Injuries and damage to the ureters

Due to the location, size and mobility of injuries and damage to the ureters when exposed to external forces 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 of the ureter arising from the performance of therapeutic and diagnostic manipulations (for example, catheterization of the ureters, contact ureterolithotripsy), as well as during operations (usually on the pelvic organs).

ICD-10 code

S37.1. Trauma to the ureter.

[1], [2],

What causes ureteral injury?

The least frequent ureter is damaged by external injury. Isolated ureteral gunshot injuries are rarely observed: for 100 such injuries, there are only 8 isolated injuries. As a rule, they are combined with damage to other organs (with closed ureter injuries - up to 33%, with open injuries - up to 95% of all cases). According to various sources, injuries of the ureters account for only 1-4% of the damage to the urinary organs.

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

In modern local military conflicts, damage to the ureters occurs in 5.8% of the wounded. Ureter injuries during the Great Patriotic War occurred at about 10%, and during the local conflict in Afghanistan - at 32% of all injuries of the urinary organs.

Damage to the ureters can be caused as a direct (damage to the mucous membrane, compression of the ureter suture full Z partial dissection, crush, avulsion or separation), and mediated (devascularization during electrocautery or too thorough dissection, late ureteral necrosis after radiation exposure to etc. ) exposure. Open injuries of the ureter almost always occur with gunshot wounds and in all cases are in the nature of a combined injury.

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

In laparoscopic operations (mainly laparoscopically assisted transvaginal hysterectomy), the probability of damage to the ureter is less than 2%. At the same time, electrocoagulation acts as a damaging factor leading to damage to the ureters.

Endoscopic technologies for diagnosing and treating ureteral stones, obliterations and urethral strictures, urothelial tumors can be complicated by iatrogenic damage to the ureters (2–20% of observations). Damage to the ureters during ureteroscopy mainly covers only the mucous membrane, or there may be minor damage to its wall. Potential complications of endoscopic operations include perforation, ureteral stricture, ureteral false stroke, ureteral detachment, leading to bleeding of varying intensity, infectious and inflammatory complications, up to sepsis.

Perforation and the false course of the ureter can occur during the ureteral stent or conductor, especially when it is obstructed, for example with a stone, or if the course of the ureter is twisted.

Mostly iatrogenic damage to the ureters is associated with non-observance of some rules for endoscopic manipulation. If the resistance is irresistible when a stent or conductor is being performed, retrograde pyelography should be performed to clarify the anatomy of the ureter. With the use of small-caliber ureteroscopes (less than 10 Fr), flexible ureteroscopes and temporary ureteral stents, perforation of the ureter occurs in 1.7%, strictures - 0.7% of observations.

The rupture of the dilator balloon during endoscopic dilatation of the ureter stricture as a result of a sharp increase in pressure in the balloon may also lead to iatrogenic damage.

Ureteral detachment is rare (0.6%), but the most serious complication of ureteroscopy. This usually occurs in the proximal third of the ureter when a large calculus is removed with a basket without first being fragmented. If ureteral separation has occurred, then drainage of the urinary tract (percutaneous nephrostomy) is indicated, with further restoration of the integrity of the ureter.

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 neurogenic damage to the ureters occurs mainly in the young (average age 28 years), usually unilateral and always accompanied by damage to other organs.

In 95% of cases, they occur as a result of gunshot wounds, are much less likely to be caused by cold arms and most rarely occur during car accidents. When damage to the ureters, obtained from the effects of external forces, often damaged its upper third, the distal part - much less.

In general, the damage to the lower third of the ureter accounts for 74%, and the upper and middle third accounted for 13% each. It should be noted that such damage to the ureter is also often accompanied by damage to the visceral organs: the small intestine - in 39-65%, the large intestine - in 28-33%, the kidney 10-28%. Bladder - in 5% of observations. Mortality with such combinations of damage is up to 33%.

Symptoms of ureteral injury

Symptoms of injuries and damage to the ureter are extremely scarce, and there are no pathognomonic symptoms. The patient may be disturbed by pain localized in the lumbar, iliac, or hypochondrium. An important symptom that makes it possible to suspect damage to the ureter is hematuria. According to different sources, hematuria occurs in ureter damage only in 53-70% of cases.

The severity of the condition of the victim and the lack of a characteristic clinical picture leads to the fact that 80% of the wounded in the early stages of the provision of prompt assistance do not diagnose damage to the ureter, and subsequently reveal it only at the stage of the onset of complications. Both after combined and after isolated trauma of the ureters, a ureteral-skin fistula develops. Dribbling of urine into the metropolitan uterine tissue leads to the development of infiltration 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 with 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, and the increasing retroperitoneal urohematoma is accompanied by symptoms of peritoneal irritation and intestinal paresis.

Symptoms of closed ureteral injury

Closed ureteral damage is usually found in 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 ), a closed ureteral injury also includes damage to the intramural ureter during TURP of the bladder.

Damage to the ureter with a rupture of the wall or its complete interruption causes urine to flow to the colorectal tissue. With minor tears of the ureter wall, the urine entering the retroperitoneal space gradually and in small quantities permeates the fiber and promotes the development of urinary flow and urinary infiltration. The retroperitoneal fatty tissue impregnated with urine and blood is often suppressed, which leads to the development of isolated purulent foci or, with significant necrosis and melting of fatty tissue, to urinary cellulitis, secondary peritonitis, but more often to urosepsis.

[3], [4]

Symptoms of open lesions (wounds) of the ureters

In the absolute majority of cases, damage to the ureters occurs in severe combined injuries of the organs of the chest, abdomen and pelvis. The degree and nature of damage is determined by the kinetic energy and form of the injuring projectile, the localization of the injury and the hydrodynamic effect. In a number of observations, bruises and tears of tissue arise due to the lateral effect of the shock wave of a projectile passing by.

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

Gunshot and puncture-cut injuries of the ureters may initially not manifest clinically. The main symptoms of damage to the ureter are pain in a wound, retroperitoneal hematoma or urohematoma, hematuria. The most important symptom of ureteral damage is the excretion of urine from a wound.

Moderate hematuria, which is observed only once with a complete interruption of the ureter, is observed in approximately half of the wounded. The urine outflow from the wound canal (urinary fistula) usually does not occur in the first days, it begins most often on the 4-12th day after the injury of the ureters. With a tangent wound of the ureter, the urinary fistula is intermittent in nature, which is explained by the temporary restoration of patency of the ureter. 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 urine outflow is difficult and it does not enter the abdominal cavity, it is saturated with fatty tissue, the urohematoma, urinary flow, urinary intoxication, urinary phlegmon and urosepsis develop.

[5], [6], [7], [8]

Ureteral injury classification

Mechanical damage to the ureters by type are divided into two groups: closed (subcutaneous) and open injuries of the ureters. Among the open stand out bullet, shrapnel, stabbing, cutting and other injuries. Depending on the nature of the damage, they can be isolated or combined, and on the number of damages, single or multiple.

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

The classification of closed and open injuries of the ureter, which has been used in Russia to date, categorizes them as follows:

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

By type of damage:

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

Closed ureteral damage is rare. The small diameter, good mobility, elasticity and depth of the ureters make them inaccessible for this type of injury. In rare cases, complete or partial destruction of the ureter wall or its crush can occur, leading to necrosis of the wall and urinary flow or the formation of a ureteral stricture.

Closed ureteral damage is divided into bruises, incomplete ruptures of the ureter wall (its lumen is not communicated with the surrounding tissues), complete ruptures of the ureter wall (its lumen communicates with the surrounding tissues); break ureter (with the divergence of its ends).

Open injuries of the ureter are divided into bruises, tangent ureter injuries without damage to all layers of the wall of the ureter; recess ureter; accidental injury or ligation of the ureter during instrumental examinations or laparoscopic surgical interventions.

At present, the American Association of Urology has proposed a classification scheme for ureteral injuries, which has not yet received widespread use in the domestic special literature, but consider that its use is important for choosing the right treatment method and for unifying the standards of clinical observations.

Ureteral Ureter Injury Classification American Urological Association

Damage rate	Trauma characteristic
I	Hemorrhage (hematoma) of the ureter wall
II	Wall rupture less than 50% of the perimeter of the ureter
III	Rupture of the wall more than 50% of the perimeter of the ureter
IV	Complete detachment of the ureter with the devascularization of its wall less than 2 cm
V	Complete detachment of the ureter with the devascularization of its wall more than 2 cm

Diagnosis of trauma to the ureters

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

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

[9]

Clinical diagnosis of ureteral injury

The clinical diagnosis of ureteral injury is based on the presence of relevant suspicions (for example, the location of the wound and the direction of the wound canal, the assessment of urine and wound discharge). Such suspicions arise primarily in penetrating, often gunshot, wounds of the abdomen, if the projection of the wound channel corresponds to the placement of the ureter or if after hysterectomy there is back, back pain, urine from the vagina and other relevant symptoms. To clarify the location and nature of the damage and the choice of treatment tactics, the study of urine collected during the first urination after the trauma is of great importance.

Although the early diagnosis of ureteral injuries is considered the basis for obtaining good results of treatment, nevertheless, as statistics show, this is rather an exception than a regularity. Even during iatrogenic damage to the ureter, intraoperative diagnosis is established only in 20-30% of cases.

Isolated iatrogenic damage to the ureter can be easily missed. After gynecological operations, accompanied by trauma to the ureter, patients develop back pain, urinary discharge from the vagina, and a septic condition develops. If a suspicion of ureteral injury occurs during surgery, intravenous administration of indigo carmine or methylene blue solution is recommended to detect the damaged part of the ureter, which is especially important for the detection of its partial damage. As a method of prophylaxis and for intraoperative diagnosis of ureteral injury, its catheterization is also proposed.

With a closed injury, the gap LMS, more characteristic for children, is always associated with a mechanism of sudden inhibition. Such lesions may not be recognized, since even during operations performed on other indications, by means of transabdominal palpation, the area of the ureters is almost impossible to detect. In this regard, for injuries arising from the mechanism of rapid inhibition, it is shown that high-volume excretory urography is performed with one shot (one shot IVP), and with stable hemodynamic parameters, CT scan with bolus injection of RVB. The lack of contrasting the distal ureter indicates its complete separation. Unusual findings, such as a fracture of the transverse or spinous processes of the lumbar vertebrae, may be aimed at the likely damage to the ureters from external force.

On the basis of complaints of the victim, history and clinical signs, the fact of damage to the ureter is usually established. However, the determination of the type and nature of ureteral trauma requires more in-depth instrumental examination. Depending on the evidence and the specific capabilities of the medical institution, various methods of examining the victim are used in each case.

[10]

Instrumental diagnosis of ureteral injury

Examination of the victim begins with an Ultrasonography of the abdominal organs and euryptic space. Special studies are usually recited from performing a radiography of the kidneys and urinary tract and excretory urography. And for indications, infusion urography with delayed radiographs (after 1, 3, 6 hours or more), CT. Chromocystoscopy and ureteral catheterization with the performance of retrograde uretero- and pyelography have a high diagnostic value. Instrumental methods are most often used at the final stage of diagnosis and for severe injuries immediately before surgery.

If ureter damage is suspected, including iatrogenic ones that occur during instrumental manipulations, the introduction of a contrast agent in the ureteral catheter, stent or loop catheter helps to determine the localization of the injury and the incidence of lesions, which contributes to the timely diagnosis of such damage and the proper provision of adequate assistance.

The general principles of examination of an injured person with suspected ureter injury are the same as with closed injuries of this organ.

It is important to remember that the severity of the condition of the wounded does not allow the use of many diagnostic methods. So, intravenous urography in all its variants, chromocytoscopy. Radioisotope methods are uninformative in the wounded in a state of shock. Any transurethral diagnosis is generally contraindicated for a wounded person in this state. If the condition of the wounded allows, then the most informative results of ultrasound and CT.

The ultrasound examination of fluid formation in the retroperitoneal tissue (urohematoma) makes it possible to suspect damage to the urinary tract.

Recognizing fresh ureteral damage (gunshot, puncture-incised) can be especially difficult. Severe associated damage usually attracts the attention of surgeons in the first place, with the result that ureteral injury is often seen. Analysis of such observations shows that ureteral trauma is almost not usually diagnosed even during the initial surgical treatment of the wound and is detected only a few days after it.

For the diagnosis of ureteral damage, excretory urography can be successfully used, which, with sufficient kidney function, shows the state and degree of patency of the ureter, the level of its damage, and the flux of the contrast agent into the surrounding tissue. Chromocytoscopy, in addition to assessing the condition of the bladder, provides information about the patency of the ureter; Intravenous intravenous indigo carmine can also be detected in urine released from the wound channel.

If there is evidence, they perform catheterization of the ureter and retrograde pyelo-ureterography, if necessary supplemented with fistulography.

The foregoing concerns also the diagnosis of iatrogenic (artifactual) damage to the ureters.

[11], [12]

Diagnostic capabilities of radiation diagnostic methods

In most clinical situations, an overview snapshot of the abdominal organs and excretory urography can be used to assess the extent of damage and to outline treatment tactics. Indications for urography are hematuria and urohematoma. In case of shock or life threatening bleeding, urography should be performed after stabilization of the condition or during surgical intervention.

In unclear situations, retrograde ureteropyelography or CT is performed, which is the most informative study. If the condition of the victim is unstable, the examination is reduced before performing infusion or high-volume urography, and the final diagnosis is carried out during surgery.

Damage to the ureters can be manifested by obstruction of the upper urinary tract, but the most reliable radiological symptom of their damage is the flow of the RVB beyond its limits.

To detect this, an excretory urography is performed with intravenous administration of PKB in the amount of 2 ml / kg. Currently, instead of excretory urography, CT scan with bolus administration of RVB is performed more often, which allows detecting associated injuries. When these studies are not informative, a radiographic review of the urinary system is shown 30 minutes after administration of a double dose of a contrast agent. If after this it is impossible to completely eliminate damage to the ureters, and the suspicion persists, retrograde ureteropyelography is produced, which in such situations is considered the “gold standard” of diagnosis.

[13], [14], [15]

Intraoperative diagnosis of ureteral injury

The most effective method for diagnosing damage to the ureters is direct visualization of the damaged area, as with the help of both pre- and intraoperative studies this is usually possible in 20% of cases! That is why during the revision of the abdominal cavity at the slightest suspicion of injury to the ureters, the retroperitoneal space should also be revisited, especially if there is a hematoma.

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

• Absolute indications: continued bleeding or pulsating kidney 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 injuries of the abdominal cavity (this approach avoids unnecessary revision of the retroperitoneal space).

[16], [17], [18]

Differential diagnosis of ureteral injury

For the purpose of differential diagnosis between wounds of the ureter and bladder, the method of filling the bladder with colored fluid (methylene blue, indigo carmine) is used. If the bladder is damaged, the colored fluid is released from the urinary fistula; in cases of damage to the ureter, unpainted urine is still excreted from the fistula.

[19], [20]

Treatment of ureteral injury

Indications for hospitalization

Suspected damage to the ureter is an indication for emergency hospitalization of the patient.

[21], [22], [23], [24]

Treatment of ureteral trauma: general principles

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

First aid in the military field in case of ureteral injury provides for anesthesia with trimeperidine (promedol) from a syringe tube or its analogue, carrying out the simplest antishock measures, giving inside broad-spectrum antibiotics, immobilizing if you suspect a spinal fracture or pelvic bones, for injuries - applying an aseptic dressing and evacuating on a stretcher while lying down.

The first medical assistance is to reapply painkillers, eliminate defects in transport immobilization, administer antibiotics and tetanus toxoid for open lesions, bladder catheterization according to indications. In case of injuries of the ureters, the dressings are checked with bandaging, and when indicated, a temporary or final stop of external bleeding (clamping, wound dressing in the wound), antishock measures.

For health reasons, victims with penetrating abdominal injuries, as well as those who have signs of ongoing internal bleeding, are operated on.

Specialized care is provided in urological departments. When rendering it, the victims are removed from shock, further treatment of wounds according to the principles generally accepted in urology, repeated surgical treatments or surgical interventions on the ureter with elements of reconstructive surgery are performed. It includes the implementation of delayed surgical interventions in case of damage to the ureter, treatment of complications (suppuration, fistula, pyelonephritis, narrowing of the urinary tract), performing rokonstruktinno-rehabilitation operations.

Surgical treatment of ureteral injury

In case of minor lesions of the ureters (the most maximal - partial rupture of its wall) can be limited to nephrostomy or stenting of the ureter (preferably the latter). Stenting can be performed both retrograde and antegrade under X-ray control and contrast ureteropyelography using a flexible conductor. In addition to stenting, bladder catheterization is also performed to prevent reflux. The stent is removed on average after 3 weeks. In order to clarify the conductivity of the ureter produce excretory urography or dynamic nephroscintigraphy after 3-6 months.

Treatment of ureteral injury is predominantly surgical. Any surgery for damage to the ureter should be completed drainage of the retroperitoneal space, the imposition of a nephrostomy, or drainage of the CLS by internal or external drainage with stent-type catheters.

If, however, damage to the ureters occurred during surgery, the primary restoration of the integrity of the ureter with the use of a ureteral stent and external inactive drainage of the surgical area is recommended first.

Quick access is determined by the nature of the damage. With isolated damage to the ureter, it is preferable to perform a lumbotomy, lumbar extraperitoneal incision in the eleventh intercostal space or pararectal incision, and if the lower third of the ureter is damaged or if there are signs of combined damage to the abdominal cavity, a laparotomy, usually median.

With a complete rupture of the ureter, the only acceptable method of treatment is the prompt restoration of its integrity.

The principles of ureteral reconstruction do not differ from the principles 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, extensive mobilization of the ureter to ensure the imposition of a tight (waterproof) anastomosis without tension and good drainage of the wound. It is also desirable to cover the anastomosis with an omentum on the nutritive stem.

Depending on the level of the reconstruction of the ureter perform various operations.

• the upper third is ureteroureterostomy, transureturoureterostomy, ureterocaricostomy;
• middle third of ureteroureterostomy, transuret-ureterostomy, operation Boari;
• lower third various types of ureterocystoneostomy;
• the entire ureter, the replacement of the ureter by the ileum, the autotransplantation of the kidney.

If the ureter is damaged above the pelvic ring, it is necessary to economically resect its edges and sew the ends on the endotracheal tube, perform nephrostomy and drain the retroperitoneal tissue.

With a larger defect of the ureter resorted to the movement and fixation of the kidney below the usual place. If the lower third of the ureter is damaged, it is ligated and applied to the nephrostoma. Reconstructive surgery (operations Boari, Demel) perform after subsiding of the inflammatory process.

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

[25],

Treatment of closed ureteral injury

Conservative treatment in case of damage to the ureters during instrumental manipulations and subcutaneous injury is permissible only in cases of bruises and tears in the wall of the ureter without compromising the integrity of all its layers. Treatment consists of prescribing anti-inflammatory drugs, thermal procedures, according to the indications of ureteral ulceration, and treatment aimed at preventing the development of perioureterites and strictures.

Clinical practice convinces. That in case of closed injury of the ureters, it is possible to use surgical treatment in the order of emergency care. The main indications are an increase in internal bleeding, a rapid increase in the urethral urohematoma, intense and prolonged hematuria with a deterioration in the general condition of the victim, and signs of a combination of ureteral injury with damage to other internal organs. Anesthesia is preferably common.

Iatrogenic damage to the ureters is not so much due to technical reasons, but as a result of topographic-anatomical changes in the surgical field, abnormalities of the development of the urinary organs and urologists urge for maximum radicality during operations on the pelvic organs.

In case of iatrogenic damage to the ureter during endoureteral manipulations (for example, ureteroscopy, ureterolithotripsy, calculus extraction, endoureteral removal of tumors), when all layers are disturbed and there is leakage into the surrounding urethral tissue, as well as when parietal peritoneal injury is suspected, an operative treatment of the parietal peritoneum is always indicated, an operative prevention of possible iatrogenic ureteral injury when performing surgical interventions for various diseases of the abdominal cavity and pelvis is to study the state of the upper urinary tract of operational period. A luminescent visualization of the ureters during surgery, which is performed using intravenous fluorescein sodium, is a fairly promising method for the prevention of intraoperative damage. As a result, a luminescent luminescence of the ureter occurs, which allows visual control of their position without skeletonization. An effective way to prevent iatrogenic damage to the ureters is to use conventional or special luminous catheters. Allowing to control the position of the ureters during surgery.

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

The surgical wound in the lumbar region, regardless of the nature of the surgery on the ureter, is carefully checked for hemostasis and foreign bodies, drained and sutured. If an operative intervention on the damaged ureter was performed through the abdominal cavity, contraception is applied in the lumbar or iliac region, the back sheet of the peritoneum is sutured in the projection of the damaged ureter, and the abdominal cavity is sutured tightly. In the immediate postoperative period, the whole range of conservative measures aimed at preventing complications continues.

Treatment of open ureteral injury

With open injuries (wounds) of the ureters, predominantly surgical treatment is carried out (up to 95%).

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

With isolated injuries of the ureters, one of the varieties of lumbar incisions or pararectal access is used; with combined injuries, access is determined by the nature of injuries of the organs of the abdomen, chest and pelvis, but at the same time tend to use typical thoraco-lyumbo-and laparotomy in various combinations. Most urologists with combined injuries of the ureters and abdominal organs prefer midline laparotomy. When intervening on wounded organs, it is desirable to observe a certain sequence: first, all measures are used to stop severe bleeding, the source of which is often the parenchymal organs and mesentery vessels; then the necessary interventions are performed on the hollow organs (stomach, small and large intestine): the wounds of the urinary tract (ureter, bladder) are last treated. When the ureter is destroyed for a long time, it is applied to the nephrostoma and the ureter is intubated.

For injuries of the ureters, stitching its ends after excision is permissible with a diastasis of no more than 5-6 cm; it is first necessary to mobilize its distal and proximal ends. To prevent further narrowing at the site of anastomosis, the following interventions are possible: when resecting the damaged area of the ureter, the proximal and distal ends of it are crossed obliquely and anastomosed by U-shaped sutures: anastomosis is performed in an "end to side" type after ligation of the distal end; carry out the anastomosis type "side to side" after ligation of the distal and proximal ends. This is possible only with a sufficient length of the ureter. After the ureter's wound is sutured or resected, followed by an anastomosis, ureteropyelonephrostomy is performed (if the ureter is damaged in the upper third) or ureterocystomy (if the ureter is damaged in the middle or lower third).

A great contribution to the development of plastic surgery on the upper urinary tract, aimed at a feeling of kidney function, was made by both domestic and foreign urologists. Considerable technical difficulties arise in the diagnosis of recurrent hydronephrosis, specific lesions of the upper urinary tract. The effects of traumatic, including iatrogenic, injuries, ureteral-skin fistulas with extensive, complicated strictures of the proximal ureter. Of the many proposed technical solutions in clinical practice in such cases, operations according to the methods of HA Lopatkin are used. Calpe de Wyrd, Neuvert, replacement of the ureter with intestine and autotransplantation of the kidney. Intestinal ureteroplasty is indicated for bilateral ureterohydronephrosis, single kidney hydronephrosis, ureteral fistula, long and recurrent ureteral strictures, including post-traumatic and post-early genesis, and can be considered as an alternative to nefroureterectomy.

These surgical interventions fall into the category of increased complexity and do not always end successfully, and therefore they often make decisions about lifelong nephrostomy drainage or in favor of nephrectomy. With a single kidney, such a tactic condemns a patient to lifelong existence with nephrostomy drainage. B.K. Komyakov and B.G. Guliyev (2003) with extensive defects of the proximal ureter suggested an original method of surgery - displacing the pelvic ureter upward by cutting out a flap from the bladder along with the corresponding half of the Lietho triangle and the mouth.

Operation technique

The pararectal access from the rib arc to the trunk widely opens the retroperitoneal space and resects the pathologically changed part of the ureter. Then, the peripheral end of the resected ureter (up to the mouth) and the side wall of the bladder are mobilized without damaging the peritoneum and the superior vesicles. An oval incision grasping the corresponding half of the triangle of the bladder, cut out from its side wall a wide flap along with the mouth, which is displaced in the cranial direction. The integrity of the mouth and ureter in this area is not disturbed, thereby maintaining their blood supply due to the vessels of the bladder. The distal ureter moved in this way is stitched to its prilochane department or pelvis.

Sew with his prilohanochnym department or pelvis. The resulting defect in the bladder is sutured with a nodal vicryl suture, a Foley catheter is inserted through the urethra. Preserve or shape the nephrostoma. Intubator is introduced into the proximal ureter or is inserted through the nephrostoma and anastomosis. The perirenal and paravesical spaces are drained with silicone tubes, the wound is sutured.

With extensive ureteral gunshot defects, with ureteral necrosis in patients with a transplanted kidney, with iatrogenic extensive ureteral injuries, multiple ureteral fistulas, one of the treatment methods is drainage of the kidney by percutaneous nephrostomy or autotransplantation of the kidney. With a sufficient length of the ureter, it is possible to perform the operation of imposing a new anastomosis of the ureter with the bladder. A difficult problem is the treatment of patients with a complete defect of the ureter. In the absence of a full ureter, the main method of treatment is the imposition of an anastomosis between the bladder flap (operation of the Boari type) in patients after an auto- or donor kidney transplant. D.V. Perlin et al. (2003). R.H. Galeev et al. (2003) by clinical observation prove the possibility of complete replacement of the ureter by pyelocysthoanastomosis.

According to the data of the complex, including radiological and radiological, research, it is only possible to judge the details of the morphological changes in the wall of the ureter. The visual revision of the ureter during surgery suffers from subjectivism. The identification of structural changes and their extent in the wall of the ureter during the operation does not create a clear view. According to a visual assessment, the boundaries of the ureteral part of the contraction turn out to be 10–20 mm less than the EMG indices performed during the operation on the bare ureter. It is only at a distance of 40-60 mm that electrical potentials in the wall of the ureter, which are close to normal, are detected. This means that a direct ureterocystoneostomy can be performed with altered tissues. As a result, the urinary tract is not sufficiently restored, and the surgery itself cannot be categorized as radical.

A mandatory element of the operative aid in case of open (especially gunshot) injuries of the ureters is surgical treatment of the wound (s), including, in addition to stopping the bleeding, excision of non-viable tissues, dissection of the wound channel, removal of foreign bodies, cleaning the wound from dirt, introduction of solutions into it and around it. Antibiotics.

After intervention on the damaged ureter and surgical treatment of wounds (wounds), reliable drainage of the urethral space is provided, including by imposing controversies.

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

As for the possible outcomes of late diagnosis of ureteral injuries, different authors report completely contradictory data. So, DM McGinty et al. In 9 patients with a late diagnosis of ureteral trauma there was mainly adverse outcome with a high rate of nephrectomy, while D. Medina et al. 3 similar patients recovered with a favorable outcome.

Currently, the search continues for alternative treatments for ureteral damage that could reduce the invasiveness of interventions and / or improve the quality of life. Among these interventions is the endoscopic method of dissecting the strictures of the lower third of the ureter to 1 cm using the "cut-to-the-light" technique and an alkaline titanyl-phosphate laser, which leads to a long-lasting, lasting result. Complications

There are early and late complications of ureteral damage. Among the early complications are urinary streaks, development of urohematoma and various infectious and inflammatory complications (pyelonephritis, retroperitoneal phlegmon, urinary peritonitis, sepsis). Late complications include stricture and obliteration of the ureter, ureterohydronephrosis and urinary fistula.

[26], [27], [28]

Ureteral injury forecast

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 with combined injuries, on timeliness and the amount of assistance provided. Patients undergoing ureteral injury remain at high risk of late complications.

The experience of many urologists in performing various options for reconstructive operations on the urinary tract, including those accompanied by significant ureteral trauma, makes it necessary to individually approach the restoration of the ureteral patency in each particular observation.

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

• Most of the damage to the ureters is iatrogenic in nature and is caused by gynecological operations. Such lesions affect the lower portion of the ureter. An effective method of diagnosis in this case is intraoperative, the preferred method of treatment is reimplantation of the ureter into the bladder.
• In case of damage to the ureters caused by external force, the upper third of the ureters is mainly affected. They are almost always accompanied by concomitant damage to other organs. The main reason are penetrating gunshot injuries of the ureters. Under conditions of stable hemodynamics, the preferred diagnostic method is CT with contrast. When gunshot wounds can occur due to reactive shaking and devascularization of the adventitious layer, therefore, in the course of surgical treatment, a wide refreshment of its edges is required before recovery.
• Closed ureteral damage is mainly found in children, encompassing LMS and is associated with a mechanism of abrupt inhibition.

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