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Ureteric injury: a challenging condition to diagnose and manage

Nature Reviews Urology volume 10, pages 108–115 (2013)Cite this article

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Abstract

Although ureteric injury is relatively uncommon, it is a serious event that can result in intra-abdominal sepsis, renal failure, and loss of the ipsilateral renal unit. Most injuries are iatrogenic and remain undiagnosed until the patient presents with symptoms postoperatively. In addition to compromising patient safety, missed ureteric injuries frequently result in litigation. Over the past 20 years, there has been a rapid uptake of laparoscopic and robotic techniques within urology and other surgical specialties. This trend, coupled with increased use of ureteroscopy, has increased the risk of injury to the ureter. The key to diagnosing and managing a ureteric injury is to have a low threshold for suspecting its presence. Diagnosis can be achieved using retrograde pyelography, ureteroscopy, CT, or intravenous urography. Initial management should involve ureteric stent placement or percutaneous nephrostomy drainage. In selected patients, surgical reconstruction might be the optimal approach. Decisions regarding surgical technique (open, laparoscopic, or robotic) are guided by the clinical situation and surgical expertise available.

Key Points

  • The close proximity of the ureters to important abdominal and pelvic structures increases the risk of iatrogenic injury; the ureter is particularly vulnerable during prolonged ureteroscopy and laparoscopically assisted vaginal hysterectomy

  • Ureteric injuries sustained in the trauma setting are often accompanied by a myriad of other serious injuries

  • The key to diagnosing and managing a ureteric injury is to have a low threshold for suspecting its presence

  • Retrograde pyelography, ureteroscopy, CT urography, and intravenous urography can be used to confirm the diagnosis

  • First-line management options include ureteric stenting and percutaneous nephrostomy drainage

  • In some cases, surgical reconstruction might be required; the use of open, laparoscopic, or robotic techniques will depend upon the clinical situation and surgical expertise

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Figure 1
Figure 2: Contrast-enhanced CT images of a left ureteric perforation managed conservatively with stent insertion.

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Acknowledgements

P. Dasgupta and K. Ahmed acknowledge financial support from the Department of Health courtesy of a National Institute for Health Research comprehensive Biomedical Research Centre award to Guy's & St Thomas' NHS Foundation Trust in partnership with King's College London and King's College Hospital NHS Foundation Trust. They also acknowledge the support of the MRC Centre for Transplantation, London Deanery, London School of Surgery.

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Authors and Affiliations

  1. Royal Sussex County Hospital, Easter Road, Brighton, BN2 5BE, UK

    Hamid Abboudi

  2. MRC Centre for Transplantation, King's College London, 5th Floor Tower Wing, Guy's Hospital, London, SE1 9RT, Great Maze Pond, UK

    Kamran Ahmed, Mohammed Shamim Khan & Prokar Dasgupta

  3. Department of Urology, Aberdeen Royal Infirmary, Forester Hill, AB25 2ZN, Aberdeen, UK

    Justine Royle & James N'Dow

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  1. Hamid Abboudi
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Contributions

H. Abboudi researched, wrote, discussed, and edited this Review. K. Ahmed proposed, designed, and critically reviewed the article. J. Royle reviewed and edited the manuscript. M. S. Khan, P. Dasgupta, and J. N'Dow made substantial contributions towards discussions of content and reviewed the manuscript prior to submission.

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Correspondence to Kamran Ahmed.

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K. Ahmed receives grant support from National Institute of Health Research, MRC Centre for Transplantation, and Olympus.

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Abboudi, H., Ahmed, K., Royle, J. et al. Ureteric injury: a challenging condition to diagnose and manage. Nat Rev Urol 10, 108–115 (2013). https://doi.org/10.1038/nrurol.2012.254

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