It cannot be stressed enough that intraoperative recognition is the most important factor in achieving a successful outcome after ureteral injury. Types of injury can vary from crush injuries to complete transection. Urine in the operative field indicates obvious injury, and immediate surgical repair should be undertaken once the site is identified. If the site of injury cannot be readily identified, but transec-tion is suspected, intravenous indigo carmine and Lasix can be administered to verify injury, identify the site, and allow immediate repair. Alternatively, one can perform an on-table intravenous pyelogram (IVP) by administering 2 mL/kg of contrast and taking a plain film of the abdomen after 10 minutes.5 If extravasation is noted, surgical repair is performed. If there is no extravasation, then a significant ureteral injury is ruled out and the surgery can continue. If ligation with either a suture or clip is suspected, the area in question should be dissected and the ureter inspected. If one is unsure of the level of ligation, but suspicion is high, then a cystotomy can be made with retrograde passage of a ureteral catheter. If the catheter passes freely, then there is no injury. Inability to pass the catheter confirms ureteral obstruction and provides the surgeon with an idea of the level of injury. In the case of inadvertent ligation, the clip or offending suture should simply be removed and the ureter inspected for viability. Determination of viability is somewhat subjective, but active peristalsis of the segment in question indicates an intact smooth muscle layer and can usually be managed with observation. If there is any question of viability, then a ureteral stent should be left in place. If the ureter has been partially transected, then primary repair can be performed with a spatulated anastomosis over a ureteral stent as described later.

Quite often, however, the injury is not recognized until the postoperative period. The patient may present with hematuria, fever, flank or abdominal pain, ileus, or even fistula with drainage of urine. With unilateral injury, urine output will be of little or no value in making the diagnosis. Bilateral ureteral injury is rare but does occur, usually at the time of hysterectomy, and is easily identified by the presence of anuria in the recovery room.

Postoperative diagnosis is best made with an IVP, which may show extravasation, delayed renal function, or obstruction with hydroureteronephrosis. Computed tomography may show any of these as well as the presence of a urine collection in the retroperitoneal space; however, an IVP will usually give much better anatomic information when planning reconstruction. In the presence of any of these findings, retrograde pyelography (RPG) should be performed. The RPG will allow assessment of the level and, possibly, the length of injury. If a stent can be placed safely at the time of RPG, then this may be all that is necessary. If a stent cannot be safely manipulated past the injury because of complete obstruction or transection, then immediate decompression with percutaneous nephrostomy should be performed. Antegrade stenting can then be attempted, either immediately, or sometimes more successfully after a period of 48 hours. If stenting fails, then exploration with surgical repair is the only option. Nuclear renograms are usually only necessary if the time delay from injury to recognition is long (>6 weeks). In these cases, measurement of residual renal function may help to determine whether a reconstructive salvage procedure is warranted versus a nephrectomy.

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