History

The key to managing any ureteral injury, regardless of its etiology, is maintaining a high index of suspicion.

Most iatrogenic injuries (70%-80%) are diagnosed postoperatively. The presenting signs and symptoms may include the following^[17]:

Flank pain (36%-90%)
Fever and sepsis (10%)
Fistula (ureterovaginal and/or ureterocutaneous)
Urinoma
Prolonged ileus
Renal failure secondary to bilateral obstruction (10%)

Other rare but reported injuries include an aortoureteric or graft-ureteric fistula, which may present as mild-to-massive gross hematuria, or a silent obstruction, which can present later as hypertension and nephrotic syndrome.

In patients with external trauma, ureteral involvement may not be obvious, especially when associated with multiorgan involvement. Therefore, the diagnosis of a ureteral injury may be delayed as other critical injuries are addressed. Nevertheless, as discussed above, a high index of suspicion for ureteral involvement must be maintained.

Physical Examination

Again, with the patient's history in mind, a carefully performed physical examination may be revealing. The following findings are especially suggestive:

An abdominal or flank mass
Costovertebral angle tenderness
Peritoneal signs
Fluid drainage from the wound or vagina

Workup

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Media Gallery

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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Author

Mathew D Sorensen, MD, MS, FACS Associate Professor and Residency Program Director, Department of Urology, University of Washington School of Medicine; Clinical Staff, Department of Veterans Affairs, Puget Sound Health Care System

Mathew D Sorensen, MD, MS, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Endourological Society, Research on Calculus Kinetics (ROCK) Society, Society of Academic Urologists, Society of Urologic Robotic Surgeons, Society of Women in Urology, Urological Research Outcomes Collaboration, Western Endourology STone (WEST) Research Consortium, Western Section of the American Urological Association

Disclosure: Scientific advisory board for: Sonomotion, Inc.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Laparoscopic and Robotic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Additional Contributors

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, MD is a member of the following medical societies: American Urological Association

Disclosure: Received consulting fee from lilly for consulting; Received consulting fee from abbott for consulting; Received consulting fee from auxilium for consulting; Received consulting fee from actient for consulting; Received honoraria from journal of urology for board membership; Received consulting fee from endo for consulting.

Richard A Santucci, MD, FACS Senior Surgeon, Crane Surgical Services

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, International Society of Urology

Disclosure: Nothing to disclose.

Shlomo Raz, MD Professor, Department of Surgery, Division of Urology, University of California, Los Angeles, David Geffen School of Medicine

Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, California Medical Association

Disclosure: Nothing to disclose.

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 Surgeons, American Osteopathic Association, American Urological Association, American College of Osteopathic Surgeons, Sigma Sigma Phi

Disclosure: Nothing to disclose.

Acknowledgements

Heinric Williams, MD Resident Physician, Department of Urology, Harper Hospital, Wayne State University School of Medicine

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