Prevention and management of ureteral injuries during aortic surgery

Ureteral injury during aortic surgery may lead to life-threatening consequences. Unlike gynecologic or abdominal surgical procedures in which ureteral injuries more commonly occur, this type of iatrogenic injury may be particularly hazardous because of the presence of prosthetic graft material. Ureteral obstruction by extrinsic compression, from an anteriorly placed graft limb or retroperitoneal fibrosis, is the most commonly reported type of ureteral complication. In most vascular surgical series, direct ureteral injury occurs in less than 1% of cases, and ureteral obstruction occurs from 2% to 14% of aortoiliac reconstructions. Prevention of ureteral injury begins with an intimate knowledge of the anatomy of the ureter along its entire course from the abdomen to the pelvis, and a realization of possible anomalies. Recognition of an injury is the next key to a successful outcome. Intraoperative recognition of an injury may allow immediate repair with a high rate of success. There are many options for the management of ureteral injuries depending on the nature of the injury, the time of diagnosis, and the level of the ureter at which the injury has occurred. The authors review the anatomy and most common causes of ureteral injury during aortic surgery and provide a guide to appropriate surgical management of these injuries.