ureteral avulsion is conventionally defined as injuries of the ureter caused by blunt ( non - penetrating ) trauma with acute deceleration or acceleration movement mechanism due to motor vehicle accidents . with the invention of endourology tools ,
ureteral avulsion can also occur as a result of stretching in the weakest point of the ureter .
ureteral avulsion and perforation during ureteroscopy are the most common cause of iatrogenic ureteral injuries .
the rate of ureteral injury dropped to 7% in 1990 due to increased surgical experience and development of more advanced uertroscopy tools .
the incidence of ureteral perforation has been reported in 1.5% of such procedures of which 0.2% have required surgery . in spite of the prevalent use of ureteroscopy in the treatment of ureteral stones and replacement of open surgical procedures with ureteroscopic procedures , the rate major and severe complications such as avulsion and perforation commands attention [ 6 , 7 ] .
ureteral avulsion from the pelvis can be managed by ureteral reimplantation , transureteroureterostomy and ureteroneocystostomy [ 810 ] .
renal autotransplantation can be an appropriate whenever a considerable length of the ureter is lost or a previous surgery has failed .
meanwhile , sometimes after such procedure renal impairment is encountered . in the present case ,
we report a successful autotransplantatioin in a patient who underwent urgent operation following avulsion of the ureter at a distance of 4 cm from the pelvis .
surgeons should be aware of possible complications attributed to transureteral lithotripsy ( tul ) and their knowledge and expertize in managing such complications .
the patient was a 51-year - old lady with left flank colicky pain associated with nauseas and vomiting for a month .
study of kub ( kidney , ureter , and bladder x - ray ) and non - contrast abdominopelvic spiral ct scan images revealed a 1-cm proximal left ureteral stone ( fig .
1 ) . accordingly the patient was selected to undergo tul and ureteral stenting . 
 figure 1:abdominopelvic spiral ct scan of the patient before surgery .
abdominopelvic spiral ct scan of the patient before surgery . due to a narrow ureteral lumen proceeding with the procedure seemed impossible and we decided to terminate the surgery . while taking out the ureteroscope we noticed avulsion of the ureter at a point approximately 4 cm from ureteropelvic junction .
the avulsed ureter was handing on the tip of the ureteroscope and the avulsed fragment came out along with the ureteroscope .
after thorough evaluation of various possible methods to approach the problem , the patient was brought to a left flank position from her original lithotomy position . with a left intercostal incision nephrectomy was done .
subsequently , the position of the patient was changed to supine and a gibson incision was made over the right lower quadrant of the abdomen .
following dissection of the iliac vessels , renal vessels were anastomosed to the iliac vessels ( renal artery to the internal iliac artery and renal vein to the external iliac vein ) . using the lich 
given the fact that only a short segment of the avulsed ureter ( 4 cm ) was left , we considered implantation of the ureter to the bladder .
a drainage tube was inserted to drain any possible bleeding from the operation site and then the surgical wound was closed .
the patient was discharged in a good general condition after 3 days and the drainage tube removed .
an ultrasound imaging study of the genitourinary system 8 months into the patients follow up showed normal size , echo and cortical thickness in the operated kidney after renal autotransplantation . in follow up , 2 months after renal autotransplantation , the arterial and venous flow of the transplanted kidney were normal on color doppler ultrasound imaging ( figs . 2 and 3 ) .
the mean parenchymal arterial vascular resistance in the transplanted kidney was 0.63 which was in the normal range .
the height , anteroposterior diameter and cortical thickness of the transplanted kidney were 117.41 mm and 13 mm , respectively .
the values of urea and creatinine 3 months after transplantation were 26.4 and 1.09 , respectively .
size , echo and cortical thickness of the transplanted kidney were reported normal in the follow up ultrasound 8 months after autotransplantation ( fig .
figure 3:color doppler ultrasound of the transplanted kidney 2 months after surgery in the zoomed area of the image . 

figure 4:gray - scale ultrasonography of the patient 's transplanted kidney 8 months after surgery .
color doppler ultrasound of the transplanted kidney 2 months after surgery in the zoomed area of the image .
ureteroscopy is widely used for lithotripsy procedure and resection of malignant tumors , but this method may lead to urethral mucosal trauma , hematuria , ureteral stenosis , urinary tract infection and ureteral perforation . among all complications of ureteroscopic lithotripsy procedure ,
complete avulsion of the proximal ureter is one of the most challenging that happens in 0.060.45% of the cases .
it is evident that appropriate decision making and a timely surgical intervention can prevent the need for nephrectomy and possible complications in the future .
in general , management of ureteral avulsion depends on the location of injury , the length of the traumatized ureter , time of diagnosis , patient 's age and general health .
boari flap and psoas hitch techniques are used in proximal and distal injury of the ureter .
finally , in the absence of the previous conditions , autotransplantation can be done as a vital method .
it is evident that such surgical procedures require substantial expertize among all healthcare providers , a patient in a suitable physical status and proper age , and an accurate and timely decision making .
autotransplantation was done in our patient after quick evaluation and review of different options to repair a traumatized ureter and clinical evidences supported the accomplishment of a successful outcome .
 abstractthe patient was a 51-year - old lady with left flank colicky pain accompanied with nausea and vomiting for a month . 
 transurethral lithotripsy and ureteral stent placement was considered for the patient . 
 the patient had a narrow ureteral lumen and while bringing the ureteroscope out , ureteral avulsion occurred at a distance approximately 4 cm from ureteropelvic junction . after bringing the uretroscope out , 
 the avulsed ureter was observed hanging at the tip of the ureteroscope . 
 anastomosis of the ureter to the bladder was accomplished with lich  
 gregoir technique . 
 a drainage tube was inserted at the site of incision and the surgical wound closed . 
 the patient was discharged with acceptable general condition after 3 days and the drainage tube removed . 
 the ureteral stent was removed 4 weeks later by cystoscopy . 
 an ultrasound imaging study of the genitourinary system 8 months into the patients follow up showed normal size , echo and cortical thickness in the operated kidney after renal autotransplantation . 