Detection of Bladder and Ureter Injuries During General Surgery
Direct inspection of the ureter and bladder should always be performed during emergency laparotomy when injury is suspected, with intraoperative use of methylene blue or indigo carmine (40 mg IV) to enhance detection of urinary tract injuries. 1
Intraoperative Detection Strategies
For Suspected Ureteral Injuries
Maintain high clinical suspicion in high-energy blunt trauma with deceleration mechanisms, multi-system involvement, and all penetrating abdominal trauma 1
Direct visual inspection of the ureter is mandatory during any emergency laparotomy when ureteral injury is suspected 1
Administer indigo carmine (40 mg IV) by slow intravenous infusion to visualize urine leakage intraoperatively; a second 40 mg dose can be given 20-30 minutes after the first if needed 1
Intravenous urography may be useful in unstable patients during surgery when CT scanning is not available and urinary tract injury is suspected 1
For Suspected Bladder Injuries
Retrograde cystography (conventional radiography or CT-scan) is the gold standard for bladder injury detection, superior to IV contrast-enhanced CT with delayed phase 1
Direct inspection of the intraperitoneal bladder should always be performed during emergency laparotomy whenever feasible 1
Inject dyed saline solution (methylene blue or indigo carmine) via an indwelling urinary catheter to improve detection rates of bladder defects 1
- This technique is particularly useful for dome injuries that may not be immediately visible 1
Postoperative Detection
Clinical Indicators
Gross hematuria and abdominal tenderness are the most common presenting symptoms of missed bladder injuries 1
For ureteral injuries, suspect delayed diagnosis when patients develop fever, flank pain, decreased renal function, or signs of peritonitis 1, 2
Biochemical markers can aid diagnosis: increased serum inflammatory markers (C-RP), decreased renal function, increased peritoneal fluid creatinine and urea, or altered serum-to-peritoneal fluid creatinine ratio 1
Imaging Approach
CT urography with both nephrographic and excretory phases is the gold standard for postoperative diagnosis of iatrogenic urinary tract injuries 1
For ureteral injuries specifically, intravenous contrast-enhanced CT scan with delayed phase should be performed in hemodynamically stable patients 1
For bladder injuries, CT cystography with bladder distention using >300 mL of diluted contrast media has 85-100% accuracy 1
Critical Timing Considerations
Prompt identification is paramount: Delayed diagnosis of ureteral injury correlates directly with unsuccessful repair and increased morbidity 2. Only 17.6% of iatrogenic ureteral injuries are identified during primary surgery, yet immediate repair when detected intraoperatively achieves good results 1.
Ureteral injuries diagnosed postoperatively should be treated as soon as possible to avoid complications and sepsis 1
Common Pitfalls to Avoid
Thermal injuries are more subtle than direct transection and harder to recognize, leading to delayed diagnosis 1
Do not rely solely on IV contrast-enhanced CT with delayed phase for bladder injuries—it is less sensitive and specific than retrograde cystography 1
In pelvic bleeding requiring angioembolization, postpone cystography until after the angiographic procedure to avoid affecting angiography accuracy 1
Failing to inspect the ureter during laparotomy in penetrating abdominal trauma or high-energy blunt trauma is a critical error 1
Classification and Documentation
Once identified, classify injuries using the American Association for the Surgery of Trauma (AAST) organ-specific injury scoring scale 1. For bladder injuries, also document anatomical classification (extraperitoneal, intraperitoneal, or combined) 1.