[Non-iatrogenic injuries of the ureter]

The increasing number of non-iatrogenic ureteric injuries can be explained by the increasing crime rate in certain large cities and by the performance of intensive car teams, both in civilian practice civil and in a context of war. The discovery of an ureteric injury during salvage laparotomy for vascular or visceral lesions is no longer exceptional. The initial diagnosis is missed in 10 to 20% of cases, due to the absence of any specific clinical signs, as radiological opacification of the urinary tract is rarely performed and the clinical situation is dominated by associated lesions. The treatment of ureteric injuries is guided by the severity and septic nature of associated lesions and the ballistic context. When the ureteric lesion is short and associated lesions are limited, urinary continuity can be restored, after debridement of the extremities, by end-to-end anastomosis for the upper 2/3 and by direct vesical reimplantation or into a psoas bladder for the lower 1/3. Drainage is ensured is by an externalised ureteric catheter or a double J stent and must be kept in place for at least 3 weeks. In the presence of a defect of the upper two-thirds of the ureter, mobilization of the kidney and the renal pedicle or transureteroureterostomy may be considered. In the case of unstable haemodynamic status, very septic associated lesions or in the presence of multiple fragments, urinary diversion by nephrostomy or in situ ureterostomy is indicated. Extensive contusion of the ureteric wall must be intubated to prevent fistula secondary to necrosis. Nephrectomy is inevitable in 10 to 20% of patients.