[Ureteral injuries. Diagnostic and treatment algorithm].

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%.