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1、Section Ureteral Trauma,Ureter is the least commonly injured portion of the genitourinary tract , because of its small caliber and mobility and because it is well protected NOTE: caliber【医】管径；口径,Cause,The cause of ureteral injury may be categorized as due to external trauma or to iatrogenic events.,
2、External trauma Isolated ureteral injuries from external trauma are exceedingly rare. Injury from small-caliber missiles or stab wounds are the usual causes of penetrating ureteral trauma.NOTE: exceedingly【标】ad. 非常地; 极度地; caliber【医】管径；口径; missile【医】投射器; avulsion【医】撕脱伤,Iatrogenic events Iatrogenic ur
3、eteral injuries predominate in most civilian and rural population. NOTE: vulnerable【医】易损的;脆弱的； iatrogenic【标】a. 医源性的,The surgical sub specialties and the associated open pelvic procedures most likely to produce iatrogenic ureteral injury are as follows: Gynecology-hysterectomy, oophorectomy, bladder
4、neck suspension; General surgery-colectomy, appendectomy; Vascular surgery-aortoiliac bypass; Urology-ureterolithotomy, ureteral reimplantation. Lumbar laminectomy is an infrequent cause of ureteral injury.,The increasing array of pelvic endoscope and laparoscopic procedures is associated with a new
5、 group of ureteral injuries, as follows: Gynecology -laser treatment of endometriosis, tubal ligation; Urology- pelvic lymphadenectomy, ureteroscopy, stone removal; General surgery-appendectomy, bowel resection.,Devascularization may occur with extensive pelvic lymph node dissections or after radiat
6、ion therapy to the pelvis for pelvic cancer. In this situations, ureteral fibrosis and subsequent strictures formation may developed along with ureteral fistulas.NOTE: Devascularization【医】血行阻断,Pathogenesis and pathology,Sepsis and severe renal damage，renal atrophy A partially divided ureter urinary
7、extravasation a large urinoma ureterovaginal or ureterocutaneous fistula Intraperitoneal extravasation of urine ileus and peritonitis. After partial transection of the ureter, some degree of stenosis and reactive fibrosis develops, with concomitant mild to moderate hydronephrosis.,Clinical manifesta
8、tion,Acute hydronephrosis or urine leak the postoperative course is marked by fever as well as flank and lower quadrant pain. paralytic ileus with nausea and vomiting early in the postoperative cause. Signs and symptoms of acute peritonitis,Anuria Bilateral ureteral injury is manifested by postopera
9、tive anuria.,Fistula If ureterovaginal or cutaneous fistula develops, it usually does so within 2-3 weeks Watery vaginal leakage in patient after pelvic surgery,Hematuria Hematuria is an unreliable indicator present in 90% of ureteral trauma owing to external violence but present in only 1% of iatro
10、genic cases.,Diagnosis,A diagnosis of ureteral injury is based primarily on suspicion: there are no classic signs or symptoms. Persistent abdominal painfeverileus rising creatinine Five percent are asymptomatic and may be diagnosed years after with a nonfunctioning and hydronephrotic kidney.,In pati
11、ents with penetrating trauma, the site of injury should raise suspicion. The mid portion of the ureter seem to be the most common site of penetrating injury. There are usually associated vascular and other abdominal visceral injuries.,A plain film of the abdomenmay demonstrate a large area of increa
12、sed density in the pelvis or in the area of retroperitoneum where injury is suspected,IVP exravasation of contrast delayed function mild ureteral dilation proximal to the injury. Delayed excretion may be noted with hydronephrosis. A retrograde ureterogram Retrograde pyelography establisheds the leve
13、l and extent of the ureteral injury,The IVP and retrograde pyelogram are the most useful studies The diagnosis of ureteral injury is establish-ed by demonstration and localization of urinary extravasation or high grade obstruction on imaging studies.,Ultrasonography outlines hydroureter of urinary e
14、xtravasation as it develops into a urinoma perhaps the best means of ruling out ureteral injury in the early postoperative period. It has the advantage of being nonivasive and rapid. Ultrasound, radionuclide scan, or abdominal CT may provide the first clues for delayed diagnosis of ureteral injury.,
15、Fistula identification Water discharge from the wound or vagina may be identified as urine by determining the creatinine concentration Urine has may times the creatinine concentration found in serum Intravenous injection of indigo carmine or methylene blue that is then excreted in the urine can be a
16、 helpful adjunct.,Occasionally the diagnosis is made in the operating room during abdominal exploration.,Treatment,Selection of appropriate surgical management depends on the patients condition the site of injury the extent of injury the time diagnosis.,Following tangential injury or following a cla
17、mp or suture injury during surgery, passage of an indwelling double-J ureteral catheter may allow complete healing of the ureter. When inadvertent ureteral ligation is suspected in the immediate postoperative period, laparoscopy may allow confirmation and removal of the suture followed by endoscopic placement of a ureteral stent.,
