The patient underwent open exploration of the upper ureter through a lumbotomy approach. Significant scarring of the retroperitoneum was found. Following dissection of the scar tissue, the upper and lower ends of the ureter were isolated, leaving an 8 cm gap between them (Fig. 13.3).

In order to re-approximate the ureteral ends, the distal ureter was mobilized all the way to the bladder, and the left kidney was completely mobilized and descended. These maneuvers allowed the formation of a tension-free uretero-ureteral anastomosis (Fig. 13.4). The anastomoric site was further wrapped with retroperitoneal fat in order to minimize the risk of retroperitoneal fibrosis. The internal stent and nephrostomy remained for an additional 8 weeks and then removed.

The long-term follow-up of ureteral reconstruction is usually good. Yet the majority of ureteral injuries are associated with iatrogenic damage related to electric spark injuries, transection, or ligation of the ureter during elective or urgent surgery (e.g., caesarian section). Differing by the level of injury, Syrian war injuries were characterized by severe local damage to soft tissues, associated damage to adjunct viscera, significant blood loss, and following preliminary treatment and damage control procedures—an extensive locoregional fibrosis.

During an emergency surgery, no attempt should be made to re-anastomose the ureter; the tissue is burned, unprepared for reconstructive surgery due to local spillage; and associated life-threatening injuries are often present. The fastest way to secure the ureter is to perform a simple tube ureterostomy. In this fast procedure, a simple 5–8 Fr. feeding tube is inserted through a simple skin incision. The tube is inserted through the ureteral stump up to the renal pelvis and secured with a vicryl 3:0 suture on the stump and a 0 silk suture on the skin level. The procedure is rapid. It can be performed by one surgeon, while others continue their life-saving procedures. Alternatively, the ureter can be ligated and marked with a metal clip, and percutaneous nephrostomy can be placed later in the angiography suite or bedside.

Following recovery, a reconstructive surgery can be performed safely between 3 and 6 months from the injury.

The factors which predict the success of ureteral anastomosis are the tension over the anastomosis, the presence of active infection, the blood supply to the ureteral stumps, and the development of re-fibrosis around the anastomotic site.

During surgery, careful dissection of the ureteral stumps, combined with renal mobilization, can produce a tension-free anastomosis. Appropriate drainage and antibiotic coverage will decrease the risk of reinfection. Wrapping the ureter with local fat tissue (preferably the omentum) will decrease the risk of recurrent periureteral fibrosis and external compression. Under such conditions, the long-term rate of patent anastomosis is excellent.

A 32-year-old male suffered multiple gunshot wounds to the left lower abdomen and pelvis. He was operated urgently in a frontline facility where he underwent ligation of bleeding vessels in the pelvis, colectomy, Hartman’s procedure, and temporary ileostomy. The left ureter was lacerated and sutured over a feeding tube. The patient was transferred to our center with significant ischemia of the left leg and pelvis and underwent left hemipelvectomy. During the procedure, the feeding tube was found floating in the pelvis. Due to hemodynamic instability, further dissection of the ureter was not attempted. On postoperative day no. 6, urine was noted to appear in the surgical drain.