Ureteral Trauma Workup

  • Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: May 21, 2012
 

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[19] , as only 74% of cases involve gross or microscopic hematuria.[4] A failure to observe hematuria may be seen with a completely transected ureter or partial transection of an adynamic segment.
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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.

Delayed images must be obtained if the clinician has an index of suspicion because subtle findings on initial CT scanning can suggest ureteral or ureteropelvic junction injury. Findings on early or noncontrasted images of perinephric stranding, low-density fluid around the kidney and ureters, and perinephric hematomas may raise suspicion of ureteral or renal pelvis injury.[20]

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%.[4] 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.

Magnetic resonance imaging (MRI)

Cost and time has precluded the widespread use of MRI in the acute, particularly, traumatic situation. MR urography (MRU) is a more recent imaging concept in evaluating the urinary tract. In MRU, a low-dose diuretic injection is used to enhance excretion of the contrast agent gadopentetate dimeglumine. MRU sequences are generally repeated 5 and 15 min after contrast agent injection. T2-weighted sequences have been shown to be rapid, safe, and noninvasive for reliable depiction of the urinary tract while avoiding exposure to ionizing radiation and iodinated contrast agents.[21, 22]

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.

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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.[23]
    • 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.
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Contributor Information and Disclosures
Author

Richard A Santucci, MD, FACS  Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University 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)

Craig B Hunter, DO  Resident Physician, Department of Urology, Detroit Medical Center

Craig B Hunter, DO, is a member of the following medical societies: American College of Osteopathic Surgeons, American College of Surgeons, American Osteopathic Association, American Urological Association, and Sigma Sigma Phi

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

Allen Donald Seftel  MD, Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Allen Donald Seftel is a member of the following medical societies: American Urological 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; endo Consulting fee Consulting; nature publishing journal editor

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

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: Nothing to disclose.

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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Psoas hitch in ureteral trauma.
Boari flap procedure in ureteral trauma.
Ureteroureterostomy in ureteral trauma.
Transureteroureterostomy in ureteral trauma.
Complete ureteral replacement utilizing ileum in ureteral trauma.
Ileovesical anastomosis. Bladder to the left, ileum to the right.
Dual injury during hysterectomy. Combination transection of the right ureter with extravasation and left ureter ligation. Image from combined intraoperative intravenous pyelogram IVP and retrograde pyelogram.
 
 
 
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