What is the management approach for a mid ureteral injury?

From the Guidelines

The management of a mid ureteral injury typically involves surgical repair, with the specific approach depending on the extent of injury and timing of diagnosis, and immediate ureteroureterostomy is the preferred treatment when identified early and if the ends can be brought together without tension 1. For complete transections or significant injuries, this procedure should be performed over a ureteral stent (typically a double-J stent, 6-8 Fr) and with placement of a surgical drain. If direct anastomosis would create tension, a Boari flap or psoas hitch procedure may be necessary to bridge the gap. The principles for a proper ureteric reconstruction are good vascular supply, adequate drainage, and a wide spatulated tension-free mucosa-to-mucosa anastomosis 1. Some key points to consider in the management of mid ureteral injuries include:

• The role of the urologist in the operating room is fundamental when an IUTI is suspected 1
• Ureteral injuries should be repaired operatively when discovered during laparotomy or in cases where conservative management has failed 1
• Ureteral stenting should be attempted in cases of partial ureteral injuries diagnosed in a delayed fashion; if this approach fails, and/or in case of complete transection of the ureter, percutaneous nephrostomy with delayed surgical repair is indicated 1
• In any ureteral repair, stent placement is strongly recommended 1
• CT urography with both nephrographic and excretory phases represents the gold standard technique in case of suspected ureteral injuries 1
• The main goals of IUTI management are preserving renal function, ensuring adequate drainage by stenting or nephrostomy, and minimizing surgical morbidity 1 Postoperatively, the stent is typically left in place for 4-6 weeks, and patients receive prophylactic antibiotics (such as trimethoprim-sulfamethoxazole or nitrofurantoin) while the stent remains. The surgical approach is preferred over endoscopic management for mid ureteral injuries because this segment has less robust blood supply than the proximal ureter and lacks the supportive tissues that surround the distal ureter, making proper healing more challenging without direct repair. In cases of delayed diagnosis of incomplete ureteral injuries or delayed presentation, an attempt of ureteral stent placement should be done; however, retrograde stenting is often unsuccessful, and in these cases, delayed surgical repair should be considered 1.

From the Research

Management Approach for Mid Ureteral Injury

The management of mid ureteral injuries can be complex and depends on various factors such as the type, location, and degree of injury, as well as the time of diagnosis and the patient's overall clinical condition 2.

• Immediate Repair: Immediate repair is preferred when feasible, but delayed recognition of the injury is more common 3.
• Deferred Repair: Deferred repair can be performed when the injury is missed, and it has been shown that there is no difference in success rates between immediate and deferred repair 3.
• Ureteral Stenting: Ureteral stenting can be used as a temporary measure to manage the injury, especially in cases where immediate repair is not possible 4.
• Surgical Repair: Surgical repair is often necessary to manage mid ureteral injuries, and various techniques such as ureteroureterostomy, ureteroneocystostomy, and Boari flap can be used 2, 5, 6.
• Complex Repairs: Complex repairs, including ileal ureter substitution, can be used to manage long-segment ureteral defects 2, 6.

Factors Influencing Management

The management of mid ureteral injuries can be influenced by various factors, including:

• Location and Length of Injury: The location and length of the injury can affect the choice of management, with proximal injuries often requiring more complex repairs 2, 5.
• Time of Diagnosis: The time of diagnosis can also affect the management, with immediate repair often preferred when the injury is recognized early 3.
• Patient's Clinical Condition: The patient's overall clinical condition can also influence the management, with deferred repair often considered in patients with significant comorbidities or instability 3.