Guideline sources The following summarized guidelines for the evaluation and management of ureteral injury are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the World Society of Emergency Surgery (WSES/AAST 2019), and the American Urological Association (AUA 2014). 1 2 3 Guidelines 1. Screening and diagnosis Diagnosis: As per EAU 2022 guidelines, suspect ureteral injury in all cases of abdominal penetrating trauma, and in deceleration-type blunt trauma. A As per WSES 2019 guidelines, suspect ureteral injury in patients with high-energy blunt trauma, particularly in deceleration injuries with multi-system involvement and in all cases of penetrating abdominal trauma. B 2. Diagnostic investigations Comp ted tomograph : https://web.pathway.md/diseases/recb3UHl58oQ5HTLM 1/3 6/29/23, 3:48 AM Ureteral injury Pathway Computed tomography: As per WSES 2019 guidelines, obtain IV contrast-enhanced CT with delayed phase in hemodynamically stable or stabilized patients with suspected ureteral injury. B As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with delayed imaging (urogram) in stable patients with trauma with suspected ureteral injuries. B 3. Therapeutic procedures Ureteral stenting: As per EAU 2022 guidelines, perform nephrostomy tube/JJ stent urinary diversion for the management of iatrogenic ureteral injuries with delayed diagnosis. A As per WSES 2019 guidelines, perform ureteral stenting in patients with ureteral contusions with impaired urine flow. B Show 3 more As per AUA 2014 guidelines, attempt performing ureteral stenting in patients with incomplete ureteral injuries diagnosed postoperatively or in a delayed setting. B Show 2 more 4. Surgical interventions Indications for surgery: As per EAU 2022 guidelines: Perform immediate repair of iatrogenic ureteral injuries detected during surgery. A Perform ureteral reconstruction of ureteral strictures according to the location and length of the affected segment. A As per WSES 2019 guidelines, perform direct inspection of the ureter during emergency laparotomy in patients with suspected ureteral injury. B Show 2 more As per AUA 2014 guidelines, inspect the ureters directly during laparotomy in patients with suspected ureteral injury without preoperative imaging. B Show 6 more 5. Specific circumstances Patients with ureterovaginal fistula: perform stenting in patients with ureterovaginal fistula, when possible. Consider performing additional surgical intervention if the stent fails. B 6. Preventative measures Prevention of iatrogenic injury: Visually identify the ureters to prevent ureteral trauma during abdominal and pelvic surgery. A https://web.pathway.md/diseases/recb3UHl58oQ5HTLM 2/3 6/29/23, 3:48 AM Ureteral injury Pathway Use preoperative prophylactic stents in high-risk cases. A 7. Follow-up and surveillance Serial imaging assessment: obtain CT with delayed phase as the choice of follow-up imaging in patients with ureteral injuries. B Clinical findings Symptoms Past medical history Dysuria Abdominal trauma Flank pain Bladder injury Hematuria Kidney trauma Pelvic fracture Past events Pelvic trauma Sepsis Motor vehicle accident Abdominal exam Genitourinary exam Abdominal distension urine output Abdominal tenderness Ascites Palpable abdominal mass Lab findings serum creatinine serum urea References 1. Morey AF, Brandes S, Dugi DD rd et al. Urotrauma: AUA guideline. J Urol. 2014 Aug;192 2 327 35. Open 2. N.D. Kitrey Chair), F. Campos-Juanatey, P. Hallscheidt et al. EAU Guidelines on Urological Trauma. EAU. 2022. Open 3. Federico Coccolini, Ernest E Moore, Yoram Kluger et al. Kidney and uro-trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 2;14 54. Open 4. Expert Panel on Urological Imaging, Matthew T Heller, Aytekin Oto et al. ACR Appropriateness Criteria Penetrating Trauma-Lower Abdomen and Pelvis. J Am Coll Radiol. 2019 Nov;16 11S S392 S398. Open https://web.pathway.md/diseases/recb3UHl58oQ5HTLM 3/3