ureteral injury
Introduction
Introduction to ureteral injury Due to the small diameter of the ureter and its flexibility, and the good protection of the back muscles and retroperitoneal fat and bony structure, ureteral injury is the least common damage in the genitourinary system. In the ureteral injury, most of them are medical. Source damage, accounting for about 82%, the rest is exogenous damage. In the exogenous injury, penetrating injury accounts for about 90%, and blunt injury accounts for about 10%. basic knowledge The proportion of illness: 0.0025%, more common in trauma Susceptible people: no special people Mode of infection: non-infectious Complications: urinary fistula edema hydronephrosis
Cause
Causes of ureteral injury
Traumatic injury (25%):
Permeation injury is the most common cause of ureteral injury, mainly gunshot wounds or sharp puncturing injuries; non-penetrating injuries are rare, mostly in car accidents, falling from high places, often occurring in pelvis, post-peritoneal surgery, such as colon , rectal, hysterectomy and large vascular surgery, due to the complex anatomy of the above parts, the surgical field is unclear, hastily stopped bleeding, large clamps, ligation, it is easy to accidentally injure the ureter.
Iatrogenic injury (75%):
(1) Surgical injury: seen in the lower abdomen or pelvic surgery, more common in the lower third of the ureter, retrograde ureteral intubation through cystoscopy, expansion, taking (crushing) stone and other operations can lead to ureteral injury, when When the ureter has stenosis, distortion, adhesion or inflammation, the ureter may be torn or even broken. It is most common in gynecological surgery, accounting for more than 50% of iatrogenic injuries.
(2) examination of instrument damage: more common in ureteral intubation, pedicure, ureteroscopy, etc., resulting in ureteral perforation or tear.
(3) Radioactive injury: High-intensity radioactive substances cause congestion, edema and inflammation of the ureter and surrounding tissues, and eventually narrow due to localized scar fibrosis adhesion.
Prevention
Ureteral injury prevention
First, surgical ureteral injury prevention points:
(1) First of all, you must be familiar with the relationship between the anatomy of the ureter and the adjacent organs, especially the above-mentioned vulnerable parts.
(2) When the sigmoid colon peritoneum is cut open, the incision of the left posterior peritoneum should be on the lateral side of the ureter, and the incision of the right peritoneum of the sigmoid colon in the pelvic cavity should be on the inside of the ureter.
(3) Before ligation of the inferior mesenteric artery, the left ureter should be found at the left common iliac bifurcation, the right ureter should be found on the right side, and the ureteric mesenteric root should continue to be revealed upward, and then the left ureter is introduced. To the outside, the inferior mesenteric artery is ligated under clear vision so as to avoid damage to the ureter.
(4) Before treating the rectal ligaments on both sides, the lower segment of the ureter and the bladder should be retracted. If necessary, the bilateral ureters should be exposed downward to the bladder, and the rectum should be lifted to the upper side, close to the direct view. The wall of the pelvic wall splits the lateral ligament.
(5) In the operation, the anatomical level should always be discerned, the operation is gentle, careful separation, avoiding large ligation, avoid blind clamping and stop bleeding, otherwise it may damage the ureter, and always pay attention to the ureter may be adhered to the colon mesentery, so When ligating the mesangial vessels, it must be clear that the ureter is not cut.
(6) If the tumor is larger, more fixed, has a history of pelvic inflammatory disease, has done pelvic or lower abdominal surgery, or pelvic radiotherapy, preoperative urography should be performed to understand whether the ureter is displaced, deformed or other The lesions, if necessary, can be further used for cystoscopy and ureteral retrograde intubation, in order to facilitate the identification of the ureter during surgery, the ureter can be exposed in the normal part of the operation, and then according to its travel relationship in order to trace protection.
(7) In order to reduce the damage to the ureteral nutrient vessels, the ureter should only be exposed during the operation and should not be free. It should not be more than 10cm when it is free, and care should be taken to keep the outer membrane intact, otherwise the blood supply to the ureter will be damaged. This is because the blood supply of the ureter is multi-sourced, different parts of the blood have different sources of blood, because the blood source is not constant, and a small number of ureteral artery anastomosis is small, so if the free range of ureteral surgery is too large, it can affect the ureter Blood transport, there is the risk of ischemia and necrosis. Because the arteries supplying blood to the ureter are mostly from the medial side, they should be freed outside the ureter during surgery to reduce the damage of blood supply.
(8) When suturing the pelvic floor peritoneum, you should see the ureter and avoid it.
(9) Before the end of surgery, the integrity of the bilateral ureters should be checked again in order to find the problem in time and repair it immediately. Otherwise, it will cause serious consequences and difficult treatment.
Second, when the ureter is damaged, it should be repaired as soon as possible to ensure smoothness, protect kidney function, urinary extravasation should be completely drained, avoid secondary infection, and mild ureteral mucosal injury, can be applied to hemostatic drugs, antibiotic treatment, and closely observe symptoms Small perforations can be self-healing if they can be inserted and retained in a suitable ureteral stent tube.
Complication
Ureteral injury complications Complications, urinary edema, hydronephrosis
(1) ureteral stenosis: ureteral intubation, dilatation or indwelling double J-shaped ureteral stent drainage tube (F6), depending on the circumstances, the length of indwelling, severe stenosis or unsuccessful catheterization, surgery should be determined according to the specific conditions Periureal adhesions or stenosis.
If the complete ureteral obstruction can not be relieved, the renal ostomy can be performed first, and the ureteral repair can be performed 1 to 2 months later.
(2) urinary fistula: ureteral skin fistula or ureteral vaginal fistula occurred about 3 months after the occurrence of wound edema, urinary extravasation and infection caused by inflammatory reaction subsided, the patient's general condition allows, ureteral repair should be performed, generally should find the ureter near End, after the free fit with the bladder or bladder wall flap.
(3) Others: For severe hydronephrosis or infection caused by injurious ureteral stricture, severe renal damage or loss, if the contralateral kidney is normal, nephrectomy may be performed.
Ureteral injuries caused by penetrating injuries often have obvious concomitant injuries. The incidence of injury in these tissues and organs is small intestine, colon, liver, pancreas, bladder, duodenum, rectum and large blood vessels. 11 cases of ureteral gunshot wounds Of the 6 patients with iliac vein injury, blunt ureteral injuries were almost always associated with fractures and/or kidneys, bladder and other visceral ruptures and contusions.
Symptom
Symptoms of ureteral injury Common symptoms Urinary extravasation ureteral fistula cold hematuria lower back pain
The clinical manifestations of ureteral injury are determined by the time of discovery, unilateral or bilateral injury, the presence or absence of infection, and the timing and location of urinary fistula.
1. History: history of pelvic surgery and ureteral instrument operation injury or a history of severe penetrating injury, surgical injury including radical hysterectomy, giant ovarian tumor resection, colon or rectal tumor radical surgery and retroperitoneal fibrosis Surgery.
2. Low back pain: After the ureter is ligated or clamped, the ureter is completely and partially obstructed, causing kidney and ureteral water to cause lumbar pain. During the physical examination, the affected kidney area has tenderness and snoring pain, and the upper abdomen can touch the pain and Swollen kidneys.
3. Urinary fistula or extravasation: If the ureter is not cut or cut in time, the incision may leak urine, vaginal leaking urine, abdominal cavity accumulation or abdominal cystic mass.
4. No urine or hematuria: After bilateral ureteral rupture or complete ligation, there may be no urine symptoms, such damage is easy to be discovered in time, in addition, some patients may also have hematuria; but no hematuria can not rule out the possibility of ureteral injury.
5. Fever: After ureteral injury, due to unobstructed urine drainage or extravasation of urine, secondary infection or local tissue necrosis may occur. At this time, symptoms such as chills and fever may occur, and peritonitis may occur when urine penetrates into the abdominal cavity. symptom.
Because early symptoms and signs are non-specific, the diagnosis of ureteral injuries should be highly vigilant. 30% of patients do not have hematuria. First intravenous urography, if the angiographic results can not be concluded, retrograde ureteral pyelography should be performed. Occasionally, a diagnosis is made during the abdominal exploration of the operating room. If the diagnosis is not timely, the clinical manifestations of intestinal obstruction, extravasation of urine, urinary tract obstruction, no urine and sepsis.
Examine
Ureteral injury examination
90% of ureteral injuries caused by external violence are microscopic hematuria. Urinary examinations and other tests for ureteral injuries caused by other causes are of little help to the diagnosis. Unless bilateral ureteral obstruction is present, serum creatinine levels are normal.
1. Intravenous urography: more than 95% of ureteral injuries can be diagnosed by intravenous urography, 50% can locate the level of ureteral injury, can be expressed as complete ureteral obstruction; ureteral distortion or angulation; ureteral rupture, perforation, The expression is extravasation of contrast agent, and the ureter and ureteral dilatation above the lesion.
2. Retrograde ureteral intubation and renal pelvic ureterography: When intravenous pyelography can not be clearly diagnosed or in doubt, retrograde ureteral intubation and renal pelvic ureteral angiography should be used to confirm the diagnosis.
3. Ultrasound examination: water and urine extravasation can be found, which is a good means of examination for the early removal of ureteral injury.
4. CT examination: CT performance is different due to different injury sites and properties. The ureteral rupture caused by pelvic surgery often has contrast agent leakage, CT scan to high density ascites.
5. Rouge intravenous injection test: When the ureter is suspected to be damaged during the operation, the rouge is injected intravenously, and the blue urine will flow out from the ureteral rupture.
Intraoperative or postoperative cystoscopy, and intravenous injection of rouge, such as the side of the ureteral orifice without blue urine, ureteral intubation to the injury site blocked, mostly ureteral obstruction.
6. Methylene blue test: Injecting the methylene blue solution through the catheter can identify the ureter and bladder spasm. If the fluid from the bladder or vaginal wound is still clear, the bladder spasm can be ruled out.
7. Excretory urography and computed tomography: can show urinary extravasation, urinary leakage or obstruction at the ureteral injury, retrograde pyelography can show obstruction or contrast agent extravasation.
8. Radionuclide renal imaging: can show upper urinary tract obstruction on the ligation side.
Diagnosis
Diagnosis and diagnosis of ureteral injury
diagnosis
The early diagnosis of ureteral injury is very important, timely diagnosis, and correct treatment, the consequences are good, so in the treatment of trauma or abdominal operation, pelvic surgery, should pay attention to check whether there is urinary extravasation, whether the traumatic wound through the ureteral movement, Whether there is oozing in the surgical field, or directly seeing the ureteral injury.
Differential diagnosis
Ligation of bilateral ureters caused by anuria should be differentiated from acute tubular necrosis, if necessary, cystoscopy and bilateral ureteral intubation to determine the presence or absence of obstruction.
1. Kidney injury: history of trauma, urinary extravasation, perirenal effusion and renal dysfunction, similar to ureteral injury, but obvious renal hemorrhage, local formation of hematoma, shock more common, check kidney The area is often seen with ecchymosis, swelling, tenderness, IVU visible contrast agent spilled from the renal parenchyma, severe renal pelvis, renal pelvis and ureter are unclear, B-ultrasound and CT examination showed renal parenchymal rupture or subcapsular hemorrhage.
2. Bladder injury: When there is no urine or acute peritonitis after trauma or surgery, especially when the urine flows out from the wound, the two are easy to be confused, but the bladder injury often involves pelvic fracture. Although there is urinary sensation, there is no urine discharge or There is only a little hematuria, bladder emptiness is found during catheterization, or there is very little hematuria. Inject 100-150ml of sterile physiological saline into the bladder, wait for a while and then withdraw it. The amount of fluid extracted is obviously less than or more than the amount injected. Bladder angiography showed contrast agent spillover.
3. Acute peritonitis: similar to urinary peritonitis caused by urinary infiltration into the abdominal cavity, but acute peritonitis is often caused by perforation of digestive tract ulcers, intestinal obstruction, secondary appendicitis, often chills, fever symptoms; no history of surgery and trauma There are no symptoms of urinary fistula and extravasation.
4. Bladder vaginal fistula: vaginal fistula with ureteral injury, easy to be confused with vaginal fistula, but patients with vaginal fistula may have trauma, birth injury and other medical history, excretory upper urography, generally no abnormal findings, cystoscopy can be The gargle was found, the gauze was inserted into the vagina, and the methylene blue solution was injected into the bladder.
