Renal and Ureteral Injuries

Question 1

How to evaluate patient with Renal or Ureteral injury

Answer 1

CT scan with IV contrast three critical phases: arterial, nephrogram, and pyelogram.

Intraoperative cystoscopy with retrograde pyelograms

Single-shot intravenous pyelogram (IVP) , identify presence of contralateral kidney and an apparent ureteral injury

Question 2

What sign on imaging pathognomonic for renal pelvis or ureteral injury ?

Answer 2

Contrast Extravasation on Delayed Phase image

Question 3

What may Suggest ureteral injury on presentation

Answer 3

gross hematuria, urinoma, or hydronephrosis

Question 4

Indications for Non Opertive management in renal injury

Answer 4

Hemodynamic stability
Grade of Injury

Initial Management :
-bed rest
-serial hemoglobin levels
-hemodynamic monitoring.
-active surveillance for blood transfusion with or without angioembolization.
-follow-up imaging for deep lacerations ( IV– V ) or clinical signs of complications

Question 5

Patient on non operative management developed urinary extravasation with enlarging urinoma or fever

Answer 5

Consider Ureteral Stent or Percutanous Nephrostomy

Question 6

Indications for IR management in renal injury

Answer 6

-can be utilized in hemodynamically unstable patients
-perirenal hematoma (> 4 cm)
-vascular contrast extravasation.

surgical intervention may be necessary for deep or complex renal lacerations (AAST III– V).

Question 7

Absolute indications for operative management in Renal Injury

Answer 7

-Expanding/Pulsatile hematoma
-Renal Pedicle avulsion
-Persistent or Life threatening Shock or hemorrhage
-Ureteropelvic Junction Avusion/Disruption

Question 8

Relative Indications for Operative management in Renal injury

Answer 8

-Urinary Extravasation wihtout viable tissue
-Concurrent colon/ pancreas/ trauma exploration with incomplete staging or grade III or greater concurrent renal injury
-Renovascular hypertension
-Failed embolization

Question 9

Complications post renal repair or IR

Answer 9

-delayed bleed, AV fistula, or pseudoaneurysm

-If the collecting system was repaired :
delayed urine leak, leading to a urinoma or perirenal abscess.

Question 10

MC Etiology for Ureteral injury

Answer 10

Penetrating Trauma

Question 11

Pt with ureteral contusion without a urinary leak in undergoing exploratory laparotomy.

Answer 11

Ureteral Stent

Question 12

when a delayed ureteral injury is recognized or when severe urinary extravasation

Answer 12

Nephrostomy drainage

Question 13

Immediate repair vs Delayed Repair

Answer 13

Immediate :
trauma patient undergoing exploratory laparotomy.

ureteral repair may be performed if the injury is identified within 7 days

after 7 days, a delayed repair is attempted several weeks after the urinary leakage and acute inflammation have resolved.

Question 14

describe the Coarse of the Ureter

Answer 14

-traverses the retroperitoneum beneath the gonadal vessels, on top of the psoas, over the iliac vessels near the iliac bifurcation

-The ureter blood supply varies by location; distally, the supply is lateral, then posterior as it travels over the iliac vessels, and then transitions to medially as the ureter travels to the renal hilum.

Question 15

What suture for Ureteral repair used

Answer 15

4-0 or 5-0 absorbable interrupted
with a stent

Question 16

Patient in extremis

Answer 16

damage control and bailout: tying off the ureter, temporary urinary drainage, and delayed repair.

Question 17

Proximal Ureter Repair (Cephalad to Iliac Crest)

Answer 17

-A pyeloplasty may be required if a ureteropelvic junction (UPJ) is avulsed or severely injured.

-A ureteroureterostomy (UU) will be required if the injury is found more distal on the proximal ureter.

Question 18

Midureter (Caudal to Iliac Crest, Cephalad to Sacroiliac)

Answer 18

-The UU is most often performed procedure in the midureter in an acute setting.

-On occasion, a trans-UU is required, passing the injured ureter retrosigmoid and performing an end-to-side anastomosis.
-contraindicated in patients with a history of urolithiasis

-psoas hitch can be performed with subsequent transverse incising of the bladder with cephalad mobilization (Boari flap).

Question 19

Distal Ureter (Caudal to Sacroiliac)

Answer 19

-ureteral reimplant (ureteroneocystostomy).

-To maintain the reimplant off-tension, performing a psoas hitch is often required

Question 20

When placing Suture for Psoas hitch

Answer 20

avoid nerve entrapment of either the genitofemoral or femoral nerve.

Question 21

Options for Injury > 10 cm

Answer 21

-Bladder Flap
-Downward Nephropexy
-Ileal Ureter ( 15 cm from IC junction )
-Autotransplantation of the kidney

For bilateral repairs, a reverse seven ileal interposition

Question 22

how to avoid complications post repair

Answer 22

nephrostomy tube, ureteral stent, and Foley catheter.