eMedicine Specialties > Urology > Trauma

Ureteral Trauma: Workup

Author: Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Coauthor(s): Heinric Williams, MD, Resident Physician, Department of Urology, Wayne State University School of Medicine/Harper Hospital
Contributor Information and Disclosures

Updated: Nov 12, 2009

Workup

Laboratory Studies

  • Laboratory evaluation should include urinalysis, urine culture, complete blood count, and creatinine determination from the serum and drainage.
  • Interestingly, hematuria is not a reliable finding in ureteral injuries, as only 74% of cases involve gross or microscopic hematuria.1 A failure to observe hematuria may be seen with a completely transected ureter or partial transection of an adynamic segment.

Imaging Studies

  • Computed tomography: Computed tomography (CT) scanning is the criterion standard for evaluating abdominal injuries due to blunt trauma in stable patients. Contrast-enhanced CT scanning is highly sensitive in detecting urine extravasation and thus can be considered the primary imaging modality to evaluate for ureteral integrity in the stable patient. However, delayed imaging at least 10-15 minutes after contrast injection must be performed to adequately evaluate for urine extravasation.
  • Excretory urography or intravenous pyelography
    • Formal intravenous pyelography (IVP) is not appropriate in the acute setting. However, in patients who must undergo immediate exploratory laparotomy for a penetrating injury to the abdomen, the ureters may be evaluated with a one-shot IVP. This is performed by obtaining a single anterior-posterior abdominal film on the gurney or operating-room table 10 minutes after the intravenous injection of a 2 mL/kg (maximum of 150 mL) bolus of contrast material. The advantage of this study is that, when performed correctly, surgical intervention is not delayed, allowing for concurrent assessment of renal function and staging of upper urinary tract injuries.
    • Findings suggestive of an injury include delayed renal function or excretion, ureteral dilatation or deviation, extravasation of contrast, and nonvisualization of the ureter.
    • Unfortunately, this study yields a wide range of sensitivity, from 0% to 100%, with an average of 61%.1 As a result, negative findings do not preclude the surgical exploration of the ureter if damage is suspected, but completely normal findings indicate that significant ureteral injury is unlikely.
  • Retrograde pyelography: Retrograde pyelography (RPG) is the most sensitive radiographic study for the diagnosis of ureteral injury. It is not always appropriate for use in the acute setting but may be used in the stable patient as an adjunct to other imaging modalities when other clinical information is needed. It also has the added advantage of facilitating the placement of a ureteral stent in the same session, if indicated.
  • Antegrade ureterography: Antegrade ureterography is not routinely used in diagnosing ureteral injuries. It is useful in conjunction with percutaneous nephrostomy tube placement or placement of an antegrade ureteral stent.

Missed injuries

Delayed presentation of ureteral injuries or those missed on initial presentation may be suggested by signs such as fever, leukocytosis, local peritoneal irritation, and leakage of urine from the wound. These should be evaluated with CT scanning, but RPG may ultimately be necessary.

Diagnostic Procedures

  • Surgical exploration of the retroperitoneum with direct visualization of the ureter is the best method of diagnosing ureteral injury.
    • An average of 89.3% of ureteral injuries are detected with intraoperative inspection.13
    • Inspection of the ureter involves mobilization of the ureter and visualization of the entire wall for evidence of contusion, hemorrhage, or disruption. Neither blind palpation nor observation of ureteral peristalsis is a reliable indicator of a healthy ureter.
    • Intravenous indigo carmine or methylene blue injection is a useful adjunct with simultaneous inspection for ureteral dye leakage. Alternately, 1-2 mL can be injected directly in the renal pelvis with a 27-gauge needle and the ureter examined for leakage. This is particularly helpful in patients with hypotension in whom intravenous dye may not be excreted efficiently. The lack of dye extravasation is only guardedly reassuring; as a damaged ureteral wall may not leak immediately but may leak or extravasate later. This indicates the importance of visualization of the entire ureteral segment in question. In some cases, the dye itself may hinder diagnosis by staining local tissues and impeding visualization of the specific leakage points.
    • Gunshot wounds near the ureter warrant careful inspection of the entire ureteral wall for continuity, hemorrhage, and contusion. Indigo carmine or methylene blue may administered, as described above. If the bladder is already open, the dye may be injected in a retrograde fashion; otherwise, ureteral catheters may be passed up the ureter. If the catheter passes easily and no obvious defect in the continuity of the ureter is observed, a ureteral injury is unlikely.
  • Cystoscopy with RPG is the best procedures to detect ureteral injuries in the stable patient and allows for ureteral stent placement in the same session, as indicated.

More on Ureteral Trauma

Overview: Ureteral Trauma
Workup: Ureteral Trauma
Treatment: Ureteral Trauma
Follow-up: Ureteral Trauma
Multimedia: Ureteral Trauma
References
Further Reading
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References

  1. Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol. Oct 2003;170(4 Pt 1):1213-6. [Medline].

  2. Härkki-Sirén P, Sjöberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol. Jul 1998;92(1):113-8. [Medline].

  3. Larson DM, Malone JM Jr, Copeland LJ, Gershenson DM, Kline RC, Stringer CA. Ureteral assessment after radical hysterectomy. Obstet Gynecol. Apr 1987;69(4):612-6. [Medline].

  4. Mathevet P, Valencia P, Cousin C, Mellier G, Dargent D. Operative injuries during vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol. Jul 2001;97(1):71-5. [Medline].

  5. St Lezin MA, Stoller ML. Surgical ureteral injuries. Urology. Dec 1991;38(6):497-506. [Medline].

  6. Vakili B, Chesson RR, Kyle BL, Shobeiri SA, Echols KT, Gist R, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol. May 2005;192(5):1599-604. [Medline].

  7. Dandolu V, Mathai E, Chatwani A, Harmanli O, Pontari M, Hernandez E. Accuracy of cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct. Dec 2003;14(6):427-31. [Medline].

  8. Dowling RA, Corriere JN Jr, Sandler CM. Iatrogenic ureteral injury. J Urol. May 1986;135(5):912-5. [Medline].

  9. Ostrzenski A, Radolinski B, Ostrzenska KM. A review of laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol Surv. Dec 2003;58(12):794-9. [Medline].

  10. Coburn M. Ureteral injuries from surgical trauma. In: McAninch JW. Traumatic and Reconstructive Urology. Philadelphia, PA: WB Saunders Co; 1996:181-97.

  11. Blasco FJ, Saladié JM. Ureteral obstruction and ureteral fistulas after aortofemoral or aortoiliac bypass surgery. J Urol. Feb 1991;145(2):237-42. [Medline].

  12. Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: a 20-year experience in treating 165 injuries. J Urol. Mar 1996;155(3):878-81. [Medline].

  13. Digiacomo JC, Frankel H, Rotondo MF, Schwab CW, Shaftan GW. Preoperative radiographic staging for ureteral injuries is not warranted in patients undergoing celiotomy for trauma. Am Surg. Oct 2001;67(10):969-73. [Medline].

  14. Andreoni CR, Lin HK, Olweny E, Landman J, Lee D, Bostwick D. Comprehensive evaluation of ureteral healing after electrosurgical endopyelotomy in a porcine model: original report and review of the literature. J Urol. Feb 2004;171(2 Pt 1):859-69. [Medline].

  15. Spirnak JP, Hampel N, Resnick MI. Ureteral injuries complicating vascular surgery: is repair indicated?. J Urol. Jan 1989;141(1):13-4. [Medline].

  16. Adams JR Jr, Mata JA, Culkin DJ, Venable DD. Ureteral injury in abdominal vascular reconstructive surgery. Urology. Jan 1992;39(1):77-81. [Medline].

  17. Andersson A, Bergdahl L. Urologic complications following abdominoperineal resection of the rectum. Arch Surg. Sep 1976;111(9):969-71. [Medline].

  18. Azimuddin K, Ivatury R, Porter J, Allman DB. Damage control in a trauma patient with ureteric injury. J Trauma. Dec 1997;43(6):977-9. [Medline].

  19. Azimuddin K, Milanesa D, Ivatury R, Porter J, Ehrenpreis M, Allman DB. Penetrating ureteric injuries. Injury. Jun 1998;29(5):363-7. [Medline].

  20. Badenoch DF, Tiptaft RC, Thakar DR, Fowler CG, Blandy JP. Early repair of accidental injury to the ureter or bladder following gynaecological surgery. Br J Urol. Jun 1987;59(6):516-8. [Medline].

  21. Best CD, Petrone P, Buscarini M, Demiray S, Kuncir E, Kimbrell B, et al. Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale. J Urol. Apr 2005;173(4):1202-5. [Medline].

  22. Bodie B, Novick AC, Rose M, Straffon RA. Long-term results with renal autotransplantation for ureteral replacement. J Urol. Dec 1986;136(6):1187-9. [Medline].

  23. Boxer RJ, Fritzsche P, Skinner DG, Kaufman JJ, Belt E, Smith RB, et al. Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients. J Urol. Jun 1979;121(6):728-31. [Medline].

  24. Boxer RJ, Johnson SF, Ehrlich RM. Ureteral substitution. Urology. Sep 1978;12(3):269-78. [Medline].

  25. Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int. Aug 2004;94(3):277-89. [Medline].

  26. Bright TC 3rd, Peters PC. Ureteral injuries due to external violence: 10 years' experience with 59 cases. J Trauma. Aug 1977;17(8):616-20. [Medline].

  27. Cangiano TG, de Kernion JB. Urologic complications of vascular surgery. AUA update series. 1998;17 (39):306-311.

  28. Carlton CE Jr, Guthrie AG, Scott R Jr. Surgical correction of ureteral injury. J Trauma. Jun 1969;9(6):457-64. [Medline].

  29. Coburn M. Damage control for urologic injuries. Surg Clin North Am. Aug 1997;77(4):821-34. [Medline].

  30. Corriere JN Jr. The obstructed ureter in the patient with cancer. In: Miller TJ, Dudrick, eds. The management of difficult surgical problems. Austin, Tex: University of Texas Press; 1978:109-115.

  31. Ehrlich RM, Skinner DG. Complications of transureteroureterostomy. J Urol. Apr 1975;113(4):467-73. [Medline].

  32. Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am. Feb 2006;33(1):55-66, vi. [Medline].

  33. Ghoneim MA. Replacement of ureter by ileum. Curr Opin Urol. Nov 2005;15(6):391-2. [Medline].

  34. Guerriero WG. Ureteral injury. Urol Clin North Am. May 1989;16(2):237-48. [Medline].

  35. Harabayashi T, Shinohara N, Kakizaki H, Ameda K, Nonomura K, Koyanagi T. Ureteral stricture developing after partial nephrectomy with a microwave tissue coagulator: case report. J Endourol. Dec 2003;17(10):919-21. [Medline].

  36. Higgins CC. Ureteral injuries during surgery. A review of 87 cases. JAMA. Jan 9 1967;199(2):82-8. [Medline].

  37. Hodges CV, Barry JM, Fuchs EF, Pearse HD, Tank ES. Transureteroureterostomy: 25-year experience with 100 patients. J Urol. Jun 1980;123(6):834-8. [Medline].

  38. Kawashima A, Sandler CM, Corriere JN Jr, Rodgers BM, Goldman SM. Ureteropelvic junction injuries secondary to blunt abdominal trauma. Radiology. Nov 1997;205(2):487-92. [Medline].

  39. Kishev SV. Psoas-bladder hitch procedure: our experience with repair of the injured ureter in men. J Urol. Jun 1975;113(6):772-6. [Medline].

  40. Kuno K, Menzin A, Kauder HH, Sison C, Gal D. Prophylactic ureteral catheterization in gynecologic surgery. Urology. Dec 1998;52(6):1004-8. [Medline].

  41. Lapides J, Caffery EL. Observations on healing of ureteral muscle: relationship to intubated ureterotomy. J Urol. Jan 1955;73(1):47-52. [Medline].

  42. Leff EI, Groff W, Rubin RJ, Eisenstat TE, Salvati EP. Use of ureteral catheters in colonic and rectal surgery. Dis Colon Rectum. Jul-Aug 1982;25(5):457-60. [Medline].

  43. Mardis HK. Self-retained internal ureteral stents: uses and complications. AUA Update Series. 1997;XVI:226-231.

  44. Mattos RM, Smith JJ 3rd. Ileal ureter. Urol Clin North Am. Nov 1997;24(4):813-25. [Medline].

  45. McGinty DM, Mendez R. Traumatic ureteral injuries with delayed recognition. Urology. Aug 1977;10(2):115-7. [Medline].

  46. Medina D, Lavery R, Ross SE, Livingston DH. Ureteral trauma: preoperative studies neither predict injury nor prevent missed injuries. J Am Coll Surg. Jun 1998;186(6):641-4. [Medline].

  47. Netter F. The CIBA Collection of Medical Illustration, Kidneys, Ureters and Urinary Bladder. New Jersey: CIBA Pharmaceutical Company; 1980:23.

  48. Passerini-Glazel G, Meneghini A, Aragona F, Oliva G, Milani C, Pagano F. Technical options in complex ureteral lesions: 'ureter-sparing' surgery. Eur Urol. 1994;25(4):273-80. [Medline].

  49. Presti JC Jr, Carroll PR, McAninch JW. Ureteral and renal pelvic injuries from external trauma: diagnosis and management. J Trauma. Mar 1989;29(3):370-4. [Medline].

  50. Schapira HE, Li R, Gribetz M, Wulfsohn MA, Brendler H. Ureteral injuries during vascular surgery. J Urol. Mar 1981;125(3):293-7. [Medline].

  51. Silverstein JI, Libby C, Smith AD. Management of ureteroscopic ureteral injuries. Urol Clin North Am. Aug 1988;15(3):515-24. [Medline].

  52. Stefanovic KB, Bukurov NS, Marinkovic JM. Non-antireflux versus antireflux ureteroneocystostomy in adults. Br J Urol. Mar 1991;67(3):263-6. [Medline].

  53. Tanagho EA. A case against incorporation of bowel segments into the closed urinary system. J Urol. Jun 1975;113(6):796-802. [Medline].

  54. Teichman JM, Lackner JE, Harrison JM. Comparison of lighted ureteral catheter luminance for laparoscopy. Tech Urol. 1997;3(4):213-5. [Medline].

  55. Townsend M, DeFalco AJ. Absence of ureteral opacification below ureteral disruption: a sentinel CT finding. AJR Am J Roentgenol. Jan 1995;164(1):253-4. [Medline].

  56. Trinchieri A, Montanari E, Salvini P, Berardinelli L, Pisani E. Renal autotransplantation for complete ureteral avulsion following lumbar disk surgery. J Urol. Apr 2001;165(4):1210-1. [Medline].

  57. Waldner M, Hertle L, Roth S. Ileal ureteral substitution in reconstructive urological surgery: is an antireflux procedure necessary?. J Urol. Aug 1999;162(2):323-6. [Medline].

  58. Webster JC, Lemoine J, Seigne J, Lockhart J, Bowers V. Renal autotransplantation for managing a short upper ureter or after ex vivo complex renovascular reconstruction. BJU Int. Oct 2005;96(6):871-4. [Medline].

  59. Wessells H, McAninch JW. An update on upper urinary tract trauma. AUA Update Series. 1996;15:110-115.

  60. Wheatley JK, Ansley JD, Smith RB 3d. Ureteroarterial fistula. Urology. Nov 1981;18(5):498-502. [Medline].

  61. Wright DJ, Ernst CB, Evans JR, Smith RF, Reddy DJ, Shepard AD, et al. Ureteral complications and aortoiliac reconstruction. J Vasc Surg. Jan 1990;11(1):29-35; discussion 35-7. [Medline].

  62. Tanaka Y, Asada H, Kuji N, Yoshimura Y. Ureteral catheter placement for prevention of ureteral injury during laparoscopic hysterectomy. J Obstet Gynaecol Res. Feb 2008;34(1):67-72. [Medline].

  63. Redan JA, McCarus SD. Protect the ureters. JSLS. Apr-Jun 2009;13(2):139-41. [Medline].

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Further Reading

For more information, see Medscape's Trauma Resource Center.

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Keywords

ureteral trauma, ureter injury, ureteral injury, ureteral laceration, ureteral damage, abdominal gunshot wound, blunt trauma, iatrogenic ureteral injury, ureteroneocystostomy, vesicopsoas hitch, Boari bladder flap, ureteroureterostomy, transureteroureterostomy, TUU, autotransplantation, ileal ureteral substitution, nephrectomy, retrograde ureteral stent placement, abdominopelvic surgery, ureteroscopy, abdominal hysterectomy

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Contributor Information and Disclosures

Author

Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Disclosure: Nothing to disclose.

Coauthor(s)

Heinric Williams, MD, Resident Physician, Department of Urology, Wayne State University School of Medicine/Harper Hospital
Heinric Williams, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American College of Surgeons, and American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Allen Donald Seftel, MD, Professor, Department of Urology, Case School of Medicine
Allen Donald Seftel, MD is a member of the following medical societies: Ohio State Medical Association
Disclosure: lilly Consulting fee Consulting; sanofi-aventis Consulting fee Consulting; auxilium Consulting fee Consulting; solvay Consulting fee Consulting; plethora Grant/research funds clinical trial; indevus Consulting fee Consulting; nature publishing  journal editor

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine
Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and California Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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