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 or contrast-enhanced CT shows extravasation of
contrast from the injured ureter.
Injury to one or both ureters during pelvic surgery:
This occurs most often during vaginal or abdominal hysterectomy when
the ureter is divided, ligated, crushed or excised,usually inadvertently.
Pre-emptive ureteric catheterisation prevents such accidents as the
catheters make it easier to identify the ureters.
Injury 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.
Deliberate ligation of the proximal ureter and temporary percutaneous
nephrostomy is then the best course until the patient is well enough for a
repair .
Injury not recognised at the time of operation
A-Unilateral injuries
There are three possibilities:
• No symptoms. Secure ligation of a ureter may simply lead to silent
atrophy of the kidney. The injury may be unsuspected until the patient
undergoes urological imaging some time later.
• Loin pain and fever, possibly with pyonephrosis, occur with infection of
the obstructed system. Urography shows no function, which will be
permanent unless steps are taken quickly to relieve the obstruction by
inserting a percutaneous nephrostomy.
• A urinary fistula develops through the abdominal or vaginal wound. The
urogram or contrast-enhanced CT shows extravasation with or without
obstruction of one or both ureters. Nephrostomies may be inserted and
repair postponed until oedema and inflammation have subsided. Early
repair is safe provided that the patient is fit for surgery.
B-Bilateral injury
Ligation of both ureters leads to anuria. Ureteric catheters will not pass
and urgent relief of obstruction by nephrostomy or immediate surgery is
essential.
Repair of the injured ureter
.
If the cut ends of the ureter can be apposed without tension, they should
be joined by a spatulated anastomosis over a double pigtail catheter. If it
is possible to insert a stent endoscopically past a partial ureteric
obstruction, an open repair may be avoidable.
If the division is very low down, the bladder may be hitched up so that
the ureter can be reimplanted into it.
Extra length may be obtained by mobilising the kidney.
In the Boari operation , a flap of bladder wall is fashioned into a tube to
replace the lower ureter.
The disadvantage of implanting the ureter end to side into the
contralateral ureter (a transureteroureterostomy) is that it risks converting
a unilateral injury into a bilateral one.
Nephrectomy may be the best course when the patient’s outlook is poor
and the other kidney is normal. When conservation of all renal tissue is
vital, replacement of the damaged ureter by a segment of ileum is
necessary
.
Methods for repairing a damaged ureter
1-If there is no loss of length Spatulation and end-to-end anastomosis
without tension
2-If there is little loss of length- Mobilise kidney
-Psoas hitch of bladder
-Boari operation
3-If there is marked loss of length- Transureteroureterostomy
-Interposition of isolated bowel loop or
mobilised appendix
-Nephrectomy
IDIOPATHIC RETROPERITONEAL FIBROSIS
In this rare condition one or both ureters are bound up in a progressive
fibrosis of the retroperitoneal tissues. Most cases are idiopathic but some
may be drug related. A similar clinical picture occurs in patients with
leaking aortic aneurysm and infiltrating retroperitoneal malignancy.
The patient complains of backache, which is unremitting for several
months. The onset of anuria and renal failure prompts investigation of the
renal tract, which reveals hydronephrosis, usually on both sides. The
excretion urogram typically shows medial displacement of the obstructed
ureters and the appearances on CT are diagnostic. The sedimentation rate
is markedly raised.
Treatment
It may be possible to insert ureteric stents as a temporary measure while
renal function recovers. If not, percutaneous nephrostomies will allow the
obstructed kidneys to drain. Some patients need renal replacement by
dialysis. Some advocate conservative treatment with high-dose steroids.
Surgical treatment involves dissection of the ureters from their fibrous
jacket (ureterolysis). Wrapping omentum around the freed ureters
discourages recurrent obstruction.