Exxcellence pearls: ureteral injuries

Question 0

How does ureteral injury typically present?

Answer 0

Flank pain, ileus, low-grade fever. Serum creatinine maybe elevated.

Question 1

What is the rate of ureteral injury during pelvic surgery?

Answer 1

1%

Question 2

What are causes of anatomic distortion that would increase the risk of ureteral injury during pelvic surgery?

Answer 2

Embryologic anomalies such as double ureters, prior surgery such a C-section, tumors such as fibroids or cancer, severe endometriosis, acute or chronic inflammatory disease.

Question 3

What imaging techniques are helpful to evaluate intact ureters?

Answer 3

Intravenous pyelogram or CT scan, pelvic renal ultrasound, retrograde pyelogram, cystoscopy or cystogram.

Question 4

Where is the ureter most commonly identified and how is this performed?

Answer 4

At the pelvic brim.

Enter the retroperitoneum lateral to the IP ligament; identify the iliopsoas muscle; identify the external iliac artery medial to the muscle; move superior along the artery to the level of the common iliac bifurcation; the ureter should cross the bifurcation of the common iliac artery and then run along the lateral edge of the medial leaf of the broad ligament

Question 5

How should postoperative ureteral blockage be initially managed?

What could be done if this fails?

What surgical interventions are necessary if conservative management fails?

Answer 5

Retrograde ureteral stent placement.

Percutaneous nephrostomy with antegrade stent placement.

Reimplantation of the ureter, segmental resection and anastomosis, and rarely ureteroileoneocystotomy.