Editing Upper Urinary Tract Trauma (section)

=== <span style="color:#ff0000">Pathogenesis ===

* '''Acute ureteral injury results from (3):''' 
*# '''Iatrogenic injury''' (open surgery, laparoscopy, and endoscopic procedures)
*# '''External violence''' from high-speed blunt mechanisms
*#*The presence of massive force injuries in the patient with blunt trauma should always increase the level of suspicion for ureteral injury
*# '''Penetrating stab and gunshot wounds'''

* '''<span style="color:#ff0000">Iatrogenic injury''' 
** '''<span style="color:#ff0000">Procedures most commonly associated with iatrogenic ureteral injuries:''' 
*** '''<span style="color:#ff0000">Hysterectomy (54%)'''
*** Colorectal surgery (14%)
*** Ovarian tumor removal (8%)
*** Transabdominal urethropexy (8%)
*** Abdominal vascular surgery
** '''Compared to open surgery, ureteral injuries during laparoscopic surgery are less likely to be recognized immediately.''' 
*** '''During laparoscopy/robotic surgery, a high index of suspicion for ureteral injury is required.'''
*** In open surgery, 1/3 of ureteral injuries are recognized immediately.
*** '''<span style="color:#ff0000">Intraoperative assessment of ureters'''  
**** Some have advocated maneuvers to check the patency of the ureter after all surgeries in which ureteric injury is commonly reported (e.g., hysterectomy).
**** '''<span style="color:#ff0000">Options (3):'''  
****# '''<span style="color:#ff0000">Direct inspection''' 
****#* '''<span style="color:#ff0000">Purposefully opening the retroperitoneum''' before or after hysterectomy has been advocated to avoid ureteral injury or at least allow intraoperative detection.
****# '''<span style="color:#ff0000">Retrograde pyelography'''
****#'''<span style="color:#ff0000">Injection of 5-10 mL of IV methylene blue or indigo carmine dye followed by cystoscopy'''  
****#* '''<span style="color:#ff0000">Poor predictor of injury'''
****#* '''<span style="color:#ff0000">Goal of cystoscopy is to document the absence of hematuria and the presence of bilateral ureteral jets'''
****#* '''IV methylene blue and indigo carmine''' are generally considered to be benign drugs, but their use has resulted in patient deaths and fetal deaths when used in pregnant women.  
****#** '''Intravenous methylene blue'''
****#***Standard 1% concentration used in clinical settings
****#****1% = 1 g in 100 ml ( =1000mg in 100ml = 10mg in 1 ml)
****#***'''Safe if used within therapeutic doses of <2mg/kg[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693951]'''
****#**Adverse events
****#***Intravenous
****#****Burning sensation
****#****Rash
****#****Abscess
****#****Necrosis
****#****Ulceration
****#***Subcutaneous and intradermal
****#****Adverse skin reactions
****#****Superficial ulcers
****#****Abscess
****#**'''Contraindications for IV methylene blue (3):[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693951]''' 
****#**#'''Pregnancy (potentially teratogenic)'''
****#**#'''Use of selective''' (e.g., paroxetine, sertraline, fluoxetine, fluvoxamine, citalopram) or nonselective (e.g., imipramine) '''serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitors'''
****#**#* Methylene blue is a potent monoamine oxidase inhibitor and has caused deaths from serotonin toxicity in patients taking medications that increase serotonin levels
****#**# '''Glucose-6-phosphate dehydrogenase deficiency'''  
****#**#* Causes methemoglobinemia and hemolysis
****#**#'''Heinz body anemia'''
****#**#Renal insufficiency
****#**#*
****#** '''Contraindications for IV indigo carmine:'''  
****#**# '''Pregnancy'''
****#*** IV indigo carmine has been implicated in rare but serious cases of bronchospasm, bradycardia, hypertension, hypotension (most common), and anaphylactoid reactions.
***** '''Not effective methods'''  
****** '''Intraoperative single-shot IVP'''
****** '''Intraoperative hydration or diuretic administration'''  
******* Has been suggested to enhance ureteral visualization and potentially decrease the risk for injury
******* No data to support this method
****** '''Digital palpation of the ureter''' 
******* '''Appears to be ineffective'''
****** '''Grasping the ureter with forceps to evoke ureteral peristalsis'''  
******* '''Highly ineffective;''' should never be relied upon.
*'''<span style="color:#ff0000">Endoscopic injury'''
**Ureteroscopy should be performed alongside or over a wire placed up into the renal pelvis
**'''Factors associated with higher complication rates during ureteroscopy (4):'''
**# '''Longer surgery times'''
**# '''Treatment of renal calculi'''
**# '''Surgeon inexperience'''
**# '''Previous irradiation'''
** '''<span style="color:#ff0000">Persistence of stone basket attempts after recognition of a ureteral tear is a cause of ureteral injury during ureteroscopy.''' 
*** '''<span style="color:#ff0000">When ureteral perforation is identified, stop the procedure and place a ureteral stent'''

* '''<span style="color:#ff0000">Intraoperative ureteral manipulation''' 
** '''<span style="color:#ff0000">Common after aortoiliac and aortofemoral bypass surgery (12-20%) and may result in hydronephrosis''' 
*** '''<span style="color:#ff0000">Management: course is benign in most; if symptomatic, can be treated with steroids'''
* '''<span style="color:#ff0000">Ureteral contusion''' 
** '''Can occur in the context of a gunshot wound with blast injury'''
** '''Complications may include delayed ureteral stricture and/or overt ureteral necrosis with urinary extravasation'''
*'''<span style="color:#ff0000">Preoperative ureteral stenting'''
** '''<span style="color:#ff0000">May increase intraoperative recognition of ureteral injury'''
** '''<span style="color:#ff0000">A [https://pubmed.ncbi.nlm.nih.gov/19165412/ randomized trial] demonstrated that prophylactic stenting does not reduce the risk of ureteral injury in women undergoing gynecologic surgery'''
** Ureteral stents are not without complications