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URETERAL

TRAUMA 

DR. Sunaryo Hardjowidjoto,dr.,Sp.B.,Sp.U

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Introduction

Ureter : A sole conduct for urinary transport from the kidney

to the bladder 

   Any ureteral injury

  Threaten kidney function

  A small, mobile, well protected external

  Uretoric trauma is rare, 1% of urinary trauma

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Etiology

Data from !" ureteral injuries : #atro$enic : & pts '(!%)  "( '(%) * $ynecolo$ic  + '1%) * $eneral sur$ery

  ( '1%) * urolo$ical sur$ery

 lunt trauma : -1 '1-%) .enetratin$ : 1 '(%)

#ocation of injury : Upper : +& '1%)

 /iddle : +1 '1%) Distal : 1 '(%)

  'Dobrowolski et, 0U nt "&&", -2 : (-3(!1)

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Diagnosis

4hould be suspected for ureteral trauma :n all cases of penetratin$ abd5 njury 'especially $unshotwounds)Deceleration trauma

4i$ns of upper traet obstruction, urinary fistula

4epsis after trauma6lank pain

7a$inal leaka$e After $ynecolo$ical pel8ic sur$ery

4eptic

4uspected ureteral injury durante operation

inject methylene blue 575 7.9etro$rade pyelo$raphy

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Gambar

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Classification of ureteral injury

rade Description

1 ;aematoma only

" #aceration < !&% of circumference

#aceration = !&% of circumference

>omplete tear < " cm of de8asculari?ation

! >omplete tear = " cm of de8asculari?ation

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Management

1. Partial injuries (grade 1 and 2)Ureteral stentin$ ante$rade or retro$rade ' weeks)

@ephrostomy to di8ert urine

oth need fluoroscopic $uidance

rade " and detected at sur$ery 'iatro$enic)

.rimary closure and stent

.lacement a non suction drain peri ureteral

ndwellin$ catheter for "3 days to a8oid reflux durin$

8oidin$

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Management"5 Complete Tears :

 .rinciples of repair for $rade 3! : Debridement of ureteral ends to fresh tissue

 4patulation of ureteral ends

 .lacement of internal stent aterti$ht closure of reconstructed ureter with

absorbable suture

.lacement of external, non3suction drain

solation of injury with peritoneum or omentum

 

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The options of reconstruction

of complete injuries : Upper third : Uretero3ureterostomy

Transuretero3ureterostomy

Ureterocalycostomy

 /iddle third : Uretero3ureterostomyTransuretero3ureterostomy

oari flap and reimplantation

 #ower third : Direct reimplantation

.soas hitch

landy cystoplasty

 >omplete : #leal interposition

 Autotransplantation

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Preention of latrogenic ureteral

injury at open surgery :

7., before : * ynecolo$ical mali$nancy operation

 *  Ad8anced endometriosis *  .el8ic inflamatory desease

ntroducin$

>arefull dissection, identified ureter 

@o panic in case of arterial bleedin$ durin$dissection

Use atraumatic 8ascular clamp