What is the immediate management for a ureteral (ureter) avulsion during removal of a mid-ureteral stone?

Management of Ureteral Avulsion During Mid-Ureteral Stone Removal

In case of ureteral avulsion during removal of a mid-ureteral stone, immediate surgical repair should be performed in stable patients to preserve renal function and prevent complications. 1

Immediate Management

• Maintain the safety guidewire if still in place, as it provides crucial access to the collecting system and facilitates management of the injury 1
• Assess the extent and location of the avulsion to determine appropriate repair strategy 1
• Directly inspect the ureter to confirm the diagnosis and evaluate the viability of the remaining ureteral tissue 1
• Ensure patient stability before proceeding with definitive repair 1

Surgical Repair Options

For Stable Patients:

• Primary repair should be performed immediately during the same procedure if the patient is hemodynamically stable 1
• Options for repair depend on the location and extent of avulsion:
  • Ureteroureterostomy (direct anastomosis) for limited avulsions with adequate remaining tissue 1
  • Ureteroneocystostomy (reimplantation into bladder) for distal ureteral avulsions 1
  • Mobilization of the kidney may be necessary for longer defects to reduce tension on the repair 2

For Unstable Patients:

• Establish temporary urinary drainage with a percutaneous nephrostomy tube 1
• Defer definitive repair until the patient is clinically stable 1
• Consider ureteral ligation followed by percutaneous nephrostomy placement as a damage control measure 1

Complex Reconstruction Options

• For extensive avulsions with significant tissue loss, consider:
  • Transureteroureterostomy if the proximal ureter has sufficient length 2
  • Boari flap (can cover 12-15 cm defects) or psoas hitch (can cover 6-10 cm defects) for distal and mid-ureteral injuries 2
  • Ileal interposition for very long defects (>15 cm) 2
  • Renal autotransplantation as a salvage procedure when other options are not feasible 3

Post-Repair Management

• Place a ureteral stent after repair to facilitate healing and prevent stricture formation 1
• Consider a nephrostomy tube in addition to the stent for complex repairs 1
• Administer appropriate antibiotic prophylaxis to prevent infection 1
• Plan for regular follow-up imaging to assess for stricture development or other complications 4

Prevention Strategies

• Always use a safety guidewire during ureteroscopy to maintain access in case of complications 1
• Avoid blind basket extraction of stones, which has historically been associated with avulsion 5
• Be cautious when the ureteroscope becomes wedged in the intramural ureter, as this can lead to a "scabbard avulsion" 5
• Consider alternative approaches for challenging stones, such as staged procedures or different modalities 1

Pitfalls to Avoid

• Delayed recognition of ureteral avulsion can lead to increased morbidity and risk of renal loss 3
• Attempting to force a ureteroscope through a tight ureter increases risk of avulsion 5
• Neglecting to place a stent after repair significantly increases the risk of stricture formation 1
• Performing nephrectomy should be considered only as a last resort when repair options have been exhausted or in cases where there is risk of vascular graft contamination 6