Trauma and injuries to the ureters

Due to the location, size and mobility of the ureters, injuries and damages to the ureters caused by external force occur relatively rarely. In particular, this is due to the fact that this organ is elastic, easily displaced and protected by powerful muscles, ribs, and iliac bones. Of particular interest from a practical point of view are iatrogenic injuries to the ureter that occur during therapeutic and diagnostic procedures (e.g. catheterization of the ureters, contact ureterolithotripsy), as well as during operations (usually on the pelvic organs).

ICD-10 code

S37.1. Injury of ureter.

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What causes ureteral injuries?

The ureter is least often damaged by external trauma. Isolated gunshot injuries to the ureters are rare: out of 100 such wounds, there are only 8 isolated injuries. As a rule, they are combined with injuries to other organs (in closed ureter injuries - up to 33%, in open - up to 95% of all cases). According to various data, ureter injuries account for only 1-4% of injuries to the genitourinary organs.

Gunshot injuries to the ureters account for 3.3-3.5% of all combat injuries to the genitourinary system during modern military operations. Injuries to the lower third of the ureters predominate, which is associated with the use of personal protective equipment.

In modern local military conflicts, ureteral injuries occur in 5.8% of the wounded. Ureteral injuries during the Great Patriotic War occurred in approximately 10%, and during the local conflict in Afghanistan - in 32% of all injuries to the genitourinary organs.

Ureteral injuries may be caused by both direct (damage to the mucous membrane, compression of the ureter by a suture, complete Z partial dissection, crushing, avulsion or rupture) and indirect (devascularization during electrocoagulation or too thorough dissection, late necrosis of the ureter after radiation exposure, etc.) effects. Open ureteral injuries almost always occur with gunshot wounds and in all cases are combined injuries.

The largest statistical study of ureteral injuries was conducted by Z. Dobrowolski et al. in Poland in 1995-1999. According to this study, 75% of ureteral injuries are iatrogenic, 18% are due to blunt trauma, and 7% are due to penetrating trauma. In turn, iatrogenic ureteral injuries occur in 73% of cases during gynecological operations, and in 14% - urological and general surgeries. According to Dobrowolski and Dorairajan, ureteral injuries during gynecological operations occur in 0.12-0.16% of cases.

In laparoscopic surgeries (mainly laparoscopically assisted transvaginal hysterectomy), the probability of ureteral damage is less than 2%. In this case, the damaging factor leading to ureteral damage is electrocoagulation.

Endoscopic technologies for diagnostics and treatment of ureteral stones, obliterations and strictures of the urethra, urothelial tumors may be complicated by iatrogenic ureteral damage (2-20% of cases). Ureteral damage during ureteroscopy mainly affects only the mucous membrane or may be minor damage to its wall. Potential complications of endoscopic operations include perforation, ureteral stricture, ureteral false passage, ureteral rupture, leading to bleeding of varying intensity, infectious and inflammatory complications, up to sepsis.

Perforation and false ureteral passage may occur during placement of a ureteral stent or guidewire, especially if it is obstructed, such as by a stone, or if the ureteral course is tortuous.

Iatrogenic ureteral injuries are mainly associated with failure to comply with certain rules for performing endoscopic manipulations. If the resistance is insurmountable during stent or guidewire insertion, retrograde pyelography should be performed to clarify the ureteral anatomy. When using small-caliber ureteroscopes (less than 10 Fr), flexible ureteroscopes and temporary ureteral stents, ureteral perforation occurs in 1.7%, strictures - 0.7% of cases.

Rupture of the dilator balloon during endoscopic dilation of ureteral stricture as a result of a sharp increase in pressure in the balloon can also lead to iatrogenic damage.

Ureteral rupture is a rare (0.6%) but most serious complication of ureteroscopy. It usually occurs in the proximal third of the ureter during removal of a large calculus with a basket without its preliminary fragmentation. If ureteral rupture has occurred, drainage of the urinary tract (percutaneous nephrostomy) with subsequent restoration of the integrity of the ureter is indicated.

The main causes of iatrogenic damage to the middle third of the ureter, in addition to endoscopic manipulations, are surgical interventions on the external iliac vessels, lymphadenectomy and suturing of the posterior leaflet of the parietal peritoneum.

Penetrating non-iatrogenic injuries of the ureters occur mainly in young people (average age 28 years), are usually unilateral and are always accompanied by damage to other organs.

In 95% of cases they occur as a result of gunshot wounds, are much less often caused by bladed weapons and most rarely occur during car accidents. When the ureters are damaged by external force, the upper third is most often damaged, the distal part is much less often.

In general, the lower third of the ureter is damaged in 74%, and the upper and middle thirds are damaged in 13% each. It should be noted that such ureteral damage is also often accompanied by damage to visceral organs: small intestine - in 39-65%, large intestine - in 28-33%, kidneys 10-28%. urinary bladder - in 5% of cases. Mortality with such combinations of damage is up to 33%.

Symptoms of Ureteral Injury

Symptoms of ureteral injuries and damage are extremely scarce, and there are no pathognomonic symptoms. The patient may be bothered by pain localized in the lumbar, iliac regions or hypochondrium. An important symptom that allows one to suspect ureteral damage is hematuria. According to various sources, hematuria occurs in only 53-70% of cases of ureteral damage.

The severity of the victim's condition and the absence of a characteristic clinical picture lead to the fact that in 80% of the wounded, ureteral injury is not diagnosed at the early stages of providing surgical care, and is subsequently detected only at the stage of complications. After both combined and isolated ureteral injury, a ureterocutaneous fistula develops. Urine leakage into the periureteral tissue leads to the development of infiltrate and suppuration, which ultimately leads to the formation of scar fibrous tissue in the wall of the ureter and around it.

In severe combined injuries accompanied by damage to sources, the clinical picture is dominated by symptoms of damage to the abdominal organs, kidneys, as well as symptoms of shock, internal bleeding; growing retroperitoneal urohematoma is accompanied by symptoms of peritoneal irritation, intestinal paresis.

Symptoms of closed ureteral injuries

Closed ureteral injuries usually occur with iatrogenic trauma during instrumental interventions on the ureter, as well as surgical and gynecological operations on the pelvic organs and retroperitoneal space (according to literary sources, from 5 to 30% of surgical interventions in the pelvic area are accompanied by trauma to the ureters); closed ureteral injury also includes damage to the intramural part of the ureter during TUR of the bladder.

Ureteral damage with a ruptured wall or its complete interruption causes urine to enter the periureteral tissue. With minor ruptures of the ureter wall, urine entering the retroperitoneal space gradually and in small quantities soaks the tissue and contributes to the development of urinary backflow and urinary infiltration. Retroperitoneal fatty tissue soaked with urine and blood subsequently often suppurates, which leads to the development of isolated purulent foci or, with significant necrosis and melting of fatty tissue, to urinary phlegmon, secondary peritonitis, but more often to urosepsis.

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Symptoms of open injuries (wounds) of the ureters

In the vast majority of cases, ureteral injuries occur with severe combined trauma to the organs of the chest, abdominal cavity and pelvis. The degree and nature of the injury is determined by the kinetic energy and shape of the wounding projectile, the location of the injury and the hydrodynamic effect. In a number of observations, bruises and tissue ruptures occur due to the lateral effect of the shock wave of a projectile flying nearby.

The general condition of the victims is serious, most of them are in shock. This is due to both the injury to the ureter and the combined damage to the kidneys, abdominal organs, pelvis, chest and spine.

Gunshot and stab injuries to the ureters may not initially manifest themselves clinically. The main symptoms of ureter injury are pain in the wound, retroperitoneal hematoma or urohematoma, and hematuria. The most important symptom of ureter injury is the release of urine from the wound.

Moderate hematuria, which is observed only once in the case of a complete rupture of the ureter, is observed in approximately half of the wounded. Urine leakage from the wound canal (urinary fistula) usually does not occur in the first days, it usually begins on the 4th-12th day after the injury of the ureters. In case of a tangential injury of the ureter, the urinary fistula is intermittent, which is explained by the temporary restoration of the ureter's patency. If the peritoneum is damaged, urine enters the abdominal cavity, and the leading clinical manifestations in this case are symptoms of peritoneal irritation; peritonitis develops. If the outflow of urine is obstructed and it does not enter the abdominal cavity, it soaks the fatty tissue, urohematoma, urinary leaks, urinary intoxication, urinary phlegmon and urosepsis develop.

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Classification of ureteral trauma

Mechanical injuries of the ureters are divided into two groups by type: closed (subcutaneous) and open injuries of the ureters. Among open ones, bullet, shrapnel, piercing, cutting and other wounds are distinguished. Depending on the nature of the injury, they can be isolated or combined, and depending on the number of injuries - single or multiple.

The ureter is a paired organ, therefore, in case of injury, it is necessary to distinguish the side of damage: left-sided, right-sided and bilateral.

The classification of closed and open ureteral injuries, used in Russia to this day, divides them as follows:

By localization (upper, middle or lower third of the ureter).

By type of damage:

• injury;
• incomplete rupture on the mucous membrane side;
• incomplete rupture of the outer layers of the ureter;
• complete rupture (injury) of the ureter wall;
• interruption of the ureter with divergence of its edges;
• accidental ligation of the ureter during surgery.

Closed ureteral injuries are rare. The small diameter, good mobility, elasticity and depth of the ureters make them difficult to access for this type of injury. In rare cases, complete or partial destruction of the ureter wall or its crushing may occur, leading to necrosis of the wall and urinary leaks or the formation of a ureteral stricture.

Closed injuries of the ureters are divided into contusions, incomplete ruptures of the ureter wall (its lumen does not communicate with the surrounding tissues), complete ruptures of the ureter wall (its lumen communicates with the surrounding tissues); ureteral interruption (with divergence of its ends).

Open injuries of the ureter are divided into contusions, tangential injuries of the ureters without damage to all layers of the ureter wall; ureteral rupture; accidental injury or ligation of the ureter during instrumental examinations or laparoscopic surgeries.

Currently, the American Urological Association has proposed a classification scheme for ureteral injuries, which has not yet been widely used in domestic specialized literature, but it is believed that its use is important for choosing the correct treatment method and for unifying clinical observation standards.

American Urological Association Classification of Ureteral Injuries

Degree of damage	Trauma characteristics
I	Hemorrhage (hematoma) of the ureter wall
II	Rupture of the wall less than 50% of the ureteral perimeter
III	Rupture of the wall of more than 50% of the ureteral perimeter
IV	Complete rupture of the ureter with devascularization of its wall less than 2 cm
V	Complete rupture of the ureter with devascularization of its wall more than 2 cm

Diagnosis of ureteral trauma

Diagnosis of ureteral injuries and trauma is based on the analysis of the circumstances and mechanism of injury, clinical manifestations and data from special research methods.

Diagnosis of ureteral trauma includes three stages: clinical, radiological and surgical.

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Clinical diagnosis of ureteral trauma

Clinical diagnosis of ureteral injuries is based on the presence of appropriate suspicions (e.g., wound localization and direction of the wound channel, assessment of urine and wound discharge). Such suspicions arise primarily in case of penetrating, often gunshot, abdominal wounds, if the projection of the wound channel corresponds to the location of the ureter or if lumbar pain, vaginal urine discharge and other appropriate symptoms appear after hysterectomy. To clarify the localization and nature of the damage and to choose treatment tactics, it is of great importance to examine urine collected during the first urination after the injury.

Although early diagnosis of ureteral injuries is considered the basis for obtaining good treatment results, statistics show that this is an exception rather than a rule. Even during iatrogenic ureteral injuries, the diagnosis is established intraoperatively only in 20-30% of cases.

Isolated iatrogenic ureteral injury can be easily missed. After gynecological surgeries involving ureteral injury, patients experience lower back pain, vaginal urine leakage, and septic conditions. If ureteral injury is suspected during surgery, intravenous indigo carmine or methylene blue solution is recommended to detect the damaged area of the ureter, which is especially important for detecting partial ureteral injury. Ureteral catheterization is also proposed as a method of prevention and intraoperative diagnostics of ureteral injury.

In case of a closed injury, a rupture of the ureteral junction, more typical for children, is always associated with a sudden braking mechanism. Such injuries may not be recognized, since even during operations performed for other indications, they are almost impossible to detect by transabdominal palpation of the ureteral region. In this regard, in case of injuries that arose due to a sudden braking mechanism, high-volume excretory urography with one shot (one shot IVP) is indicated, and in case of stable hemodynamic parameters, CT with bolus administration of RVC. The absence of contrast in the distal ureter indicates its complete rupture. Such unusual findings as a fracture of the transverse or spinous processes of the lumbar vertebrae may indicate probable damage to the ureters from the impact of an external force.

Based on the victim's complaints, anamnesis and clinical signs, the fact of ureteral injury is usually established. At the same time, a more in-depth instrumental examination is necessary to determine the type and nature of ureteral injury. Depending on the indications and specific capabilities of the medical institution, various methods of examining the victim are used in each case.

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Instrumental diagnostics of ureteral trauma

Examination of the victim begins with ultrasound of the abdominal organs and peritoneal space. Special studies usually begin with survey radiography of the kidneys and urinary tract and excretory urography. If indicated, infusion urography with delayed radiographs (after 1, 3, 6 hours or more), CT. Chromocystoscopy and catheterization of the ureters with retrograde uretero- and pyelography have high diagnostic value. Instrumental methods are most often used at the final stage of diagnostics and in severe injuries immediately before surgery.

If there is a suspicion of damage to the ureter, including iatrogenic ones that occur during instrumental manipulations, the introduction of a contrast agent through a ureteral catheter, stent or loop catheter helps to determine the location of the injury and the prevalence of leaks, which contributes to the timely diagnosis of such damage and the correct provision of adequate assistance.

The general principles of examination of a victim with suspected ureteral injury are the same as for closed injuries of this organ.

It is important to remember that the severity of the wounded person's condition does not allow the use of many diagnostic methods. Thus, intravenous urography in all its variants, chromocystoscopy, radioisotope methods are of little information in wounded in shock. Any transurethral diagnostics are generally contraindicated for a wounded person in such a state. If the wounded person's condition allows, then the most informative results are ultrasound and CT.

The detection of a fluid formation in the retroperitoneal tissue (urohematoma) during ultrasound examination allows one to suspect damage to the urinary tract.

Recognition of fresh ureteral injuries (gunshot, stab) can be especially difficult. Severe associated injuries usually attract the surgeon's attention first, as a result of which the ureteral injury is often overlooked. Analysis of such observations shows that ureteral injury is almost always not diagnosed even during the initial surgical treatment of the wound and is detected only several days after it.

Excretory urography can be successfully used to diagnose ureteral damage, which, with sufficient renal function, shows the condition and degree of ureteral patency, the level of its damage and the leakage of contrast agent into the surrounding tissues. Chromocystoscopy, in addition to assessing the condition of the bladder, provides information on the patency of the ureter; intravenously administered indigo carmine can also be detected in the urine excreted from the wound channel.

If indicated, ureteral catheterization and retrograde pyeloureterography are performed, supplemented by fistulography if necessary.

The above also applies entirely to the diagnosis of iatrogenic (artificial) damage to the ureters.

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Diagnostic capabilities of radiation diagnostic methods

In most clinical situations, a plain abdominal X-ray and excretory urography allow the extent of damage to be assessed and treatment tactics to be planned. Indications for urography include hematuria and urohematoma. In shock or life-threatening bleeding, urography should be performed after stabilization of the condition or during surgery.

In unclear situations, retrograde ureteropyelography or CT are performed, which are the most informative examination. If the patient's condition is unstable, the examination is shortened to infusion or high-volume urography, and the final diagnosis is made during surgery.

Ureteral damage may manifest itself as obstruction of the upper urinary tract, but the most reliable radiographic symptom of damage is leakage of the ureter beyond its limits.

To detect this, excretory urography is performed with intravenous administration of RCA in the amount of 2 ml/kg. Currently, instead of excretory urography, CT with bolus administration of RCA is more often performed, which allows detecting concomitant damage. If these studies are uninformative, it is recommended to perform a survey radiography of the urinary system 30 minutes after the introduction of a double dose of contrast agent. If even after this it is impossible to completely exclude damage to the ureters, and the suspicion remains, retrograde ureteropyelography is performed, which in such situations is considered the "gold standard" of diagnosis.

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Intraoperative diagnostics of ureteral trauma

The most effective method for diagnosing ureteral injury is direct visualization of the damaged area, since this is usually possible in 20% of cases using both pre- and intraoperative studies! That is why, during an abdominal revision, at the slightest suspicion of ureteral injury, a revision of the retroperitoneal space should also be performed, especially if there is a hematoma there.

There are absolute and relative indications for revision of the retroperitoneal space.

• Absolute indications: ongoing bleeding or pulsating perirenal hematoma indicating significant damage.
• Relative indications: urinary extravasation and the inability to determine the extent of damage due to the need to perform urgent intervention for combined damage to the abdominal organs (this approach allows avoiding unnecessary revision of the retroperitoneal space).

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Differential diagnosis of ureteral trauma

For the purpose of differential diagnosis between ureter and bladder injuries, a method of filling the bladder with a colored liquid (methylene blue, indigo carmine) is used. In case of bladder injury, colored liquid is released from the urinary fistula; in cases of ureter injury, uncolored urine is still released from the fistula.

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Treatment of ureteral trauma

Indications for hospitalization

Suspected ureteral injury is an indication for emergency hospitalization of the patient.

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Treatment of ureteral trauma: general principles

The choice of treatment method for ureteral damage depends on both its nature and the timing of diagnosis. In the case of late diagnosis of iatrogenic ureteral damage due to urological and non-urological operations, the need for additional interventions is 1.8 and 1.6, respectively, while in the case of intraoperative diagnosis this figure is only 1.2 additional interventions per patient.

First aid in military field conditions for ureteral trauma includes pain relief with trimeperidine (promedol) from a syringe-tube or its analogue, simple anti-shock measures, oral administration of broad-spectrum antibiotics, immobilization if a spinal or pelvic fracture is suspected, and in case of injuries - application of an aseptic dressing and evacuation on a stretcher in a prone position.

First aid consists of repeated use of painkillers, elimination of transport immobilization deficiencies, administration of antibiotics and tetanus toxoid in case of open injuries, and bladder catheterization as indicated. In case of ureter injuries, dressing control is performed with bandaging, and if indicated, temporary or final cessation of external bleeding (application of a clamp, ligation of a vessel in a wound), anti-shock measures are taken.

For vital indications, victims with penetrating cavity wounds, as well as those who show signs of ongoing internal bleeding, undergo surgery.

Specialized care is provided in urological departments. It involves bringing victims out of shock, further treating wounds according to generally accepted urological principles, performing repeated surgical treatments or surgical interventions on the ureter with elements of reconstructive surgery. It includes performing delayed surgical interventions in case of ureter damage, treating complications (suppuration, fistula, pyelonephritis, narrowing of the urinary tract), performing rock-constructive-restorative operations.

Surgical treatment of ureteral trauma

In case of minor ureteral damage (the most severe is a partial rupture of its wall), nephrostomy or ureteral stenting (the latter is preferable) may be sufficient. Stenting can be performed both retrogradely and antegradely under X-ray television control and contrast ureteropyelography, using a flexible guidewire. In addition to stenting, bladder catheterization is also performed to prevent reflux. The stent is removed after an average of 3 weeks. In order to clarify the conductivity of the ureter, excretory urography or dynamic nephroscintigraphy is performed after 3-6 months.

Treatment of ureteral injuries is mainly surgical. Any surgical intervention for ureteral injury should be completed by drainage of the retroperitoneal space, placement of a nephrostomy or drainage of the CPS by internal or external drainage with stent-type catheters.

If damage to the ureters occurs during surgery, then the first step is to restore the integrity of the ureter using a ureteral stent and external inactive drainage of the surgical area.

Surgical approaches are determined by the nature of the damage. In case of isolated damage to the ureter, it is preferable to perform lumbotomy, lumbar extraperitoneal incision in the eleventh intercostal space or pararectal incision, and in case of damage to the lower third of the ureter or in the presence of signs of combined damage to the abdominal organs - laparotomy, usually median.

In case of complete rupture of the ureter, the only acceptable method of treatment is surgical restoration of its integrity.

The principles of ureteral reconstruction are no different from those of other reconstructive interventions of the urinary tract. To achieve success, it is necessary to ensure good vascular nutrition, complete excision of the affected tissues, wide mobilization of the ureter to ensure the imposition of a hermetic (watertight) anastomosis without tension, and good drainage of the wound. It is also desirable to cover the anastomosis with an omentum on a nutrient pedicle.

Depending on the level of ureteral reconstruction, various operations are performed.

• upper third - ureteroureterostomy, transureteroureterostomy, ureterocalicostomy;
• middle third ureteroureterostomy, transureteroureterostomy, Boari procedure;
• lower third various types of ureterocystoneostomy;
• entire ureter, replacement of the ureter with the ileum, autotransplantation of the kidney.

In case of damage to the ureter above the pelvic ring, it is necessary to economically resect its edges and suture the ends on the intubation tube, perform a nephrostomy and drain the retroperitoneal tissue.

In case of a larger ureter defect, the kidney is moved and fixed below its usual place. In case of damage to the lower third of the ureter, it is ligated and a nephrostomy is applied. Reconstructive and restorative operations (Boari, Demel operations) are performed after the inflammatory process has subsided.

There is only one situation in which immediate nephrectomy is indicated, when the ureteral injury is accompanied by an aortic aneurysm or major vascular lesions requiring prosthetic replacement. This helps to avoid urine extravasation, urinoma formation and infection of the prosthesis.

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Treatment of closed ureteral injuries

Conservative treatment for ureter damage during instrumental manipulations and subcutaneous trauma is permissible only in cases of bruises and ruptures of the ureter wall without violating the integrity of all its layers. Treatment consists of prescribing anti-inflammatory drugs, thermal procedures, ureteral bougienage according to indications, and treatment aimed at preventing the development of periureteritis and strictures.

Clinical practice convinces us that in case of closed ureteral trauma, surgical treatment can be used as an emergency aid. The main indications are increasing internal bleeding, rapid enlargement of periureteral urohematoma, intense and prolonged hematuria with deterioration of the general condition of the victim, as well as signs of a combination of ureteral trauma with damage to other internal organs. General anesthesia is preferable.

Iatrogenic damage to the ureters occurs not so much due to technical reasons, but as a result of topographic and anatomical changes in the surgical field, developmental anomalies of the urinary organs and the desire of urologists for maximum radicalism in operations on the pelvic organs.

In case of iatrogenic ureteral damage during endoureteral manipulations (e.g. ureteroscopy, ureterolithotripsy, calculus extraction, endoureteral tumor removal), when all layers are damaged and there are leaks into the periureteral tissue, and also when there is a suspicion of damage to the parietal peritoneum, surgical treatment is always indicated. The main measure to prevent possible iatrogenic ureteral damage during surgical interventions for various diseases of the abdominal cavity and pelvis is an examination of the upper urinary tract in the postoperative period. A fairly promising method for preventing intraoperative damage is fluorescent visualization of the ureters during surgery, which is performed using intravenous sodium fluorescein. As a result, luminescent glow of the ureter occurs, which allows visual control of their position without skeletonization. An effective way to prevent iatrogenic ureteral damage is the use of conventional or special luminous catheters. allowing control of the position of the ureters during surgery.

The damaged ureter identified during the operation is sutured using one of the generally accepted methods after economical excision of the edges, trying to transform the transverse rupture into an oblique one. The damaged ureter is intubated with a stent or drainage tube.

The surgical wound in the lumbar region, regardless of the nature of the surgical intervention on the ureter, is carefully checked for hemostasis and foreign bodies, drained and sutured. If the surgical intervention on the damaged ureter was performed through the abdominal cavity, a counter-opening is applied in the lumbar or iliac region, the posterior leaflet of the peritoneum in the projection of the damaged ureter is sutured, and the abdominal cavity is tightly sutured. In the immediate postoperative period, the entire range of conservative measures aimed at preventing complications is continued.

Treatment of open ureteral injuries

In case of open injuries (wounds) of the ureters, surgical treatment is predominantly performed (up to 95%).

Conservative treatment of ureteral trauma is permissible only in isolated cases, with isolated wounds from cold weapons, without significant tissue destruction, with moderate and short-term hematuria and satisfactory condition of the wounded person. Treatment in these cases is carried out according to the same plan as for closed ureteral injuries.

In isolated ureter injuries, one of the types of lumbar incisions or pararectal access is used; in combined injuries, access is determined by the nature of the damage to the abdominal, chest and pelvic organs, but they strive to use typical thoraco-, lumbo- and laparotomy in various combinations. Most urologists prefer midline laparotomy for combined injuries to the ureters and abdominal organs. When performing interventions on injured organs, it is advisable to follow a certain sequence: first, all measures are taken to stop severe bleeding, the source of which is most often the parenchymatous organs and mesenteric vessels; then, the necessary interventions are performed on hollow organs (stomach, small and large intestine): lastly, wounds of the urinary tract (ureter, bladder) are treated. If the ureter is destroyed over a large area, a nephrostomy is applied and the ureter is intubated.

In case of ureteral injuries, suturing of its ends after excision is permissible if the diastasis is no more than 5-6 cm; its distal and proximal ends must first be mobilized. The following interventions are possible to prevent subsequent narrowing at the anastomosis site: when resecting the damaged section of the ureter, its proximal and distal ends are crossed obliquely and anastomosed with U-shaped sutures: an end-to-side anastomosis is performed after ligation of the distal end; a side-to-side anastomosis is performed after ligation of the distal and proximal ends. This is possible only if the ureter is long enough. After suturing the ureteral wound or its resection with subsequent anastomosis, ureteropyelonephrostomy (if the ureter is damaged in the upper third) or ureterocystotomy (if the ureter is damaged in the middle or lower thirds) is performed.

A great contribution to the development of plastic surgeries on the upper urinary tract aimed at sensing kidney function was made by both domestic and foreign urologists. Significant technical difficulties arise in diagnosing recurrent hydronephrosis, specific lesions of the upper urinary tract, consequences of traumatic, including iatrogenic, injuries, ureteral-cutaneous fistulas with extended, complicated strictures of the proximal ureter. Of the many technical solutions proposed in clinical practice, in such cases, operations are used according to the methods of N. A. Lopatkin, Calp-de-Wird, Neuwert, replacement of the ureters with intestine and autotransplantation of the kidney. Intestinal ureteroplasty is indicated for bilateral ureterohydronephrosis, hydronephrosis of a single kidney, ureteral fistulas, long and recurrent ureteral strictures, including post-traumatic and post-country genesis, and can be considered as an alternative to nephroureterectomy.

These surgical interventions are classified as highly complex and do not always end successfully, and therefore a decision is often made on lifelong nephrostomy drainage or in favor of nephrectomy. In the case of a single kidney, such tactics condemn the patient to a lifelong existence with nephrostomy drainage. B.K. Komyakov and B.G. Guliyev (2003) in the case of extended defects of the proximal ureter proposed an original method of surgical intervention - upward displacement of the pelvic section of the ureter by cutting out a flap from the bladder together with the corresponding half of the Lieto triangle and the orifice.

Technique of operation

Using pararectal access from the costal arch to the pubis, the retroperitoneal space is widely opened and the pathologically altered section of the ureter is resected. Then the peripheral end of the resected ureter (up to the orifice) and the lateral wall of the bladder are mobilized without damaging the peritoneum and the superior vesical vessels. Using an oval incision that captures the corresponding half of the bladder triangle, a wide flap is cut out from its lateral wall together with the orifice, which is displaced in the cranial direction. The integrity of the orifice and ureter in this area is not violated, thereby preserving their blood supply thanks to the vessels of the bladder. The distal section of the ureter, thus displaced, is sutured with its peripelvic section or pelvis.

They are sutured with its peri-pelvic section or pelvis. The resulting defect in the urinary bladder is sutured with a nodal vicryl suture, a Foley catheter is installed along the urethra. A nephrostomy is preserved or formed. An intubator is inserted into the proximal section of the ureter or installed through a nephrostomy and anastomosis. The paranephric and paravesical spaces are drained with silicone tubes, the wound is sutured.

In case of extended gunshot defects of the ureter, in case of ureteral necrosis in patients with a transplanted kidney, in case of iatrogenic extended injuries of the ureter, multiple ureteral fistulas, one of the treatment methods is drainage of the kidney by percutaneous puncture nephrostomy or autotransplantation of the kidney. If the ureter is long enough, it is possible to perform an operation to create a new anastomosis of the ureter with the urinary bladder. Treatment of patients with a complete ureteral defect is a complex problem. In the absence of a full-fledged ureter, the main treatment method is creating an anastomosis between a flap from the urinary bladder (Boari-type operation) in patients after transplantation of an auto- or donor kidney. D.V. Perlin et al. (2003). R.Kh. Galeev et al. (2003) prove the possibility of complete replacement of the ureter by pyelocystoanastomosis by clinical observation.

Based on the data of a comprehensive study, including X-ray radiology, it is possible to judge the details of morphological changes in the ureter wall only tentatively. Visual revision of the ureter during surgery suffers from subjectivity. Identification of structural changes and their extent in the ureter wall during surgery does not create a clear idea. According to visual assessment, the boundaries of the contracting part of the ureter are 10-20 mm smaller than according to EMG indicators performed during surgery on the exposed ureter. Only at a distance of 40-60 mm are electrical potentials in the ureter wall close to normal revealed. This means that direct ureterocystoneostomy can be performed with altered tissues. As a result, the patency of the urinary tract is not sufficiently restored, and the surgical intervention itself cannot be classified as radical.

A mandatory element of surgical intervention for open (especially gunshot) injuries of the ureters is surgical treatment of the wound(s), which includes, in addition to stopping bleeding, excision of non-viable tissue, dissection of the wound channel, removal of foreign bodies, cleaning the wound from dirt, and the introduction of antibiotic solutions into and around it.

After intervention on the damaged ureter and surgical treatment of the wound(s), reliable drainage of the periureteral space is ensured, including by applying counter-openings.

According to Z. Dobrowolski et al., different types of operations for ureteral injuries are performed with different frequencies: ureteroneocystostomy - 47%, Boari operation - 25%, end-to-end anastomosis - 20%, ureteral substitution with the ileum - 7%, and kidney autotransplantation - 1%. D. Medina et al. performed ureteral restoration with stenting in 12 out of 17 patients with early diagnosed ureteral injuries, without stenting in one, and by ureterocystoneostomy in four.

As for the possible outcomes of late diagnosis of ureteral injuries, different authors report completely contradictory data. Thus, DM McGinty et al. in 9 patients with late diagnosis of ureteral injuries noted a mainly unfavorable outcome with a high rate of nephrectomies, while D. Medina et al. in 3 similar patients performed restoration with a favorable outcome.

Currently, there is an ongoing search for alternative methods of treating ureteral injuries that could reduce the invasiveness of interventions and/or improve quality of life. Among such interventions is the endoscopic method of dissecting strictures of the lower third of the ureter up to 1 cm using the "cut-to-the-light" technique and alkaline titanyl phosphate laser, which leads to a long-term stable result. Complications

There are early and late complications of ureteral damage. Early complications include urinary leaks, development of urohematoma, and various infectious and inflammatory complications (pyelonephritis, retroperitoneal phlegmon, urinary peritonitis, sepsis). Late complications include ureteral stricture and obliteration, ureterohydronephrosis, and urinary fistulas.

[ 26 ], [ 27 ], [ 28 ]

Prognosis of ureteral injury

The prognosis for open and closed ureteral injuries depends on the degree of injury, the nature and type of damage to this organ, complications, damage to other organs in case of combined injuries, and the timeliness and volume of care provided. Patients who have suffered a ureteral injury remain at high risk of developing late complications.

The experience of many urologists in performing various types of reconstructive operations on the urinary tract, including those accompanied by significant trauma to the ureter, forces them to take an individual approach to restoring the patency of the ureter in each specific case.

In conclusion, it should be noted that all publications on treatment and diagnostic tactics for ureteral injuries are retrospective. This means that their reliability reaches only grade III or lower. Naturally, this fact implies the need for serious research to obtain more reliable results, but even so, some theses can already be outlined.

• Most ureteral injuries are iatrogenic and are caused by gynecological surgeries. Such injuries often affect the lower third of the ureter. An effective diagnostic method in this case is intraoperative, the preferred method of treatment is reimplantation of the ureter into the bladder.
• In case of ureteral injuries caused by external force, the upper third of the ureters is mainly affected. They are almost always accompanied by concomitant injuries to other organs. The main cause is penetrating gunshot injuries to the ureters. In conditions of stable hemodynamics, the preferred diagnostic method is CT with contrast. In case of gunshot wounds, they can occur due to reactive concussion and devascularization of the adventitial layer, therefore, during surgical treatment, wide refreshment of its edges is mandatory before restoration.
• Closed ureteral injuries are predominantly found in children, involve the ureteral junction, and are associated with a sudden braking mechanism.

[ 29 ], [ 30 ], [ 31 ], [ 32 ]