Vascular Surgery-Associated Ureteral Injury: Zebras Do Exist

This report describes a case of direct ureteral injury sustained during retroperitoneal vascular surgery. The diagnosis was delayed and treatment was complicated by infection. To address the patient's problem initially and then to consolidate our impressions, a literature review was undertaken. The conclusions from this review suggest that direct ureteral injury during vascular surgery is rare but most common during redo surgery, is just as likely to be missed as discovered during surgery, and when missed may be so for months. The diagnostic delay is caused by a varied and often misleading presentation, and a ureteral contrast study is the ultimate diagnostic tool. In these delayed cases the typical ureteral treatment is a stented ureteroureterostomy or nephrectomy. In the present case the patient was otherwise healthy; therefore an aggressive attitude to renal salvage was taken. This is a unique case of ileal conduit replacement of the damaged ureter for this specific situation. Five years after repair, renal function is stable without infectious complications. The current literature would suggest that the vascular graft may be left undisturbed if the urine is sterile. If infection is present, graft removal appears the standard of care and was successful in the present case.