The ureter is a muscular tube responsible for transporting urine from the kidney to the bladder. Each person typically has two ureters, one connecting to each kidney, acting as a critical conduit. Although ureter damage can be a serious medical concern, injuries are frequently treatable and repairable.
Causes and Types of Ureter Damage
Ureter damage can arise from several sources, with surgical procedures being a common cause. During complex operations, such as gynecological, colorectal, or vascular surgeries, the ureter can inadvertently be cut, ligated, or crushed due to its close anatomical proximity to other organs. External trauma, including blunt force injuries or penetrating wounds, can also directly injure the ureter, leading to tears or contusions.
Kidney stones represent another common cause of ureteral injury. A large or jagged stone moving through the ureter can cause direct damage to the ureteral lining, leading to inflammation or even perforation. Prolonged obstruction by a stone can also lead to pressure necrosis. Less common causes include radiation therapy for pelvic cancers, which can cause fibrosis and stricture formation, or certain medical conditions that lead to inflammation or external compression of the ureter.
Damage to the ureter can manifest in different forms, depending on the cause and severity. Lacerations involve cuts or tears in the ureteral wall, potentially leading to urine leakage into surrounding tissues. Strictures refer to a narrowing of the ureter, which can impede urine flow and cause kidney swelling. Avulsions describe a complete tearing away of the ureter from its connection, often at the kidney or bladder, while external compression means something outside the ureter is pressing on it, blocking urine passage.
Identifying Ureter Damage
Recognizing a damaged ureter often begins with a patient’s symptoms, which can vary depending on the nature and severity of the injury. Common indicators include flank pain, blood in the urine, or a noticeable decrease in urine output. Some individuals may also experience fever or signs of infection if urine leakage leads to inflammation or abscess formation.
Medical professionals utilize diagnostic methods to identify ureteral damage. A physical examination may reveal tenderness in the flank area or abdominal distension. Urine tests can detect the presence of blood, infection, or other abnormalities. Various imaging techniques are employed to visualize the urinary tract and pinpoint the location and extent of the injury.
Computed Tomography (CT) scans, particularly a CT urogram, are frequently used to provide detailed images of the kidneys, ureters, and bladder, revealing leaks, blockages, or other structural damage. Magnetic Resonance Imaging (MRI) offers comprehensive views without radiation exposure. Other diagnostic tools include ultrasound, which can identify kidney swelling (hydronephrosis) due to obstruction, and intravenous pyelogram (IVP). Retrograde pyelography involves inserting a thin tube through the urethra to inject contrast directly into the ureter, offering a clear view of its internal structure and any points of injury or narrowing.
Strategies for Ureter Repair
The approach to repairing a damaged ureter is individualized, depending on the injury’s location, its severity, and the patient’s overall health. Both non-surgical and surgical techniques are employed to restore the ureter’s function. The primary goal is to ensure urine can flow freely from the kidney to the bladder, preserving kidney health.
Ureteral stenting is a non-surgical method where a thin, flexible tube is temporarily placed inside the ureter to bypass an obstruction or promote healing. This stent keeps the ureter open, allowing urine to drain and the ureteral wall to repair itself. Nephrostomy tube placement is another temporary measure, where a tube is inserted through the skin directly into the kidney to drain urine externally. This diverts urine flow, allowing the ureter to rest and heal.
For more significant damage, various surgical repairs are performed. Ureteral reimplantation, also known as ureteroneocystostomy, involves detaching the ureter from the bladder and reattaching it at a new site on the bladder wall. This procedure is typically used when the damage is close to the bladder. When a short segment of the ureter is damaged, an excision and reanastomosis procedure can be performed, where the injured portion is surgically removed, and the two healthy ends are sewn back together.
If a larger section of the ureter is damaged or missing, complex reconstructive techniques may be necessary. A Boari flap involves creating a tube from a section of the bladder wall and using it to bridge a gap in the ureter. Similarly, a psoas hitch procedure anchors the bladder to the psoas muscle in the pelvis, shortening the distance between the bladder and the kidney for reattachment. In cases of extensive ureteral loss, an ileal ureter or bowel interposition may be performed, using a segment of the patient’s small intestine (ileum) to replace the damaged portion of the ureter, providing a new conduit for urine flow. These procedures can be carried out through open surgery, minimally invasive laparoscopic techniques, or with the aid of robotic surgical systems.
Post-Repair Care and Prognosis
Following ureter repair, patients undergo a recovery period varying by the procedure’s complexity and the individual’s healing capacity. Pain management is common post-operative care, and activity restrictions are usually advised for several weeks. Hospitalization typically ranges from a few days to over a week, depending on the repair’s invasiveness.
Regular follow-up appointments are important to monitor the healing process and ensure the success of the repair. These appointments often include imaging studies to check for proper urine flow and assess the integrity of the repaired ureter. The presence of stents, if used, will also require scheduled removal or exchange.
While the prognosis for a damaged ureter is generally favorable, potential complications can arise. These may include infection, persistent urine leakage, or the recurrence of strictures. Despite these possibilities, timely treatment of ureteral injuries often leads to successful outcomes, preserving kidney function and restoring the normal flow of urine.