Ureteral Injuries: External and Iatrogenic

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Anatomy

The ureter originates from the renal pelvis as the most posterior structure in the renal hilum (Fig. 1). The ureter then travels caudally through the retroperitoneum along the anterior surface of the psoas muscle, posterior to the colonic mesentery and lateral to the gonadal vein. At the pelvic inlet, the gonadal vein crosses the ureter. The ureter then crosses anterior to the common iliac vessels, courses lateral to the internal iliac vessels, and then turns medially, where it is crossed by

Types of ureteral injury

Intraoperatively, the ureter can be injured by suture ligation, sharp incision or transection, avulsion, devascularization, and heat (eg, microwave, electrocautery, or vibratory energy) or cryoablative therapy. Injury by transection, ligation, or avulsion may be immediately apparent. Injury in cases of devascularization, heat, or cryoablative therapy may not be apparent because these insults may not immediately result in any change in ureteral patency. For this reason, clinicians must maintain

Gynecologic procedures

According to estimates, 52% to 82% of operative ureteral injuries occur during gynecologic surgery [1], [2], [3], [4]. The ureter is more commonly injured during an abdominal hysterectomy (2.2%) [5], [6], [7] than a vaginal hysterectomy (0.03%) [8] and more commonly in an open abdominal hysterectomy than in a laparoscopic hysterectomy (1.3%) [9]. This difference may in part be due to a selection bias as hysterectomies complicated by infection and malignancy are approached transabdominally. Risk

Iatrogenic ureteral injuries

Many ureteral injuries go unrecognized at the time of injury. In fact, of all recognized iatrogenic ureteral injuries, 50% to 70% are not recognized acutely [2], [11]. Minor injuries may heal without sequelae. However, when not repaired, significant injuries result in fever, flank pain, nausea, and vomiting from hydronephrosis, urinoma, or ureteral fistula. To avoid a delay in diagnosis, every effort should be made to fully evaluate the ureters intraoperatively in cases at risk for ureteral

Management

After staging the traumatic or iatrogenic ureteral injury, the plan for repair should be based on the length and location of the injury, the patient's overall status, and the associated injuries. While an excellent reconstruction might be possible, a more conservative approach, such as ureteral ligation or stenting, might be more appropriate in the unstable patient. Most injuries are short and can be repaired with debridement and either ureteroneocystostomy in the distal ureter or

Summary

Both iatrogenic and traumatic ureteral injuries are rare. Missed ureteral injuries are associated with increased morbidity. Therefore a high index of suspicion is warranted. The urologist should be familiar with several methods of identifying ureteral injuries and the evaluation should be tailored to the clinical situation. Most ureteral injuries are short transections and can be repaired with debridement and ureteroureterostomy in the proximal and mid-ureter or with ureteroneocystostomy in the

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