Suspected Ureteral Injury
Penetrating trauma, iatrogenic, or delayed presentation
All Pathways
UrologyEmergency
Ureteral Trauma Management (AUA Urotrauma 2020)
Ureteral Trauma Management (AUA Urotrauma 2020): Suspected Ureteral Injury → Mechanism of Injury → When Identified? → Intraoperative Recognition → Locat...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Mechanism of Injury
Identify cause - critical for management
- Iatrogenic: Most common (75%+)
- - Gynecologic surgery (hysterectomy)
- - Colorectal surgery
- - Ureteroscopy, vascular procedures
- External trauma: Rare (<1% of GU trauma)
- - Penetrating > blunt
- - Often associated injuries
03Decision When Identified?
Intraoperative recognition vs delayed
04Action Intraoperative Recognition
Best case scenario - repair immediately
- Direct visualization of injury
- IV indigo carmine/methylene blue extravasation
- Immediate urology consult if not urologist
- Repair at time of index surgery
- Better outcomes than delayed repair
05Decision Location of Ureteral Injury?
Determines repair technique
06Action Upper/Mid Ureter Injury
Proximal to iliac vessels
- Primary ureteroureterostomy if feasible
- Spatulated, tension-free anastomosis
- Stent across repair
- Transureteroureterostomy if gap too long
- Autotransplant for complex cases
07Action Stent and Drainage
Essential adjuncts to repair
- Double-J ureteral stent across repair
- Perinephric/pelvic drain
- Stent duration: 4-6 weeks typically
- Nephrostomy if stent not possible
- Foley catheter to decompress bladder
08Action Follow-Up
Monitor for stricture and function
- Stent removal at 4-6 weeks
- Imaging before and after stent removal
- MAG3 renal scan if concern
- Watch for stricture (10-20%)
- May need redo surgery if stricture
09Outcome Expected Outcomes
Good with prompt repair
- Immediate repair: >95% success
- Delayed repair: 85-90% success
- Stricture rate: 10-20%
- Renal function usually preserved
10Action Lower Ureter Injury
Distal to iliac vessels
- Ureteroneocystostomy (reimplantation)
- With or without psoas hitch
- Boari flap for longer gaps
- Anti-reflux technique preferred
- Most common repair for iatrogenic
- Path rejoins step 07Shared downstream outcome
11Action Long Segment Loss
Extensive ureteral injury
- Ileal ureter replacement
- Appendiceal ureter (if available)
- Renal autotransplantation
- Nephrostomy tube temporization
- Rare: nephrectomy if non-functional
- Path rejoins step 07Shared downstream outcome
12Action Conservative/Endoscopic Management
For minor injuries
- Partial transection: retrograde stent
- Small perforation: stent + observe
- Urinoma: drain + stent
- Close follow-up required
- Surgery if conservative fails
- Path rejoins step 08Shared downstream outcome
13Action Delayed Diagnosis
Post-operative or late presentation
- Flank pain, fever, ileus
- Urine leak from incision/drain
- Rising creatinine
- Urinoma on imaging
- CT with delayed images diagnostic
- May present days to weeks post-op
14Action CT Urography with Delayed Phase
10-15 minute delay for ureteral opacification
- Look for contrast extravasation
- Hydroureter/hydronephrosis
- Periureteral fluid collection
- Identify level of injury
- RGP or antegrade pyelogram if CT equivocal
- Path rejoins step 05Shared downstream outcome
Guideline Source
AUA Urotrauma Guideline 2020 (Amended 2022)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address pediatric ureteral trauma
- Complex reconstructions require subspecialty expertise
- Long gap injuries may require bowel interposition
- Delayed diagnosis common - high index of suspicion needed
Contraindicated Populations
pediatric_complex
Applicable Regions
USEUUKAU
AU: RACS guidelines align with AUA
EU: EAU Urological Trauma 2024 concordant
UK: Follow AUA/EAU guidance
US: AUA Urotrauma 2020 - definitive guideline
Version 1Next review: 2028-01-11
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Related Resources
Frequently Asked Questions
What is the Ureteral Trauma Management (AUA Urotrauma 2020)?
The Ureteral Trauma Management (AUA Urotrauma 2020) is a emergency clinical algorithm for Urology. It provides a structured decision tree to guide clinical decision-making, based on AUA Urotrauma Guideline 2020 (Amended 2022).
What guideline is the Ureteral Trauma Management (AUA Urotrauma 2020) based on?
This algorithm is based on AUA Urotrauma Guideline 2020 (Amended 2022) (DOI: 10.1097/JU.0000000000001408).
What are the limitations of the Ureteral Trauma Management (AUA Urotrauma 2020)?
Known limitations include: Does not address pediatric ureteral trauma; Complex reconstructions require subspecialty expertise; Long gap injuries may require bowel interposition; Delayed diagnosis common - high index of suspicion needed. Individual patient factors may require deviation from these recommendations.
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