other divided tubular structure, and it does not bleed in the same way as a cut vessel.
In surgical injuries to the ureter where the diagnosis is not made intraoperatively, the symptoms and signs that the ureter may have been injured include:
66 J. REYNARD
1. An ileus, due to the presence of urine within the peritoneal cavity
2. Prolonged postoperative fever or overt urinary sepsis
3. Persistent drainage of fluid from abdominal or pelvic drains, from the abdominal wound, or from the vagina. This fluid should be sent to the lab for creatinine estimation. If the creati-nine level is higher than that of serum, the fluid is urine (the creatinine level will be at least 300 Limol/L).
4. Flank pain if the ureter has been ligated
5. An abdominal mass, representing a urinoma
6. Vague abdominal pain
7. The pathology report on the organ that has been removed may note the presence of a segment of ureter!
The diagnosis may be made within the first few days following surgery, but it may be delayed by weeks, months, or even years. In such cases, the presentation may be one of flank pain. Post-hysterectomy incontinence, which will usually be continuous in nature, may be due to a persistent leakage of urine (from a ureterovaginal fistula).
Making the Diagnosis Intraoperatively
Ureteric contusions and small ureteric perforations probably occur frequently during ureteroscopic stone fragmentation. Perforation by a laser fibre or guidewire is unlikely to result in significant extravasation, but in the latter case you might feel more comfortable in leaving a JJ stent in situ for a week or so after the procedure. If you do inadvertently push the ureteroscope through the wall of the ureter, then clearly the size of the hole in the ureter is bigger and the likelihood of extravasation of a significant volume of urine is increased. A JJ stent should be inserted in such cases, and if it is not possible to do so, because for example the safety guidewire has fallen out, then serious consideration should be given to placing a percutaneous nephros-tomy tube. If a radiologist who is expert in antegrade stent placement is available, then this can be inserted at the same time that the antegrade stent is positioned. This gives the added advantage of 'dual drainage' (Fig. 5.6). In many cases, temporary urine drainage, either by a JJ stent alone or combined with a percutaneous nephrostomy, is all that is required for definitive management of such injuries.