or palpated.

97. 2.PATHOLOGICAL RISK FACTORS:
1. Congenital anomalies of ureter or Kidney.
2. Ureteric displacement by:
Uterine size ≥12 weeks.
Prolapse.
Tumour{ovarian neoplasm}.
Cervical fibroid/Ca.
broad ligament swellings(fibroids , incarcirated
ovarian tumours or hematomas)
3.Adhesions:
Previous pelvic surgery.
Endometriosis.
PID.
Extention of carcinomatous indurations in broad
ligaments , post irradiation.
4.Distorted pelvic anatomy.

98. 3.TECHNICAL RISK FACTORS
• Massive intraoperative haemorrhage.
• Coexistent bladder injury.
• Technical difficulties.
• Inexperienced surgeon.

99. Vascular procedures
• Intraoperative ureteral manipulation
– results in subsequent hydronephrosis
– common after aortoiliac and aortofemoral bypass
surgery
– 12% to 20%
• Surgical devascularization can result in
symptomatic ureteral stenosis,
– delayed in presentation by months,
– occurring in 1% to 2% of these patients

100. • surgical injuries to the ureter after vascular
procedures are not recognized immediately
• symptoms of ureteral injury are:-
– flank pain,
– fever,
– ileus,
– abdominal distention, and
– urinary fistula

101. URETEROARTERIAL FISTULAS
• Rare
• life-threatening hematuria.
• mostly between the ureter and ipsilateral iliac artery,
• ETIOLOGY:-
– previous pelvic surgery,
– radiation therapy,
– indwelling ureteral stents,
– infection,
– primary vascular disease, and
– Pregnancy
• MANAGEMENT:-
– Endovascular stent grafts

102. RETROGRADE PYELOGRAPHY DEMONSTRATING
URETEROILIAC ARTERY fiSTULA

103. URETEROSCOPIC INJURY
• Kaufman et al, 1984
– first reported ureteral injury after rigid
ureteroscopy
• Johnson et al, 2004
– ureteroscopic injury is the most common cause of
iatrogenic ureteral trauma in modern series

104. • Schuster et al, 2001
– perforation rate of 1% to 5%
– 0.2% requires open surgery (Butler et al, 2004)
– 5% incidence of delayed stricture occurrence.
• Factor responsible:-
– persistence of stone basket attempts even after
recognition of a ureteral tear.

105. • Factors associated with higher complication rates
during ureteroscopy:-
– longer surgery times,
– treatment of renal calculi,
– surgeon inexperience, and
– previous irradiation
• Factors to protect against ureteral injury:-
– smaller ureteroscopes
– flexible ureteroscopes
– Placement of guide wire

106. American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Ureter

107. DIAGNOSIS
• HAEMATURIA:-
– nonspecific indicator of urologic injury.
– Absence of hematuria result from
• adynamic ureter,
• partially transected ureter or a
• complete ureteral transection
• Campbell et al, 1992
– 25% to 45% cases after violence do not demonstrate
even microscopic hematuria
– high index of suspicion is required in cases of potential
ureteral injury after penetrating trauma.

108. • INTRAOPERATIVELY:-
– trajectory of the knife or missile - carefully
examined during laparotomy
– ureteral exploration - all cases of potential injury.
– intraoperative inspection of retroperitoneum
most important means of diagnosing ureteral
injury due to penetrating trauma

109. • Methylene Blue:-
– Suspected ureteral or renal pelvis injury
– 1 to 2 mL of methylene blue dye
– directly injected into the renal pelvis
– with a 27-gauge needle to confirm the diagnosis.

110. IMAGING STUDIES
• Excretory Urography:-
– Ureteral injuries - unlike renal injuries - difficult to
detect
– IVP is often unhelpful,
– proving nondiagnostic 33% to 100% of the time
– intraoperative one-shot pyelography still recommend
• to detect ureteral injuries and
• assess the functional status of the contralateral system.

111. EXCRETORY UROGRAPHY
DEMONSTRATING EXTRAVASATION

112. • CT scan:-
– Ureteral injuries - difficult - diagnose on CT.
– Delayed images - must
– Findings:-
• medial extravasation of contrast material or
• nonopacification of the ipsilateral ureter

113. Retrograde ureterograms:-
• most sensitive radiographic test for ureteral injury,
• used in some centers as a primary diagnostic technique
• delineate the extent of ureteral injury seen on CT scan
or IVP
• Advantage:-
– allows simultaneous placement of a ureteral stent .

114. MANAGEMENT
• Principles of URETERIC INJURY REPAIR :
1. Mobilize the injured ureter - sparing the adventitia
widely - not to devascularize the ureter.
2. Debride the ureter liberally until the edges bleed,
3. Repair ureters with spatulated, tension-free, stented
watertight anastomosis

115. 4. Retroperitonealize the ureteral repair by
closing peritoneum over it.
5. With severely injured ureters, blast effect,
concomitant vascular surgery, and other
complex cases,
• consider omental interposition to isolate the repair.

116. Identification
Courses vary among normal
individuals*
* Sampson JA, John Hopkins Med Bull
1904;156:72
- Peristalsis
- Pale glistening appearance
-Longitudinal vessels on the
surface
-Unique "snap" feeling when
pressed between 2 fingers

117. • Ureteroureterostomy
– A/K/A end-to-end repair
– Used in injuries to the upper two thirds of ureter.
– success rate 90% (Carlton et al, 1971).
– Complications
• urine leakage - 10% to 24%
• Other:-
– abscess and
– fistula.
• Chronic complications:-
– ureteral stenosis - 5% to 12%

118. • STENTING:-
– Minor ureteral contusions - Stent placement.
– Caution
• minor-appearing ureteral contusions may stricture later
• break down secondary to unappreciated microvascular
damage
– When in doubt
• the injured portion of the ureter should be debrided and
• Ureteroureterostomy used to repair the injury.

119. STENTING
 Insert a ureteral stent
through the anastomosis
before closure.
Advantages :
1. Maintenance of a straight
ureter with a constant
caliber during early
healing,
2. The presence of a conduit
for urine during healing,
3. Prevention of urinary
extravasation,
4. Maintenance of urinary
diversion,
5. Easy removal

120. MANAGEMENT OPTIONS FOR URETERAL
INJURIES AT DIFFERENT LEVELS

121. UPPER URETERAL INJURIES
• Ureteroureterostomy:-
– Ureteral avulsion from the renal pelvis, or
– very proximal ureteral injury,
– managed by
• reimplantation of the ureter directly into the renal
pelvis.
• Both – open and laparoscopic

122. UPPER URETERAL INJURIES
• Bowel Interposition:-
– long segment of ureter is destroyed,
– ureteral conduit out of ileum is created to drain the
urine,
– Success rates:-
• 81% - Boxer et al, 1979;
• 100% - Bonfig et al, 2004.
– Long-term complications
• 3% anastomotic stricture and
• 6% fistula rate

123. UPPER URETERAL INJURIES
• MONTI PROCEDURE:-
• short segments of bowel
• formed into a long thin tube for ureteral reconstruction
• Ileal interposition is not suggested for
acute repair of ureteral injury but rather
would be used in delayed or staged
repairs.

124. Ileal transposition
(Syn- Uretero-ileo-neo-cystostomy/
Uretero-entero-neo-cystostomy)
• Healthy, viable segment of
distal ileum with vascular
arcade is ''collected'' after side-
to-side stapled anastomosis
• Proximal segment of ileal loop
is opened
• Ureter is spatulated
• Full thickness of ureter is
pulled through a hole made in
the anti-mesenteric border of
the ileum and sutured over a
stent
• Sero-muscular suturing is done

125. • Distal end of the ileal loop is opened and puled
over the stent through an incision (over bladder
dome) and mucosal suturing done
• Seromuscular suturing done
• "Ileal conduit" is sutured to psoas fascia to
reduce tension on the anastomosis
due to gravity
• Bladder drainage for 10 days

126. MIDURETERAL INJURIES
• Ureteroureterostomy
• Transureteroureterostomy:-
– rarely used
– performed as a secondary or delayed procedure.
– Success rate –
• Adults - 90% to 97%
• Pediatric - 70%
– Technique –
• involves bringing the injured ureter across the midline and
• anastomosing it end to side into the uninjured ureter

127. Transuretero ureterostomy

128. LOWER URETERAL INJURIES
• Ureteroneocystostomy:-
– used to repair distal ureteral injuries
– occur very close to the bladder
– Principles:-
• creation of submucosal tunnel for nonrefluxing ureter
• tunnel length three times longer than the width of ureter.
• new ureteral orifice is constructed with the use of
interrupted sutures in a watertight and nonobstructing
fashion.
• stented.

129. LOWER URETERAL INJURIES
• Psoas Bladder
Hitch:-
– injuries to the
lower third of
the ureter
– high success rate
- 95% to 100%

131. LOWER URETERAL INJURIES
• Boari Flap:-
– Injuries to the lower two thirds of the ureter
– with long ureteral defects
– too long to be bridged by bringing the bladder up
in the psoas hitch procedure
– Technique:-
• a pedicle of bladder is swung cephalad and tubularized
to bridge the gap to the injured ureter.

133. DAMAGE CONTROL
• Injured ureter is managed by deferring the
definitive treatment
• Useful:-
– too unstable patient
– Unable to tolerate the operative time required to
complete the repair.

134. DAMAGE CONTROL
• Options:-
(1) do nothing & plan a reoperation when the
patient is more stable, usually within 24 hours;
(2) place a ureteral stent and do nothing else
(3) exteriorize the ureter; or
(4) tie off the ureter and plan percutaneous
nephrostomy

135. SURGICAL INJURY
• Ligation:-
– treated by removal of ligature and
– observation of the ureter for viability.
– If viability is doubtful,
• ureteroureterostomy or
• ureteral reimplantation

136. URETEROSCOPY INJURY
• Avulsion:-
– treated in same manner as ureteral injuries after
open or laparoscopic surgery
• Perforation:-
– perforation can be treated by stenting
– usually with no subsequent complications

140. Guideline Statements
Approved by the AUA
Board of Directors
April 2014

141. Renal trauma
• 1. Clinicians should perform diagnostic
imaging with intravenous (IV) contrast
enhanced computed tomography (CT) in
stable blunt trauma patients with gross
hematuria or microscopic hematuria and
systolic blood pressure < 90mmHG.

142. • 2. Clinicians should perform diagnostic
imaging with IV contrast enhanced CT in
stable trauma patients with mechanism of
injury or physical exam findings concerning
for renal injury (e.g., rapid deceleration,
significant blow to flank, rib fracture,
significant flank ecchymosis, penetrating
injury of abdomen, flank, or lower chest).

143. • 3. Clinicians should perform IV contrast
enhanced abdominal/pelvic CT with
immediate and delayed images when there is
suspicion of renal injury.

144. • 4. Clinicians should use non - invasive
management strategies in hemodynamically
stable patients with renal injury.

145. • 5. The surgical team must perform immediate
intervention (surgery or angioembolization in
selected situations) in hemodynamically
unstable patients with no or transient
response to resuscitation.

146. • 6. Clinicians may initially observe patients with
renal parenchymal injury and urinary
extravasation.

147. • 7. Clinicians should perform follow - up CT
imaging for renal trauma patients
• having either (a) deep lacerations (AAST Grade
IV - V) or (b) clinical signs of complications
(e.g., fever, worsening flank pain, ongoing
blood loss, abdominal distention).

148. • 8. Clinicians should perform urinary drainage
in the presence of complications such as
enlarging urinoma, fever, increasing pain,
ileus, fistula or infection. (Recommendation;
Evidence Strength: Grade C) Drainage should
be achieved via ureteral stent and may be
augmented by percutaneous urinoma drain,
percutaneous nephrostomy or both.

149. Ureteral Trauma
• 9a. Clinicians should perform IV contrast
enhanced abdominal/pelvic CT with delayed
imaging (urogram) for stable trauma patients
with suspected ureteral injuries.

150. • 9b. Clinicians should directly inspect the
ureters during laparotomy in patients with
suspected ureteral injury who have not had
preoperative imaging.

151. • 10a. Surgeons should repair traumatic ureteral
lacerations at the time of laparotomy in stable
patients.

152. • 10b. Surgeons may manage ureteral injuries in
unstable patients with temporary urinary
drainage followed by delayed definitive
management.

153. • 10c. Surgeons should manage traumatic
ureteral contusions at the time of laparotomy
with ureteral stenting or resection and
primary repair depending on ureteral viability
and clinical scenario.

154. • 11a. Surgeons should attempt ureteral stent
placement in patients with incomplete
ureteral injuries diagnosed postoperatively or
in a delayed setting.

155. • 11b. Surgeons should perform percutaneous
nephrostomy with delayed repair as needed in
patients when stent placement is unsuccessful
or not possible.

156. • 12a. Surgeons should repair ureteral injuries
located proximal to the iliac vessels with
primary repair over a ureteral stent, when
possible.

157. • 12b. Surgeons should repair ureteral injuries
located distal to the iliac vessels with ureteral
reimplantation or primary repair over a
ureteral stent, when possible.

158. • 13a. Surgeons should manage endoscopic
ureteral injuries with a ureteral stent and/or
percutaneous nephrostomy tube, when
possible.

159. • 13b. Surgeons may manage endoscopic
ureteral injuries with open repair when
endoscopic or percutaneous procedures are
not possible or fail to adequately divert the
urine.