Skip to main content

Ureteral Trauma

Ureteral injuries are rare: the cited national trauma registry identified 582 among 22,706 GU injuries (about 2.6%), or approximately 3 per 10,000 trauma admissions.[1] 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 ureteral injuries, so imaging is driven by mechanism and trajectory rather than by urinalysis.[4] EAU gives a range of 50–75% for its presence and a strong recommendation to keep ureteral injury in mind in all abdominal penetrating trauma and in deceleration-type blunt trauma.[9]

Cross-Reference. Ureter-specific imaging protocols (CT delayed phase, RPG technique) are covered in detail in Imaging (Evaluation & Workup).

Epidemiology and Mechanism​

  • Penetrating trauma (ballistic > stab) is the predominant mechanism in adults[1]
  • Among external ureteral injuries, blunt mechanisms (including sudden deceleration) account for a reported 5–40%.[4] UPJ avulsion is the characteristic blunt pediatric pattern, attributed to the more mobile pediatric spine and less protective perirenal fat
  • Associated injuries are common: in the national registry, penetrating ureteral trauma involved small bowel in 46%, large bowel in 44%, and vascular structures in 38%; categories overlap.[1]
  • In one traumatic-injury series, 5/40 injuries (12.5%) were missed at initial laparotomy.[3] Delayed diagnosis increases morbidity[3]
  • Iatrogenic injury during pelvic surgery is a distinct population; one 103-patient series found delayed recognition in 20%, with more subsequent procedures and health-care use.[6] A review reported that laparoscopic gynecologic surgery accounted for 64% of iatrogenic ureteral injuries, versus 26% from general surgery and 11% from urologic procedures; in separate procedure-type data, intraoperative detection was 12.5% for laparoscopic procedures, 43.5% for open procedures, and 62.5% for endourologic procedures.[11] A 2015 review cited older reports of ureteral injury in 2.2% of hysterectomies and routine pelvic gynecologic procedures, up to 30% of radical hysterectomies, and up to 6% of laparoscopic hysterectomies.[11] In a California inpatient cohort of 223,872 hysterectomies (2007–2011), ureteral injury was diagnosed within one year in 1,753 patients (0.78%); 1,094 of these injuries (62.4%) were not recognized on the day of surgery.[25]
  • Prophylactic ureteral stenting can aid identification during complex pelvic surgery. A 46-study meta-analysis associated prophylactic stents with fewer gynecologic ureteral injuries (pooled OR 0.61; calculated number needed to stent, 224), with EAU noting selection bias among stented patients.[12][9] In complex gynecologic surgery, a 2024 meta-analysis of three randomized trials (n = 3,277) found no statistically significant injury reduction (RR 0.90, 95% CI 0.49–1.65).[26] In colorectal surgery, an 11-study observational meta-analysis (n = 71,784) found no significant injury reduction and more acute kidney injury with stents (1.7% versus 0.56%; OR 1.54, 95% CI 1.24–1.91).[27] Laparoscopic hysterectomy was associated with more injury than open surgery (pooled OR 2.12).[12][9]
  • Endoscopic stone extraction is a distinct iatrogenic mechanism: aggressive basket or forceps extraction of a large stone can avulse the ureter, described in case series and case reports. Reported reconstructive options include ureteroneocystostomy, ileal substitution and other repairs selected by defect length.[13] For endoscopic ureteral injury, AUA recommends a stent or nephrostomy when possible (Statement 13a; Recommendation, Grade C), and permits open repair if diversion is impossible or inadequate .[17] Its acute-trauma guidance advises against bowel interposition and renal autotransplantation in the acute setting.[17]

Imaging and Diagnosis​

CT with Delayed (Excretory) Phase​

AUA recommends contrast-enhanced CT with delayed images in stable patients with suspected ureteral injury (Statement 9a; Recommendation, Grade C); its discussion describes 10-minute delays and further delayed images if ureteral opacification remains inadequate.[17] The ACS guideline recommends selectively obtaining delayed images when renal or ureteral injury is suspected; it describes routine delayed images for patients with concern for renal injury as an alternative when on-table review of initial images is impractical.[4] Delayed images are traditionally taken 3–20 minutes after contrast injection, and about 10 minutes is reported as optimal for collecting-system injury:[4]

FindingSignificance
Contrast extravasation on delayed phaseDiagnostic of collecting system / ureteral injury
Periureteral fluid, retroperitoneal hematomaIndirect sign
Ipsilateral delayed or absent nephrogramSuggests UPJ avulsion or vascular compromise
Lack of ureteral opacification distal to injuryRaises concern for obstruction or disruption; inadequate timing/excretion can also prevent opacification

Ureteral Injury on Standard Trauma CT. A standard trauma CT (portal venous phase only) can miss ureteral injuries. If ureteral injury is suspected, explicitly request or add a delayed-phase acquisition (about 10 minutes). Do not rely on a single-shot IV pyelogram at laparotomy to exclude ureteral injury; only 40% of excretory urograms were diagnostic in the cited external-trauma series.[2][4] EAU likewise reports that one-shot IVP is negative in up to 60% of patients and names CT urography as the examination of choice when ureteral injury is suspected.[9]

Retrograde Pyelography (RPG)​

RPG is the most accurate imaging test when CT findings are equivocal. Urology performs it cystoscopically, and it shows the exact injury location, extent and degree of obstruction. It is indicated for:[4]

  • Equivocal CT findings
  • Operative planning before repair
  • Delayed-presentation injuries with uncertain level

Surgical drain fluid. When a drain is already in place after pelvic surgery, a spot drain-fluid creatinine above the serum creatinine is a described clue to urine leakage.[14] The injury still needs to be localized with CT or RPG.[14]

Intraoperative Detection​

AUA calls for direct ureteral inspection during laparotomy when injury is suspected and preoperative imaging was not obtained . Adjuncts include the following:[4][17]

  • Direct visual inspection of entire ureter
  • IV dye may assist inspection, but normal ureteral jet flow does not exclude ureteral injury after laparoscopic hysterectomy, including delayed thermal injury; check agent contraindications and the visualization-agent hub[17][24]
  • Direct injection of dye into the renal pelvis
  • Retrograde ureteral catheterization via cystotomy or cystoscopy

AAST Organ Injury Scale — Ureter​

GradeTypeDescription
IHematomaContusion or hematoma without devascularization
IILaceration<50% transection
IIILaceration>50% transection
IVLacerationComplete transection with <2 cm devascularization
VLacerationAvulsion with >2 cm devascularization

Advance one grade for bilateral injuries (up to grade III).[5]

Endoscopic Management​

Minor contusions (AAST grade I, without devascularization) can be managed with ureteral stent placement alone. Avoid endoscopic management when a contusion is severe or spans a long segment.[4] For a distal ureteral perforation recognized during endoscopic instrumentation, stent removal at approximately 4–6 weeks is a described practice; temporary Foley drainage to limit bladder reflux onto the stent is optional. Complete avulsion requires reconstruction; nephrostomy can provide initial drainage when immediate repair is infeasible.[14][17]

AAST Grade II Lacerations. For an acutely recognized Grade II laceration, assess tissue viability, leak and the ability to bridge the injury with a stent. EAU describes stent-supported immediate repair or urinary diversion for partial injury; the choice of formal repair depends on the injury and operative setting.[4][9] In one blunt-trauma series, 3 of 9 partial ureteral transections were observed, 4 were stented, and 2 underwent Heineke-Mikulicz repair; 8 of 9 had no hydronephrosis or obstruction on imaging at a median of 9 months across all treatments.[10] Observation or stenting is an option for selected partial injuries.[10]

AUA advises stenting or resection with primary repair for traumatic contusions at laparotomy, according to ureteral viability and the clinical situation .[17]

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.[4]

For delayed-presentation incomplete injuries, AUA recommends attempting retrograde stenting (Statement 11a; Recommendation, Grade C). If stenting fails or is impossible, place a nephrostomy with delayed repair as needed (Statement 11b; Recommendation, Grade C). Persistent leakage may require a periureteral drain or repair.[17]

Surgical Management​

Principles of Ureteral Repair​

AUA recommends repair of traumatic ureteral lacerations during laparotomy in stable patients (Statement 10a; Recommendation, Grade C).[17] Its proximal and distal repair guidance supports viable tissue, preserved blood supply, spatulation, a tension-free anastomosis and a stent (Statements 12a–12b). The following list also includes ACS technical practice:[4][17]

  1. Complete debridement of devitalized tissue to bleeding edges. As with high-velocity ballistic injury (above), thermal injury can compromise ureteral tissue beyond the visibly affected area; assess viability individually and debride back to healthy, bleeding tissue rather than assuming a fixed margin.[14]
  2. Preservation of periureteral adventitia (blood supply); balance mobilization against vascularity
  3. Spatulation of both ureteral ends (creates wider anastomosis, reduces stricture risk)
  4. Tension-free, watertight mucosa-to-mucosa anastomosis with fine absorbable suture
  5. Double-J ureteral stent across the repair
  6. Retroperitoneal closed-suction drain
  7. Isolation of the repair from adjacent structures with peritoneum or omentum (EAU lists this among its principles of repair)[9]

Repair Strategy by Injury Location​

Distal Ureter (Distal to Iliac Vessels)​

OptionIndicationSuccess Rate
UreteroneocystostomyRecommended for distal injuries whenever possible, and preferred when distal segment viability is in question. Refluxing or nonrefluxing, intravesical or extravesical techniques are all used; ACS calls the choice surgeon preference and notes that refluxing anastomoses are more common in trauma. Its cited 91–98% range combines pediatric reflux and adult Boari flap–psoas hitch stricture outcomes.[4][19][20]In Wenske’s 100 mixed-indication reimplantations (24 direct ureteroneocystostomies, 58 psoas hitches, 18 Boari flaps), hydronephrosis resolved in 81% at median 48.7 months; a direct-reimplantation or trauma-specific rate was not reported[7]
Psoas hitchWhen tension-free direct reimplantation is not possible, mobilize the bladder and fix it to the ipsilateral psoas tendon without entrapping the genitofemoral nerve.[8]At least 11/143 patients with postoperative imaging (8%) met the clinical-failure endpoint (radiographic obstruction or symptoms requiring additional surgery) at median 15-month follow-up in a 166-patient mixed-indication cohort[8]; EAU cites approximately 97% success from 181 mixed-indication psoas-hitch ureteroneocystostomies.[9][21]
Boari flapLong mid-to-lower defects beyond psoas hitch range. AUA permits a psoas hitch or Boari adjunct for tension-free acute repair when feasible[17]EAU describes Boari repair as time-consuming and unsuited to the acute setting; its 81–88% figure follows the Boari discussion, but the cited 100-patient series pools direct reimplantation, psoas hitch and Boari flap for mixed indications.[9][7]

AUA permits primary repair over a stent for selected distal injuries with viable tissue, favoring reimplantation when distal viability is doubtful (Statement 12b; Recommendation, Grade C).[17]

Proximal Ureter (Proximal to Iliac Vessels)​

OptionIndication
UreteroureterostomyPrimary spatulated anastomosis over stent for short-segment injuries; EAU states that defects shorter than 2–3 cm can usually be managed this way, with ureterocalicostomy considered when it is not feasible[9]
Heineke-Mikulicz conversionPartial transection at laparotomy — convert longitudinal tear to transverse repair over stent
Resection + primary repairHigh-velocity GSW with blast effect: resect devitalized segment, then primary anastomosis
UreteropyelostomyUPJ avulsion: anastomose proximal ureter into renal pelvis

For ureteral injuries proximal to the iliac vessels, AUA recommends primary repair with a ureteral stent across the repair when possible (Statement 12a; Recommendation, Grade C).[17]

Long Segment / Complex Defects (Deferred)​

  • Ileal ureter interposition. Usually deferred complex reconstruction; bowel preparation is not a universal prerequisite. EAU advises avoiding it with impaired renal function or known intestinal disease and following serum chemistry for hyperchloremic acidosis[9]
  • Transuretero-ureterostomy (TUU). Selected defects with a suitable healthy recipient ureter; consider the risk to both renal units. In a mixed benign/malignant 63-patient TUU series cited by EAU, 2/56 patients with follow-up imaging (3.6%, rounded to 4%) had radiographic anastomotic obstruction, and six patients (10.3%, about 10%) required intervention for obstruction or revision over mean 5.8-year follow-up[9][22]
  • Autotransplantation. Rarely required.[9][23] EAU also lists buccal mucosa ureteroplasty for long segments, especially after failed reconstruction; the cited 90% overall success is from 19 robotic repairs for revision UPJ obstruction or long/multifocal strictures (53% had prior failed reconstruction) at median 26-month follow-up.[9][23]

Damage Control Strategy​

AUA permits temporary drainage followed by delayed definitive repair in unstable patients , using ligation with nephrostomy or an externalized catheter secured to the proximal defect.[17] ACS describes additional temporizing options:[4][17]

OptionDescription
Cutaneous ureterostomyExteriorize proximal ureter through abdominal wall
Ureteral ligation + PCNLigate ureter; percutaneous nephrostomy placed in recovery
Intubated ureterostomyUreteral stent or small catheter secured to proximal end, externalized
Intraperitoneal drainageLast-resort temporary damage control when instability precludes diversion; suction via temporary abdominal closure and prompt reassessment

Definitive reconstruction is planned after resuscitation, ideally at a center with reconstructive urology expertise. Damage-control options for the kidney, bladder and urethra, and the timing of return, are collected on Damage Control in Genitourinary Trauma.

Venous Thromboembolism Prophylaxis​

Neither the ACS nor the EAU guideline gives a ureteral-injury-specific VTE recommendation. The EAU trauma guideline's general chapter notes trauma patients overall are at high DVT risk, favors compression stockings and low-molecular-weight heparin, and reports that strict bed rest after isolated renal trauma has fallen out of favor in patients able to mobilize.[9] Apply the individual risk-based approach on the VTE Prophylaxis hub — polytrauma patients undergoing laparotomy and reconstruction typically sit at moderate-to-high baseline risk.

Delayed Diagnosis Management​

For patients diagnosed late with no planned reoperation:[4] EAU strongly recommends nephrostomy or double-J stent diversion for iatrogenic injuries diagnosed late, and immediate repair of iatrogenic injuries recognized during surgery.[9]

  • Prioritize retrograde ureteral stenting for partial injuries
  • After failed retrograde stenting, place a nephrostomy for drainage; antegrade stenting through the nephrostomy may treat a delayed injury, and EAU also describes combined antegrade–retrograde (rendezvous) stent placement as another route.[9]
  • Assess healing with antegrade nephrostography before tube removal. An interval of about 6–8 weeks is common practice; neither the ACS nor the EAU guideline specifies a timing
  • Plan formal surgical reconstruction if ongoing leak, urinoma, or stricture confirmed

After definitive reconstruction, arrange clinical and upper-tract imaging follow-up to detect recurrent obstruction, including in patients without symptoms. Ultrasound, CT urography or functional renal imaging may be used according to the repair and clinical question; no standardized surveillance schedule exists.[18]

One described approach to timing: when endoscopic management is inadequate, attempt early surgical repair if the injury is recognized within the first postoperative week and inflammation is limited; beyond that window, divert or stent while inflammation subsides and plan reconstruction after about 6 weeks, with earlier surgery still reasonable for uncontrolled infection or an undrainable collection. The textbook describes a 7-day timing framework; a retrospective series of 81 iatrogenic injuries in 78 patients after nonurological surgery found no significant differences in operative time or postoperative complications among immediate, within-1-month and 3-month repair groups; its authors considered repair within a month for patients without serious urinary infection who could tolerate surgery.[15][16]

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. doi:10.1016/j.amjsurg.2009.11.001. PMID 20359576

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. doi:10.1097/01.ju.0000087841.98141.85. PMID 14501727

3. Kunkle DA, Kansas BT, Pathak A, Goldberg AJ, Mydlo JH. Delayed diagnosis of traumatic ureteral injuries. J Urol. 2006;176(6):2503–2507. doi:10.1016/j.juro.2006.08.003. PMID 17085143

4. American College of Surgeons Trauma Quality Programs. ACS TQP Best Practices Guidelines: Management of Genitourinary Injuries. Chicago, IL; August 2025. ACS guideline PDF

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. doi:10.1097/00005373-199209000-00001. PMID 1404499

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. doi:10.5489/cuaj.7271. PMID 34464249

7. Wenske S, Olsson CA, Benson MC. Outcomes of distal ureteral reconstruction through reimplantation with psoas hitch, Boari flap, or ureteroneocystostomy for benign or malignant ureteral obstruction or injury. Urology. 2013;82(1):231–236. doi:10.1016/j.urology.2013.02.046. PMID 23642933

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. doi:10.1002/bco2.85. PMID 35474876

9. Waterloos M, Campos-Juanatey F, Hallscheidt P, et al. EAU Guidelines on Urological Trauma. Limited update, March 2026. Sections 3.3.5 (thromboprophylaxis and bed rest) and 4.2.1–4.2.5 (ureteral trauma). Guideline

10. Orcutt D, Lee Z, Maldonado R, et al. Ureteral Injuries Secondary to Blunt Abdominal Trauma: A 15-Year Review of Presentation, Management, and Outcomes at a Level 1 Trauma Center. Urology. 2022;164:248–253. doi:10.1016/j.urology.2021.11.051

11. Esparaz AM, Pearl JA, Herts BR, LeBlanc J, Kapoor B. Iatrogenic urinary tract injuries: etiology, diagnosis, and management. Semin Intervent Radiol. 2015;32(2):195-208. doi:10.1055/s-0035-1549378

12. Yanagisawa T, Mori K, Quhal F, et al. Iatrogenic ureteric injury during abdominal or pelvic surgery: a meta-analysis. BJU Int. 2023;131(5):540-552. doi:10.1111/bju.15913

13. Sevinc C, Balaban M, Ozkaptan O, Yucetas U, Karadeniz T. The management of total avulsion of the ureter from both ends: our experience and literature review. Arch Ital Urol Androl. 2016;88(2):97-100. doi:10.4081/aiua.2016.2.97

14. Attalla K, Sfakianos JP. Injury Repair of Pelvic Ureter. In: Hoffman M, Hull TL, Bochner BH, eds. Major Complications of Female Pelvic Surgery: A Multidisciplinary Approach. Springer; 2025:167–173. doi:10.1007/978-3-031-66772-5_17

15. Ghavamian R, Chalouhy C. Complications of Urologic Surgery. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Elsevier; 2025:283–306.

16. Li J, Chen Z, Zhu Q, Zhao Y, Wang H, Liu W. Early repair of pelvic and abdominal nonurological surgery-induced iatrogenic ureteral injuries in three distinct waiting-for-repair time periods. Am Surg. 2012;78(11):1270-1275. doi:10.1177/000313481207801137. PMID 23089447

17. Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408. Full guideline, published 2014; amended April 2017 and August 2020.

18. Rosenfeld J, Boehm D, Raikar A, et al. "A review of complications after ureteral reconstruction." Asian J Urol. 2024;11(3):348–356. doi:10.1016/j.ajur.2024.02.007

19. Bustangi N, et al. "Extravesical Ureteral Reimplantation Following Lich-Gregoir Technique for the Correction of Vesico-Ureteral Reflux Retrospective Comparative Study Open vs. Laparoscopy." Front Pediatr. 2018;6:388. doi:10.3389/fped.2018.00388

20. Ding G, et al. "Experience managing distal ureteral strictures with Boari flap-psoas hitch and comparison of open and laparoscopic procedures." Transl Androl Urol. 2021;10(1):56–65. doi:10.21037/tau-20-789

21. Riedmiller H, et al. "Psoas-hitch ureteroneocystostomy: experience with 181 cases." Eur Urol. 1984;10(3):145–150. doi:10.1159/000463777

22. Iwaszko MR, et al. "Transureteroureterostomy revisited: long-term surgical outcomes." J Urol. 2010;183(3):1055–1059. doi:10.1016/j.juro.2009.11.031

23. Zhao LC, et al. "Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience." Eur Urol. 2018;73(3):419–426. doi:10.1016/j.eururo.2017.11.015

24. Kantarcı S, Karabulut A, Dağlı U, et al. "Role of postoperative renal ultrasound in identifying ureteral injury despite normal intraoperative jet flow." Turk J Obstet Gynecol. 2026;23(1):40–46. doi:10.4274/tjod.galenos.2026.32784

25. Blackwell RH, Kirshenbaum EJ, Shah AS, et al. "Complications of recognized and unrecognized iatrogenic ureteral injury at time of hysterectomy: A population based analysis." J Urol. 2018;199(6):1540–1545. doi:10.1016/j.juro.2017.12.067

26. 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

27. Pompeu BF, Ribeiro CT de A, Pasqualotto E, et al. "Prophylactic ureteral stent in colorectal surgery: a meta-analysis and systematic review." Int Urol Nephrol. 2025;57(2):301–312. doi:10.1007/s11255-024-04224-0