Injuries to the ureter

Rupture of the ureter

This is an uncommon result of a hyperextension injury of the spine. The diagnosis is rarely made until there is swelling in the loin or iliac fossa associated with a reduction of urine output. An excretion urogram shows extravasation of contrast from the ureter on the injured side.

Injury to one or both ureters during pelvic surgery

This is far more common and occurs most often during vaginal or abdominal hysterectomy. Typically there is a failure to recognise the ureter, which is divided, ligated, crushed or excised. Preliminary catheterisation of the ureters prevents such acci­dents as the catheters make it easy to see and feel the ureters.

In jury recognised at the time of operation

Ureterovesical continuity should be restored by one of the methods described below unless the patient’s condition is poor when deliberate ligation of the proximal end of the ureter is the best course. If the patient rallies within 2 days, temporary nephrostomy is carried out with a view to repair of the injury later.

Injury not recognised at the time of operation

Unilateral injuries. There are three possibilities.

No symptoms. Secure ligation of a ureter may simply lead to silent atrophy of the kidney that it drains. If the other kidney is functioning, the injury may be unsuspected until the patient undergoes urological imaging some time later.

Loin pain and fever, possibly with pyonephrosis occurs with infection of the obstructed system. Excretory urography shows no function, a state that will be permanent unless urgent steps are taken to relieve the obstruction, usually by inserting a percutaneous nephrostomy.

A urinary fistula develops through the abdominal or vaginal wound. The urogram shows extravasation of contrast with or without obstruction to one or both ureters. Temporary nephrostomies may be inserted and repair postponed until oedema and inflammation have subsided. The traditional delayed repair, however, leaves the patient incontinent and demoralized. Early repair is now regarded as safe provided that the patient is fit and the surgeon has the necessary experience.

Bilateral injury. Ligation of both ureters leads to anuria, Ureteric catheters will not pass and urgent relief of obstruction is mandatory.

Repair of the injured ureter (Tab 62.2)

1. If there is no loss of length and the cut ends of the ureter can be brought together without tension, they should be joined by a spatulated anastomosis over a double pigtail catheter. (A pigtail catheter is a plastic tube with preformed coils at each end. The catheter is inserted over a guide-wire which straightens its ends. When the wire is removed, the coils reform to anchor the ends of the catheter.)

2. If the division is very low down, the bladder wall may be hitched up so that the ureter can be reimplanted into it. Extra length may be obtained by mobilising the kidney.

3. Boari’s operation (Fig. 64.16). A flap of bladder wall is fashioned into a tube to replace the lower ureter.

4. The ureter may be implanted end to side into the contralateral ureter. The disadvantage of a transureteroureterostomy is that it risks converting a unilateral injury into a bilateral one.

5.Occasionally, when conservation of all renal tissue is vital, replacement of the damaged ureter by a segment of ileum is necessary.

6. Nephrectomy may be the best course when the patient’s outlook is poor and the other kidney is normal.