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Abstract

Traumatic ureteral injury is a rare and challenging condition of the urinary system. To summarize the clinical features of patients with traumatic ureteral injury and examine the literature on traumatic ureteral injuries from the past 20 years. The clinical data of 30 patients with traumatic ureteral injury in Peking University First Hospital, Beijing Jiangong Hospital, as well as Emergency General Hospital from August 2015 to August 2023 were retrospectively collected. The clinical characteristics, management strategies, and follow-up outcomes were analyzed, and a review of the literature on traumatic ureteral injury from the past 20 years was conducted. The traumatic types in the case series was composed of sharp injury, impact injury, and falling injury, with 9, 16, and 5 cases, respectively. Ureteral injury was diagnosed immediately in 12 cases, while 18 cases had a delayed diagnosis. Besides, the median time from ureteral injury to operations was 8.5 months (IQR: 4–13 months) in the patients who received upper urinary tract repair surgery, including ureteral stenting in one case, ureteroureterostomy in four cases, pyeloplasty in two cases, lingual mucosal graft ureteroplasty in one case, ileal ureter replacement in five cases, and nephrectomy in one cases. The mean follow-up time is 39.1 ± 24.8 months. Concerning renal function, postoperative creatinine was substantially lower than preoperative one (78.6 ± 13.7 µmol/L vs 88.8 ± 17.0 µmol/L, p = 0.0009), and postoperative urea was significantly lower than preoperative one (4.6 ± 1.6 µmol/L vs 5.9 ± 1. 3 mmol/L, p = 0.0016). Traumatic ureteral injury is challenging to recognize due to its deep anatomical location, making timely diagnosis crucial. It is important to choose an appropriate reconstruction method based on severity, location, length to restore urinary tract continuity as early as possible.

Plain language summary

Traumatic ureteral injury

Traumatic ureteral injury is a rare and challenging condition of the urinary system. The clinical data of 30 patients with traumatic ureteral injury in Peking University First Hospital, Beijing Jiangong Hospital, as well as Emergency General Hospital from August 2015 to August 2023 were retrospectively collected. The clinical characteristics, management strategies, and follow-up outcomes were analyzed, and a review of the literature on traumatic ureteral injury from the past 20 years was conducted. The traumatic types in the case series was composed of sharp injury, impact injury, and falling injury, with 9, 16, and 5 cases, respectively. Ureteral injury was diagnosed immediately in 12 cases, while 18 cases had a delayed diagnosis. Besides, the median time from ureteral injury to operations was 8.5 months (IQR:4-13 months) in the patients who received upper urinary tract repair surgery, including ureteral stenting in 1 case, ureteroureterostomy in 4 cases, pyeloplasty in 2 cases, lingual mucosal graft ureteroplasty in 1 case, ileal ureter replacement in 5 cases, and nephrectomy in 1 cases. The mean follow-up time is 39.1 ± 24.8 months. Concerning renal function, postoperative creatinine was substantially lower than preoperative one. Traumatic ureteral injury is challenging to recognize due to its deep anatomical location, making timely diagnosis crucial. It is important to choose an appropriate reconstruction method based on severity, location, length to restore urinary tract continuity as early as possible.

Keywords

trauma ureteral injury upper urinary tract repair

Introduction

Ureteral injury is a rare condition of the urinary system, accounting for 1% of urologic injuries.¹ The causes predominantly include iatrogenic and traumatic injuries.² Iatrogenic ureteral injury could be attributed to ureteroscopy (URS), gynecological surgery, or general surgery. Furthermore, the rate of ureteral strictures associated with URS varies substantially, ranging from 0.1 to 5.8%. This rate can increase significantly, reaching up to 34%, in patients with impacted ureteral stones.³ Traumatic ureteral injury is infrequent, occurring in less than 1% of all traumas,⁴ 4% of penetrating traumas, and less than 1% of blunt traumas,⁵ and it most commonly affects the proximal ureter.⁶ Since traumatic ureteral injury is rare, and its clinical symptoms are not typical, there is a risk of misdiagnosis and missed diagnosis, resulting in more severe complications including ureteral stricture and renal dysfunction.^7–9 Over the past 20 years, some studies have reported and summarized the clinical characteristics of traumatic ureteral injury; however, they predominantly focus on injuries resulting from gunshot wounds.^{1,4,5,10–17} In China, since guns are prohibited in society, traumatic ureteral injuries are predominantly resulted from sharp instruments, impacts, and falls, which have distinct natures, and their onset is more insidious. This study aims to summarize the clinical features of traumatic ureteral injury through a case series and review the literature on traumatic ureteral injury from the past 20 years.

Methods

Clinical data

The clinical information with traumatic ureteral injury in Peking University First Hospital, Beijing Jiangong Hospital, and Emergency General Hospital between August 2015 and August 2023 was retrospectively gathered, and basic characteristics were included. Detailed information on ureteral injury, namely, injury types, symptoms, diagnostic examination, and location was collected. Likewise, AAST (American Association for the Surgery of Trauma, AAST) classification was employed to evaluate the degree of ureteral injury. The time interval between injury and treatment was recorded to assess the timeliness of intervention. Furthermore, treatment-related information included surgical strategies, operation time, as well as estimated blood loss. The study was conducted by the Declaration of Helsinki (revised 2013), and the Ethics Committee of Peking University First Hospital approved the study protocol. The reporting of this study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE; Supplemental Material) statement.

The inclusion criteria for this study were (1) a history of waist or abdomen trauma; and (2) a definite diagnosis of traumatic ureteral injury. The exclusion criteria were (1) patients lost to follow-up; and (2) patients who disagreed to participate in this study.

Statistical analysis

The clinical data of patients with traumatic ureteral injury (including demographics, clinical characteristics, laboratory indicators, and surgical data) were gathered by adopting Excel. Continuous variables were expressed as mean ± standard deviation, and classified variables were expressed as frequency (percentage). GraphPad Prism 9.0.0 was employed for statistical analysis. A paired-sample t-test was employed to assess the differences between preoperative and postoperative laboratory indicators in the patients. A two-sided p < 0.05 indicated statistical significance.

Results

A total of 30 patients with traumatic ureteral injury were included for initial analysis (refer to Table 1). There were 24 males and 6 females, the mean age was 36.4 ± 12.8 years, and the mean BMI was 22.1 ± 5.6 (refer to Table 1). As for the trauma types, nine cases were sharp injuries, 16 cases were impact injuries, four cases were high falls, and one case was low falls.

Table 1.

Demographics and clinical characteristics analysis of patients with traumatic ureteric injury.

Variables
n	30
Age (years), mean ± SD	36.4 ± 12.8
Gender, n(%)
Male	24(80)
Female	6(20)
Height (cm), mean ± SD	170.4 ± 7.9
Weight (kg), mean ± SD	66.6 ± 12.9
Body mass index (kg/m²), mean ± SD	22.1 ± 5.6
Trauma type
Sharp instrument	9(30.0)
Impact	16(53.3)
Low fall	1(3.3)
High fall	4(13.3)
Trauma nature, n(%)
Open	10(33.3)
Closed	20(66.7)
First symptoms, n(%)
Examination	12(40.0)
Abdominal mass	2(6.7)
Flank pain	10(33.3)
Fever	3(10.0)
Hematuria	3(10.0)
First diagnosis method, n(%)
Ultrasound	5(16.7)
IVU	3(10.0)
CT	20(66.7)
MRI	1(3.3)
Percutaneous puncture	1(3.3%)
Imaging examination
Contrast agent extravasation, n(%)
Yes	12(40.0)
No	15(50.0)
NA	3(10.0)
Filling deficiency, n(%)
Yes	21(70.0)
No	6(20.0)
NA	3(10.0)
Unclear development, n(%)
Yes	12(40.0)
No	15(50.0)
NA	3(10.0)
Proximal luminal dilation, n(%)
Yes	22(73.3)
No	5(16.7)
NA	3(10.0)
Diagnostic classification, n(%)
Immediate diagnosis	12(40.0)
Delayed diagnosis	18(60.0)
Laterality, n(%)
Left	15(50.0)
Right	10(33.3)
Bilateral	5(16.7)
Position, n(%)
Upper ureter	23(73.3)
Middle ureter	2(6.7)
Lower ureter	2(6.7)
NA	3(10.0)
Combined with renal injury, n(%)
No	21(70.0)
Yes	9(30.0)

RA, robot-assisted; LS, laparoscopic; URS, ureteroscopic; NA, not available.

Concerning the first symptoms, 10 patients experienced flank pain, three had a fever, three had hematuria, two had abdominal mass, and 12 were determined by examination. Regarding the first diagnosis methods, five cases were diagnosed by B-ultrasound, three cases by IVU, 20 cases by CT (refer to Figures 1 and 2), one case by MRI, and 1 case by percutaneous puncture. Regarding laterality, there were 15 cases of left ureteral injury and 10 cases of right ureteral injury, and five cases had bilateral ureteral injury. There were 12 patients who experienced contrast agent extravasation, 21 patients had filling defects, 12 patients had unclear development, and 22 patients had proximal luminal dilation. There were 23 cases of upper ureteral injury, two cases of middle ureteral injury, and two cases of lower ureteral injury. Among the 30 patients, nine had renal injury.

Figure 1.

(a) , (b) and (c) CTU (CT urography) images show significant dilatation of the left renal pelvis and ureter, and left ureteral stricture (Li et al., 2024).¹⁸

Figure 2.

3D reconstruction of CTU shows dilatation of the left renal pelvis, ureter, and left ureteral stricture (Li et al., 2024).¹⁸

After excluding patients with unclear surgical-related information, 14 patients underwent upper urinary tract repair surgery. There were four cases with immediate diagnosis and 10 cases with delayed diagnosis. There were eight patients with AAST grade 1, two with AAST grade 4, two with AAST grade 5, and the other two with AAST grade 2, and 3, respectively. Among the four patients with immediate diagnosis, two received pyeloplasty, one received ureteroureterostomy, and one received ileal ureter. Besides, the surgical treatment for patients with delayed diagnosis included ileal ureter replacement in five cases, nephrectomy in two cases, lingual mucosal graft urethroplasty in one case, ureteroureterostomy in two cases, and ureteral stenting in one case. Concerning surgical approach, seven patients underwent open surgery, five laparoscopic surgery, one robotic-assisted laparoscopic surgery, and one ureteroscopic surgery.

The median operation time was 316.5 min (IQR: 123–346.5 min), and the median estimated blood loss was 50 mL (IQR: 18.75–184.75 mL), and the mean follow-up time is 39.1 ± 24.8 months. The postoperative creatinine of 78.6 ± 13.7 μmol/L was significantly lower than the preoperative creatinine of 88.8 ± 17.0 μmol/L (p = 0.0009). The postoperative urea of 4.6 ± 1.6 mmol/L was substantially lower than the preoperative urea of 5.9 ± 1. 3 mmol/L (p = 0.0016) (Table 2).

Table 2.

Perioperative and follow-up analysis of patients with traumatic ureteric injury.

Variables
n	14
From trauma to operation(months), median (IQR)	8.5(4–13)
AAST Classification, n(%)
I	8(57.1)
II	1(7.1)
III	1(7.1)
IV	2(14.3)
V	2(14.3)
Management, n(%)
Ureteral stent	1(7.1)
Ureteroureterostomy	4(28.6)
Pyeloplasty	2(14.3)
Lingual Mucosal Graft Ureteroplasty	1(7.1)
Ileal ureter	5(35.7)
Nephrectomy	1(7.1)
Surgical approach, n(%)
Open	7(50.0)
Laparoscopic	5(35.7)
Robotic-assisted laparoscopic	1(7.1)
Ureteroscopic	1(7.1)
Operative time (min), median (IQR)	316.5(123–346.5)
Estimated blood loss (mL), median (IQR)	50(18.75–184.75)
Preoperative creatinine (μmol/L), mean ± SD	88.8 ± 17.0
Preoperative urea (mmol/L), mean ± SD	5.9 ± 1.3
Postoperative creatinine (μmol/L), mean ± SD	78.6 ± 13.7
Postoperative urea (mmol/L), mean ± SD	4.6 ± 1.6

RA, robot-assisted; LS, laparoscopic; URS, ureteroscopic; NA, not available.

Discussion

The ureter is a slender peristaltic tube-shaped organ located in the retroperitoneal space. It is protected by the surrounding psoas major, spine, paravertebral muscles, and abdominal organs, and has a certain space and scope of activity, consequently, it is rare to suffer external trauma. Besides, traumatic ureteral injury can result in severe complications including urinary fistula, abscess, ureteral stricture, and even leading to renal function damage if not identified in time or mishandled.^19,20 Furthermore, the nature of trauma mainly includes open trauma and closed trauma. Open trauma primarily results from gunshot wounds and stab wounds, while closed trauma mainly arises from collisions, car accidents, and falls. In the past 20 years, 11 English literature on traumatic ureteral injuries from the United States, Korea, Turkey, Canada, and India have been published, most of which are associated with gunshot wounds (refer to Table 3). In this case series from China, the most common type of ureteral trauma was closed injury, accounting for 66.7%, and the most common type of trauma was impact injury, accounting for 53.3%, followed by sharp instrument injury, accounting for 30%, without any associated gunshot wounds. This is significantly different from the 95% of gunshot wounds reported in international studies,²¹ which is rooted in the difference in gun control between China and other countries.

Table 3.

The literatures of traumatic ureteral injury in recent 20 years.

Author	Year	Country	Patients	Mean/median age (years)	Gender	Trauma type	Trauma nature	Symptoms	First diagnosis method	Diagnostic classification	Laterality	Position	Renal injury	Management	Surgical approach	Mean follow-up (months)
Hughes	2020	USA	2	56	2 Male	1 traffic accident, 1 low fall	2 Closed	1 Abdominal tenderness, 1 hematuria	2 CT	2 immediate diagnosis	1 left,1 right	1 Lower	NO	1 Ureteral stent, 1 NA	Ureteroscopic	NA
Park	2019	Korea	1	34	Female	Stab	Open	Abdominal tenderness	IVU	Immediate diagnosis	Right	NA	NO	Uretero-ureterostomy	Open	2
Baloda	2018	USA	1	71	Male	Low fall	Closed	Hematuria	CT	Immediate diagnosis	Left	Upper	NO	Ureteral stent	Ureteroscopic	2
Debbink	2017	USA	1	13	Female	Handlebar	Open	Wound bleeding	IVU	Immediate diagnosis	Left	Middle	NO	Uretero-ureterostomy	Open	1.5
Sönmez	2008	Turkey	1	5	Male	Traffic acciden	Closed	Preshock state, confused	Retrograde pyelography	Immediate diagnosis	Bilateral	Upper	NO	Uretero-ureterostomy	Open	1
Slobogean	2007	Canada	1	10	Female	Traffic accidents	Closed	Abdominal wall ecchymoses	IVU	Delayed diagnosis	Right	Upper	Yes	Psoas hitchand Boari flap	Open	NA
Madhok	2007	India	1	15	Female	Arrow	Open	Pale	X-ray	Immediate diagnosis	Right	Upper	NO	Uretero-ureterostomy	Open	1.5
Kunkle	2006	USA	40	26.7	39 Male, 1 Female	37 gunshot, 3 blunt	Open	18 hematuria	29 operative exploration, 4 IVU, 2 CT, 5 Other	35 immediate diagnosis, 5 delayed diagnosis	24 left, 16 right	12 Upper, 11 Middle, 12 Lower	NA	11 ureteroureterostomy, 6 stent, 6 closure, 4 ureteral ligation, 3 ureteroneocystostomy, 3 Boari flap, 2 observation, 1 nephrectomy	Open	NA
Akay	2006	Turkey	21	27.85	40 Male, 1 Female	21 gunshot	Open	15 hematuria	7 IVU, 8 ultrasonography, 2 cystography, 1 retrograde pyelography	Immediate diagnosis	9 left, 12 right	3 Upper, 6 Middle, 3 Lower	3 renal injury	15 uretero-ureterostomy, 1 ureteroneocystostomy, 1 transureteroureterostomy, 1 Nephrectomy, 1 primarily repair, 1 Intra-operative exitus, 1 nephrostomy	Open	12.6
Carver	2004	USA	12	30.3	11 Male, 1 Female	11 gunshot, 1 stab	Open	9 hematuria	7 CT, 4 IVU, 1 exploratory laparotomy	9 immediate diagnosis, 3 delayed diagnosis	NA	12 Upper, 6 Middle, 4 Lower	1 renal injury	7 Ureteroneocystostomy, 2 Ureteroureterostomy, 2 Ureteral stent, 1 Nephrectomy	10 Open, 2 Ureteroscopic	NA
Elliott	2003	USA	38	NA	NA	24 gunshot, 9 stab, 5 blunt	Open	24 hematuria	13 IVU, 25 laparotomy	35 immediate diagnosis, 3 delayed diagnosis	NA	27 Upper, 3 Middle, 8 Lower	7 renal injury	2 Ureteral stent, 12 primary closure, 14 ureteroureterostomy, 5 ureteroneocystostomy, 1 transureteroureterostomy, 1 Boari flap, 1 nephrectomy	34 Open, 2 Ureteroscopic	NA

The clinical manifestations of traumatic ureteral injury are diverse and atypical. In this research, the initial symptoms or signs of the patients with traumatic ureteral injury included flank pain (33.3%), fever (10.0%), hematuria (10.0%), as well as abdominal mass (6.7%). Open ureteral injury frequently presents with wound bleeding, and closed ureteral injury may occur with hematuria, dysuria, urinary extravasation, urinary cyst, flank pain, as well as mass in the flank and abdomen.^5,21 On the condition that the adjacent tissue is infected, patients with traumatic ureteral injury may present with fever and even symptoms of systemic poisoning.²² Traumatic ureteral injury complicated with ureteral stricture can manifest as hydronephrosis or renal impairment. These symptoms or signs may be masked, leading to a missed diagnosis of ureteral injury.

The diagnosis of ureteral injury can be divided into immediate and delayed diagnoses according to time.⁶ In the last 20 years, 87.9% were immediate diagnoses and 12.1% were delayed diagnoses (refer to Table 3). In this case series, merely 40.0% were immediate diagnoses, and 60.0% were delayed diagnoses. It is evident that early detection of traumatic ureteral injury in China is challenging and prone to being overlooked. In this work, it was determined that patients with delayed diagnosis were more likely to require complex procedures such as ileal ureter replacement and lingual mucosal graft ureteroplasty due to more severe ureteral injury compared to those with an immediate diagnosis, and two cases with delayed diagnosis received nephrectomy due to severe renal injury or loss of renal function. Additionally, the immediate diagnosis of ureteral injury can reduce the incidence of complications,²³ assist in subsequent repair and reconstruction treatment, and enhance the prognosis of patients. For patients with delayed diagnosis, adhesions and scarring resulting from local inflammatory reactions will increase the difficulty of reconstruction surgery.¹⁴

The diagnosis of traumatic ureteral injury is predominantly based on clinical manifestations, combined with B-ultrasound, IVU, CT, MRI, retro/antegrade urography, and diuretics renography.^12,24 Computed tomography with delayed phase imaging is a sensitive test to detect ureteral injuries following blunt trauma, and computed tomography can distinguish between partial and complete transections.²⁵ Meanwhile, it is necessary to combine creatinine and renal dynamics to evaluate whether renal function is damaged. In this study, 16.7% of the patients were first diagnosed by ultrasound, 10.0% by IVU, 66.7% by CT, 3.3% by MRI, and 3.3% by percutaneous puncture, consequently, the majority of the patients were diagnosed by CT for the first time. CTU images from one of these case series reveal significant dilation of the left renal pelvis and ureter, and ureteral stricture (refer to Figure 1(a)–(c)). 3D reconstruction of CTU is helpful for further diagnosis (refer to Figure 2). For patients with penetrating abdominal injury, it is essential to explore the ureter for injury to prevent it from being missed or misdiagnosed.²³ Microscopic or gross hematuria is an important sign of urinary system injury. Nonetheless, in this research, 90% of the patients with ureteral injury did not have hematuria, and the absence of hematuria could not rule out ureteral injury. Hence, hematuria is not a sensitive indicator for diagnosing ureteral injury, which aligns with previous studies.²⁶ In addition, the majority of the patients in the present study suffered upper ureter injury, which may be due to the fact that the pelvis provides better protection for the middle and lower ureters from injury, and 30.0% of the patients had renal injury, indicating that when trauma occurs, attention should be given not only to ureteral injury but also to renal injury.

The principle of ureteral injury treatment is to repair and reconstruct the ureter, restore the integrity and continuity of the urinary tract, protect renal function as much as possible, and reduce the occurrence of complications including local stricture and urinary fistula.²³ In our retrospective case series, the vast majority of patients had upper ureteral injuries. The repair procedures we selected on the basis of the severity and length of traumatic ureteral injuries include ureteroureterostomy, pyeloplasty, lingual mucosal graft ureteroplasty, and ileal ureter. Meanwhile, in our retrospective case series, there were two patients with lower ureteral injury. One of them, due to mild symptoms, required only the placement of a DJ catheter. Following extubating, there were no symptoms, hydronephrosis, or urinary leakage during follow-up. In the process of repairing and reconstructing the ureter, it is essential to preserve the vitality of ureteral tissue, thoroughly remove scars and inactive tissue, which helps to ensure a high success rate and prevent recurrent ureteral stricture. Besides, the end of the ureter should be cut flat, and an absorbable suture should be employed to make sure that the anastomosis is impermeable and tension-free.⁶ The specific treatment plan for traumatic ureteral injury should be determined in accordance with the time, degree, nature, and location of the injury. If open injuries can be diagnosed promptly, it is preferable to proceed with immediate surgery. For the first-stage surgery of traumatic ureteral injury, the combined injury requires attention to the exploration and repair of other organs, evaluating whether the patient has active bleeding and stable blood flow dynamics. Depending on the severity, a DJ tube or nephrostomy can be chosen to allow additional time for addressing more serious organ injuries. For the second stage of surgery, it is necessary to focus on assessing the renal function of the affected kidney and whether the affected kidney has preservation value, and then choose a repair strategy based on the size and length of the injury. Ureteral reconstruction should be performed for stable patients, while urinary diversion is the preferred option for unstable patients.² Surgical repair operations for ureteral injury predominantly include ureteral stenting, end-to-end ureteral anastomosis, ureter-bladder reimplantation, ureteral end-to-side anastomosis, ureteral replacement, as well as autologous kidney transplantation.^{5,20,23,27,28} In this case series, ureteral stenting was employed in 1 case (7.1%), ureteroureterostomy in 4 cases (28.6%), pyeloplasty in 2 cases (14.3%), lingual mucosal graft ureteroplasty in 1 case (7.1%), ileal ureter replacement in 5 cases (35.7%), nephrostomy in 1 case (7.1%), and nephrectomy in 1 case (7.1%). One of the patients was stabbed in the abdomen with a steel rod, resulting in an upper right ureteral injury with AAST grade 1. Due to the concurrent right kidney injury and severe right kidney function impairment (GFR 10 mL/min), the patient underwent laparoscopic right nephrectomy surgery and recovered well postoperatively. Furthermore, the creatinine and urea in the patients following surgery were significantly enhanced compared with those before surgery, indicating that upper urinary tract repair surgery can substantially improve renal function in patients with traumatic ureteral injury. Nonetheless, further studies with larger sample sizes and longer follow-ups are needed to validate these results.

To our knowledge, this study has systematically gathered and reviewed the clinical features and perioperative data from a case series of traumatic ureteral injuries, excluding those related to gunshot wounds. However, there remain some limitations in this study, including a small sample size, loss of follow-up, and some missing data in retrospective studies. Based on these findings, a more extensive, longer-term, prospective study with long-term follow-up will be conducted in the future.

Conclusion

Traumatic ureteral injury is occult, atypical, and challenging to detect. Timely diagnosis is crucial. It is important to choose an appropriate reconstruction method based on severity, location, and length to restore urinary tract continuity as early as possible.

Supplemental Material

sj-docx-1-tau-10.1177_17562872241297541 – Supplemental material for Traumatic ureteral injury: an initial outcome and experience

Supplemental material, sj-docx-1-tau-10.1177_17562872241297541 for Traumatic ureteral injury: an initial outcome and experience by Mancheng Xia, Xinfei Li, Fangzhou Zhao, Pengcheng Jiao, Zhihua Li, Shengwei Xiong, Peng Zhang, Bing Wang, Hongjian Zhu, Kunlin Yang, Liqun Zhou, Kai Zhang and Xuesong Li in Therapeutic Advances in Urology

Footnotes

Acknowledgements

The authors wish to extend their gratitude to all the participants involved in this study.

Declarations

ORCID iD

Mancheng Xia

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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