Making the Diagnosis Postoperatively
When a ureteric injury is suspected some days or weeks post-operatively, on the basis of the symptoms and signs discussed above, an IVU or retrograde ureterogram should be done. Ultra-sonography may demonstrate hydronephrosis, but hydronephro-sis may be absent when urine is leaking out of a transected ureter into the retroperitoneum or peritoneal cavity. The IVU usually shows an obstructed ureter (Fig. 5.7). Occasionally contrast can be seen leaking from the site of injury (Fig. 5.8). It is our policy to perform bilateral retrograde ureterography in all cases immediately prior to operation for repair of a ureteric injury (if not done already) in order to determine whether the contralateral ureter has been injured or not.
When to Do the Repair
In general terms, the best time to repair the ureter is as soon as the injury has been diagnosed. This is certainly the case when the injury has been recognized intraoperatively. However, there are situations where delayed repair is a better option, and in these situations temporary urine drainage will need to be achieved until definitive repair can be carried out.
Definitive ureteric repair is best delayed when (a) the patient's condition is such that they would not tolerate a procedure under
70 J. REYNARD
FIGURE 5.7. A ureter obstructed by a distal injury. The ureter had been ligated during hysterectomy.
5. TRAUMATIC UROLOGICAL EMERGENCIES 71
FIGURE 5.8. Leak of contrast from the ureter in a case of distal injury, as demonstrated by retrograde ureterography. Note the drain tube in situ adjacent to the ureteric injury which has been demonstrated by leakage of contrast from the ureter.
general anaesthetic, which is likely to last an hour or more; or (b) there is evidence of active infection at the site of proposed ureteric repair. Thus, if there is an infected urinoma, this should be drained radiologically, intravenous antibiotics given, and ureteric repair delayed until the patient is apyrexial.
Traditional teaching held that surgical repair should be delayed when the injury was diagnosed between roughly day 7 and day 14 after ureteric injury, because this period was believed to represent the time during which oedema and inflammation at the site of injury was maximal. However, favourable outcomes have been demonstrated after early repair (after 7 days) and the time of the original injury is nowadays seen as a less important determinant of time of definitive repair. Blandy and colleagues (1991) reported favourable results of repair (by Boari flap) of