What is the role of imaging studies in the workup of ureteral injuries in gynecologic surgery?

Updated: Nov 12, 2020
  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

If the ureteral injury is noted intraoperatively and an imaging study is necessary to localize the lesion, the best choice is retrograde ureteropyelography. After placement of a cystoscope in the bladder and cannulation of the affected ureteral orifice with a ureteral catheter, dilute diatrizoate (eg, Cystografin) is injected into the ureter under fluoroscopy or while taking a kidneys, ureters, bladder (KUB) image. If the dye is seen in the renal pelvis without any ureteral extravasation or significant narrowing along the ureter, the ureter is in continuity and the case may be managed conservatively, with either observation or stent placement.

If ureteral injury is suspected postoperatively, imaging studies evaluating for hydronephrosis, ipsilateral renal function, and continuity of the ureter are necessary. These imaging studies may include intravenous urography (IVU), abdominal and pelvic computed tomography (CT) scan with intravenous contrast, renal ultrasonography, and/or retrograde ureteropyelography.

While IVU largely has fallen out of favor in the evaluation of stone disease, many urologists believe that an IVU is the best imaging study to evaluate for continuity of the ureter in cases of ureteral injury. Unlike renal ultrasonography and a retrograde ureteropyelography, IVU is used to assess for function of the ipsilateral kidney and the drainage of the ureter in a series of sagittal images. Hydronephrosis, ureteral integrity, and any extravasation can usually be seen readily with IVU.

A CT scan can also be used to assess for both function of the ipsilateral kidney and drainage of the ureter. Because CT images are a series of cross sections, visualizing ureteral integrity and continuity is often more difficult with CT scanning than with IVU. However, CT scanning has the advantage of imaging for concomitant conditions at the same time.

Renal ultrasonography is perhaps the best noninvasive method to visualize the kidney and shows hydronephrosis with great sensitivity. Renal ultrasonography cannot be used to assess kidney function or the continuity of the ureter. Therefore, if renal ultrasonography is performed, retrograde ureteropyelography is often necessary to evaluate the course of the ureter.


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