Editing Upper Urinary Tract Trauma (section)

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

* '''<span style="color:#ff0000">Based on hemodynamic stability'''
** '''<span style="color:#ff0000">If hemodynamically stable:'''
*** '''<span style="color:#ff0000">Traumatic ureteral lacerations should be repaired immediately'''
**** '''<span style="color:#ff0000">A longitudinal laceration is converted into a transverse one''' '''so as not to narrow the ureteral lumen (Heineke-Mikulicz procedure)'''
** '''<span style="color:#ff0000">If hemodynamically unstable: temporary urinary drainage followed by delayed definitive repair'''
*** '''<span style="color:#ff0000">Options for temporary urinary drainage (4):'''
***# '''<span style="color:#ff0000">Ureteral stent''' (internalized double J or exteriorized single J) '''only'''
***# '''<span style="color:#ff0000">Short period of observation with a plan for reoperation when the patient is more stable, usually within 24 hours'''
***# '''<span style="color:#ff0000">Exteriorize the ureter'''
***# '''<span style="color:#ff0000">Tie off the ureter''' (with long silk sutures for easy identification at time of delayed repair) '''<span style="color:#ff0000">and plan percutaneous nephrostomy'''
**** Definitive repair of the injury should be performed when patient has improved/stabilized
* '''<span style="color:#ff0000">Special scenarios'''
** '''<span style="color:#ff0000">Ureteral contusion'''
*** '''<span style="color:#ff0000">Options, depending on ureteral viability and clinical scenario (2):'''
***# '''<span style="color:#ff0000">Ureteral stenting'''
***# '''<span style="color:#ff0000">Resection with primary repair'''
**** '''<span style="color:#ff0000">Indications for resection with primary repair (2):'''
****# '''<span style="color:#ff0000">Severe or large areas of contusion'''
****# '''<span style="color:#ff0000">Gun-shot related ureteric contusions'''
****#* '''<span style="color:#ff0000">With a gun-shot related injury, excise devitalized tissue and an adjacent segment of normal-appearing ureter to eliminate late ischemia and stricture formation from the blast effect.''' Once both ends of the ureter have been adequately trimmed to healthy areas, mobilized, and correctly oriented, they are spatulated for ≈5-6 mm. Spatulation is performed for both ureteral segments at 180° apart
**** '''<span style="color:#ff0000">In ureteral contusions that do not appear to require excision/anastomosis, a ureteral stent should be placed'''; only truly minor injuries can go untreated, but the patients should be watched for signs of delayed urine leak.
** '''<span style="color:#ff0000">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'''
*** '''<span style="color:#ff0000">Campbell's 11th edition: postoperatively discovered injuries should be immediately repaired when detected within 72 hours.'''
** '''<span style="color:#ff0000">Endoscopic injury: ureteral stent +/- percutaneous nephrostomy tube'''
*** Ureteral perforation during ureteroscopy can be treated by ureteral stenting, usually with no subsequent complications
*** If endoscopic or percutaneous procedures are not possible or fail to adequately divert the urine, open or laparoscopic repair may be performed.
** '''<span style="color:#ff0000">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%
** '''<span style="color:#ff0000">Ligation of the ureter: removal ligature and observe the ureter for viability'''
*** '''<span style="color:#ff0000">If viability uncertain, perform ureteroureterostomy or ureteral reimplantation'''
** '''Ureteroarterial fistula'''
*** '''A rare and potentially catastrophic condition that should be diagnosed and treated immediately because it can cause life-threatening hematuria'''
*'''<span style="color:#ff0000">Principles of managing the injured ureter:'''
*# '''Mobilize''' '''the injured ureter''', sparing the adventitia widely, so as not to devascularize the ureter further
*# '''Debride the ureter''' '''minimally''' but judiciously until edges bleed, especially in gunshot wounds
*# '''Repair ureters with spatulated, tension-free, stented, watertight anastomosis, using fine absorbable monofilament''' such as 5-0 polydioxanone (PDS) and retroperitoneal '''drainage''' afterward. Use optical magnification if necessary.
*# '''Retroperitonealize the ureteral repair''' by closing peritoneum over it if possible
*# Do not tunnel ureteroneocystostomies but rather create a widely spatulated nontunneled anastomosis
*# '''With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition to isolate the repair when possible'''
* '''<span style="color:#ff0000">Surgical management'''
** '''<span style="color:#ff0000">See [[Ureteric Stricture Disease|Ureteric Stricture Disease Chapter Notes]]'''
** '''<span style="color:#ff0000">Options for repair/reconstruction,</span> choice depends on location and length of injury'''
*** '''<span style="color:#ff0000">Upper ureteral injuries (above iliac vessesls)'''
***# '''<span style="color:#ff0000">Ureterocalycostomy'''
***# '''<span style="color:#ff0000">Ureter-ureterostomy'''
***# '''<span style="color:#ff0000">Trans-ureterostomy'''
***# '''<span style="color:#ff0000">Ileal or other interposition (not recommended in acute setting)'''
***# '''<span style="color:#ff0000">Autotransplant (not recommended in acute setting)'''
***# '''Rarely, acute nephrectomy is required to treat ureteral injury after external violence'''
*** '''<span style="color:#ff0000">Lower ureteral injuries (below iliac vessesls)'''
***# '''<span style="color:#ff0000">Ureteroneocystostomy'''
***# '''<span style="color:#ff0000">Psoas hitch'''
***# '''<span style="color:#ff0000">Boari flap'''
** '''<span style="color:#ff0000">Follow-up after repair'''
*** '''<span style="color:#ff0000">6 weeks: remove stent'''
**** At the time of stent removal, retrograde ureterogram can be perform to document healing without leakage or stenosis.
*** 10 weeks: furosemide (Lasix) renogram can document that the system continues to be unobstructed.
*** 4 months: renal US can document lack of hydronephrosis, which itself might indicate late obstruction