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Ureteral injury
Most ureteral injuries are iatrogenic in gynaecological, colorectal and urological surgery; an injury recognised at surgery is repaired at once, and one found late is first drained by nephrostomy or stent. The type of repair depends on the level of injury and the length of the gap.
Why it matters in the exam
The exam shows a patient after hysterectomy, colorectal surgery (for example low anterior resection) or ureteroscopy who develops, days later, fever, flank pain, ileus, a rising creatinine or urine leakage from the vagina or the drain. The diagnostic test is CT urography with a delayed phase, which shows leakage, a urinoma or obstruction. External ureteral trauma is rare and mainly due to penetrating injury. To lower the risk in complex pelvic surgery, ureteral catheters can be placed before the operation, but they do not prevent injury — they mainly help to recognise it during surgery.
The ureteral blood supply comes from several sources: in the upper part from the medial side (from the renal artery, aorta and gonadal arteries), and in the pelvic part from the lateral side (from the iliac and vesical arteries). So at surgery the ureter is mobilised while preserving the adventitia, so as not to damage the vascular network running along it. Repair principles: viable ends, a spatulated anastomosis, tension-free, watertight, over a stent and with a drain.
Repair by level: a partial or small injury — JJ stent; a complete injury of the upper or middle ureter with a short gap — end-to-end anastomosis (ureteroureterostomy); an injury to the distal ureter — reimplantation into the bladder (ureteroneocystostomy), with a psoas hitch or a Boari flap when the gap is longer. A very long gap — anastomosis to the opposite ureter (transureteroureterostomy), ureteral replacement with an ileal segment or renal autotransplantation. An injury found late in an unstable patient — nephrostomy and an attempt at an antegrade stent, with planned repair later.
Key points
- Most injuries are iatrogenic.
- CT urography with a delayed phase.
- Upper or middle — end-to-end anastomosis.
- Distal — reimplantation, psoas hitch or Boari.
- Late and unstable — nephrostomy.
Summary table
| Site and type | Repair | Note |
|---|---|---|
| Partial injury | JJ stent | Sometimes with nephrostomy |
| Upper or middle ureter, short gap | End-to-end anastomosis | Tension-free and over a stent |
| Distal ureter | Reimplantation into the bladder | Psoas hitch or Boari for a long gap |
| Very long gap | Transureteroureterostomy, ileum or autotransplantation | Complex cases |
| Late recognition in an unstable patient | Nephrostomy and delayed repair | Antegrade stent if possible |
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Sources
- EAU Guidelines on Urological Trauma, 2025 edition — Ureteral trauma
- AUA Guideline: Urotrauma, 2020 — Ureteral injuries
- Campbell-Walsh-Wein Urology, 12th edition (2020) — Upper Urinary Tract Trauma
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.