Ureteral Trauma
Most ureteral injuries are iatrogenic and easily missed — they present late with urine leak or obstruction, are confirmed by delayed-phase CT urogram or retrograde pyelogram, and are repaired according to the level and length of injury.
The big picture
Ureteral trauma is most often iatrogenic — gynaecological, colorectal, vascular and ureteroscopic procedures — and less commonly penetrating; blunt deceleration can cause UPJ avulsion. Because the injury is easy to miss intra-operatively, many present in a delayed fashion with flank pain, urine leak (from a drain or vaginally), ileus, fever or a rising creatinine.
Suspect it (especially after pelvic surgery), prove it with delayed imaging/retrograde study, decompress, then repair by location — a missed ureteral injury presents late and badly.
Red flags
Suspect a missed ureteral injury — image with delayed phase and localise.
Could be urinary leak/ascites, not bowel — check drain fluid creatinine.
Decompress urgently before reconstruction.
Symptom sorter
The common presentation.
Diagnostic algorithm
Each step answers one question. Tap to expand.
Treatment ladder
Control urine leak and obstruction first, then definitively repair according to the level and length of the defect, tension-free and well vascularised.
Complications
- Urinoma, urinary fistula, urosepsis
- Obstruction and renal loss
- Anastomotic stricture/leak
- Ileal ureter metabolic/mucus issues
- Tension-free, spatulated, stented, well-vascularised repair
- Choose the right level-based reconstruction
- Stent/drain leaks
- Revise strictures
Summary tables
Repair by injury location
| Level | Reconstruction |
|---|---|
| Distal third | Reimplant (± psoas hitch / Boari flap) |
| Mid/upper third | Ureteroureterostomy (spatulated, stented) |
| Long defect | Boari flap / ileal ureter / autotransplant |
| UPJ avulsion | Surgical repair |
Memory hooks
Most are iatrogenic and missed.
Presents late: leak, obstruction, fever, rising creatinine.
Delayed CT urogram + retrograde study localise it.
Repair by location: distal → reimplant; mid/upper → ureteroureterostomy; long → Boari/ileal.
Board traps
Late presentation after hysterectomy with urine leak — missed ureteral injury.
Diagnosing 'ileus' when drain creatinine reveals urine.
Choosing primary anastomosis for a long defect instead of a Boari flap/ileal ureter.
Clinical cases
Five days after a difficult hysterectomy, a woman develops flank pain, low-grade fever and watery vaginal discharge. Creatinine of the discharge fluid is far higher than serum.
What is the diagnosis and the next steps?