Committee VII
Upper Urinary Tract Trauma
Prof. Mohamed El Gammal, MD Professor of Urology, Kasr El-Ainy Medical School, Cairo University
Prof. Hany Yassa, FRCS Professor of Urology, Military Academy
Prof. Ahmed Fahim, MD Professor of Urology, Faculty of medicine, Al Azhar University
Hany ElFayoumy, MD, MRCS, FEBU Professor of Urology, Kasr El-Ainy Medical School, Cairo University
Contents
VII.1 List of Abbreviations
- AAST - American Association for the Surgery of Trauma
- AUA - American Urological Association
- CT - Computed Tomography
- EUA - European Urologic Association
- IVU - Intra-venous Urography
- MOH - Egyptian Ministry of Health
- PUJ - Pelvi-ureteric Junction
- US Ultrasound
VII.2 Abstract.
VII.2.1 Introduction.
VII.2.2 Methodology.
1. Two guidelines (including their latest updates), namely European Urological Association [EUA], American Urologic Association [AUA]
2. Review of several guides, position statements, meta-analyses and leading institutional protocols.
3. Relevant Egyptian publications.
4. A panel of 4 Urology trauma surgeons representing most trauma referral centers in Egypt
VII.2.3 Results.
VII.2.4 Conclusions.
VII.3 Guidelines
The kidney is the most commonly injured urologic organ from external trauma. Renal trauma can be classified into blunt, sharp, and iatrogenic.
VII.3.1 Recommendations of trauma initial evaluation
We strongly recommend taking detailed history including age, type of trauma, history of pre-existing renal disease, known solitary kidney, known pre-existing renal abnormality.
We strongly recommend vital signs measurements, trauma assessment regarding airway, breathing, circulation, deformities, and exposure of other body parts.
We recommend physical examination to assess the injury.
We strongly recommend routine urine analysis, blood tests including hematocrit value, and renal function tests.
VII.3.2 Recommendations of radiographic assessment
• We strongly recommend multi-phase CT scanning in trauma patients with
o Visible hematuria
o Non-visible hematuria and one episode of hypotension o History of rapid deceleration injury and/or significant associated injuries
o penetrating trauma
o Clinical signs suggesting renal trauma e.g. flank pain, abrasions, fractured ribs, abdominal distension and/or a mass and tenderness. (1)
• Advantages of CT outweigh the risks, which include contrast related complications, radiation exposure, and the dangers of transporting a patient away from the resuscitation environment. (2)
• Standard intravenous pyelogram may be used in rare cases where CT is not available, but is inferior(2)
• Ultrasound may be used in children, although CT is preferred. (2)
• Ultrasound is not routinely used for assessment of solid organ injury as it is insensitive, operator dependent, does not define the injury well, and is inferior to CT. It is an option for follow-up (1)
• An intraoperative one-shot IVP may be used to confirm that a contralateral functioning kidney is present in rare cases where the patient is taken to the operating room without a CT scan. (2)
• MRI has diagnostic accuracy similar to CT. However, its logistics are not practical in the trauma setting. (1)
• Radionuclide scans has no role in the immediate evaluation of trauma patient.
VII.3.3 Renal Injury Grading System
Based on contrast CT findings; renal injuries can be graded according to the AAST grading scale. The scaling system is validated, predicts morbidity and the need for intervention (3-4)
Table VII:1 Renal injury grading system
Grade*
Description of injury
1 Contusion or non-expanding subcapsular haematoma
No laceration
2 Non-expanding peri-renal haematoma
Cortical laceration < 1 cm deep without extravasation
3 Cortical laceration > 1 cm deep (not reaching collecting system) without urinary extravasation
4 Parenchymal laceration: through corticomedullary junction into collecting system
Or
Vascular: segmental renal artery or vein injury with contained hematoma, or partial vessel laceration, or vessel thrombosis
5 Parenchymal: shattered kidney Or Vascular: renal pedicle or avulsion
*Advance one grade for bilateral injuries up to grade 3
VII.3.4 Recommendations on management of renal trauma patients:
• We strongly recommend that haemodynamic stability is the most important parameter for selecting patients to either non-surgical or surgical management
• A haemodynamically stable patient is one whose vital signs are stable and not consistent with shock with stable serial hematocrit values over time (2)
• The management plan depends upon proper classification of injury using contrast CT whenever possible, otherwise an IVU is an alternative, and ultrasound is a weak imaging tool.
• In haemodynamically stable patient with G 1- 3 injuries the management is usually conservative with bed rest, blood transfusion, and ICU admission for monitoring and resuscitation if necessary. (2)
• In hemodynamically stable patients with G4-5 injury management can also be conservative except for bilateral artery injuries or injuries involving a solitary functioning kidney. (5) If renal pelvis avulsion or proximal ureteral avulsion injury is present (suggested by the medial extravasation of dye and absence of contrast in the distal ureter); drainage of the kidney using nephrostomy tube or DJ stent may be promptly required to avoid urinoma formation. (6)
• Selective angio-emblization is effective (when available) in high grade renal trauma with high success rates & can be used in severe polytrauma to embolize the main renal artery. (1)
• When conservative management has been chosen according to haemodynamic stability and the grade of renal trauma, repeat imaging should be performed after 2-4 days after the injury.
• If a urinoma was found in follow up imaging; drainage of the kidney by nephrostomy/DJ stenting should be done according to the clinical situation along with placement of a percutaneous drain.
• Surgical treatment:
o Indications for exploration include:
o Non or transient response to initial fluid resuscitation
o Grade 5 vascular injury
o The need to explore for associated abdominal injuries
o Expanding or pulsatile peri-renal haematoma at laparotomy
o Operative findings & reconstruction:
o Access:
o Transperitoneal approach is recommended in most series (7-8)
o Access to the renal pedicle is obtained by making an incision in the posterior peritoneum over the aorta, just medial to the inferior mesenteric vein, then placing a vascular clamp on the renal hilum. (9)
o Stable haematomas detected during exploration for associated injuries should not be opened. Central or expanding haematomas indicate injuries of the renal pedicle, aorta, or vena cava and are potentially life-threatening and require further exploration. (10)
o Renorrhaphy:
Repair of injured renal parenchyma is the most commonly performed reconstructive technique
o Partial nephrectomy:
Removal of all non-viable renal tissues with watertight closure of the collecting system is strongly recommended. (European Urology Guidelines, 2020)
o When available, the use of hemostatic agents and sealants is helpful. (11)
o Vascular repair:
Should be attempted in solitary kidney or bilateral injuries, results are rarely effective (12-13)
o Dissection or bleeding of the main renal artery can be managed with a vascular stent (1)
o Nephrectomy:
Can be lifesaving in vascular injuries
Placement of a drain is a must after corrective surgery or nephrectomy.
• Follow up
o Follow up is strongly recommended after renal trauma to assess recovery of renal function and potential complications.
o Physical examination, blood pressure measurements, urinalysis, serum creatinine, and imaging studies including ultrasound, CT scans, and nuclear scans.
VII.3.5 Special considerations in pediatric age group:
• Children are more prone than adults to renal injury after blunt trauma. A child’s kidney is larger in relation to the rest of the body with less per-renal fat, weaker abdominal muscles, and finally less ossified compressible thoracic cage. (14)
• Blood pressure cannot be a reliable measure of the renal involvement in pediatric trauma as children can maintain their blood pressure despite hypovolemia unlike adults. (15)
• Use imaging in all children who have sustained a blunt or penetrating trauma with any level of hematuria, especially when the history reveals a deceleration trauma, direct flank trauma or a fall from a height. (1)
• Use rapid spiral computed tomography with delayed images scanning for diagnostic and staging purposes. (1)
• Manage most injured kidneys conservatively. (1)
• Offer surgical intervention in case of hemodynamic instability and a Grade V renal injury.(1)
VII.3.6 Complications of renal trauma:
• Early:
o Bleeding, infection, sepsis, perinephric abcess, urinary fistula, urinary extravasation and urinoma formation.
• Delayed:
o Delayed bleeding, hydronephrosis, stone formation, chronic pyelonephritis, hypertention, AVF, and pseudoaneurysm.
VII.3.7 Recommendations of medico-legal issues of renal trauma:
• We strongly recommend written documentation of the condition the patient was first assessed and the first aid, resuscitation measured performed, also keeping records of all investigations done during the evaluation of the patient. (1D)
• We strongly recommend detailed counselling with the patient and relatives whenever applicable regarding options of management and documenting the counselling session. (1D)
• We strongly recommend a fully informed consent whenever applicable from patient or relatives before deciding on a specific line of management. (1D)
Table VII:2 Recommendation for Management of Renal Trauma
Recommendations
Strength rating
1. Assess haemodynamic stability upon admission. Strong
2. Test for haematuria in a patient with suspected renal injury Strong
3. Perform a multiphase computed tomography scan in vitally stable trauma patients with:
• Visible haematuria;
• Non-visible haematuria and one episode of hypotension;
• A history of rapid deceleration injury and/or significant associated
injuries;
• penetrating trauma;
• Clinical signs suggesting renal trauma e.g. flank pain, abrasions, fractured ribs, abdominal distension and/or a mass and tenderness. Strong
4. Manage stable patients with blunt renal trauma non-operatively with close monitoring and re-imaging as required Strong
5. Use selective angioembolisation for active renal bleeding if there are no other indications for immediate surgical exploration. Strong
6. Proceed with renal exploration in the presence of:
• Persistent haemodynamic instability;
• Grade 5 vascular or penetrating injury;
• Expanding or pulsatile peri-renal haematoma. Strong
7. Repeat imaging in high-grade injuries and in cases of fever, worsening flank pain, or falling haematocrit. Strong
8. Follow-up approximately three months after major renal injury with:
• Physical examination;
• Urinalysis;
• Individualised radiological investigation including nuclear
scintigraphy;
• Blood pressure measurement;
• Renal function tests. Weak
9. Measure blood pressure annually to diagnose renovascular hypertension. Strong
VII.4 Ureteral Trauma
Ureteral injuries represent 1-2.5% of all urinary tract injuries with those resulting from iatrogenic causes being far more common than accidents or external violence causes. Whereas the lower ureters are more involved in the earlier, the upper segments’ injuries are more encountered in the latter. (16-18)
VII.4.1 Iatrogenic ureteral trauma
VII.4.1.1 Incidence
Traumatic injuries to the ureter during diagnostic or therapeutic maneuvers represent about 80% of all ureteral injuries. (19) The incidence of such injuries during different interventions is summarized in table 1 (20-25)
Ureteral injuries have also been reported during laparoscopic and robotic interventions, minimally invasive hysterectomy, vaginal mesh surgeries, flexible uretero-renoscopy (URS), laser lithotripsy and retrieval of neglected double J stents
VII.4.1.2 Predisposing factors, grading and pathogenesis
Most of the iatrogenic ureteral injuries occur when they are least expected and the possibility of surgeons’ negligence or overconfidence frequently cannot be ruled out. However, some predisposing factors could be cited including for instance prior surgery or irradiation, advanced malignancy, anatomical abnormalities, inflammations, colonic diverticulitis and endometriosis. (26-28)
Grading of ureteral trauma suggested by the American association for the surgery of trauma (29) has not gained wide acceptance as the case of renal trauma grading but it might help in academic reporting.
Table VII:3 Grading System of Ureteral Trauma
Grade
Type
Description
I
Haematoma
Contusion or Haematoma without devascularization
II Laceration < 50% transection
III Laceration > 50% transection
IV Laceration Complete transection with < 2cm devascularization
V Laceration Avulsion with > 2cm devascularization
Advance one grade for bilateral insults up to grade III
• The mechanism of iatrogenic ureteral injuries during open or laparoscopic interventions includes laceration, ligation or kinking, crushing, partial or complete transection, thermal injury and ischemic devascularization injuries.
• On the other hand, endoscopic manipulations might entail mucosal abrasions, submucosal false passages, ureteral perforation, resection, intussusception, avulsion and thermal or laser injuries.
VII.4.2 Ureteral injuries during endoscopic manipulations:
VII.4.2.1 Intra-operative diagnosis
o Ureteral injuries in such settings are frequently diagnosed by direct vision as a mucosal laceration, tear or complete perforation with peri-ureteral fat evident in the field.
o A retrograde ureterogram is quite conclusive when it reveals contrast extravasation into the retroperitoneum. (Brandes S, 2004) This mandates the availability of fluoroscopy during all endoscopic manipulations involving the ureter. Any impression apart from free contrast flow up the ureter should raise suspicions because a false passage might allow contrast flow in a sleeve fashion in the ureteral sub-adventitia mimicking a normal ureter and deceiving the novice.
o The visualization of an intussuscepted part of the ureter into the bladder or the urethra is diagnostic for ureteral avulsion.
o Failure to diagnose an injured ureter during endoscopic manipulations may result in more extensive sequelae and complications. (Wu HH, 2006) (Lucarelli G, 2013) The manifestations, diagnosis and treatment of delayed presentation are described in section (4.4).
VII.4.2.2 Prevention:
Sticking to the basic principles of endoscopic handling of the ureter minimizes the risk of ureteral injury. The following list summarizes most of these principles:
o Preliminary passage of guide wires
o The use of slippery guide wires when necessary
o Fluoroscopic guidance
o Proper dilation of the intramural ureter
o The use of small caliber ureteroscopes
o Maintaining a continuous irrigation
o Hydraulic dis-impaction of stones
o Under-vision introduction and withdrawal of ureteroscopes
o Proper fragmentation of sizable stones
o Judicious use of lithotripters and keeping them always under vision o Judicious use of stone baskets and extractors
o The use of ureteral access sheaths when repeated endoscope introduction is anticipated
VII.4.2.3 Treatment:
o Mild mucosal lacerations usually require no further treatment.
o Submucosal false passages should be managed by temporary ureteric stent/DJ.
o Perforations should be managed by temporary double J stenting (4-6 weeks). Thermal injuries may require longer term stenting (6-8 weeks).
o Later follow up by intravenous urography or retrograde pyelography should be taken into account to watch for the development of ureteral strictures. (31)
o Ureteral intussusception and/or avulsion should be surgically explored and ureteral gaps bridged as will be explained in (4.6)
VII.4.3 Ureteral injuries during open or laparoscopic surgeries
VII.4.3.1 Diagnosis:
o Often the urologist is consulted in a case without the leisure of previous knowledge of the patient’s history or prior evaluation.
o A quick assessment of the available imaging studies can be informative about the preoperative status.
o Proper exposure of the suspected injured segment is usually the first advisable step.
o Ligatures might be cut only if they will not jeopardize hemostasis.
o If such an exposure is not feasible, the advisable options include:
o I.V. injection of indigo carmine and watching for the extravasating dye
o Cystoscopy and retrograde injection of indigo carmine or passage of a guide wire or a ureteric catheter into the involved ureter. Gentle manipulations are mandatory to avoid aggravating the injury.
o Intra-operative retrograde ureterography under fluoroscopy
o If none of the above is feasible, a small longitudinal ureterotomy may be performed through which a well lubricated ureteric catheter, a small caliber Nelaton catheter or a guide wire may be gently passed through the suspected injured site.
VII.4.3.2 Prevention:
o It is advisable in complex surgeries in the vicinity of the ureter to have the ureters identified and secured away from clamps and ligatures.
o Mass cauterization, clamping and ligation should be strictly avoided.
o The possibility of having duplex systems should be put in mind during assessment of the available imaging studies prior to ureteric surgeries.
o The preliminary placement of ureteral stents prior to complex pelvic surgery has been debated whether it will guard against injuries or it will just facilitate intra-operative identification of the injury. (23, 32-33) However, the committee feels that prior stenting might facilitate identification of the ureter during surgery in patients with predisposing factors (prior surgery or irradiation, advanced malignancy, anatomical abnormalities, inflammations, colonic diverticulitis and endometriosis)
VII.4.3.3 Treatment:
o Ureters mildly involved in sutures or ligatures may be managed by de-ligation and temporary ureteral stenting.
o Partial tears may be repaired with stenting.
o More severe injuries including crush injuries, thermal injuries and transection warrant resection of the involved segment and ureteral re-anastomosis or resorting to one of the gap-bridging solutions according to the level of the injury (section 4.6).
o If the intra-operative circumstances do not permit proper ureteral reconstruction, a damage-control policy may be resorted to: proximal urinary diversion by a nephrostomy tube and ureteral ligation as distal as the injury would allow with a deferred plan for re-construction. (34)
o If nephrostomy tube fixation is not feasible a ureteric catheter may be exteriorized to drain the involved ureter.
VII.4.4 Iatrogenic ureteral injuries that passes undiagnosed intraoperatively:
VII.4.4.1 Diagnosis:
o Ureteral ligation or intussusception injuries inflicted during surgical or endoscopic procedures and not identified intra-operatively may pass silently and stay unrecognized only to be diagnosed accidently later on or even not at all.
o Otherwise, patients may present in the post-operative period similar to transection and perforation injuries with one or more of the following:
o Fever and sepsis
o Flank pain
o Abdominal pains due to retroperitoneal urinoma or intraperitoneal collection
o Anuria (in bilateral insults or in cases with jeopardized contralateral unit)
o Urine leakage from the vagina, the rectum, the abdominal wound or the fixed drain.
o Pneumaturia or fecaluria
o Ischemic and thermal injuries frequently manifest later than transection injuries. A high level of suspicion should be kept in vague situations.
o The estimation of the creatinine concentration in the leaking fluid clarifies the nature of the fluid whether it is serum, lymph or urine; being almost ten-times the serum level in the latter situation.
o Abdominal ultrasonography is usually the initial diagnostic tool that should be reenforced by contrast-enhanced abdomino-pelvic CT to identify the site of extravasation, the intra-abdominal collection and the presence of back pressure. Absence of the latter should not rule out ureteral trauma because acute complete ureteral ligation or crushing may result in acute renal shut down with negligible or even no pelvi-caliceal dilatation.
o Renal duplex studies with measurement of the arterial resistive index or renal radionuclide studies may be resorted-to in order to settle the diagnosis in such circumstances. (35-36)
o The sensitivity of IVU remains below that of CT in the diagnostic algorithm as it might miss up to 60% of the cases. (19,26)
o In doubtful cases, retrograde (or antegrade) uretero-pyelography should be performed to confirm the diagnosis.
VII.4.4.2 Treatment:
o Cases diagnosed within one week of the injury without associated urinomas or infection may withstand an accelerated approach including trial for endoscopic stenting, or accelerated surgical reconstruction. (26)
o Later diagnosis in the context of a mild injury, retro- or antegrade ureteral stenting may be tried. However, the success rates are quite limited. (37,38) Otherwise, US- or CTguided percutaneous drainage of the urine collection and fixation of a nephrostomy tube for urine diversion are the most widely accepted approaches. A period of 3-6 months has been advocated to wait for re-assessment and surgical correction accordingly.
VII.4.5 Broad principles for reconstruction of ureteral injuries:
o Debridement of necrotic tissue
o Avoid de-sheathing
o Spatulation of ureteral ends
o Watertight mucosa-to-mucosa anastomosis with absorbable sutures
o Tension-free anastomosis
o Internal stenting o External drainage
o Isolation of injury with peritoneum or omentum
VII.4.6 Methods of bridging ureteral gaps:
VII.4.6.1 Lower or Middle ureter
o Uretero-neocystostomy (non-refluxing or refluxing techniques)
o Bladder psoas hitch
o Bladder Boari flap
VII.4.6.2 Upper or Middle ureter
o Renal mobilization
o Trans-uretero-ureterostomy
o Pelvi-ureteric re-anastomosis
o Uretero-calicostomy
VII.4.6.3 Extensive segments
o Ileal ureter replacement
o Renal auto-transplantation
o Buccal mucosal grafts (limited experience)
VII.4.7 Non-Iatrogenic ureteral trauma
Ureteral injury in external violence trauma is a rare entity. Their small size, their flexibility in the horizontal plane and their protection by surrounding bone, muscles and fat render them partially safe.
Ureteral injuries may ensue as a result of rapid deceleration trauma with subsequent avulsion at the level of the PUJ or penetrating injuries due to stab wounds, fire arm or blast injuries.
High velocity bullet injuries from gun rifles are of particular interest due to the cavitation wave they induce resulting in a wider field of impact than that expected from the bullet trajectory per se.
The majority of penetrating ureteral injuries are associated with other organ injuries.
VII.4.7.1 Diagnosis and treatment in the acute stage:
VII.3.1 Recommendations of trauma initial evaluation
We strongly recommend vital signs measurements, trauma assessment regarding airway, breathing, circulation, deformities, and exposure of other body parts.
We recommend physical examination to assess the injury.
We strongly recommend routine urine analysis, blood tests including hematocrit value, and renal function tests.
VII.3.2 Recommendations of radiographic assessment
o Visible hematuria
o Non-visible hematuria and one episode of hypotension o History of rapid deceleration injury and/or significant associated injuries
o penetrating trauma
o Clinical signs suggesting renal trauma e.g. flank pain, abrasions, fractured ribs, abdominal distension and/or a mass and tenderness. (1)
• Advantages of CT outweigh the risks, which include contrast related complications, radiation exposure, and the dangers of transporting a patient away from the resuscitation environment. (2)
• Standard intravenous pyelogram may be used in rare cases where CT is not available, but is inferior(2)
• Ultrasound may be used in children, although CT is preferred. (2)
• Ultrasound is not routinely used for assessment of solid organ injury as it is insensitive, operator dependent, does not define the injury well, and is inferior to CT. It is an option for follow-up (1)
• An intraoperative one-shot IVP may be used to confirm that a contralateral functioning kidney is present in rare cases where the patient is taken to the operating room without a CT scan. (2)
• MRI has diagnostic accuracy similar to CT. However, its logistics are not practical in the trauma setting. (1)
• Radionuclide scans has no role in the immediate evaluation of trauma patient.
VII.3.3 Renal Injury Grading System
Grade* |
Description of injury |
|---|---|
No laceration |
|
Cortical laceration < 1 cm deep without extravasation |
|
Or Vascular: segmental renal artery or vein injury with contained hematoma, or partial vessel laceration, or vessel thrombosis |
|
VII.3.4 Recommendations on management of renal trauma patients:
• We strongly recommend that haemodynamic stability is the most important parameter for selecting patients to either non-surgical or surgical management
• A haemodynamically stable patient is one whose vital signs are stable and not consistent with shock with stable serial hematocrit values over time (2)
• The management plan depends upon proper classification of injury using contrast CT whenever possible, otherwise an IVU is an alternative, and ultrasound is a weak imaging tool.
• In haemodynamically stable patient with G 1- 3 injuries the management is usually conservative with bed rest, blood transfusion, and ICU admission for monitoring and resuscitation if necessary. (2)
• In hemodynamically stable patients with G4-5 injury management can also be conservative except for bilateral artery injuries or injuries involving a solitary functioning kidney. (5) If renal pelvis avulsion or proximal ureteral avulsion injury is present (suggested by the medial extravasation of dye and absence of contrast in the distal ureter); drainage of the kidney using nephrostomy tube or DJ stent may be promptly required to avoid urinoma formation. (6)
• Selective angio-emblization is effective (when available) in high grade renal trauma with high success rates & can be used in severe polytrauma to embolize the main renal artery. (1)
• When conservative management has been chosen according to haemodynamic stability and the grade of renal trauma, repeat imaging should be performed after 2-4 days after the injury.
• If a urinoma was found in follow up imaging; drainage of the kidney by nephrostomy/DJ stenting should be done according to the clinical situation along with placement of a percutaneous drain.
• Surgical treatment:
o Indications for exploration include:
o Non or transient response to initial fluid resuscitation
o Grade 5 vascular injury
o The need to explore for associated abdominal injuries
o Expanding or pulsatile peri-renal haematoma at laparotomy
o Operative findings & reconstruction:
o Access:
o Transperitoneal approach is recommended in most series (7-8)
o Access to the renal pedicle is obtained by making an incision in the posterior peritoneum over the aorta, just medial to the inferior mesenteric vein, then placing a vascular clamp on the renal hilum. (9)
o Stable haematomas detected during exploration for associated injuries should not be opened. Central or expanding haematomas indicate injuries of the renal pedicle, aorta, or vena cava and are potentially life-threatening and require further exploration. (10)
o Renorrhaphy:
Repair of injured renal parenchyma is the most commonly performed reconstructive technique
o Partial nephrectomy:
Removal of all non-viable renal tissues with watertight closure of the collecting system is strongly recommended. (European Urology Guidelines, 2020)
o When available, the use of hemostatic agents and sealants is helpful. (11)
o Vascular repair:
Should be attempted in solitary kidney or bilateral injuries, results are rarely effective (12-13)
o Dissection or bleeding of the main renal artery can be managed with a vascular stent (1)
o Nephrectomy:
Can be lifesaving in vascular injuries
Placement of a drain is a must after corrective surgery or nephrectomy.
• Follow up
o Follow up is strongly recommended after renal trauma to assess recovery of renal function and potential complications.
o Physical examination, blood pressure measurements, urinalysis, serum creatinine, and imaging studies including ultrasound, CT scans, and nuclear scans.
VII.3.5 Special considerations in pediatric age group:
• Children are more prone than adults to renal injury after blunt trauma. A child’s kidney is larger in relation to the rest of the body with less per-renal fat, weaker abdominal muscles, and finally less ossified compressible thoracic cage. (14)
• Blood pressure cannot be a reliable measure of the renal involvement in pediatric trauma as children can maintain their blood pressure despite hypovolemia unlike adults. (15)
• Use imaging in all children who have sustained a blunt or penetrating trauma with any level of hematuria, especially when the history reveals a deceleration trauma, direct flank trauma or a fall from a height. (1)
• Use rapid spiral computed tomography with delayed images scanning for diagnostic and staging purposes. (1)
• Manage most injured kidneys conservatively. (1)
• Offer surgical intervention in case of hemodynamic instability and a Grade V renal injury.(1)
VII.3.6 Complications of renal trauma:
• Early:
o Bleeding, infection, sepsis, perinephric abcess, urinary fistula, urinary extravasation and urinoma formation.
• Delayed:
o Delayed bleeding, hydronephrosis, stone formation, chronic pyelonephritis, hypertention, AVF, and pseudoaneurysm.
VII.3.7 Recommendations of medico-legal issues of renal trauma:
• We strongly recommend detailed counselling with the patient and relatives whenever applicable regarding options of management and documenting the counselling session. (1D)
• We strongly recommend a fully informed consent whenever applicable from patient or relatives before deciding on a specific line of management. (1D)
Recommendations |
Strength rating |
|---|---|
• Visible haematuria; • Non-visible haematuria and one episode of hypotension; • A history of rapid deceleration injury and/or significant associated injuries; • penetrating trauma; • Clinical signs suggesting renal trauma e.g. flank pain, abrasions, fractured ribs, abdominal distension and/or a mass and tenderness. |
|
• Persistent haemodynamic instability; • Grade 5 vascular or penetrating injury; • Expanding or pulsatile peri-renal haematoma. |
|
• Physical examination; • Urinalysis; • Individualised radiological investigation including nuclear scintigraphy; • Blood pressure measurement; • Renal function tests. |
|
VII.4 Ureteral Trauma
VII.4.1 Iatrogenic ureteral trauma
VII.4.1.1 Incidence
Traumatic injuries to the ureter during diagnostic or therapeutic maneuvers represent about 80% of all ureteral injuries. (19) The incidence of such injuries during different interventions is summarized in table 1 (20-25)
Ureteral injuries have also been reported during laparoscopic and robotic interventions, minimally invasive hysterectomy, vaginal mesh surgeries, flexible uretero-renoscopy (URS), laser lithotripsy and retrieval of neglected double J stents
VII.4.1.2 Predisposing factors, grading and pathogenesis
Ureteral injuries have also been reported during laparoscopic and robotic interventions, minimally invasive hysterectomy, vaginal mesh surgeries, flexible uretero-renoscopy (URS), laser lithotripsy and retrieval of neglected double J stents
VII.4.1.2 Predisposing factors, grading and pathogenesis
Grading of ureteral trauma suggested by the American association for the surgery of trauma (29) has not gained wide acceptance as the case of renal trauma grading but it might help in academic reporting.
Grade |
Type |
Description |
|---|---|---|
I | Haematoma | Contusion or Haematoma without devascularization |
• On the other hand, endoscopic manipulations might entail mucosal abrasions, submucosal false passages, ureteral perforation, resection, intussusception, avulsion and thermal or laser injuries.
VII.4.2 Ureteral injuries during endoscopic manipulations:
VII.4.2.1 Intra-operative diagnosis
o Ureteral injuries in such settings are frequently diagnosed by direct vision as a mucosal laceration, tear or complete perforation with peri-ureteral fat evident in the field.
o A retrograde ureterogram is quite conclusive when it reveals contrast extravasation into the retroperitoneum. (Brandes S, 2004) This mandates the availability of fluoroscopy during all endoscopic manipulations involving the ureter. Any impression apart from free contrast flow up the ureter should raise suspicions because a false passage might allow contrast flow in a sleeve fashion in the ureteral sub-adventitia mimicking a normal ureter and deceiving the novice.
o The visualization of an intussuscepted part of the ureter into the bladder or the urethra is diagnostic for ureteral avulsion.
o Failure to diagnose an injured ureter during endoscopic manipulations may result in more extensive sequelae and complications. (Wu HH, 2006) (Lucarelli G, 2013) The manifestations, diagnosis and treatment of delayed presentation are described in section (4.4).
VII.4.2.2 Prevention:
Sticking to the basic principles of endoscopic handling of the ureter minimizes the risk of ureteral injury. The following list summarizes most of these principles:
o Preliminary passage of guide wires
o The use of slippery guide wires when necessary
o Fluoroscopic guidance
o Proper dilation of the intramural ureter
o The use of small caliber ureteroscopes
o Maintaining a continuous irrigation
o Hydraulic dis-impaction of stones
o Under-vision introduction and withdrawal of ureteroscopes
o Proper fragmentation of sizable stones
o Judicious use of lithotripters and keeping them always under vision o Judicious use of stone baskets and extractors
o The use of ureteral access sheaths when repeated endoscope introduction is anticipated
VII.4.2.3 Treatment:
o Mild mucosal lacerations usually require no further treatment.
o Submucosal false passages should be managed by temporary ureteric stent/DJ.
o Perforations should be managed by temporary double J stenting (4-6 weeks). Thermal injuries may require longer term stenting (6-8 weeks).
o Later follow up by intravenous urography or retrograde pyelography should be taken into account to watch for the development of ureteral strictures. (31)
o Ureteral intussusception and/or avulsion should be surgically explored and ureteral gaps bridged as will be explained in (4.6)
VII.4.3 Ureteral injuries during open or laparoscopic surgeries
o Ureteral injuries in such settings are frequently diagnosed by direct vision as a mucosal laceration, tear or complete perforation with peri-ureteral fat evident in the field.
o A retrograde ureterogram is quite conclusive when it reveals contrast extravasation into the retroperitoneum. (Brandes S, 2004) This mandates the availability of fluoroscopy during all endoscopic manipulations involving the ureter. Any impression apart from free contrast flow up the ureter should raise suspicions because a false passage might allow contrast flow in a sleeve fashion in the ureteral sub-adventitia mimicking a normal ureter and deceiving the novice.
o The visualization of an intussuscepted part of the ureter into the bladder or the urethra is diagnostic for ureteral avulsion.
o Failure to diagnose an injured ureter during endoscopic manipulations may result in more extensive sequelae and complications. (Wu HH, 2006) (Lucarelli G, 2013) The manifestations, diagnosis and treatment of delayed presentation are described in section (4.4).
VII.4.2.2 Prevention:
o Preliminary passage of guide wires
o The use of slippery guide wires when necessary
o Fluoroscopic guidance
o Proper dilation of the intramural ureter
o The use of small caliber ureteroscopes
o Maintaining a continuous irrigation
o Hydraulic dis-impaction of stones
o Under-vision introduction and withdrawal of ureteroscopes
o Proper fragmentation of sizable stones
o Judicious use of lithotripters and keeping them always under vision o Judicious use of stone baskets and extractors
o The use of ureteral access sheaths when repeated endoscope introduction is anticipated
VII.4.2.3 Treatment:
o Mild mucosal lacerations usually require no further treatment.
o Submucosal false passages should be managed by temporary ureteric stent/DJ.
o Perforations should be managed by temporary double J stenting (4-6 weeks). Thermal injuries may require longer term stenting (6-8 weeks).
o Later follow up by intravenous urography or retrograde pyelography should be taken into account to watch for the development of ureteral strictures. (31)
o Ureteral intussusception and/or avulsion should be surgically explored and ureteral gaps bridged as will be explained in (4.6)
VII.4.3 Ureteral injuries during open or laparoscopic surgeries
VII.4.3.1 Diagnosis:
o Often the urologist is consulted in a case without the leisure of previous knowledge of the patient’s history or prior evaluation.
o A quick assessment of the available imaging studies can be informative about the preoperative status.
o Proper exposure of the suspected injured segment is usually the first advisable step.
o Ligatures might be cut only if they will not jeopardize hemostasis.
o If such an exposure is not feasible, the advisable options include:
o I.V. injection of indigo carmine and watching for the extravasating dye
o Cystoscopy and retrograde injection of indigo carmine or passage of a guide wire or a ureteric catheter into the involved ureter. Gentle manipulations are mandatory to avoid aggravating the injury.
o Intra-operative retrograde ureterography under fluoroscopy
o If none of the above is feasible, a small longitudinal ureterotomy may be performed through which a well lubricated ureteric catheter, a small caliber Nelaton catheter or a guide wire may be gently passed through the suspected injured site.
VII.4.3.2 Prevention:
o It is advisable in complex surgeries in the vicinity of the ureter to have the ureters identified and secured away from clamps and ligatures.
o Mass cauterization, clamping and ligation should be strictly avoided.
o The possibility of having duplex systems should be put in mind during assessment of the available imaging studies prior to ureteric surgeries.
o The preliminary placement of ureteral stents prior to complex pelvic surgery has been debated whether it will guard against injuries or it will just facilitate intra-operative identification of the injury. (23, 32-33) However, the committee feels that prior stenting might facilitate identification of the ureter during surgery in patients with predisposing factors (prior surgery or irradiation, advanced malignancy, anatomical abnormalities, inflammations, colonic diverticulitis and endometriosis)
VII.4.3.3 Treatment:
o Ureters mildly involved in sutures or ligatures may be managed by de-ligation and temporary ureteral stenting.
o Partial tears may be repaired with stenting.
o More severe injuries including crush injuries, thermal injuries and transection warrant resection of the involved segment and ureteral re-anastomosis or resorting to one of the gap-bridging solutions according to the level of the injury (section 4.6).
o If the intra-operative circumstances do not permit proper ureteral reconstruction, a damage-control policy may be resorted to: proximal urinary diversion by a nephrostomy tube and ureteral ligation as distal as the injury would allow with a deferred plan for re-construction. (34)
o If nephrostomy tube fixation is not feasible a ureteric catheter may be exteriorized to drain the involved ureter.
VII.4.4 Iatrogenic ureteral injuries that passes undiagnosed intraoperatively:
VII.4.4.1 Diagnosis:
o Ureteral ligation or intussusception injuries inflicted during surgical or endoscopic procedures and not identified intra-operatively may pass silently and stay unrecognized only to be diagnosed accidently later on or even not at all.
o Otherwise, patients may present in the post-operative period similar to transection and perforation injuries with one or more of the following:
o Fever and sepsis
o Flank pain
o Abdominal pains due to retroperitoneal urinoma or intraperitoneal collection
o Anuria (in bilateral insults or in cases with jeopardized contralateral unit)
o Urine leakage from the vagina, the rectum, the abdominal wound or the fixed drain.
o Pneumaturia or fecaluria
o Ischemic and thermal injuries frequently manifest later than transection injuries. A high level of suspicion should be kept in vague situations.
o The estimation of the creatinine concentration in the leaking fluid clarifies the nature of the fluid whether it is serum, lymph or urine; being almost ten-times the serum level in the latter situation.
o Abdominal ultrasonography is usually the initial diagnostic tool that should be reenforced by contrast-enhanced abdomino-pelvic CT to identify the site of extravasation, the intra-abdominal collection and the presence of back pressure. Absence of the latter should not rule out ureteral trauma because acute complete ureteral ligation or crushing may result in acute renal shut down with negligible or even no pelvi-caliceal dilatation.
o Renal duplex studies with measurement of the arterial resistive index or renal radionuclide studies may be resorted-to in order to settle the diagnosis in such circumstances. (35-36)
o The sensitivity of IVU remains below that of CT in the diagnostic algorithm as it might miss up to 60% of the cases. (19,26)
o In doubtful cases, retrograde (or antegrade) uretero-pyelography should be performed to confirm the diagnosis.
VII.4.4.2 Treatment:
o Cases diagnosed within one week of the injury without associated urinomas or infection may withstand an accelerated approach including trial for endoscopic stenting, or accelerated surgical reconstruction. (26)
o Later diagnosis in the context of a mild injury, retro- or antegrade ureteral stenting may be tried. However, the success rates are quite limited. (37,38) Otherwise, US- or CTguided percutaneous drainage of the urine collection and fixation of a nephrostomy tube for urine diversion are the most widely accepted approaches. A period of 3-6 months has been advocated to wait for re-assessment and surgical correction accordingly.
VII.4.5 Broad principles for reconstruction of ureteral injuries:
o Debridement of necrotic tissue
o Avoid de-sheathing
o Spatulation of ureteral ends
o Watertight mucosa-to-mucosa anastomosis with absorbable sutures
o Tension-free anastomosis
o Internal stenting o External drainage
o Isolation of injury with peritoneum or omentum
VII.4.6 Methods of bridging ureteral gaps:
VII.4.6.1 Lower or Middle ureter
o Uretero-neocystostomy (non-refluxing or refluxing techniques)
o Bladder psoas hitch
o Bladder Boari flap
VII.4.6.2 Upper or Middle ureter
o Renal mobilization
o Trans-uretero-ureterostomy
o Pelvi-ureteric re-anastomosis
o Uretero-calicostomy
VII.4.6.3 Extensive segments
o Ileal ureter replacement
o Renal auto-transplantation
o Buccal mucosal grafts (limited experience)
VII.4.7 Non-Iatrogenic ureteral trauma
Ureteral injury in external violence trauma is a rare entity. Their small size, their flexibility in the horizontal plane and their protection by surrounding bone, muscles and fat render them partially safe.
Ureteral injuries may ensue as a result of rapid deceleration trauma with subsequent avulsion at the level of the PUJ or penetrating injuries due to stab wounds, fire arm or blast injuries.
High velocity bullet injuries from gun rifles are of particular interest due to the cavitation wave they induce resulting in a wider field of impact than that expected from the bullet trajectory per se.
The majority of penetrating ureteral injuries are associated with other organ injuries.
VII.4.7.1 Diagnosis and treatment in the acute stage:
o Ureteral ligation or intussusception injuries inflicted during surgical or endoscopic procedures and not identified intra-operatively may pass silently and stay unrecognized only to be diagnosed accidently later on or even not at all.
o Otherwise, patients may present in the post-operative period similar to transection and perforation injuries with one or more of the following:
o Fever and sepsis
o Flank pain
o Abdominal pains due to retroperitoneal urinoma or intraperitoneal collection
o Anuria (in bilateral insults or in cases with jeopardized contralateral unit)
o Urine leakage from the vagina, the rectum, the abdominal wound or the fixed drain.
o Pneumaturia or fecaluria
o Ischemic and thermal injuries frequently manifest later than transection injuries. A high level of suspicion should be kept in vague situations.
o The estimation of the creatinine concentration in the leaking fluid clarifies the nature of the fluid whether it is serum, lymph or urine; being almost ten-times the serum level in the latter situation.
o Abdominal ultrasonography is usually the initial diagnostic tool that should be reenforced by contrast-enhanced abdomino-pelvic CT to identify the site of extravasation, the intra-abdominal collection and the presence of back pressure. Absence of the latter should not rule out ureteral trauma because acute complete ureteral ligation or crushing may result in acute renal shut down with negligible or even no pelvi-caliceal dilatation.
o Renal duplex studies with measurement of the arterial resistive index or renal radionuclide studies may be resorted-to in order to settle the diagnosis in such circumstances. (35-36)
o The sensitivity of IVU remains below that of CT in the diagnostic algorithm as it might miss up to 60% of the cases. (19,26)
o In doubtful cases, retrograde (or antegrade) uretero-pyelography should be performed to confirm the diagnosis.
VII.4.4.2 Treatment:
o Later diagnosis in the context of a mild injury, retro- or antegrade ureteral stenting may be tried. However, the success rates are quite limited. (37,38) Otherwise, US- or CTguided percutaneous drainage of the urine collection and fixation of a nephrostomy tube for urine diversion are the most widely accepted approaches. A period of 3-6 months has been advocated to wait for re-assessment and surgical correction accordingly.
VII.4.5 Broad principles for reconstruction of ureteral injuries:
o Debridement of necrotic tissue
o Avoid de-sheathing
o Spatulation of ureteral ends
o Watertight mucosa-to-mucosa anastomosis with absorbable sutures
o Tension-free anastomosis
o Internal stenting o External drainage
o Isolation of injury with peritoneum or omentum
VII.4.6 Methods of bridging ureteral gaps:
VII.4.6.1 Lower or Middle ureter
o Uretero-neocystostomy (non-refluxing or refluxing techniques)
o Bladder psoas hitch
o Bladder Boari flap
VII.4.6.2 Upper or Middle ureter
o Debridement of necrotic tissue
o Avoid de-sheathing
o Spatulation of ureteral ends
o Watertight mucosa-to-mucosa anastomosis with absorbable sutures
o Tension-free anastomosis
o Internal stenting o External drainage
o Isolation of injury with peritoneum or omentum
VII.4.6 Methods of bridging ureteral gaps:
VII.4.6.1 Lower or Middle ureter
o Uretero-neocystostomy (non-refluxing or refluxing techniques)
o Bladder psoas hitch
o Bladder Boari flap
VII.4.6.2 Upper or Middle ureter
o Renal mobilization
o Trans-uretero-ureterostomy
o Pelvi-ureteric re-anastomosis
o Uretero-calicostomy
VII.4.6.3 Extensive segments
VII.4.7 Non-Iatrogenic ureteral trauma
Ureteral injuries may ensue as a result of rapid deceleration trauma with subsequent avulsion at the level of the PUJ or penetrating injuries due to stab wounds, fire arm or blast injuries.
High velocity bullet injuries from gun rifles are of particular interest due to the cavitation wave they induce resulting in a wider field of impact than that expected from the bullet trajectory per se.
The majority of penetrating ureteral injuries are associated with other organ injuries.
VII.4.7.1 Diagnosis and treatment in the acute stage:
o A high degree of suspicion should be raised in patients with rapid deceleration injuries (e.g. road traffic accidents and falling from heights) and in penetrating injuries related to the course of either ureters even if no other injuries can be confirmed.
o Hematuria is a non-dependable finding.
o A contrast enhanced abdomino-pelvic CT with delayed films is more conclusive than a standard IVU to reach a reliable diagnosis.
o Finally, a retrograde uretero-pyelography may be required in unsettled situations.
o Most of the ureteral injuries, however, are associated with other vital organ injuries and are frequently diagnosed during laparotomy performed to handle these injuries (e.g. bleeding vessels, parenchymatous organ tears and intestinal injuries).
o Exclusion or confirmation of the injury during laparotomy might require adequate ureteral exposure, I.V. injection of indigo carmine or other maneuvers similar to those described for iatrogenic injuries occurring during open or laparoscopic surgeries
o The treatment algorithm is also similar to that adopted for treating open iatrogenic ureteral injuries. However, a damage control policy is more frequently resorted to as dictated by the patient’s stability and associated injuries
VII.4.7.2 Diagnosis and treatment in the late stage:
• The treatment algorithm also follows the same path
Recommendations |
Strength rating |
|---|---|
VII.5 References
1. AUA Trauma Guidelines. (n.d.).
2. Brandes S, C. M. (2004). Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int., 94(3), 277-89.
3. Brandes, S. B., & Eswara, J. R. (2021). Upper Urinary Tract Trauma. In A. W. Partin, R. R. Dmochowski, L. R. Kavoussi, & C. A. Peters, Campbell-Walsh-Wein Urology 12th Edition. Philadelphia: Elsevier.
4. Burks FN, S. R. (2014). Management of iatrogenic ureteral injury. . Ther Adv Urol., 6(3), 115-24.
5. Chou MT, W. C. (2009). Prophylactic ureteral catheterization in gynecologic surgery: a 12-year randomized trial in a community hospital. . Int Urogynecol J Pelvic Floor Dysfunct., 20(6), 689693.
6. Coccolini F, M. E.-Z., Mefire AC, Ordonez C, Chiarugi M, Machado F,, Sakakushev B, Matsumoto J, Maier R, di Carlo I, & Catena F. (2019). WSES-AAST Expert Panel. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg, 14, 54.
7. Elliott SP, M. J. (2006). Ureteral injuries: external and iatrogenic. 2006 Feb;33(1):55-66. Urol Clin North Am., 33(1), 55-66.
8. European Urology Guidelines. (2020).
9. Gilmour DT, D. S. (2006). Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. . Obstet Gynecol, 107(6), 1366-72.
10. Gonzalez RP, F. M. (1999). Surgical management of renal trauma: is vascular control necessary? J Trauma, 47, 1039.
11. Halabi WJ, J. M. (2014). Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States. 2014 Feb;57(2):179-86. Dis Colon Rectum., 57(2), 179-86.
12. Hassinger TE, M. J. (2018). Ureteral stents increase risk of postoperative acute kidney injury following colorectal surgery. . Surg Endosc., 32(7), 3342-3348.
13. Hesselman S, H. U. (2017). Effect of remote cesarean delivery on complications during hysterectomy: a cohort study. Am J Obstet Gynecol., 217(5), 564.e1-564.e8.
14. Jawas A, A.-Z. F. (2008). Management algorithm for complete blunt renal artery occlusion in multiple trauma patients: case series. 2008. 6: 317. Int J Surg, 6, 317.
15. Jhaveri JK, P. F.-I. (2014). Jhaveri JK, Penna FJ, Diaz-InUreteral injuries sustained during robotassisted radical prostatectomy. J Endourol. , 28(3), 318-24.
16. Johnson DB, P. M. (2004). Complications of ureteroscopy. Urol Clin North Am., 31(1), 157-71.
17. Knudson MM, H. P. (2000). Outcome after major renovascular injuries: a Western trauma association multicenter report. J. Trauma, 49, 1116.
18. Lucarelli G, D. P. (2013). Lucarelli G, DitDelayed relief of ureteral obstruction is implicated in the long-term development of renal damage and arterial hypertension in patients with unilateral ureteral injury. J Urol, 189(3), 960-5.
19. McGeady JB, B. B. (2013). Current epidemiology of genitourinary trauma. . Urol Clin North Am, 40(3), 323-334.
20. Miller RC, S. S. (1966). The incidental discovery of occult abdominal tumors in children following blunt abdominal trauma. J. Trauma, 6, 99.
21. Nash PA, B. J. (1995). Nephrectomy for traumatic renal injuries. J. Urol., 135, 609.
22. Pereira BM, O. M.-R. (2010). A review of ureteral injuries after external trauma. Scand J Trauma Resusc Emerg Med, 18, 6.
23. Platt JF, R. J. (1989). Distinction between obstructive and nonobstructive pyelocaliectasis with duplex Doppler sonography. . AJR Am J Roentgenol., 153(5), 997-1000.
24. Png JC, C. C. (2000). Principles of ureteric reconstruction. Curr Opin Urol, 10(3), 207-12.
25. Pokala N, D. C. (2007). A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. Int J Colorectal Dis, 22(6), 683-7.
26. Robert M, D. N. (1996). Management of major blunt renal lacerations: surgical or nonoperative approach? Eur. Urol., 30, 335.
27. Rostas J, S. J. (2016). Intraoperative management of renal gunshot injuries: is mandatory exploration of Gerota’s fascia necessary? Am J Surg., 211, 783.
28. Santucci RA, M. J. (2001). Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma, 50, 195.
29. Shariat SF, Roehrborn CG, Karakiewicz PI, Dhami G, Stage KH. (2007). Evidence-based validation of the predictive value of the American Association for the Surgery of Trauma kidney injury scale. J Trauma, 62, 933.
30. Shekarriz B, S. M. (2002). The use of fibrin sealant in urology. J. Urol., 167, 1218.
31. Siram SM, G. S. (2010). Ureteral trauma: patterns and mechanisms of injury of an uncommon condition. Am J Surg, 199, 566.
32. Smith TG 3rd, C. M. (2013). Damage control maneuvers for urologic trauma. Urol Clin North Am, 40(3), 343-50.
33. Stein JP, K. D. (1994). Blunt renal trauma in the pediatric population: indications for radiographic evaluation. Urology, 44, 406.
34. Taylor, A. (2014). Radionuclides in nephrourology, Part 2: pitfalls and diagnostic applications. J Nucl Med., 55(5), 786-98.
35. Tillou A, R. J. (2001). Renal vascular injuries. Surg Clin North Am, 81, 1417.
36. Trauma., T. A. (n.d.). The American Association for the Surgery of Trauma. Retrieved from http://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx#ureter
37. Visco AG, T. K. (2001). Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy.2001 May;97(5 Pt 1):685-92. Obstet Gynecol., 5(1), 685-92.
38. Wu HH, Y. P. (2006). The detection of ureteral injuries after hysterectomy. J Minim Invasive Gynecol., 13(5), 403-8.
2. Brandes S, C. M. (2004). Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int., 94(3), 277-89. 3. Brandes, S. B., & Eswara, J. R. (2021). Upper Urinary Tract Trauma. In A. W. Partin, R. R. Dmochowski, L. R. Kavoussi, & C. A. Peters, Campbell-Walsh-Wein Urology 12th Edition. Philadelphia: Elsevier.
4. Burks FN, S. R. (2014). Management of iatrogenic ureteral injury. . Ther Adv Urol., 6(3), 115-24.
5. Chou MT, W. C. (2009). Prophylactic ureteral catheterization in gynecologic surgery: a 12-year randomized trial in a community hospital. . Int Urogynecol J Pelvic Floor Dysfunct., 20(6), 689693.
6. Coccolini F, M. E.-Z., Mefire AC, Ordonez C, Chiarugi M, Machado F,, Sakakushev B, Matsumoto J, Maier R, di Carlo I, & Catena F. (2019). WSES-AAST Expert Panel. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg, 14, 54.
7. Elliott SP, M. J. (2006). Ureteral injuries: external and iatrogenic. 2006 Feb;33(1):55-66. Urol Clin North Am., 33(1), 55-66.
8. European Urology Guidelines. (2020).
9. Gilmour DT, D. S. (2006). Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. . Obstet Gynecol, 107(6), 1366-72.
10. Gonzalez RP, F. M. (1999). Surgical management of renal trauma: is vascular control necessary? J Trauma, 47, 1039.
11. Halabi WJ, J. M. (2014). Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States. 2014 Feb;57(2):179-86. Dis Colon Rectum., 57(2), 179-86.
12. Hassinger TE, M. J. (2018). Ureteral stents increase risk of postoperative acute kidney injury following colorectal surgery. . Surg Endosc., 32(7), 3342-3348.
13. Hesselman S, H. U. (2017). Effect of remote cesarean delivery on complications during hysterectomy: a cohort study. Am J Obstet Gynecol., 217(5), 564.e1-564.e8.
14. Jawas A, A.-Z. F. (2008). Management algorithm for complete blunt renal artery occlusion in multiple trauma patients: case series. 2008. 6: 317. Int J Surg, 6, 317.
15. Jhaveri JK, P. F.-I. (2014). Jhaveri JK, Penna FJ, Diaz-InUreteral injuries sustained during robotassisted radical prostatectomy. J Endourol. , 28(3), 318-24.
16. Johnson DB, P. M. (2004). Complications of ureteroscopy. Urol Clin North Am., 31(1), 157-71.
17. Knudson MM, H. P. (2000). Outcome after major renovascular injuries: a Western trauma association multicenter report. J. Trauma, 49, 1116.
18. Lucarelli G, D. P. (2013). Lucarelli G, DitDelayed relief of ureteral obstruction is implicated in the long-term development of renal damage and arterial hypertension in patients with unilateral ureteral injury. J Urol, 189(3), 960-5.
19. McGeady JB, B. B. (2013). Current epidemiology of genitourinary trauma. . Urol Clin North Am, 40(3), 323-334.
20. Miller RC, S. S. (1966). The incidental discovery of occult abdominal tumors in children following blunt abdominal trauma. J. Trauma, 6, 99.
21. Nash PA, B. J. (1995). Nephrectomy for traumatic renal injuries. J. Urol., 135, 609.
22. Pereira BM, O. M.-R. (2010). A review of ureteral injuries after external trauma. Scand J Trauma Resusc Emerg Med, 18, 6.
23. Platt JF, R. J. (1989). Distinction between obstructive and nonobstructive pyelocaliectasis with duplex Doppler sonography. . AJR Am J Roentgenol., 153(5), 997-1000.
24. Png JC, C. C. (2000). Principles of ureteric reconstruction. Curr Opin Urol, 10(3), 207-12.
25. Pokala N, D. C. (2007). A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. Int J Colorectal Dis, 22(6), 683-7.
26. Robert M, D. N. (1996). Management of major blunt renal lacerations: surgical or nonoperative approach? Eur. Urol., 30, 335.
27. Rostas J, S. J. (2016). Intraoperative management of renal gunshot injuries: is mandatory exploration of Gerota’s fascia necessary? Am J Surg., 211, 783.
28. Santucci RA, M. J. (2001). Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma, 50, 195.
29. Shariat SF, Roehrborn CG, Karakiewicz PI, Dhami G, Stage KH. (2007). Evidence-based validation of the predictive value of the American Association for the Surgery of Trauma kidney injury scale. J Trauma, 62, 933.
30. Shekarriz B, S. M. (2002). The use of fibrin sealant in urology. J. Urol., 167, 1218.
31. Siram SM, G. S. (2010). Ureteral trauma: patterns and mechanisms of injury of an uncommon condition. Am J Surg, 199, 566.
32. Smith TG 3rd, C. M. (2013). Damage control maneuvers for urologic trauma. Urol Clin North Am, 40(3), 343-50.
33. Stein JP, K. D. (1994). Blunt renal trauma in the pediatric population: indications for radiographic evaluation. Urology, 44, 406.
34. Taylor, A. (2014). Radionuclides in nephrourology, Part 2: pitfalls and diagnostic applications. J Nucl Med., 55(5), 786-98.
35. Tillou A, R. J. (2001). Renal vascular injuries. Surg Clin North Am, 81, 1417.
36. Trauma., T. A. (n.d.). The American Association for the Surgery of Trauma. Retrieved from http://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx#ureter
37. Visco AG, T. K. (2001). Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy.2001 May;97(5 Pt 1):685-92. Obstet Gynecol., 5(1), 685-92.
38. Wu HH, Y. P. (2006). The detection of ureteral injuries after hysterectomy. J Minim Invasive Gynecol., 13(5), 403-8.