Editing AUA: Urotrauma (2020) (section)

===== '''Ureteral trauma''' =====

* Ureteral injuries are rare, accounting for 1% of urologic injuries.
* '''Ureteral injuries tend to be iatrogenic, occurring during gynecologic, urologic, or colorectal surgery'''.
* '''The majority of ureteral injuries originating outside of the operating room are a result of penetrating trauma'''

* '''Diagnosis and evaluation'''
** '''History and physical exam'''
*** '''Absence of hematuria cannot be relied upon to exclude ureteral injury'''
** '''Imaging'''
*** '''Indications (contrast enhanced CT with 10 minute delayed films) for imaging (1)'''
***# '''Stable trauma patients with suspected ureteral injuries and not proceeding directly to laparotomy'''
**** If the initial delayed images do not adequately opacify the ureters, further delayed imaging may be necessary if ureteral injury is still suspected.
*** '''Findings suggestive of ureteral injury (4):'''
***# '''Contrast extravasation'''
***# '''Lack of contrast in the ureter distal to the suspected injury'''
***# '''Ipsilateral delayed pyelogram'''
***# '''Ipsilateral hydronephrosis'''
** '''Other'''
*** '''Direct inspection during laparotomy in trauma patients with suspected ureteral injury who have not had preoperative imaging'''
* '''Management'''

** '''Based on hemodynamic stability'''
*** '''If hemodynamically stable:'''
**** '''Traumatic ureteral lacerations should be repaired immediately'''
*** '''If hemodynamically unstable: temporary urinary drainage followed by delayed definitive management'''
**** '''In damage control settings when immediate ureteral repair is not possible at time of initial laparotomy, urinary extravasation can be prevented with ureteral ligation followed by'''
****# '''Percutaneous nephrostomy tube placement'''
****# '''Externalized ureteral catheter secured to the proximal end of the ureteral defect'''
**** Definitive repair of the injury should be performed when patient has improved/stabilized
** '''Special scenarios'''
*** '''Ureteral contusion'''
**** '''Options, depending on ureteral viability and clinical scenario (2):'''
****# '''Ureteral stenting'''
****# '''Resection with primary repair'''
***** '''Indications for resection with primary repair (2):'''
*****# '''Severe or large areas of contusion'''
*****# '''Gun-shot related ureteric contusions'''
*** '''Delayed diagnosis: ureteral stent'''
**** '''If ureteral stent placement unsuccesful or not possible''' (proximal ureter is completelely transected or patient instability preculdes attempts at retrograde placement)''', perform percutaneous nephrostomy with delayed repair'''
***** If nephrostomy alone does not adequately control the urine leak, options then include placement of a periureteral drain or immediate open ureteral repair
**** '''Indications for immediate repair for delayed diagnosis (within 1 week of injury) (2):'''
****# '''Injury located near a surgically closed viscus, such as bowel or vagina'''
****# '''Patient is being re-explored for other reasons'''
*** '''Endoscopic injury: ureteral stent +/- percutaneous nephrostomy tube'''
**** If endoscopic or percutaneous procedures are not possible or fail to adequately divert the urine, open or laparoscopic repair may be performed.
*** '''Ureterovaginal fistula: ureteral stent'''
**** In females who undergo vaginal surgery (such as hysterectomy) or sustain penetrating pelvic trauma involving the vagina, an initially unrecognized ureteral injury can present in a delayed manner with ureterovaginal fistula.
**** Success rates range from64%-100% for ureterovaginal fistula who are initially managed with ureteral stent placement
**** Patients who failed with ureteral stent insertion went on to undergo ureteral reimplantation with or without Boari flap or psoas hitch, or transureteroureterostomy with success rates approaching 100%
** '''Options for repair'''
*** '''Ureteral injuries located proximal to the iliac vessels: primary repair over a ureteral stent, when possible'''
**** When the ureter is injured above the iliac vessels, a spatulated, tension-free primary ureteral repair over a ureteral stent is advisable after all non-viable ureteral tissue has been judiciously debrided.
**** In situations where the anastomosis cannot be performed without tension, mobilization of the ureter should be performed in a manner that preserves maximal ureteral blood supply.
**** '''If an anastomosis can still not be performed after mobilization, a ureteral reimplantation can be attempted, incorporating ancillary maneuvers such as a bladder psoas hitch and/or Boari bladder flap.'''
**** '''Interposition with bowel and auto-transplant are not recommended in the acute setting'''
**** If the injury cannot be managed adequately in the acute setting, ureteral ligation with percutaneous nephrostomy tube placement is advised followed by delayed ureteral reconstruction.
*** '''Ureteral injuries located distal to the iliac vessels: ureteral reimplantation or primary repair over a ureteral stent, when possible'''
**** Tension-free reimplantation may require ancillary maneuvers such as a bladder mobilization with psoas hitch or flap