Ureteral injuries, though uncommon, involve damage to the tubes that transport urine from the kidneys to the bladder. If not identified and addressed promptly, these injuries can have serious consequences. This article provides information on ureteral injuries, from their definition to recovery.
What is a Ureteral Injury?
Ureters are narrow, muscular tubes that connect each kidney to the bladder. Their function is to propel urine from the kidneys to the bladder. This movement occurs through rhythmic muscle contractions known as peristalsis.
A ureteral injury involves damage to one or both of these tubes. This damage can manifest as a complete cut (transection), a partial cut (laceration), crushing, or a blockage. The injury’s severity can vary, impacting the ureter’s ability to transport urine effectively and potentially leading to urine leakage or obstruction.
Causes of Ureteral Injuries
Ureteral injuries most frequently arise as an unintended consequence of medical procedures. These injuries commonly occur during various types of surgery performed in the abdomen and pelvis. Gynecological procedures, particularly hysterectomies, account for 52% to 82% of these injuries. Colorectal surgery also contributes, accounting for about 14% of cases.
Urological procedures, such as ureteroscopy, also carry a risk, potentially involving perforation, stricture, or avulsion. In laparoscopic surgeries, injuries are often caused by cauterization or clipping. Outside of surgical settings, ureteral injuries can result from external trauma, though this is less common due to the ureters’ protected location. Penetrating injuries, such as gunshot or stab wounds, are the most frequent cause of non-iatrogenic ureteral trauma, often affecting the upper ureter. Blunt force trauma, from incidents like car accidents or falls, can also lead to ureteral damage, but these instances are rare, occurring in less than 1% of all blunt genitourinary trauma cases.
Signs and Symptoms
The signs and symptoms of a ureteral injury can be varied and sometimes non-specific, which can make initial recognition challenging. Abdominal pain or pain in the flank, the area between the ribs and the hip, are common complaints. Patients might also experience a fever, which can indicate an infection resulting from persistent urine leakage.
Nausea and vomiting may also occur. More specific signs can include blood in the urine, known as hematuria, or a noticeable decrease in urine output, especially if both ureters are affected. Urine leakage, which can form a collection of urine in the body called a urinoma, or discharge of urine from a surgical wound, are also direct indicators of ureteral damage. Given that symptoms can be delayed or mimic other conditions, a high degree of suspicion is important, particularly following recent abdominal or pelvic surgery or significant trauma.
Diagnosis and Management
Diagnosing a ureteral injury often begins with clinical suspicion, especially if a patient develops symptoms after a relevant surgical procedure or trauma. Imaging techniques are important in confirming the presence and location of an injury. A computed tomography (CT) scan with contrast (CT urogram) is frequently used to visualize the urinary tract and identify leaks or obstructions.
A retrograde pyelogram, which involves injecting contrast dye directly into the ureter through a cystoscope, is a sensitive diagnostic method and can also allow for stent placement. An antegrade pyelogram can be performed if a patient already has kidney access. Surgical exploration and direct visualization of the ureter is another accurate method to identify an injury.
Management of ureteral injuries depends on the injury’s location, extent, and timing of diagnosis. Minor injuries, such as small lacerations or contusions, may be treated non-surgically with a ureteral stent to allow healing. A percutaneous nephrostomy, where a tube is inserted through the skin into the kidney to drain urine, might be used if a stent cannot be placed or if there is an obstruction.
Surgical repair is necessary for more significant injuries.
Surgical Repair Options
- Primary repair involves debriding damaged tissue and suturing the ureter back together over a stent.
- For injuries to the lower ureter, ureteroneocystostomy, which involves re-implanting the ureter into the bladder, may be performed, sometimes with a psoas hitch to reduce tension.
- Injuries to the middle or upper ureter might require a ureteroureterostomy, connecting the two ends of the injured ureter.
- Another option is a transureteroureterostomy, joining the injured ureter to the healthy one.
- In rare cases, for extensive damage, a Boari flap (creating a tube from the bladder) or even renal autotransplantation might be considered.
Recovery and Long-Term Considerations
Recovery following treatment for a ureteral injury varies depending on the severity of the injury and the type of intervention performed. Patients typically remain in the hospital for 1 to 3 days after surgical repair, with pain management being a primary focus. Initial discomfort, including bladder spasms and burning sensations during urination, is common but usually subsides within the first week.
Follow-up appointments and imaging studies are important to monitor the healing process and identify any potential complications. These may include recurrent urinary tract infections, the formation of strictures (narrowing of the ureter), or, in rare severe cases, impaired kidney function if the injury was extensive or diagnosis was delayed. Stents placed during surgery are typically removed after 3 to 6 weeks, following radiographic confirmation of proper healing. While many patients can resume light activities within a few weeks, strenuous activities are often restricted for a longer period, typically 4 to 6 weeks, to ensure complete healing.