Ureteral Trauma
Ureteral injuries account for <1% of all urologic trauma. The ureter's retroperitoneal location, small caliber, and mobility protect it from most external forces — but when injury does occur, delayed or missed diagnosis is common and leads to serious morbidity including urinoma, abscess, stricture, and renal loss.[1] Hematuria is absent in up to 55% of cases, making mechanism-driven imaging essential over symptom-based workup.
:::note Cross-Reference — Imaging Ureter-specific imaging protocols (CT delayed phase, RPG technique) are covered in detail in Imaging (Evaluation & Workup). A summary is included below. :::
Epidemiology and Mechanism
- Penetrating trauma (ballistic > stab) is the predominant mechanism in adults[1]
- Blunt deceleration accounts for 5–40% of ureteral injuries; UPJ avulsion is the characteristic blunt pediatric pattern due to the hyperextensible pediatric spine and less protective perirenal fat
- Associated injuries with penetrating ureteral trauma: bowel ~46%, vascular structures ~14%[2]
- Up to 12.5% of intraoperative ureteral injuries are missed at initial laparotomy; delayed diagnosis (days to weeks) leads to urinoma, sepsis, and renal failure[3]
- Iatrogenic ureteral injury during pelvic surgery (hysterectomy, colorectal resection, aortoiliac surgery) is numerically more common than traumatic ureteral injury overall
Imaging and Diagnosis
CT with Delayed (Excretory) Phase
The first-line modality for stable patients. The delayed phase (5–10 minutes after contrast injection) is mandatory when ureteral injury is suspected:[4]
| Finding | Significance |
|---|---|
| Contrast extravasation on delayed phase | Diagnostic of collecting system / ureteral injury |
| Periureteral fluid, retroperitoneal hematoma | Indirect sign |
| Ipsilateral delayed or absent nephrogram | Suggests UPJ avulsion or vascular compromise |
| Lack of ureteral opacification distal to injury | Localizes level of complete disruption |
:::note Ureteral Injury on Standard Trauma CT A standard trauma CT (portal venous phase only) will miss most ureteral injuries. If ureteral injury is suspected, explicitly request or add a delayed-phase acquisition (5–10 minutes). Do not rely on a single-shot IV pyelogram at laparotomy to exclude ureteral injury.[4] :::
Retrograde Pyelography (RPG)
The most accurate test for suspected or confirmed ureteral injury. Performed cystoscopically by urology. Provides exact injury location, extent, and degree of obstruction. Indicated for:[4]
- Equivocal CT findings
- Operative planning before repair
- Delayed-presentation injuries with uncertain level
Intraoperative Detection
When ureteral injury is suspected at laparotomy and preoperative imaging was not obtained:[4]
- Direct visual inspection of entire ureter
- IV methylene blue or sodium fluorescein (observe for ureteral leak)
- Direct injection of dye into the renal pelvis
- Retrograde ureteral catheterization via cystotomy or cystoscopy
AAST Organ Injury Scale — Ureter
| Grade | Type | Description |
|---|---|---|
| I | Hematoma | Contusion or hematoma without devascularization |
| II | Laceration | <50% transection |
| III | Laceration | ≥50% transection |
| IV | Laceration | Complete transection with <2 cm devascularization |
| V | Laceration | Avulsion with >2 cm devascularization |
Advance one grade for bilateral injuries (up to grade III).[5]
Endoscopic Management
Grade I contusions can be managed with ureteral stent placement alone in the absence of devascularization.[4]
:::warning High-Velocity Ballistic Injuries Blast effect from high-velocity projectiles causes microvascular injury extending well beyond the visible wound. Delayed ureteral necrosis may occur 5–7 days after injury with subsequent stricture formation over weeks. Avoid endoscopic stenting alone for significant ballistic contusions — plan for early re-evaluation and low threshold for formal repair.[6] :::
For delayed-presentation incomplete transections: obtain RPG first; attempt retrograde ureteral stenting. Place percutaneous nephrostomy tube when stenting fails or significant leakage persists despite stent.
Surgical Management
Principles of Ureteral Repair
All successful repairs depend on:[4]
- Complete debridement of devitalized tissue to bleeding edges
- Preservation of periureteral adventitia (blood supply) — balance mobilization against vascularity
- Spatulation of both ureteral ends (creates wider anastomosis, reduces stricture risk)
- Tension-free, watertight mucosa-to-mucosa anastomosis with fine absorbable suture
- Double-J ureteral stent across the repair
- Retroperitoneal closed-suction drain
Repair Strategy by Injury Location
Distal Ureter (Distal to Iliac Vessels)
| Option | Indication | Success Rate |
|---|---|---|
| Ureteroneocystostomy | Standard distal repair when blood supply compromised | 91–98%[7] |
| Psoas hitch | When tension-free direct reimplant is not possible; bladder mobilized and fixed to ipsilateral psoas tendon | ~97%[8] |
| Boari flap | Long mid-to-lower ureteral defects beyond psoas hitch range; technically demanding — defer acutely if expertise unavailable | Variable |
Proximal Ureter (Proximal to Iliac Vessels)
| Option | Indication |
|---|---|
| Ureteroureterostomy | Primary spatulated anastomosis over stent for short-segment injuries |
| Heineke-Mikulicz conversion | Partial transection at laparotomy — convert longitudinal tear to transverse repair over stent |
| Resection + primary repair | High-velocity GSW with blast effect: resect devitalized segment, then primary anastomosis |
| Ureteropyelostomy | UPJ avulsion: anastomose proximal ureter into renal pelvis |
Long Segment / Complex Defects (Deferred)
- Ileal ureter interposition — elective, requires bowel preparation; not performed acutely
- Transuretero-ureterostomy (TUU) — for combined bilateral or difficult pelvic access
- Autotransplantation — rarely required
Damage Control Strategy
In hemodynamically unstable polytrauma patients, defer definitive repair. Temporizing options:[4]
| Option | Description |
|---|---|
| Cutaneous ureterostomy | Exteriorize proximal ureter through abdominal wall |
| Ureteral ligation + PCN | Ligate ureter; percutaneous nephrostomy placed in recovery |
| Intubated ureterostomy | Ureteral stent or small catheter secured to proximal end, externalized |
| Intraperitoneal drainage | Temporary closure with suction; definitive repair at re-look |
Definitive reconstruction is planned after resuscitation, ideally at a center with reconstructive urology expertise.
Delayed Diagnosis Management
For patients diagnosed late with no planned reoperation:[4]
- Prioritize retrograde ureteral stenting for partial injuries
- Percutaneous nephrostomy when stenting fails
- Antegrade nephrostogram 6–8 weeks later to assess healing
- Plan formal surgical reconstruction if ongoing leak, urinoma, or stricture confirmed
References
1. Siram SM, Gerald SZ, Greene WR, et al. Ureteral trauma: Patterns and mechanisms of injury of an uncommon condition. Am J Surg. 2010;199(4):566–570. PMID 20417921
2. Elliott SP, McAninch JW. Ureteral injuries from external violence: The 25-year experience at San Francisco General Hospital. J Urol. 2003;170(4):1213–1216. PMID 14501733
3. Kunkle DA, Kansas BT, Pathak A, Goldberg AJ, Mydlo JH. Delayed diagnosis of traumatic ureteral injuries. J Urol. 2006;176(6):2503–2507. PMID 17085155
4. American College of Surgeons Trauma Quality Programs. ACS TQP Best Practices Guidelines: Management of Genitourinary Injuries. Chicago, IL; August 2025. Available at: facs.org/cot
5. Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling. III: Chest wall, abdominal vascular, ureter, bladder, and urethra. J Trauma. 1992;33(3):337–339. PMID 1404507
6. Locke JA, Neu S, Herschorn S. Morbidity and predictors of delayed recognition of iatrogenic ureteric injuries. Can Urol Assoc J. 2022;15(1):E1–E6. PMID 33819160
7. Wenske S, Olsson CA, Benson MC. Outcomes of distal ureteral reconstruction through reimplantation with psoas hitch, Boari flap, or ureteroneocystostomy. Urology. 2013;82(1):231–236. PMID 23735579
8. Groen VH, Lock MTWT, de Angst IB, et al. Psoas hitch procedure in 166 adult patients: The largest cohort study before the laparoscopic era. BJUI Compass. 2021;2(5):331–337. PMID 35474982