TREATMENT

In patients who are too unstable to undergo ureteral reconstruction, a “damage control” approach is appropriate. Two common strategies include bringing the ureter to the abdominal wall (temporary cutaneous ureterostomy) or ureteral ligation followed by percutaneous nephrostomy. Definitive reconstruction is delayed until the patient stabilizes.

In stable patients, injuries should be explored and repaired.

Ureteral contusions can lead to strictures if untreated and should thus be stented and drained. If the contusion is severe, the ureter should be segmentally resected; debrided until a bleeding edge is reached; reanastomosed tension-free over a stent; and drained.

Ruptures of the upper and midureter can be repaired with primary ureteroureterostomy, an end-to-end anastomosis over a stent. Ruptures of the distal ureter are repaired by reimplanting the ureter into the bladder (ureteroneocystostomy). If there is extensive loss of the distal ureter, a section of the bladder is sewn to the ipsilateral psoas minor tendon (psoas hitch) to help bridge the gap. The ureter is then reimplanted into the bladder. If the bladder is too small or noncompliant for stretching, a transureteroureterostomy can be performed, in which the injured ureter is brought across the midline and sewn to the side of the contralateral ureter. This procedure is also useful when there are associated rectal, pelvic, or vascular injuries.

Complex reconstructions of extensive ureteral injuries may be performed on an elective basis but are not appropriate for acute management (see Plate 10-36). Such procedures include ileal interposition, in which the small bowel is used as a ureteral replacement; Boari flap, in which a section of the bladder is reconstructed as a tube; and autotransplantation, in which the kidney is relocated to the ipsilateral pelvis.