33. Injury to the ureter

Question 1

what is the location of the ureter

Answer 1

retroperitioneally

Question 2

Classification of ureteric traumas

(3 forms)

Answer 2

• Open (external) -
• Closed (internal) - most common form is iatrogenic traumas
• Combined/Associated/ isolated

Question 3

what is the most common trauma of the ureter

give examples from

1. abdominal surgery
2. gynaea
3. URO
   
   • open
   • fistula
   • endoscopic
     
     • retrograde
       
       • dg / rx

Answer 3

iatrogenic causes

1. Extended abdominal surgery,
   
   • the most common surgery is for colerectal carcinoma
2. Gynaecological operations
   
   • gynaecological malignancies e.g. endometrial and cervical carcinoma
3. Urological operations
   
   1. ​​ open urological operation = Radical prostatectomy - best option for localised prostate carcinoma.
   2. Operation for vesico-vaginal and ureto-vaginal fistulas
   3. Endoscopic operations: as a rule they may be diagnostic and therapeutic.
      
      • diagnostic:
        
        • retrograde Catherisation of the ureter can cause perforation & closed renal trauma
        • rigid Ureterorenoscopy-
      • therapeutic:
        
        • ​Lithotripsy +URS
        • Stenting +URS (can cause closed renal trauma)

Question 4

• best option for localised prostate carcinoma.

Answer 4

Radical prostatectomy

Question 5

Types of Iatrogenic traumas to the ureter

iatrogenic C I P L E D ureter

Answer 5

1. Complete rupture of ureter - with dislodgement at ends of ureter
2. Incomplete rupture of ureter
3. Perforation of the ureter
4. ligation by a suture in External abdominal surgery may lead to and cause obstruction
5. Excision of part of ureter - most severe
6. Division

Question 6

why is the type of trauma to the ureter important

Answer 6

the clinical presentation of ureteric trauma depends on the type of trauma - complete, incomplete etc.

Question 7

when is it possible to recognise/ diagnose iatrogenic ureteral trauma

Answer 7

1. Intraoperarivley At the time of surgery,

cardinal sx:

• leakage of urine in the operative field,

management

• immediate operation= reconstruction at this time is strongly recommended

2. Post operatively days-wks

cardinal sx:

• anuria
• leakage of urine from the drainage => indicates emerg surg

​management: 2 options depending on ECOG

1. if ECOG is good emerg surg immediately
2. if severe general status, reconstructive surgery is not indicated
   
   • _​​_option here is proximal drainage of urine aka percutaneous nephrostomy and then delayed reconstructive surgery

Question 8

at the time of surgery how is ureter injury managed

Answer 8

management

immediate operation= reconstruction at this time is strongly recommended

Question 9

management of injury of the ureter after surgery

Answer 9

management: 2 options depending on ECOG

re-operation immediately

if severe general status, the reconstructive surgery is not indicated

​​option here is proximal drainage of urine aka percutaneous nephrostomy and then delayed reconstructive surgery

Question 10

how is trama of the ureter diagnosed

Answer 10

CT scan with contrast material

shows obstructed ureter or leakage of urine from the ureter at the site of injury.

Question 11

how is trama of the ureter treated

Answer 11

depends on the type of injury

• according to thickness of ureter wall
  
  • complete rupture: radical reconstructive operation - according to time sx recognised intrasurgery to post operative.
  • incomplete: stent, for 14-21days is enough
• Ligated ureter and acute pyelonephritis: (severe ECOG) percutaneous nephrostomy and delayed reconstructive surgery
• Excised distal part of the ureter, MC: reimplantation of the ureter in urinary bladder.

Question 12

how is ncomplete rupture to the ureter rxed

Answer 12

stent, for 14-21days is enough.

Question 13

rxment for complete rupture of the ureter

Answer 13

radical operation - according to the type of injuries recognised at time of surgery to post operative.

Question 14

rx if the distal part of ureter is excised, which is most common,

Answer 14

reimplantation of the ureter in urinary bladder.

Question 15

rx of ligated ureter and acute pyelonephritis

Answer 15

percutaneous nephrostomy and delayed reconstructive surgery.