Harnleitertrauma

Abstract

The most common cause of iatrogenic injuries to the ureter (75%) is a gynecological or surgical pelvic procedure. The diagnosis of ureteral injuries is delayed in 66% (after days or weeks). Lack of hematuria is an unreliable sign to exclude injury, since 30% of all ureteral injuries do not even demonstrate microscopic hematuria or classic clinical symptoms and signs. In view of this, the diagnosis must be one of suspicion and further evaluations are mandatory in all cases of penetrating or blunt abdominal injuries. The most accurate diagnostic tools are CT scan with delayed excretory images and retrograde ureterography, which can also be used to guide stent placement. Low-grade injuries can be sufficiently treated with urinary diversion by PCN drainage or endoscopic ureteric stenting. The treatment of high-grade injuries depends on the localization and extent of the damage. The principles of repair include débridement, spatulation, lack of tension, stenting, postoperative drainage, and a watertight anastomosis with fine nonreactive absorbable suture. A delay in diagnosis is the most important factor contributing to the morbidity of ureteric injuries, and early treatment can reduce the complication rate to below 5%.

Iatrogenic Obliteration of Ureter with Spontaneous Recanalization

“…Ureteral injuries may or may not be identified intraoperatively. However, intraoperative identification of a ureteral injury has been shown to have a significant effect on the ultimate treatment, the number of procedures required to treat, ultimate fate of the affected renal unit, and overall morbidity [3, 8]. Loss of renal function is very rare when such injuries are identified and treated intraoperatively [8].…”

“…Severe ureteral injuries involve complete ligation, transection, obliteration, or avulsion of the involved ureter [1, 2] and require open or laparoscopic surgical repair since it is usually not possible to place a ureteral stent across a completely occluded, transected, or avulsed ureter [3, 4]. We report an interesting case of spontaneous recanalization of a completely occluded midureteral injury that occurred as a result of a suture injury during a complex transabdominal urogynecologic reconstructive operation.…”

52-jähriger Patient mit schmerzhaftem Aszites nach Fahrradsturz

“…Iatrogene Verletzungen kommen insbesondere bei gynäkologischen Eingriffen [5,6], aber auch bei gefäßchirurgischen Operationen der Bauchgefäße vor [4]. Bei Aortenoperationen werden die Ureteren in 1% direkt verletzt [7].…”

“…Kleine Leckagen kön-nen sich klinisch sehr verschleiert darstellen [3]. Bei 30% der Patienten mit Verletzung der Ureteren finden sich weder Mikrohämaturie noch andere klinische Zeichen [6]. Kleinere Verletzungen der Ureteren werden initial mit einem perkutanen Nephrostoma oder -wenn möglich -mit einem endoskopisch platzierten Ureterstent behandelt [6].…”

“…Bei 30% der Patienten mit Verletzung der Ureteren finden sich weder Mikrohämaturie noch andere klinische Zeichen [6]. Kleinere Verletzungen der Ureteren werden initial mit einem perkutanen Nephrostoma oder -wenn möglich -mit einem endoskopisch platzierten Ureterstent behandelt [6]. Bei größeren Verletzungen empfiehlt sich je nach Ausmaß und Lokalisation u. a. die Ureterrekonstruktion [5] oder eine Neu-Anastomose des Ureters [6].…”