Iatrogenic ureteric injury: recognition and repair

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Where the ureter is injured, and by whom Most ureteric injuries are made by a surgeon, and most of those are gynaecological: hysterectomy in about one in a hundred to one in two hundred, more with a large uterus, endometriosis, bleeding or previous surgery, then colorectal resection, vascular surgery on the iliacs, and the urologist's own ureteroscope. The distal third takes about three quarters of them, at four points: the pelvic brim where the infundibulopelvic ligament and the gonadal vessels are clamped, the crossing beneath the uterine artery, the lateral vaginal fornix and cardinal ligament where the clamp is placed blind in bleeding, and the bladder base. External trauma is rare, a stab or a gunshot in the retroperitoneum, and is found at the laparotomy for everything else.
2. Recognition at the time: look, dye, retrograde Only about a third are recognised at the time, and those do best. The ureter is traced from the brim to the bladder and watched for peristalsis, for a clip or a tie across it, for a dusky segment and for urine in the field. Where there is doubt, intravenous methylene blue or indocyanine green with a near-infrared camera shows a leak or a blocked ureter within minutes; rigid cystoscopy shows whether the jets are present, and a 5 French ureteric catheter to the kidney or a retrograde pyelogram proves the ureter intact or shows the level of the stop or the extravasation. A catheter that passes freely does not exclude a crush or a burn that declares itself later.
   where it bites: a clean cut is the easy injury; the crush and the diathermy burn look intact today and necrose in a week.
3. The clip, the tie, the burn: immediate management A clip or a tie found within minutes is removed and the segment watched: pink, peristalsing and not narrowed, it is stented for four to six weeks and left; dusky, flattened or narrowed, it is excised to bleeding tissue and repaired. A crush from a clamp is treated as a devascularised segment. A diathermy burn is excised with a margin beyond the visible white because thermal spread is wider than it looks. A partial cut, less than half the circumference, is closed with interrupted 4-0 or 5-0 absorbable over a stent. A complete transection is repaired by level. Every repair is mucosa to mucosa, spatulated, tension-free, watertight, over a stent, with a drain and, where there is bowel or a vaginal cuff beside it, omentum or peritoneum between.
4. The injury found late The unrecognised ureter presents in the first week or two: loin pain or a tender mass over an obstructed kidney, fever, an ileus that will not settle, urine from the wound, the drain or the vagina, and a creatinine that rises as the urinoma is reabsorbed across the peritoneum. Anuria after a pelvic operation is bilateral ureteric injury until proven otherwise. Drain fluid creatinine well above serum is urine. The first move is drainage of the kidney and of the collection, not a repair: an inflamed, infected pelvis is not the place to sew a ureter that will not stay sewn.
   where it bites: the missed injury is the one that costs the kidney; a rising creatinine, an ileus or a drain that will not dry up after pelvic surgery is a ureter until proven otherwise.
5. Imaging the leak A CT urogram with a delayed phase at ten to fifteen minutes shows contrast outside the ureter, the level, the urinoma and the state of the kidney, and whether the other ureter is intact; a portal venous phase alone misses it. A retrograde pyelogram at cystoscopy defines the level and length of the gap and may allow a stent to be passed, which is treatment as well as diagnosis. Where nothing passes, a nephrostomy under ultrasound decompresses the kidney and an antegrade study from above, with a retrograde from below, measures the defect exactly, which is what the reconstruction will be planned on. A renogram is for later, to document what function the kidney has kept.
6. Principles of repair The same six rules whatever the level: debride to bleeding tissue; mobilise the ureter with its adventitia and periureteric fat intact, because the blood supply runs longitudinally in the adventitia, from the medial side above the brim and the lateral side below it; spatulate the ends so the anastomosis is oblique and wide; join mucosa to mucosa with fine absorbable suture, interrupted or running, without tension; stent it, with a drain beside it; and isolate it from any associated bowel, vascular or vaginal repair with omentum or peritoneum. Tension is the enemy that cannot be sutured away: if the ends will not meet without pull, the plan changes to a hitch, a flap or a substitution rather than a tighter knot.
7. Repair by level Above the iliac vessels a short defect is a ureteroureterostomy over a stent. Below them, the distal ureter is reimplanted into the bladder, directly if it reaches, with a psoas hitch for a gap of a few centimetres, and a Boari flap for ten to fifteen centimetres; the distal stump is not used because its blood supply is doubtful and reimplantation is more reliable than a low ureteroureterostomy. A long or mid-ureteric loss beyond a flap is a transureteroureterostomy, an ileal ureter or an autotransplant, and in a poorly functioning kidney, a nephrectomy. An injury at the pelviureteric junction is treated as a pyeloplasty.
   where it bites: the distal stump below a pelvic injury is not a partner for anastomosis; reimplant the ureter, hitch or flap the bladder, and leave the stump.
8. Nephrostomy and delayed reconstruction An injury found late, a septic patient, an inflamed field or a surgeon without the experience to hand: nephrostomy and, if it passes, an antegrade or retrograde stent, drainage of the urinoma, antibiotics and time. A stented partial injury or a released tie often heals without an operation and is re-imaged at four to six weeks when the stent comes out. A defect that does not heal is reconstructed once the inflammation has settled, classically at about three months, with the defect remeasured on the antegrade and retrograde studies just before. Early reconstruction within the first week or two is reasonable if the patient is well and the tissues are clean; between then and three months the field is at its worst.
9. Documentation and after The note records who called, what was found, the mechanism, the level and length of the injury, what was done to prove it, the repair and its suture, the stent and its planned removal date, the drain, and what the patient has been told. A stent is a device with a removal date in a register, not a memory. The catheter stays a week to ten days after a reimplant and the drain comes out when it is dry. The stent comes out at four to six weeks, and an ultrasound at three months, with a renogram if there is doubt, shows what function the kidney has kept. Duty of candour: the patient is told plainly that the ureter was injured, with the other surgeon present where possible.

Complications and immediate saves

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FRCS viva questions

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Evidence and guidance