The ureter can occasionally be injured during hysterectomy or other gynecological pelvic surgery because it runs close to the uterus, cervix, ovaries and major pelvic blood vessels. Injury may be recognised during the operation or appear later as flank pain, fever, hydronephrosis, urine leakage through the vagina or drain, or rising creatinine. Early recognition gives the best chance of straightforward repair. Management may involve immediate repair, DJ stenting, nephrostomy or later ureteric reconstruction depending on the type, site and timing of injury.

How can the ureter be injured?

• Complete or partial transection.
• Ligation or clipping.
• Crush injury.
• Thermal injury from energy devices.
• Devascularisation from excessive dissection.
• Kinking or incorporation into a suture.

When is it detected?

How is delayed injury diagnosed?

CT urography with delayed excretory images can show hydronephrosis, contrast extravasation and injury level. Cystoscopy and retrograde pyelography may determine whether the ureter can be stented from below. Ultrasound and kidney-function tests assess obstruction.

If recognised immediately

Repair can often be performed during the same operation if the patient is stable and reconstructive expertise is available. Key principles are preserving blood supply, removing clearly non-viable tissue and creating a tension-free watertight repair.

If diagnosed later

The immediate priority is safe urinary drainage and infection control. A DJ stent is attempted in suitable partial injuries; nephrostomy may be needed if the ureter cannot be crossed. Definitive reconstruction is then planned according to tissue condition.

Which reconstruction may be needed?

Could vaginal urine leakage be from the bladder instead?

Yes. Continuous vaginal urine after hysterectomy can arise from ureterovaginal or vesicovaginal fistula. Dye testing, cystoscopy and upper-tract imaging distinguish them.

Early recognition changes the treatment options

A ureteric injury recognised during the gynaecological operation is usually easier to repair than one discovered after urine has leaked for days. A simple ligature may be released and stented; a partial injury can sometimes be repaired over a stent; a complete injury may need immediate uretero-ureterostomy or ureteric reimplantation depending on its location. Current EAU trauma guidance recommends immediate repair of recognised iatrogenic ureteral injuries when the patient’s condition and surgical setting permit.

Delayed injuries often present with flank pain, fever, ileus, urinoma, rising creatinine, hydronephrosis or continuous vaginal/drain urine. CT urography with delayed images is useful, and retrograde/antegrade studies can define continuity. Initial management commonly establishes drainage with a DJ stent, nephrostomy or both. Definitive reconstruction is planned after sepsis/inflammation settles when endoluminal healing is unlikely.

Gynaecological ureteric injury most often affects the distal ureter, which is why reimplantation, psoas hitch and Boari flap are common reconstructive terms in this setting. The exact choice is based on the length of healthy ureter remaining and whether the bladder can be mobilised to create a tension-free join.

Can ureteric injuries be prevented during gynaecological surgery?

Most ureteric injuries are uncommon and can occur despite appropriate surgery, especially when anatomy is distorted by endometriosis, prior operations, malignancy, radiation or major bleeding. Direct identification of the ureter during difficult pelvic dissection remains the basic preventive principle.

Prophylactic ureteric stents can make the ureter easier to identify or palpate in selected high-risk surgery, but they do not guarantee prevention. Current EAU guidance does not support routine stenting for every gynaecological operation. The decision belongs to the operating team based on anticipated complexity.

When injury is suspected intra-operatively, early urology involvement and direct assessment can prevent delayed urinoma, infection and loss of renal function. The key advantage is preserving the maximum number of reconstructive options while tissue is fresh and the anatomy is already exposed.

Where injuries occur during pelvic surgery

The ureter is vulnerable where it crosses the pelvic brim, runs close to the uterine artery and approaches the bladder. Injury may be a clean transection recognised immediately, a ligature or clip, thermal damage that declares itself days later, or partial devascularisation that scars over weeks.

Recognition during the original operation is ideal because the injury can often be repaired before urine leaks or the kidney becomes obstructed. When recognised later, CT urography with delayed images helps show hydronephrosis, contrast leak or non-opacification; cystoscopy and retrograde study may then define the distal anatomy.

Thermal injury deserves caution because the visible damaged segment can underestimate tissue devascularisation. A reconstruction must be made to healthy, bleeding tissue rather than simply joining the apparent cut edges.

What to bring for consultation

• Ultrasound, CT urography/CT abdomen or MR urography reports and images if available.
• Renogram report (DTPA/MAG3) if performed.
• Serum creatinine and recent kidney-function reports.
• Urine routine and culture reports.
• Previous operative notes, discharge summaries and pathology reports if the problem followed surgery.
• Details of any DJ stent or nephrostomy: side, date placed and last change.
• A list of current medicines and any history of radiation, stones, endoscopy or pelvic surgery.

FAQs

Related reading

• Ureterovaginal Fistula After Hysterectomy
• Urinary Leakage After Hysterectomy: Could It Be a Urinary Fistula?
• Ureteric Reimplantation Explained
• Psoas Hitch Surgery Explained
• Boari Flap Surgery Explained
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Urological Trauma, 2026 https://uroweb.org/guidelines/urological-trauma
• Bourillon A, et al. Ureteral stricture: current treatment algorithm and key surgical principles in the robotic upper urinary tract reconstruction era. World J Urol. 2026;44:102. PMID: 41546831 https://pubmed.ncbi.nlm.nih.gov/41546831/
• Hook S, et al. Update on ureteral reconstruction 2024. Die Urologie. 2024;63:25-33. PMID: 37989869 https://pubmed.ncbi.nlm.nih.gov/37989869/