Ureter Injury

What the ureters are

Each ureter is a muscular tube about 25 to 30 cm (10 to 12 inches) long and a few millimeters wide, running from the kidney down the back of the abdomen, across the pelvic blood vessels and into the bladder. In the pelvis it passes very close to the uterine artery, the ovaries and the colon, which is why pelvic operations put it at risk.

Causes

Surgery (iatrogenic injury)

Most ureter injuries occur during operations:

• gynecologic surgery: hysterectomy is the most common, along with surgery for endometriosis, ovarian masses and prolapse
• colorectal surgery: for cancer or diverticulitis
• urologic procedures: ureteroscopy for kidney stones
• vascular and spine surgery
• cesarean section, especially emergency cesareans

Injuries can be a cut, tie (ligation) with a stitch, crush with a clamp, heat damage from electrical instruments, or loss of blood supply, which may cause a delayed leak or narrowing.

External trauma

Gunshot and stab wounds cause most traumatic injuries. Blunt trauma rarely injures the ureter.

Symptoms

Many injuries are not recognized during surgery. Symptoms may appear in the following days or weeks:

• flank or back pain on one side
• fever and chills
• belly pain, bloating, nausea or swelling from urine leaking into the abdomen (urinoma) or peritonitis
• urine leaking continuously from the vagina (ureterovaginal fistula) or from a surgical drain or wound
• reduced urine output or a rise in creatinine
• blood in the urine

A tied or blocked ureter can cause hydronephrosis (swelling of the kidney) and, if both are blocked, kidney failure.

Diagnosis

• during surgery: surgeons may inspect the ureters, inject dye, or perform cystoscopy to check urine flow from each ureter
• CT urogram: CT with contrast and delayed images shows leaks, blockages and kidney swelling
• retrograde pyelogram: dye injected through a cystoscope directly into the ureter
• kidney ultrasound: shows hydronephrosis
• creatinine level of drain or vaginal fluid: fluid much higher in creatinine than blood is urine
• blood tests: kidney function

Treatment

Treatment depends on when the injury is found, its location and severity:

Leaked urine collections may be drained. Follow-up imaging checks for narrowing (stricture) after healing.

Complications

• urinoma (a collection of leaked urine)
• infection and sepsis
• ureteral stricture
• fistula to the vagina or skin
• hydronephrosis and loss of kidney function
• in rare cases, loss of the kidney

Prevention

Surgeons reduce risk by identifying the ureters during surgery, careful technique near the uterine vessels, sometimes placing ureteral stents or lighted catheters beforehand in complex cases, and checking ureteral function with cystoscopy after high-risk procedures.

Frequently asked questions

What are the symptoms of a ureter injury after surgery?

Common symptoms include flank pain, fever, belly swelling or pain, nausea, reduced urine, and watery leakage from the vagina or wound. They may appear days to weeks after pelvic or abdominal surgery and should be reported promptly.

How common is ureter injury during hysterectomy?

It is uncommon, occurring in a small fraction of hysterectomies, often well under 1 percent depending on the type of surgery and complexity. Risk is higher with endometriosis, large fibroids, cancer surgery and previous pelvic surgery.

How is an injured ureter repaired?

Small injuries often heal with a stent placed inside the ureter for several weeks. Larger injuries need surgery to reconnect the ureter or reimplant it into the bladder. A nephrostomy tube may drain the kidney until repair.

Can you live with one damaged ureter?

Yes. If a ureter cannot be repaired and the kidney is lost, the other kidney usually maintains normal function. Most injuries, however, are repaired successfully and kidney function is preserved.