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Intraoperative Urologic Consultation

Intraoperative urologic consultation is the urologist's response to suspected or confirmed iatrogenic urinary tract injury (IUTI) or trauma recognized during another specialist's operation. The call typically comes from a colorectal, gynecologic, general, vascular, or obstetric surgeon asking for immediate assessment of the ureter, bladder, urethra, or kidney, with the patient under anesthesia, the field open, and a decision window measured in minutes. The goals are the same every time: immediate recognition, appropriate repair or temporization, preservation of renal function, and a durable plan that prevents the patient from returning to the clinic with a delayed diagnosis.[1][2]

The role has shifted over the last three decades. The old paradigm of primary-surgeon management has shifted toward greater urologic consultant involvement, with the division of repairs varying by organ and setting: in a selected series of 269 colorectal operations with an accidental perforation, 7 of 9 ureteral injuries (78%) were diagnosed intraoperatively and repaired by a consulting urologist. In a follow-up series of 65 patients with iatrogenic bladder perforation, 63 were treated intraoperatively by a consultant urologist, and long-term success of the vesicorrhaphy was 98.4%.[2] The 2023 WSES guidelines describe the urologist's role in the operating room as fundamental when injury is suspected.[2]

For the specific non-urologic operations that generate these injuries, see the nested Procedures Causing GU Injury reference. For organ-specific trauma management outside the iatrogenic context, see Ureteral Trauma, Bladder Trauma, Renal Trauma, PFUI, and GU Injury Overview.

When to Get the Call​

Urologic consultation should be obtained in the following situations:[2]

  • Suspected or confirmed ureteral injury during pelvic or abdominal surgery
  • Bladder injury requiring complex repair or involving the trigone / ureteral orifices
  • Urethral injury during pelvic surgery (rectal resection, taTME)
  • Renal vascular injury or significant renal trauma
  • Uncertainty about urinary tract anatomy or extent of injury
  • Need for intraoperative diagnostic maneuvers: cystoscopy, retrograde pyelography, indigo-carmine assessment of ureteral jets

A low threshold is appropriate. For ureteric injury after gynecologic or colorectal surgery, intraoperative recognition was associated with less complication-management failure (see the Timing section).[6]

What to Bring​

When the call comes from a field outside the urologist's routine practice, arrive prepared:

  • Cystoscope (flexible and rigid) with light cord and camera
  • Guidewires. Atraumatic access wires and appropriate support wires; confirm intraluminal position before advancing a stiff support wire
  • Ureteral catheters. 5-Fr open-ended for retrograde pyelogram; 6-Fr cone tip
  • Double-J ureteral stents in a range of sizes (4.7-Fr × 22, 24, 26; 6-Fr for edematous ureters)
  • Indigo carmine (BLUDIGO: 5 mL [40 mg] IV over 1 minute for its labeled adult cystoscopic indication after urologic or gynecologic surgery; withdraw from the glass ampule through a 5-micron or smaller filter straw/needle), or an appropriate alternative dye for urinary efflux assessment, with agent-specific contraindications checked[28]
  • Absorbable suture: 4-0 / 5-0 Vicryl or PDS for ureter; 2-0 / 3-0 for bladder
  • Closed-suction drain (10-Fr round or 15-Fr flat)

Before scrubbing, establish where the injury is, how stable the patient is, what the primary team has already done, and whether anything has been transected, clipped or tied.

General Repair Principles​

The initial approach depends on the injured organ; the five principles below primarily address ureteral reconstruction.[4][2]

  1. Choose repair by injury location. AUA recommends primary repair over a stent for injury proximal to the iliac vessels and reimplantation or selected primary repair distally (Statements 12a–12b; Recommendation, Grade C).[18] Bladder dome injury is managed differently than trigonal injury.
  2. Debride devitalized tissue. Thermal, crush, and delayed-recognition injuries extend beyond the visible margin; trim back to viable, well-perfused tissue.
  3. Preserve the adventitia. Over-mobilization strips periureteral blood supply and converts a repairable injury into a necrotic segment.
  4. Tension-free, watertight, mucosa-to-mucosa anastomosis with spatulated ends and fine absorbable suture.
  5. Stent, drain, and image. Double-J ureteral stent for every ureteral repair, retroperitoneal drain near every anastomosis, with the follow-up imaging and device-removal plan tailored to the organ and repair.

Damage Control — "Drain Now, Fix Later"​

In the hemodynamically unstable patient, when urologic expertise is limited, or when contamination and tissue condition make durable repair unsafe, use damage-control drainage. Options include:[4][2]

  • External urinary drainage. Percutaneous nephrostomy for upper tract, large-bore Foley ± SPT for lower tract
  • For a transected ureter, proximal-stump ligation is an option only with a prompt nephrostomy plan; alternatively externalize the proximal ureter with a catheter. AUA permits temporary drainage followed by delayed repair in unstable patients [18]
  • Wide retroperitoneal or pelvic drain
  • Reassess definitive repair after resuscitation and source control; timing depends on tissue condition, associated injuries and available expertise.[2][18]

Delayed staged repair in this setting can preserve the kidney and avoid converting a reconstructable injury into a nephrectomy indication.

Ureteral Injury​

Epidemiology and Detection Failure​

Large database studies report ureteral injury in about 0.28–0.69% of colorectal operations.[2] A systematic review reported ureteral-injury rates of 0–1.9% in stent/catheter studies and 0–1.2% in fluorescent-dye studies.[3] The dominant clinical problem is detection failure: 50–70% of ureteral injuries are missed intraoperatively, and 50/284 (17.6%) iatrogenic ureteral injuries in a 38-center retrospective series were identified during primary surgery (294 ureteral injuries overall).[2][19] Intraoperative detection, compared with postoperative detection, was associated with lower odds of complication-management failure: pooled OR 0.22 (95% CI 0.12–0.41).[6]

Intraoperative Recognition​

When ureteral injury is suspected, the following maneuvers are high-yield:[4][2]

  • Direct inspection of the ureter when injury is suspected during laparotomy without preoperative imaging [18]
  • Cystoscopy with ureteral efflux assessment. Normal jets do not exclude partial, ischemic or thermal injury; absent or bloody efflux warrants further evaluation.
  • Retrograde pyelogram. Via cystoscopy or through an open cystotomy when cystoscopic access is not feasible. A described technique obtains and saves a fluoroscopic scout image of the distal and mid ureters first, then uses a 30-degree cystoscope with a cone- or whistle-tip catheter through a sheath of at least 21 Fr; dilute (50/50) contrast is injected slowly under active fluoroscopy, following the ureter to the renal pelvis and stopping once both are opacified (usual collecting-system volume 3–10 mL, higher with hydronephrosis), with images reviewed for filling defects, kinking or extravasation.[16]
  • Intravenous indigo carmine. If using BLUDIGO, give 40 mg (5 mL) IV over one minute after checking for hypersensitivity and renal impairment (not recommended if eGFR <30 mL/min). Coordinate blood-pressure and rhythm monitoring with anesthesia, and alert the team that BLUDIGO can transiently lower measured SpO2 artifactually; watch for dye leakage or absent ureteral efflux. See Indigo Carmine for preparation and other cautions.[20]
  • Direct injection of methylene blue or fluorescein into the renal pelvis demonstrates leakage at the injury site.
  • IV sodium fluorescein. In a prospective observational study after laparoscopic hysterectomy, 25 mg of 10% IV sodium fluorescein produced bilateral colored ureteral jets in 28 of 30 patients; 3 of 30 developed hypotension within five minutes of injection and required ephedrine.[13] Retrograde pyelography follows if suspicion persists.[13]
  • Retrograde passage of a ureteral catheter. Helps assess patency; do not force it across an obstruction. A recognized ligation injury requires assessment for suture release and stenting or reconstruction.
  • Limited longitudinal ureterotomy. In selected cases of substantial fibrosis or anatomic distortion where a stent cannot be safely passed through the existing lumen, a short longitudinal ureterotomy gives direct access: minimize ureteral and periureteral dissection, place lateral stay sutures for traction, pass the stent antegrade into the bladder or retrograde into the kidney, and close around the stent with interrupted absorbable sutures that include adventitia and only superficial ureteral muscle, leaving a drain until output subsides.[12]

The 2023 WSES guidelines call intraoperative cystoscopy with retrograde pyelogram the gold standard for detecting ureteral injury . It requires a hemodynamically stable patient, urologic expertise and appropriate positioning. When positioning is not feasible, cystotomy for retrograde cannulation is an acceptable alternative.[2]

Injury Types​

  • Complete transection. Define the level, defect length and tissue viability; repair immediately when the patient's condition and available expertise permit, or drain and stage reconstruction.[2]
  • Partial transection. May heal with stenting alone or may require primary repair.
  • Complete occlusion (ligation or clipping): a common iatrogenic injury pattern (neither the ACS nor the EAU guideline ranks injury types) and the one most likely to be recognized only after postoperative hydronephrosis and flank pain.
  • Thermal / crush injury. The most subtle and most dangerous. Damage can extend beyond the visible lesion and present later as a leak or stricture; the extent and timing are variable. Thermal injuries require aggressive debridement back to healthy tissue.[2]

Repair by Location​

Injury levelFirst-line repairAdjunct / alternative
Upper ureter (renal pelvis to iliacs)Ureteroureterostomy when viable ends meet without tensionFor a long defect, divert and stage if primary repair is unsafe; selected reimplantation with a long Boari flap and psoas hitch may be attempted only when bladder reach, tissue quality, patient condition and expertise permit[2][18]
Mid ureter (over iliac vessels)UreteroureterostomyTUU if available contralateral ureter
Distal ureter (caudal to iliacs)UreteroneocystostomyPsoas hitch, Boari flap
Extensive loss (>5–8 cm)Assess defect level, viable tissue, bladder reach and patient stability; divert and stage if safe tension-free acute repair is impossibleA Boari flap is an option for a suitable defect reachable from the bladder, usually in the mid/lower ureter; staged alternatives include transureteroureterostomy, ileal substitution or renal autotransplantation[2][18]
Severe peritonitis or physiological instabilityDrainage/source control and staged reconstructionMajor reconstruction only after recovery
[2][5]

Core technique (applies to all repairs):[4]

  • Debride devitalized ends back to viable, spatulated mucosa
  • Spatulate both ends on opposite sides to maximize lumen
  • Tension-free, watertight, single-layer interrupted 4-0 or 5-0 absorbable anastomosis
  • Double-J ureteral stent across the anastomosis; BAUS recommends removal at 4–6 weeks and upper-tract imaging at 3 and 12 months.[33]
  • Closed-suction retroperitoneal drain near (not on) the anastomosis
  • Avoid skeletonization — preserve adventitia and longitudinal collaterals

Minimally invasive repair. Laparoscopic and robotic ureteroureterostomy is feasible in experienced hands.[2] Ureteroureterostomy and reimplantation treat different defect locations.[2] In the 38-center retrospective series cited by WSES, 29 patients with iatrogenic injury underwent immediate ureteral reconstruction; 13/29 (44.8%) retained the operative approach, and one laparoscopy-to-open conversion due to injury was reported.[2][19]

The Skokan Algorithm​

A useful teaching algorithm (widely disseminated through Kato et al.'s A Clinical Guide to Urologic Emergencies, Chapter 7, 2021, and attributed to Alexander Skokan, MD) structures the decision flow for iatrogenic ureteral injury around time of recognition:[1]

  • Intraoperative detection. Direct evaluation of injury, then spatulated primary repair over DJ stent for short defects; reimplantation (± psoas hitch / Boari) for distal injuries; damage-control drainage if unstable.
  • Postoperative detection. Delayed-phase CT and, where needed, retrograde pyelography, then retrograde or antegrade stent and/or nephrostomy for drainage, then reconstruction of persistent injury after inflammation and infection are controlled. Timing is individualized.

AUA recommends attempting stenting for delayed incomplete injury, with nephrostomy if stenting is unsuccessful or impossible (Statements 11a–11b; Recommendation, Grade C).[18] Drainage is usually the first step in delayed-recognition injury. A well-selected early repair remains possible; persistent obstruction, tissue viability, sepsis and specialist expertise guide the decision.

The original figure is copyrighted in the published chapter and not reproduced here; see Kato et al. Chapter 7 for the schematic.[1]

Bladder Injury​

Epidemiology​

One emergency-laparoscopy case series reported 0.36% bladder injury and recognition of only 1 of 6 injuries intraoperatively.[2] In a review of benign gynecologic and obstetric operations, 542/595 reported bladder injuries (91.1%) were recognized intraoperatively.[7] The proximity of the bladder to the operative field and routine intraoperative bladder filling and dye instillation are likely contributors.

Intraoperative Recognition​

Signs of bladder injury:

  • Clear or urine-colored fluid in the field
  • Visible Foley balloon or mucosa
  • Gross hematuria in the Foley drainage
  • Gas in the Foley tubing (during laparoscopy: pneumoperitoneum entering the bladder)

Confirmation maneuvers:

  • For suspected intraperitoneal bladder injury when preoperative imaging is unavailable, fill the bladder retrograde via the Foley with sterile saline or dilute methylene blue until distended (about 300 mL in most patients), observing for extravasation; a negative test does not exclude extraperitoneal injury.[29]
  • Intraoperative cystoscopy to define the location of injury relative to the trigone and ureteric orifices
  • Indigo carmine IV with cystoscopic confirmation of bilateral ureteral jets, which is needed when the injury is near the trigone

Repair​

Direct repair is feasible with good outcomes in most cases:[2][4]

  • Watertight absorbable closure. The WSES emergency digestive surgery guideline recommends two-layer absorbable closure for intraperitoneal injury , and ACS also favors two layers.[2][4] EAU finds no evidence that two layers are superior to a watertight single layer; choose by defect and tissue condition.[2][4][30]
  • Urethral catheter drainage for 7–14 days (standard)
  • Suprapubic tube considered for: spinal cord injury, complex repair, significant hematuria, associated urethral injury, prolonged catheterization needs
  • Closed-suction drain in the pelvis
  • Post-repair cystogram. ACS recommends imaging for most repairs, with longer drainage for complex injuries; EAU permits omission after selected simple repairs.[4][30] Use the cystography follow-up framework and document the chosen plan

Special Considerations​

  • Injury near the trigone or ureteral orifices. Inspect the orifices and assess drainage; use ureteral catheters or stents selectively to define or protect an orifice during closure. For a wide intraperitoneal injury or one close to the orifices, stenting or nephrostomy is an option. If an orifice cannot be preserved, reimplant the ureter into healthy bladder wall.[2]
  • Intraperitoneal injury. Traumatic ruptures and major iatrogenic injuries require repair. During emergency digestive surgery, WSES recommends direct repair of intraperitoneal injuries recognized intraoperatively .[2] For selected small, isolated uncomplicated postoperative iatrogenic intraperitoneal or extraperitoneal bladder injuries without peritonitis or ileus, WSES says catheter drainage under close specialist observation may be considered .[2] ACS recommends catheter drainage for uncomplicated blunt extraperitoneal bladder injuries.[4]
  • Extraperitoneal injury. Uncomplicated blunt or iatrogenic injuries can usually be managed with catheter drainage. In blunt trauma, bladder-neck involvement, vaginal or rectal injury, intravesical bone fragments, or bladder-wall entrapment warrant repair; repair is also considered during pelvic internal fixation. Large iatrogenic defects or adjacent orthopedic implants favor repair.[4][2][25]
  • Laparoscopic bladder injury. Laparoscopic or robotic repair is feasible with sufficient expertise; when that expertise is unavailable, drainage with delayed repair or conversion to open repair can be considered.[2]
  • Dense bladder–uterine adhesions. Advancing a sponge stick or finger aggressively through dense adhesions between the bladder and lower uterine segment or cervix (for example after prior cesarean section) can thin or perforate the bladder; sharp dissection is used instead to mobilize the adherent bladder and obtain a tension-free closure if cystotomy occurs. This inter-organ dissection plane is distinct from using an intravaginal sponge stick as an external landmark during retropubic exposure (see below).[11]

Transvesical Approach for Complex Extraperitoneal Injury​

For extraperitoneal injuries involving the bladder neck or when ureteral orifice proximity is uncertain, a transvesical approach via wide anterior cystotomy provides the best exposure. This allows direct inspection of the entire bladder lumen, including the bladder neck and ureteral orifices, and permits direct ureteral catheterization to rule out concurrent ureteral injury.[4]

When a transvaginal approach is chosen instead, deep vaginal retractors (Heaney, Nichols, Jackson) and a headlamp aid visualization; if a retropubic approach is used, a silicone or metal stent, or a sponge stick, placed in the vagina can help delineate the vaginal wall from the bladder during mobilization and repair. As a general starting point, backfill a two-layer bladder closure after its first layer to check for leakage, then choose a urethral catheter for adequate drainage and any needed irrigation; select volume and catheter size for the individual repair (see Methylene Blue on leak-test volume).[31][4]

Bladder Within an Inguinal Hernia​

A general surgeon repairing an inguinal hernia who finds the bladder in the sac (present in an estimated 1–4% of inguinal hernias) should page urology intraoperatively.[10] Decompress first with a large-bore urethral catheter; if the herniated portion does not drain, cystoscopic cannulation of the herniated segment and aspiration can decompress it. Once decompressed, the hernia can usually be reduced without resection. Reserve partial bladder resection for bladder wall necrosis, herniation of a true bladder diverticulum, a tight hernia neck, or tumor within the herniated segment; resection can be completed through the inguinal approach or by conversion to midline laparotomy, depending on surgeon comfort and the need for pelvic exposure.[10]

Outcomes​

  • In a 65-patient single-center series (mean follow-up 36 months), bladder repair succeeded in 64/65 (98.4%); intraoperative urology consultation was obtained in 63/65.[2][26]
  • Across 26 studies/595 gynecologic and obstetric injuries, 14 complications were reported (2.4% observed); the pooled random-effects estimate was 1.0% (95% CI 0.15–1.89%). Meta-regression found no statistically significant association with catheter duration (p = 0.23).[7]

Urethral Injury​

Setting​

Iatrogenic urethral injury can occur during deep mesorectal dissection (APR or taTME) and synthetic suburethral sling insertion. If urethral injury is recognized during sling placement, repair the urethra immediately and abandon sling insertion.[2][8][22] Other settings include radical prostatectomy (intraoperative rectal injury with secondary urethral involvement), complex pelvic reconstruction, and prolonged urethral catheterization leading to pressure necrosis.

The taTME Experience​

A multicenter international study identified 34 urethral injuries during taTME over 7 years.[8] The injuries clustered on the learning curve: 20 of 39 reported urologic injuries occurred during teams' first eight taTME cases; the remaining 19 occurred between cases 12 and 101.[8] In this retrospective series of 39 reported urologic injuries, the following were operative outcomes and, at median 27.6-month follow-up (range 3–85 months), urethral-repair outcomes:[8]

  • 22% conversion to open
  • 8% rate of unplanned APR or Hartmann procedure
  • 26% urethral repair complication rate
  • 9% rate of failed repair requiring permanent urinary diversion
  • 18% of patients with successful repair reported persistent urinary dysfunction

Prevention Strategies[8]​

  • Structured taTME training and proctoring for early-experience injuries
  • Stringent case selection for later-experience injuries related to case complexity
  • Preoperative urethral catheterization with a large-caliber catheter (e.g., 20-Fr) to aid identification
  • Consideration of cystoscopic light-wand illumination or NIR-imaging of the catheter balloon in difficult cases

Repair​

For a urethral defect recognized during taTME, direct transperineal suture repair has been described. Evidence is insufficient to specify one catheter duration for this setting; arrange drainage and follow-up according to the defect and repair. See PFUI for the separate pelvic-fracture trauma framework.[8][21]

Posterior prostate capsule involvement. When a perineal colorectal dissection (for example APR) directly involves the posterior prostate capsule rather than the membranous urethra itself, this is a distinct injury pattern from membranous urethral disruption: the prostate can be partially resected with the capsule reapproximated, or the capsular defect simply cauterized, with careful attention to hemostasis and to the proximity of the external sphincter.

Renal Injury​

Most renal trauma is managed non-operatively. Iatrogenic renal injury during other operations is typically a hilar vascular injury, for example during laparoscopic adrenalectomy, donor nephrectomy, retroperitoneal lymphadenectomy or emergency laparotomy for trauma. See Renal Trauma for the full framework.

Indications for Intraoperative Operative Management[4][5]​

  • Hemodynamic instability not responding to resuscitation
  • Grade V injuries with complete hilar avulsion (high likelihood of nephrectomy)
  • Severe renal vascular injury without self-limiting bleeding
  • Main renal vein injury without self-limiting bleeding (angioembolization is not indicated for venous injury)

Operative Technique for Grade IV Salvage​

When a Grade IV renal injury is encountered during indicated renal exploration, salvage may be attempted if the patient remains hemodynamically stable.[4]

  • Control bleeding with cautery, topical hemostatic agents (oxidized cellulose, fibrin sealant), and suture ligation of individual vessels
  • Repair collecting system injuries with running absorbable sutures (watertight closure)
  • Reapproximate parenchymal defects with bolstered capsular sutures (pledget or Gelfoam bolster)
  • Consider partial nephrectomy for superior- or inferior-pole injuries involving the collecting system
  • Omental pedicle flap buttress when local tissue is unavailable
  • Closed-suction drain after any collecting system repair

Vascular Injury Management[4][5]​

  • Segmental vessels. Ligation can control bleeding, accepting loss of the supplied parenchymal territory when necessary
  • Main renal vein injury. Primary repair is feasible if narrowing is at most 50%; greater narrowing may be tolerated on the left because of collateral drainage, whereas compromised right renal venous outflow may require nephrectomy[4]
  • Main renal artery injury. Options include primary repair, end-to-end anastomosis, saphenous vein interposition, or selected endovascular stenting; results depend on injury, ischemia time and expertise, and a single success percentage is misleading
  • Nephrectomy is the typical outcome for major hilar injuries, particularly in the unstable patient

Unstable Patient​

For an explored high-grade renal injury with ongoing life-threatening hemorrhage, ACS prioritizes rapid nephrectomy when the patient remains unstable or needs ongoing blood/pressor resuscitation.[4] EAST conditionally favors attempted kidney preservation over nephrectomy for unstable adults with an expanding Zone II hematoma requiring exploration, when feasible without prolonging physiologic compromise; its supporting evidence has very low certainty.[32] Instability from another source is not, by itself, an indication to remove an otherwise salvageable kidney; do not open a stable blunt-trauma perirenal hematoma merely because another organ is bleeding.[4]

Prevention — Preoperative Risk Stratification​

High-Risk Situations[2]​

Risk factors for IUTI include the following. The odds ratios are from a colectomy database analysis (Coakley) summarized in the WSES guidelines:

  • Diverticular disease (OR 2.12)
  • T4 malignancy (OR 1.80)
  • Open surgery (OR 1.32)
  • Previous radiotherapy
  • Locally advanced colorectal cancers
  • Visceral obesity
  • Previous colorectal or gynecologic surgery
  • Inflammation and large tumors

Prophylactic Ureteral Stenting​

  • Gynecologic surgery: a 2023 mixed-design meta-analysis reported an association with fewer injuries (OR 0.61, 95% CI 0.39–0.96; estimated NNT 224).[6]
  • A 2024 review of complex gynecologic surgery found no demonstrated reduction in its three RCTs (3,277 participants; RR 0.90, 95% CI 0.49–1.65).[9] Select stents for anatomic identification in high-risk cases.[9]
  • An earlier (2020) systematic review and meta-analysis of five RCTs found a lower ureteral-injury risk with prophylactic catheterization before laparoscopic gynecologic surgery (RR 0.44, 95% CI 0.20–0.97). This earlier, smaller pooled result has not been confirmed by the larger 2024 review above.[15]
  • Colorectal surgery. Lighted or fluorescent catheters can aid identification in selected high-risk cases, but an injury-prevention benefit remains unproven.[2] A 2026 meta-analysis of 17 retrospective cohorts (104,162 patients) found no statistically significant difference in ureteral injury and reported higher UTI and hematuria rates associated with prophylactic stents.[27] The 2023 WSES guideline found no randomized comparison of prophylactic stenting versus no stent and suggests considering stents in selected high-risk emergency digestive operations .[2][6] In the same NSQIP colectomy database used above for risk factors, prophylactic ureteral catheter placement was associated on multivariate analysis with a lower rate of 30-day ureteral injury (OR 0.45, 95% CI 0.25–0.81); univariate comparisons showed higher rates of ileus, wound infection, urinary tract infection and 30-day readmission.[14]
  • Preoperative imaging. CT with excretory phase defines urinary tract anatomy and variations in high-risk patients.[2]
  • Trocar sites. In emergency laparoscopic digestive surgery, the WSES guidelines describe visual inspection of suprapubic trocar sites during insertion and extraction as essential to avoid unrecognized bladder injury.[2]

Timing and Outcome​

Timing of recognition is an important, potentially modifiable determinant of outcome. Intraoperative detection is associated with a markedly lower rate of complication management failure: pooled OR 0.22 (95% CI 0.12–0.41) compared with postoperative detection.[6] Delayed-diagnosis ureteral injuries are more likely to require nephrectomy; delayed bladder injuries are more likely to present as urinary peritonitis, sepsis, or fistula.

In a case series of non-endoscopic bladder injuries summarized in the WSES guidelines, delayed diagnosis was more likely after laparoscopic surgery than after open surgery.[2] Early urologic consultation and a low threshold for intraoperative cystoscopy during high-risk minimally invasive pelvic procedures follow from these data.

Ethical Decision-Making for Complex or Irreversible Repair​

When time and patient stability permit, gather the primary surgeon's account, relevant records and imaging, anesthesiologist input, and the designated surrogate's knowledge of the patient's wishes before committing to a potentially irreversible complex reconstruction or other unplanned procedure. For a major, higher-morbidity or irreversible reconstruction, weigh patient condition, procedure morbidity, reversibility, long-term quality of life, and the harm of a second anesthetic or delayed repair. Most such decisions are best deferred with temporizing measures until the patient can participate in shared decision-making; selected exceptions are reasonable when deferral itself causes greater harm. The consulting urologist supplies the urologic assessment and options to the primary surgeon and anesthesiologist.[17] If the patient cannot participate and no surrogate is available, AMA ethics guidance permits urgently needed treatment without prior consent, with prompt notification and consent for ongoing care when feasible.[23] For a deferrable major decision when the patient lacks capacity and no surrogate can be found, consult an ethics committee or other institutional resource.[24]

Documentation and Handoff​

Every intraoperative consultation should produce:

  • A urology operative note distinct from the primary team's note: injury type, location, mechanism, repair technique, suture material, stent placement, drain location
  • A postoperative catheter and stent management plan. Catheter duration, cystogram timing, stent removal date, clinic follow-up
  • Imaging follow-up plan. An individualized assessment for leak/obstruction and device removal; cystography where indicated after bladder repair
  • Direct communication with the primary team and the patient (postoperatively) about the injury and the recovery timeline

Key Guideline Recommendations​

WSES Guidelines (2023)[2]​

  • In confirmed IUTI, intraoperative repair is preferred when patient condition and urologic expertise permit .[2]
  • Three factors influence outcome: (1) injury characteristics, (2) patient condition, (3) available urologic expertise.
  • The urologist's role in the operating room is fundamental when IUTI is suspected.
  • Repair success depends on dynamic management and urologic expertise.

ACS Best Practices Guidelines (2025)[4]​

  • Direct inspection of the ureter at laparotomy in patients with suspected ureteral injury.
  • Damage-control approach with external urinary drainage for unstable patients.
  • Double-J ureteral stent for repair of all ureteral injuries, adult and pediatric.

References​

1. Kato H, Iijima K, Oguchi T, et al. Iatrogenic Ureteral Injury. Chapter 7 in: A Clinical Guide to Urologic Emergencies. Wiley-Blackwell; 2021. ISBN: 9781119021476. (Figure 2: Algorithm for the evaluation and management of iatrogenic ureteral injury detected intraoperatively and postoperatively, courtesy Alexander Skokan, MD, University of Washington.) doi:10.1002/9781119021506.ch7

2. de'Angelis N, Schena CA, Marchegiani F, et al. 2023 WSES Guidelines for the Prevention, Detection, and Management of Iatrogenic Urinary Tract Injuries (IUTIs) During Emergency Digestive Surgery. World Journal of Emergency Surgery. 2023;18(1):45. doi:10.1186/s13017-023-00513-8

3. Brollo PP, Puggioni A, Tumminelli F, et al. Preventing Iatrogenic Ureteral Injury in Colorectal Surgery: A Comprehensive and Systematic Review of the Last 2 Decades of Literature and Future Perspectives. Surgery Today. 2024;54(4):291–309. doi:10.1007/s00595-022-02639-9

4. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons. 2025.

5. Coccolini F, Moore EE, Kluger Y, et al. Kidney and Uro-Trauma: WSES-AAST Guidelines. World Journal of Emergency Surgery. 2019;14:54. doi:10.1186/s13017-019-0274-x

6. Yanagisawa T, Mori K, Quhal F, et al. Iatrogenic Ureteric Injury During Abdominal or Pelvic Surgery: A Meta-Analysis. BJU International. 2023;131(5):540–552. doi:10.1111/bju.15913

7. Jensen AS, Heinemeier IIK, Schroll JB, Rudnicki M. Iatrogenic Bladder Injury Following Gynecologic and Obstetric Surgery: A Systematic Review and Meta-Analysis. Acta Obstetricia Et Gynecologica Scandinavica. 2023;102(12):1608–1617. doi:10.1111/aogs.14641

8. Sylla P, Knol JJ, D'Andrea AP, et al. Urethral Injury and Other Urologic Injuries During Transanal Total Mesorectal Excision: An International Collaborative Study. Annals of Surgery. 2021;274(2):e115–e125. doi:10.1097/SLA.0000000000003597

9. Gurumurthy M, McGee AE, Saraswat L. Prophylactic ureteric catheterisation during complex gynaecological surgery: a systematic review and meta-analysis. BJOG. 2024;131(10):1341–1351. doi:10.1111/1471-0528.17823.

10. Kraft KH, Sweeney S, Fink AS, Ritenour CW, Issa MM. Inguinoscrotal bladder hernias: report of a series and review of the literature. Can Urol Assoc J. 2008;2(6):619–623. doi:10.5489/cuaj.980

11. Karram MM, Gebhart JB. Repair of Advertent and Inadvertent Cystotomy. In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:1071–1078.

12. Maggio M, Trabuco EC, Gebhart JB. Managing Ureteral Injury During Pelvic Surgery. In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:1099–1112.

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