Approach to Ureteral Injuries 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Background:  
Ureteral 
injuries 
are 
rare 
and 
often 
challenging to diagnose without cross-sectional 
imaging. They are also often difficult to treat, as 
exposure can be limited and surgeons are required to 
have knowledge of many different reconstructive 
techniques to manage different types and locations of 
injuries. Treatment of ureteral injuries can often be 
delayed until patients are hemodynamically stable; 
temporizing measures are an option in settings where 
definitive 
reconstruction 
is 
not 
possible 
or 
appropriate. The vast majority of ureteral injuries are 
penetrating injuries and both traumatic and 
iatrogenic scenarios are common. Restoring and 
maintaining drainage from the kidney, whether 
externally or internally, should always be the 
priority, especially given the importance of renal 
function in post-trauma recovery and the profound 
resources required should dialysis be necessary. 
 
Ureteral injuries may be subtle, and thus 
recognizing and diagnosing these injuries can be 
difficult. Delays in diagnosis and repair can lead to 
significant morbidity and further complicate both 
repair of the ureter as well as repair of associated 
injuries. The surgeon should have a high index of 
suspicion for ureteral involvement in penetrating 
trauma when the projectile courses near or through 
the retroperitoneum.  Patients with high-energy blunt 
trauma (falls from a height or motor vehicle 
collisions with rapid deceleration) are also at risk for 
ureteral injury, but these injuries are exceedingly 
uncommon. 
Intraoperative 
iatrogenic 
ureteral 
injuries are often recognized at the time of the injury, 
and surgeons should fully evaluate not only partial or 
complete transections, but also ureteral bruising, 
discoloration 
or 
associated 
hematomas, 
as 
devascularization and electrocautery injuries may 
continue to evolve for some time after an unrepaired 
injury. Delayed presentations can include fever, 
flank pain and ileus, due to urinoma or abscess 
formation, and can even lead to renal failure and 
potential loss of the affected kidney. 
 
Preoperatively, imaging should be used when 
available to stage ureteral injuries if the mechanism 
of injury raises concern for ureteral involvement. 
While hematuria may foster further clinical concern, 
it is generally unreliable as an indicator of injury and 
its absence does not rule out the need for imaging.  
When CT Urography is not available, do an 
Intravenous Pyelogram to evaluate the collecting 
system. Take a plain abdominal x-ray 10 minutes 
after administering 2cc/kg of IV contrast. Contrast 
media extravasation proximally indicates a renal 
pelvis or ureteropelvic junction injury while a 
ureteral injury more distally may be identified by 
contrast extravasation or absence of distal ureteral 
opacification. The presence of hydronephrosis or a 
delayed nephrogram are less specific, but they may 
also be associated with a ureteral injury.  
Urine extravasation into the peritoneum can 
sometimes lead to elevated serum creatinine levels 
due to reabsorption in the absence of true renal 
injury. This finding should not preclude contrasted 
imaging for patients who are otherwise healthy. 
In many settings preoperative imaging is 
either unavailable or falsely negative. Surgeons 
should therefore explore the retroperitoneum if the 
mechanism and/or ballistic trajectory raises concern 
for ureteral injury. 
 
Normal intravenous pyelogram taken 10 minutes after 
intravenous injection of contrast. The renal calyces, pelvis, 
ureters, and bladder can all be seen in this study. Case courtesy 
of Dr MT Niknejad, From the case 
https://radiopaedia.org/cases/85286?lang=us  
 
Approach to Ureteral Injuries 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Delayed-phase CT imaging showing left distal ureteral 
extravasation (Red arrow.) Case courtesy of Dr Chris 
O'Donnell, From the case 
https://radiopaedia.org/cases/36562?lang=us  
 
 
Hydronephrosis (Red arrow) and a delayed CT nephrogram 
associated with a distal ureteral injury. Case courtesy of Dr 
Vikas Shah, From the case 
https://radiopaedia.org/cases/55591?lang=us 
 
 
In general, a retrograde pyelogram may be 
performed prior to surgical exploration in two cases: 
for patients with an endoscopic ureteral injury for 
whom ureteral stenting may be appropriate, or for 
patients with equivocal preoperative imaging whose 
only indication for surgical exploration is a possible 
ureteral injury. However, for patients who will 
undergo exploration for other injuries, direct 
inspection of the ureters at the time of laparotomy is 
the gold standard, and retrograde urography can be 
omitted. Intraoperative identification can be difficult, 
given the sometimes subtle appearance of a ureteral 
injury. In these cases, the collecting system can be 
pressurized by injecting saline or methylene blue 
directly into the ureter or renal pelvis, to help identify 
extravasation. This should be done with the smallest 
available needle. Alternatively, if the ureter cannot 
be identified due to surrounding tissue damage and a 
cystoscope is available, canalization of the distal 
ureter endoscopically with injection of saline or 
methylene blue may help identify the distal extent of 
the injury. 
 
Anatomy:  
The ureter originates from the renal pelvis at 
the ureteropelvic junction, just distal and posterior to 
the renal hilum. It courses caudally in the 
retroperitoneum along the psoas muscle, lateral to the 
gonadal vessels initially, before crossing medially 
and deep to them at the level of the aortic bifurcation. 
The ureter then passes over the bifurcation of the 
iliac vessels as it dives posteriorly to insert into the 
detrusor wall, emptying into the bladder at the 
trigone. This relational anatomy is essential to both 
isolating the ureter surgically and deciding upon the 
optimal strategy for repair. 
 
The course of the ureters (Black arrows) in relation to 
surrounding anatomy.  
 
Approach to Ureteral Injuries 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
The ureteral blood supply is variable and 
dependent on the section of ureter being considered. 
The ureter is divided into three sections based on 
vascular supply. The proximal ureter is fed by the 
renal artery; the mid ureter has a variable supply 
including the gonadal vessels, aorta, and the iliac 
vessels; and the distal ureter relies on supply from the 
superior and inferior vesical arteries off the internal 
iliac. These larger arteries feed subsequently smaller 
branches which anastomose within the fibrous 
adventitia of the ureter along its entire length. 
Therefore, while loss of any single large vessel will 
not necessarily devitalize the entire ureter, careful 
tissue handling of the ureter and its adventitia is 
essential to avoid damage to these small vessels. The 
small caliber of the periureteral vascular arcades also 
requires ureteral anastomoses to be done in a tension-
free manner to maintain uncompromised flow 
though those vessels. These vascular considerations 
are what often drive the choice of ureteral repair 
technique, with distal injuries best suited to 
reimplantation into the bladder (augmented by 
bladder reconstruction as needed), while proximal 
injuries are treated most frequently with primary 
repair. 
 
 
Layers of the ureter in cross section. The fibrous adventitia 
houses the microvasculature of the ureter along its entire 
length. It is essential to appose the mucosal layer in a watertight 
closure.  
 
Within the adventitia is the smooth muscle of 
the ureter, lined by urothelial mucosa. It is paramount 
that any ureteral repair, whether primary or via 
reimplantation, includes circumferential mucosa-to-
mucosa apposition. Failing to ensure this critical step 
leads to urine leakage and periureteral scaring, 
fibrosis and stricture formation. 
 
Principles of Ureteral Repair: 
The success of open ureteral repair is dictated 
by five principles: 
 
1. Selection of the appropriate repair: 
 
Repair selection should be based on patient 
stability, injury etiology and location of the injury. 
This is due to the wide variability of patient 
presentations (stable vs. unstable), vascular supply 
along the length of the ureter (proximal, middle and 
distal) and the time needed to perform different 
repairs (stenting, primary repair and bladder 
reimplant). 
 
2. Minimizing ureteral dissection: 
 
As larger vessels feed the ureter via a network 
of small periureteral vessels within the ureteral 
adventitia, overly aggressive dissection can result in 
disruption of the vascular supply needed to feed the 
healing anastomosis. Thus, ureteral dissection and 
debridement should be done judiciously with the 
goal of removing any devitalized tissue and 
mobilizing the ureter no more than is needed for a 
tension-free, spatulated anastomosis. 
 
3. Mucosa-to-mucosa apposition: 
 
Mucosal apposition facilitates a watertight 
closure and resultant healing. Direct contact between 
urothelial mucosa and ureteral smooth muscle or 
adventitia leads to fibrosis and scarring with resultant 
ureteral stricture formation. Furthermore, leakage of 
urine from the repair can lead to a similar fibrosis as 
well as fluid collections and abscesses that put the 
patient at risk for infection and complicate future 
attempts at repair. 
 
4. Tension-free anastomosis: 
 
Ensuring both the apposed urothelium and 
the ureteral adventitia are under minimal-to-no 
tension once anastomosed protects against urine 
Approach to Ureteral Injuries 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
leakage from the anastomosis, as well as against 
microvascular compromise to the delicate small 
vessels of the apposed tissue due to mechanical 
stretching. 
 
5. Adequate upper tract drainage: 
 
Maintaining a low pressure upper urinary 
tract following ureteral repair minimizes the 
opportunity for urine to leak from suture lines, 
optimizing tissue healing. This should be done, at a 
minimum, with a ureteral stent and can be augmented 
with a foley catheter to reduce urine reflux along the 
stent. Add a nephrostomy tube for proximal 
decompression when a repair is considered at high 
risk of failing. In settings where a ureteral stent is not 
available, ureteral repair without a stent can be 
performed; however, there is likely a higher risk of 
leak and/or stricture formation. If upper tract 
drainage is not available with either a nephrostomy 
tube or a stent, we would recommend extended 
retroperitoneal drainage with a closed suction drain 
to minimize risk of urinoma formation and infection. 
 
Decision Making: 
The Unstable Patient: 
The first consideration in evaluating a 
ureteral injury is patient stability. For unstable 
patients with a partial ureteral injury, a ureteral stent 
can be placed with the understanding that 
reconstruction can be considered when the patient is 
no longer critical. For complete ureteral disruptions 
in the unstable patient, the proximal ureter should be 
clipped or tied off just proximal to the injury, and a 
nephrostomy tube can be placed. When nephrostomy 
tube placement is not feasible or available, drainage 
may be achieved in one of two ways. First, the 
proximal ureter can be brought to the skin and 
matured as a cutaneous ureterostomy, ideally with an 
indwelling stent. Alternatively, a single-J or double-
J stent can be placed into the proximal ureter and 
renal pelvis and secured with a non-absorbable 
suture, with the other end then brought through the 
skin as a drain to allow temporary urinary drainage. 
Finally, if patient stability does not allow for even 
these maneuvers, ureteral injuries can be left in situ 
for a short term (1-2 days), preferably with a 
temporary abdominal vacuum closure, as the 
majority of urine will be removed via suction (See 
Temporary Abdominal Closure.) 
 
The Stable Patient 
For the stable patient, ureteral injuries should 
be repaired at the time of identification whenever 
possible. In general, other intra-abdominal injuries 
should not preclude reconstruction for the stable 
patient. However, long mid-to-proximal ureteral 
injuries that would require extensive reconstruction, 
such as a creation of an ileal ureter, are generally not 
preferable in the acute setting and should be 
postponed for a later procedure.  
As previously stated, the location of the 
injury guides the repair. Distal injuries are best 
reimplanted into the bladder due to the detrusor 
muscle’s robust blood supply from the bilateral 
superior and inferior vesical arteries. This blood 
supply also directly feeds the distal ureter and is ideal 
for anastomotic healing and responsible for the low 
rate of ureteroneocystostomy strictures. The bladder 
can be mobilized using a psoas hitch with or without 
a Boari flap in order to bridge the gap to healthy 
ureter. These strategies can make even mid-ureteral 
injuries re-implantable into the bladder. For injuries 
that are too proximal for even aggressive bladder 
mobilization 
and 
reconstruction, 
uretero-
ureterostomy should be performed. Regardless of the 
injury location, a ureteral stent should be placed 
across repairs when available and a closed-suction 
drain left in the abdomen. 
 
The decision to debride ureteral tissue prior 
to repair can be difficult considering the sometimes 
competing goals of a tension free anastomosis and 
minimal ureteral dissection. Injury etiology should 
also be considered. The extent of injuries due to high-
velocity weapons may not be fully apparent at the 
time of the operation. In such situations, we 
recommend slightly more extensive debridement 
prior to repair to ensure the health of tissue to be 
incorporated. These injuries include blasts, hunting 
or 
military-style 
rifles, 
and 
high-energy 
electrocautery injuries. Low energy injuries from 
knives, scalpels or low-velocity and caliber gunshots 
can be debrided more judiciously as secondary 
cavitation risk is less. 
 
Delayed Recognition of Ureteral Injuries 
Approach to Ureteral Injuries 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Given the subtle appearance of ureteral 
injuries, they can often be missed initially and 
recognized in a delayed fashion. Signs and 
symptoms concerning for a missed ureteral injury 
include flank and abdominal pain or distention, urine 
leakage 
from 
abdominal 
wounds, 
laboratory 
evidence of acute kidney injury, oliguria, hematuria, 
ileus and fever. Staging imaging with intravenous 
pyelography, retrograde pyelography or CT should 
be pursued. Retrograde pyelograms should be 
acquired if other imaging is equivocal, since 
ultrasonography, intravenous pyelography and CT 
may only show secondary signs of injury like 
hydronephrosis or a delayed nephrogram. For most 
incomplete injuries, where extravasation is present 
but contrast traverses the injury, a stent should be 
placed. This stent should be left in place for at least 
6 weeks with a foley catheter remaining for at least 1 
week. 
For complete injuries, where contrast does 
not traverse the area of extravasation, or in cases 
when the patient will be taken back to the operating 
room for other injuries, open surgical repair should 
be attempted using the techniques outlined above. 
Such repairs are best done within 7 to 10 days from 
the initial injury. Outside of this window, a 
percutaneous nephrostomy should be placed if 
feasible, with open repair reserved only for cases 
with no endoscopic or percutaneous options. 
 
Patient Follow-Up 
 
Follow-up care for ureteral injuries is 
difficult to define as these injuries are rare and 
variable in presentation. For repairs deemed to have 
a high likelihood of success, drains can often be 
removed in the first few postoperative days as long 
as they remain low output. For drains with high 
output, measuring the creatinine level of the drain 
fluid can aid in the decision to keep or remove the 
drain in settings where this test is available. Stents 
can often be removed in 6 weeks. For higher-risk 
repairs or injuries that were treated only with ureteral 
stenting, retrograde pyelograms at the time of stent 
removal may be used to confirm appropriate healing. 
After stent removal, patients should be followed with 
ultrasound, intravenous pyelography or cross-
sectional imaging in the coming months to monitor 
for signs of ureteral stricture. Follow-up plans should 
be adjusted on a patient-by-patient basis given the 
heterogeneity of ureteral injuries and repairs. 
 
 
 
George E. Koch MD  
Vanderbilt University Medical Center 
USA 
 
Niels V. Johnsen MD, MPH 
Vanderbilt University Medical Center 
USA 
 
 
Resource-Rich Settings 
CT Urography: 
Contrasted CT of the abdomen and pelvis with 
arteriovenous phase and a 10-minute delayed phase. 
Gold standard imaging modality for diagnosing a 
ureteral injury. 
Aids in surgical planning and may augment injury 
identification intraoperatively. 
