Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXI: Wounds and Injuries of the Genitourinary Tract
Wounds of Ureter
United States Department of Defense
Ureteral injuries are rare and are frequently overlooked. The diagnosis is made only if the possibility of such an injury is considered in all cases of retroperitoneal hematoma and injuries of the fixed portions of the colon, the duodenum, and the spleen. Ureteral injuries are diagnosed preoperatively by the IVP. Intraoperative location of the ureteral injury, if required, is facilitated by intravenous injection of indigocarmine.
Surgical repair is based upon three factors: the anatomical segment of the traumatized ureter, other associated injuries, and the clinical stability of the patient. Debridement, hemostasis, and drainage are key factors in any successful repair, especially with high-velocity missile injuries.
If a small segment of ureter in its upper or middle segment is damaged, the proximal and distal segments may be spatulated for 1 cm and a ureteroureterostomy performed using interrupted 4-0 absorbable sutures. In the injury near the bladder, a ureteroneocystostomy should be performed. Upper and midureteral injuries in which a large ureteral segment has been damaged may require a temporizing cutaneous ureterostomy with stent placement or transureteroureterostomy. In the presence of duodenal, pancreatic, large bowel, or rectal injuries, proximal urinary diversion with a nephrostomy tube and internal ureteral stent management are required. When a distal ureteral injury is associated with a rectal injury, a ureteral reimplantation is not recommended, and a transureteroureterostomy should be performed. Adequate retroperitoneal drainage is always employed using soft rubber or silicone drains.
If the ureteral injury is not diagnosed initially and manifests itself at a later date, diversion with a nephrostomy tube is performed and ureteral repair should be delayed for 3-6 months.