From the Guidelines
Management of traumatic ureteral injuries should prioritize prompt recognition and intervention based on injury severity, with conservative management using ureteral stenting for minor injuries and surgical intervention for more severe injuries, as recommended by the most recent guidelines 1.
Initial Assessment and Management
Initial assessment should include CT urography or retrograde pyelography to identify the location and extent of injury. For minor injuries (contusions or partial tears with preserved ureteral continuity), conservative management with ureteral stenting for 2-6 weeks is often sufficient.
- 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.
Surgical Intervention
More severe injuries require surgical intervention. For mid to distal ureteral injuries, ureteroureterostomy (direct anastomosis of injured ends) is preferred, while proximal injuries may require ureteropyelostomy.
- When significant tissue loss occurs, options include Boari flap (using bladder tissue to bridge the gap), psoas hitch (mobilizing the bladder to reach the proximal ureter), or ileal interposition for extensive defects 1.
- IUTI of the lower third of the ureter requires direct reimplantation (ureteroneocystostomy) 1.
- The psoas hitch technique or a Boari flap can be used to minimize tension at the anastomosis if the distal part of the ureter is severely injured or completely resected 1.
Post-Operative Care
All repairs should include placement of a double-J ureteral stent (typically 6-8 Fr) for 4-6 weeks to maintain patency and a surgical drain to detect any urine leakage.
- Prophylactic antibiotics (such as cefazolin 1g IV every 8 hours) should be administered perioperatively.
- Long-term follow-up with periodic imaging is essential to detect stricture formation, which occurs in 5-10% of cases despite appropriate management.
- Delayed recognition of ureteral injuries increases complication rates, including urinoma formation, infection, and stricture development, which is why high clinical suspicion and early imaging are crucial in trauma patients with flank pain, hematuria, or concerning mechanism of injury 1.
From the Research
Management Options for Traumatic Ureteral Injuries
The management of traumatic ureteral injuries can be challenging due to their deep anatomical location, making timely diagnosis crucial 2. The choice of reconstruction method depends on the severity, location, and length of the injury to restore urinary tract continuity as early as possible.
- Surgical Procedures: Various surgical procedures can be used to manage traumatic ureteral injuries, including:
- Ureteroureterostomy: a common procedure for repairing ureteral injuries, which involves connecting the two ends of the ureter 3, 4
- Ureteroneocystostomy: a procedure that involves connecting the ureter to the bladder 3
- Pyeloplasty: a procedure that involves repairing the renal pelvis 2
- Ileal ureter replacement: a procedure that involves replacing the ureter with a segment of intestine 2
- Nephrectomy: a procedure that involves removing the kidney, which may be necessary in severe cases 2, 3
- Non-Surgical Procedures: Non-surgical procedures, such as ureteral stenting, can also be used to manage traumatic ureteral injuries 2, 3
- Timing of Intervention: The timing of intervention is critical in managing traumatic ureteral injuries. Delayed diagnosis and treatment can lead to poor outcomes 4, 5
- Associated Injuries: Associated injuries are common in patients with traumatic ureteral injuries and can impact the management and outcome of the injury 3, 4, 5