URETERIC INJURIES MANAGEMENT

Ureteric injuries: management
When to repair the ureteric injury
Generally, the best time to repair the ureter is as soon as the injury has been diagnosed.
Delay definitive ureteric repair when:
- the patient is unable to tolerate a prolonged procedure under general anaesthetic
- there is evidence of active infection at the site of proposed ureteric repair (infected urinoma).

A percutaneous nephrostomy should be placed, the infection drained radiologically (percutaneous drain), intravenous antibiotics given, and ureteric repair delayed until the patient is apyrexial.
Traditional teaching held that surgical repair should be delayed when the injury was diagnosed between roughly day 7 and day 14 after ureteric injury, the time when maximal oedema and inflammation at the site of repair was believed to occur. However, favourable outcomes have been demonstrated after early repair and the time of the original injury is nowadays seen as a less important determinant of time of definitive repair.

Definitive treatment of ureteric injuries
The options depend on:
- whether the injury is recognized immediately
- level of injury
- other associated problems.

The options are:
- JJ stenting for 3 - 6 weeks (e.g. ligature injury recognized immediately)
- primary closure of partial transection of the ureter
- direct ureter to ureter anastomosis (primary ureteroureterostomy) if the defect between the ends of the ureter is of a length where a tension-free anastomosis is possible
- reimplantation of the ureter into the bladder (ureteroneocystostomy) either using a psoas hitch or a Boari flap
- transureteroureterostomy
- autotransplantation of the kidney into the pelvis where the segment of damaged ureter is very long
- replacement of the ureter with ileum where the segment of damaged ureter is very long
- permanent cutaneous ureterostomy where the patient's life expectancy is very limited
- nephrectomy traditionally advocated for ureteric injury during vascular graft procedures (e.g. aortobifemoral graft for AAA), but the trend is towards ureteric repair and renal preservation, reserving nephrectomy only where a urine leak develops post-operatively (continuing drainage of urine from the drain placed at the site of ureteric anastomosis).

General principles of ureteric repair
- The ends of the ureter should be debrided, so that the edges to be anastomosed are bleeding freely.
- The anastomosis should be tension free.
- For complete transection, the ends of the ureter should be spatulated, to allow a wide anastomosis to be done.
- A stent should be placed across the repair.
- Mucosa to mucosal anastomosis should be done, to achieve a watertight closure.
- Use 4/0 absorbable suture material.
- A drain should be placed around the site of anastomosis.