Ureteral rupture

Definition

Ureteral injury is rare but potentially severe. The most common cause is iatrogenic trauma during gynecological, colorectal, or urological procedures.

Goals of emergency care:

• promptly recognize urinary leakage;
• establish urinary drainage;
• prevent sepsis, urinary ascites, and loss of kidney function.

When to suspect it

• Flank pain, fever, reduced urine output.
• Urinary infiltration of tissues, urine appearing in a drain.
• An unexplained rise in creatinine.
• After endoscopy or surgery: a change in the pattern of pain and failure of urine output to recover as expected.

Diagnosis

• Initial assessment: CBC, creatinine, electrolytes, urinalysis, and culture if infection is suspected.
• Ultrasonography: hydronephrosis, fluid.
• CT with a urographic phase is the key investigation in a stable patient (contrast extravasation).
• Retrograde pyelography is highly accurate when planning stent placement.

Emergency management

• In partial injury with preserved patency, provide internal drainage with a ureteral stent and monitor leakage.
• In complete transection, inability to traverse the injured segment, or severe infection, perform nephrostomy followed by reconstruction.
• If recognized intraoperatively, immediate reconstruction is preferred when the patient's condition and available resources permit.

Treatment

• The central principle is to establish urinary drainage and control infection.
• Minor injuries: stenting and observation.
• Significant leakage, complete injury, or failed stenting: nephrostomy.
• After inflammation subsides: reconstruction (reimplantation, ureteroureterostomy).

Algorithm

Cross-references: Chapters 16 and 46.