From the Guidelines
The treatment for a distal ureteral avulsion primarily involves surgical repair with ureteroneocystostomy, often with a psoas hitch or Boari flap, to restore urinary drainage and prevent complications. Immediate management includes urinary diversion through percutaneous nephrostomy placement to prevent urine extravasation and subsequent complications. Definitive treatment depends on the extent and location of the injury. For distal avulsions, ureteroneocystostomy is typically performed, as it allows for a tension-free anastomosis and promotes healing 1. If the proximal ureter is long enough, direct anastomosis may be possible. During repair, a ureteral stent is placed to maintain patency and promote healing, typically left in place for 4-6 weeks 1.
Some key considerations in the management of distal ureteral avulsions include:
- The importance of early intervention to prevent complications such as urine leakage, stricture formation, or infection 1
- The need for a tension-free anastomosis to promote healing and prevent complications 1
- The use of ureteral stents to maintain patency and promote healing 1
- The potential need for ancillary maneuvers such as a psoas hitch or Boari flap to bridge longer defects without tension 1
For extensive injuries where direct repair is impossible, options include ileal interposition, autotransplantation of the kidney, or in severe cases with poor renal function, nephrectomy 1. Postoperatively, patients require close monitoring for complications such as urine leakage, stricture formation, or infection. Early intervention is crucial as delayed treatment can lead to significant morbidity including renal dysfunction, urinoma formation, and sepsis 1.
From the Research
Treatment Options for Distal Ureteral Avulsion
The treatment for distal ureteral avulsion can vary depending on the severity of the injury and the patient's overall health. Some possible treatment options include:
- Ureterovesical anastomosis, which involves reconnecting the ureter to the bladder 2
- Boari flap procedure, which involves creating a flap from the bladder to replace the damaged portion of the ureter 3, 4
- Psoas hitch procedure, which involves attaching the bladder to the psoas muscle to help replace the damaged portion of the ureter 4
- Autotransplantation of the kidney, which involves transplanting the kidney to a different location in the body to repair the damaged ureter 5, 2
- Ureteroneocystotomy, which involves reconnecting the ureter to the bladder using a robotic-assisted laparoscopic technique 6
Considerations for Treatment
When treating distal ureteral avulsion, it is important to consider the patient's overall health and the severity of the injury. In some cases, a combination of treatment options may be necessary to achieve the best possible outcome. For example, a Boari flap procedure may be used in combination with a psoas hitch procedure to replace a longer segment of the ureter 4. Additionally, robotic-assisted laparoscopic techniques may be used to perform ureteral reconstruction, including ureteroneocystotomy, psoas hitch, and Boari flap 6.
Outcomes and Complications
The outcomes and complications of treatment for distal ureteral avulsion can vary depending on the severity of the injury and the treatment options used. In general, treatment options that involve reconnecting the ureter to the bladder or replacing the damaged portion of the ureter with a flap or graft can result in good outcomes, with preservation of renal function 3, 2. However, complications such as hydronephrosis and renal atrophy can occur, especially if the injury is severe or if treatment is delayed 3, 2.