What is the management of a patient with suspected ureter rupture and pneumoperitoneum?

Management of Suspected Ureter Rupture and Pneumoperitoneum

For patients with suspected ureter rupture and pneumoperitoneum, immediate surgical exploration and repair is indicated, with intraperitoneal bladder ruptures requiring primary repair and ureteral injuries managed according to injury type and patient stability. 1

Initial Assessment and Diagnosis

• Imaging: IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images (10-minute delay) is the gold standard for diagnosing ureter injuries 1

  • Look for: contrast extravasation, ipsilateral delayed pyelogram, ipsilateral hydronephrosis, lack of contrast in ureter distal to suspected injury
  • For pneumoperitoneum: CT will show free air in the peritoneal cavity

• Clinical indicators:

  • Ureter rupture: flank pain, hematuria (may be absent in complete transection)
  • Pneumoperitoneum: abdominal distention, peritoneal signs, shock

Management Algorithm

1. For Hemodynamically Unstable Patients:

• Immediate surgical intervention (laparotomy) is mandatory 1
• During laparotomy:
  • Direct inspection of ureters is necessary when ureteral injury is suspected 1
  • For ureteral injuries in unstable patients:
    • Temporary urinary drainage with delayed definitive repair 1
    • Options include ureteral ligation with percutaneous nephrostomy or externalized ureteral catheter 1
  • For intraperitoneal bladder rupture causing pneumoperitoneum:
    • Primary surgical repair is required 1, 2

2. For Hemodynamically Stable Patients:

A. Ureteral Injuries:

• Management based on injury type:

  • Contusions: Ureteral stenting 1
  • Partial lesions: Conservative management with stent placement, with/without diverting nephrostomy 1
  • Complete transections/avulsions:
    • Primary repair plus double J stent
    • Ureteral re-implant for distal lesions 1

• For injuries diagnosed in delayed fashion:

  • Attempt ureteral stent placement for incomplete injuries 1
  • If stent placement fails or is impossible, perform percutaneous nephrostomy with delayed repair 1

B. Bladder Injuries with Pneumoperitoneum:

• Intraperitoneal bladder rupture: Surgical exploration and primary repair is mandatory 1, 3, 2

  • Laparoscopy may be considered for isolated intraperitoneal injuries if patient is hemodynamically stable 1

• Combined intra/extraperitoneal bladder rupture: Surgical repair of intraperitoneal component is required 3

Post-Intervention Management

• Urinary drainage:

  • In adults: Urethral catheter (without suprapubic catheter) after surgical repair of bladder injuries 1
  • In pediatric patients: Suprapubic cystostomy is recommended 1

• Follow-up imaging:

  • CT scan with delayed phase imaging for monitoring recovery 3
  • Repeat imaging if complications develop (fever, worsening pain, ongoing blood loss, abdominal distention) 1

Important Caveats

• Never underestimate pneumoperitoneum: While commonly caused by hollow viscus perforation, intraperitoneal bladder rupture is a rare but important cause 2, 4, 5

• Stent placement is strongly recommended in any ureteral repair to prevent stricture formation 1

• Delayed complications to monitor for:

  • Ureteral stricture
  • Urinoma formation
  • Infection/abscess
  • Renal impairment

• Pitfall to avoid: Assuming pneumoperitoneum is always from gastrointestinal perforation. Bladder or ureter rupture with peritoneal communication can cause pneumoperitoneum and should be considered when no obvious GI source is found 2, 4, 5