Ureteral Trauma Management (AUA Urotrauma 2020)

Algorithm Steps

1. ▶

   Start

   Suspected Ureteral Injury

   Penetrating trauma, iatrogenic, or delayed presentation

   1. ●

      Action

      Mechanism of Injury

      Identify cause - critical for management

      • Iatrogenic: Most common (75%+)
      • - Gynecologic surgery (hysterectomy)
      • - Colorectal surgery
      • - Ureteroscopy, vascular procedures
      • External trauma: Rare (<1% of GU trauma)
      • - Penetrating > blunt
      • - Often associated injuries
      1. ◆

         Decision

         When Identified?

         Intraoperative recognition vs delayed

         1. ●

            Action

            Intraoperative Recognition

            Best case scenario - repair immediately

            • Direct visualization of injury
            • IV indigo carmine/methylene blue extravasation
            • Immediate urology consult if not urologist
            • Repair at time of index surgery
            • Better outcomes than delayed repair
            1. ◆

               Decision

               Location of Ureteral Injury?

               Determines repair technique

               1. ●

                  Action

                  Upper/Mid Ureter Injury

                  Proximal to iliac vessels

                  • Primary ureteroureterostomy if feasible
                  • Spatulated, tension-free anastomosis
                  • Stent across repair
                  • Transureteroureterostomy if gap too long
                  • Autotransplant for complex cases
                  1. ●

                     Action

                     Stent and Drainage

                     Essential adjuncts to repair

                     • Double-J ureteral stent across repair
                     • Perinephric/pelvic drain
                     • Stent duration: 4-6 weeks typically
                     • Nephrostomy if stent not possible
                     • Foley catheter to decompress bladder
                     1. ●

                        Action

                        Follow-Up

                        Monitor for stricture and function

                        • Stent removal at 4-6 weeks
                        • Imaging before and after stent removal
                        • MAG3 renal scan if concern
                        • Watch for stricture (10-20%)
                        • May need redo surgery if stricture
                        1. ✓

                           Outcome

                           Expected Outcomes

                           Good with prompt repair

                           • Immediate repair: >95% success
                           • Delayed repair: 85-90% success
                           • Stricture rate: 10-20%
                           • Renal function usually preserved
               2. ●

                  Action

                  Lower Ureter Injury

                  Distal to iliac vessels

                  • Ureteroneocystostomy (reimplantation)
                  • With or without psoas hitch
                  • Boari flap for longer gaps
                  • Anti-reflux technique preferred
                  • Most common repair for iatrogenic
               3. ●

                  Action

                  Long Segment Loss

                  Extensive ureteral injury

                  • Ileal ureter replacement
                  • Appendiceal ureter (if available)
                  • Renal autotransplantation
                  • Nephrostomy tube temporization
                  • Rare: nephrectomy if non-functional
               4. ●

                  Action

                  Conservative/Endoscopic Management

                  For minor injuries

                  • Partial transection: retrograde stent
                  • Small perforation: stent + observe
                  • Urinoma: drain + stent
                  • Close follow-up required
                  • Surgery if conservative fails
         2. ●

            Action

            Delayed Diagnosis

            Post-operative or late presentation

            • Flank pain, fever, ileus
            • Urine leak from incision/drain
            • Rising creatinine
            • Urinoma on imaging
            • CT with delayed images diagnostic
            • May present days to weeks post-op
            1. ●

               Action

               CT Urography with Delayed Phase

               10-15 minute delay for ureteral opacification

               • Look for contrast extravasation
               • Hydroureter/hydronephrosis
               • Periureteral fluid collection
               • Identify level of injury
               • RGP or antegrade pyelogram if CT equivocal