Ureteral injury is damage to the ureteral wall. It is manifested by heaviness, bursting pains in the lumbar, iliac and subcostal areas, hematuria, rarely — anuria. With combined injuries, it is usually masked by symptoms of damage to other organs. It is diagnosed using ultrasound, CT, MRI, retroperitoneal MSCT, intravenous urography, retrograde ureteropyelography, general urine analysis. In case of bruises, conservative therapy with analgesics, absorbable drugs, preventive administration of antibiotics is possible. In other cases, ureteral stenting, nephrostomy, suturing of ruptures, reconstructive operations are performed.
ICD 10
S37.1 Ureteral injury
Meaning
Ureteral injuries are detected in 1.0-5.7% of patients with damage to the genitourinary organs. The peculiarities of the structure of the ureteral wall and its protection from external damaging influences caused a characteristic distribution of the causes of injuries depending on the age and gender of the victims. In women, the risk of injury to the ureter increases at the age of 25-35 years, which is associated with the realization of reproductive function, and after 45 years due to the growth of oncopathology requiring radical surgical treatment.
Among the male population up to 28-32 years old, injuries due to accidents and violent actions prevail, after 50 years — injuries received during cystoscopic interventions. In recent years, there has been an increase in the prevalence of pathology, which is caused by the expansion of the possibilities of surgical treatment of gynecological and urological diseases. At the same time, the main problem is that more than 70% of ureteral lesions are detected only after surgery.
Causes
The specificity of the distribution of etiological factors contributing to organ damage is due to its high elasticity, easy displacement, anatomical location features, good protection from accidental external influences. In more than 75% of patients, the ureter is injured due to invasive medical manipulations and only 25% — as a result of blunt trauma and penetrating wounds. Specialists in the field of clinical urology and traumatology name the following causes of organ damage:
- Gynecological operations. Up to 55% of ureteral injuries are caused by surgical interventions in the field of obstetrics and gynecology. Usually, the integrity of the organ is violated during oncogynecological interventions for cervical cancer, less often — with the removal of malignant neoplasms of other localization, intraligmental tumors, the imposition of obstetric forceps, cesarean section with transverse dissection of the uterus in the lower segment, abortion, craniotomy, extra-vaginal, abdominal hysterectomy, etc.
- Urological interventions. In 11% of cases, the ureter is damaged during endoscopic examinations and treatment of diseases of the urinary system. Wounds of the mucous membrane, perforation, complete detachment are possible with ureteroscopy, stenting, ureteral augmentation, balloon dilation, removal of ureteral stones without preliminary fragmentation. Most often, the injury becomes a consequence of a violation of the technique of performing manipulation.
- General surgical and vascular operations. The result of such interventions is up to 9% of ureteral injuries. Damage to the middle third of the organ occurs during pelvic and paraaortic lymphadenectomy, operations on the external iliac vessels, suturing of the posterior leaf of the parietal peritoneum. The integrity of the ureter is violated if the rules for performing low anterior resection of the large intestine are not followed, and the abdominal aortic aneurysm is promptly eliminated.
- Traumatism and violent actions. In 18% of cases, ureteral injuries develop when falling from a height, direct blows to the abdomen, other mechanical impacts received in an accident, domestic and industrial conditions. 7% of patients are diagnosed with gunshot and knife wounds of the organ. The peculiarities of such injuries are localization mainly in the upper third, combination with injuries to the pelvic bones, spine, and other internal organs, which complicates the diagnostic search.
Pathogenesis
The mechanism of damage to the ureter during injuries depends on the characteristics of the destructive effect. The ureteral wall can be partially or completely dissected by surgical instruments, squeezed by a seam or clamp, bent. The impact of significant mechanical loads leads to tears, tears, separation. A feature of iatrogenic injuries of the ureter is frequent necrosis due to mediated effects – devascularization during electrocoagulation, innervation disorders with extensive dissection. With closed non-iatrogenic injuries with bruising and rupture of blood vessels, the formation of a hematoma in the ureteral wall and surrounding tissues is possible.
Classification
The systematization of ureteral injuries is carried out taking into account the side, place, and nature of the damage. Usually the lesion is unilateral, because of its closer location in relation to the funnel-phase ligament, it is localized on the left. Right—sided injuries are less often detected, in exceptional cases – bilateral injuries. By localization, damage to the ureter is distinguished in the upper, middle and lower third.
According to the number of affected areas, the injury can be single or multiple, taking into account the safety of the surrounding organs — isolated and combined. In the absence of communication with the environment, they talk about closed damage, if the integrity of the skin is violated, they talk about open damage. An important role in choosing the method of reconstructive technique is played by determining the nature of the injury:
Non-penetrating damage to the ureter. In more than 75% of cases, the integrity of the urethral wall is not violated. Less often a bruise is detected, more often an incomplete rupture on the part of the epithelial membrane or outer layers. In the absence of end-to-end injuries, conservative management of the patient or stenting of the organ is possible. Surgical tactics in case of accidental dressing are chosen taking into account the time of its detection.
End-to-end injuries of the ureter. They occur both directly at the moment of the damaging effect, and some time after it (with necrosis against the background of devascularization or denervation of the wall). In case of perforation, a complete circular break without divergence or with divergence of the edges, urgent reconstructive plastic intervention is necessary to restore the integrity of the shells.
Symptoms of ureteral injury
A feature of the clinical picture is the absence of specific symptoms, which in almost 80% of cases leads to late diagnosis of the lesion. With intraoperative and open wounds, urine may leak into the wound. In the postoperative period and in patients with non—neurogenic isolated injuries, blunt bursting pains may be observed in the lumbar region, the arches of the iliac bones, less often in the hypochondrium. In 70% of patients, a visible admixture of blood appears in the urine, which, with a unilateral complete rupture, is a single one.
For infrequent bilateral injuries with a circular break or ligation of the ureters, the absence of urine is characteristic. With combined injuries, damage to the urethral wall is masked by the clinic of irritation of the peritoneum and damage to nearby organs — sharp abdominal pain, abdominal muscle tension, nausea, vomiting, flatulence, increasing symptoms of traumatic shock and internal bleeding.
Complications
Non-penetrating injuries of the ureter can be complicated by the formation of strictures, and in more complex cases by complete obstruction with retention changes of the overlying sections, the development of ureterohydronephrosis and chronic renal failure. With the through destruction of the wall, urinary infiltration, intra- and retroperitoneal urine congestion, urogematomas occur, which, with the secondary attachment of infection, become the basis for the formation of peritoneal abscesses, retroperitoneal phlegmon, the development of peritonitis and urosepsis.
A long-term consequence of injury to the ureteral membranes is the formation of external urinary, ureteral-uterine, ureteral-vaginal fistulas. In some patients, postrenal stagnation of urine leads to urolithiasis, chronic pyelonephritis.
Diagnostics
In most patients, diagnosis is difficult due to the lack of specific symptoms. Therefore, in any cases of macrohematuria, lower back pain, and especially the absence of urine after gynecological, urological, abdominal surgery, closed or open abdominal trauma, it is important to exclude damage to the ureter. The following methods are the most informative in diagnostic terms:
- Echography. The results of ultrasound of the ureter are more indicative of ligation and rupture of the organ. The violation of the outflow of urine is indicated by an increase in the size of the kidney, the expansion of the cup-pelvic system and the distal third of the ureter, swelling of the paranephral fiber. When the wall breaks, free fluid in the pelvic cavity, hypoechoic urinoma or retroperitoneal urogematoma can be determined.
- Intravenous urography. The passage of the radiopaque substance allows you to identify damage to the ureteral membranes, its localization and features. Intravenous urography is usually performed with indigocarmine. In accordance with the recommendations of the European Community of Urologists, delayed standard urograms are recommended for detecting ureteral injury half an hour after the introduction of X-ray contrast.
- Ascending ureteropyelography. The introduction of contrast fluid directly into the ureter is the gold standard for the diagnosis of its traumatic damage. The presence of a defect in the ureteral wall is indicated by the output of X-ray contrast outside the organ. With the help of retrograde UPG, the site of the injury is localized quite accurately and its nature is approximately estimated (perforation, rupture).
- Tomography of the retroperitoneal space. CT of the retroperitoneal region is more effective with contrast. A three-dimensional image of the urinary organs through which the contrast preparation passes allows you to accurately detect the area of damage, identify urinomas, urogematomas, and assess their volume. Alternatively, a complex MSCT or MRI of the retroperitoneal space with contrast can be performed.
In the general analysis of urine, erythrocyturia is determined in 80-85% of the victims. In the presence of bleeding, a general blood test confirms a decrease in the level of erythrocytes and hemoglobin. In some cases, the final diagnosis is established only intraoperatively. Differential diagnosis is carried out with injuries of the kidneys, bladder, other abdominal and pelvic organs, genitourinary fistulas, ureteral strictures. In addition to consulting a specialist urologist, patients are shown an examination by a traumatologist, surgeon, anesthesiologist-resuscitator, therapist, proctologist, obstetrician-gynecologist for women.
Treatment of ureteral injury
A wait-and-see tactic with preventive antibiotic therapy, the appointment of analgesic and resorbing agents is permissible only with a reliably confirmed traumatic injury of the organ without signs of damage to the wall and normal passage of urine. The remaining patients are shown surgical interventions of various volumes aimed at ensuring normal urine excretion and restoring the integrity of the ureteral membranes:
- With non-penetrating wounds and small ruptures. The operation of choice is the stenting of the ureter with the installation of a hollow cylinder made of metal mesh in its lumen. The intervention is performed through a cystoscope. For some patients, percutaneous puncture nephrostomy is performed to unload the kidneys, less often a nephrostomy is applied through an incision in the lumbar region.
- With incomplete lateral dissection. Usually this situation occurs during emergency or planned abdominal operations. It is allowed to apply several stitches to the ureter membranes with mandatory stenting for an average of 3 weeks. This approach prevents the formation of urinary congestion, the formation of fistulas and strictures, the development of peritonitis.
- At full intersection or separation. Usually, the victim requires reconstructive plastic surgery (applying ureterocystoanastomosis, performing Boari surgery, in the acute and long—term period – performing intestinal plastic surgery). With early detection of injury, resection of the damaged area is possible, followed by suturing of the ends (primary ureteral suture).
Prognosis and prevention
With timely detection of ureteral injury, the correct choice of tactics for the management of the victim and the volume of the operation, the prognosis is favorable. More serious complications and long-term consequences are observed with late diagnosis and combined injuries of the ureter.
For the prevention of iatrogenic traumatization, careful management of childbirth with reasonable use of surgical methods, compliance with the technique of cystoscopic and abdominal interventions is recommended. Bilateral catheterization of the ureters before operations on the pelvic organs, a thorough examination of the likely areas of damage after the main intervention, proper separation of the ureter from the uterine ligaments allows to significantly reduce the number of intraoperative ureteral injuries.
