Operative procedure

Ureteroureterostomy

In cases of crush or similar injury, the injured ends of the damaged ureter are trimmed if necessary to reach viable bleeding tissues. This is generally not necessary for transection injuries. Each end is partially spatulated by making an incision of approximately 3-5 mm longitudinally in each ureter. These incisions should be 180° apart (Figure 1).

The ureter can be stented either by passing a stent through the injured ends towards both the bladder and the renal pelvis or by performing a cystotomy and passing a stent up through the ureter to the renal pelvis. This should be done before suturing the ureter. A closed suction drain should be placed in the operative field (Figure 2).

For ureteral injuries occurring in the pelvis, the ureter is divided and the distal end permanently ligated with non-absorbable suture

Figure 4

For ureteral injuries occurring in the pelvis, the ureter is divided and the distal end permanently ligated with non-absorbable suture

Interrupted 4-0 absorbable sutures (polyglycolic acid) are used to create the anastomosis. Care should be exercised to avoid tying the sutures too tightly or putting in too many sutures. Generally, four to six sutures are sufficient (Figure 3).

Ureteroneocystotomy with or without psoas hitch and bladder flap

In cases of crush injury or obstruction, ligate and divide the ureter as distally as possible, being mindful of the presence of fibrosis such as from radiation therapy. The distal stump is ligated with a permanent suture, such as 2-0 silk. If the ureter has been transected, the distal end should still be identified and ligated with a permanent suture. The proximal end is trimmed as necessary to ensure that the terminal ureter has adequate vascular supply to allow healing of the anastomosis. The ureter is also partially freed from its peritoneal attachments to provide mobility of the most distal segment. Care is taken to avoid disruption of the adventitial layer which carries the blood and nerve supply to the ureter (Figure 4).

If the ureter and the bladder can be placed in approximation without tension, then the surgeon may proceed with the anastomosis. Otherwise, an extending bladder flap may be necessary (see below).

Figure 5

Working through an incision in the dome of the bladder, the ureter is brought through the bladder wall at a point that will ensure the most tension-free anastomosis

A longitudinal extraperitoneal incision is made in the dome of the bladder. At the conclusion of the repair, this is closed transversely to take further tension off the anastomosis. A finger or a long, curved instrument is then placed in the bladder to indicate the posterolateral position on the bladder that most closely approximates to the ureter, and a cystotomy is made at this point. The ureter is then brought through the incision (Figure 5).

The ureter is spatulated by making two 5 mm longitudinal incisions 180° apart (Figure 6). The angles of the incisions are sutured using 4-0 absorbable sutures (polyglycolic-acid) which are tagged with the needles left on. A 28-30 cm, 7 or 8 Fr single or double J is then passed up the ureter towards the renal pelvis.

The anastomosis is performed using 4-0 absorbable interrupted sutures which include the full thickness of the ureter, but only the mucosa and submucosa of the bladder (Figure 7). Generally six sutures are required, including the previously placed angle sutures. The cystotomy is then closed and a closed suction drain is placed in the area of the anastomosis. Closure may be accomplished with interrupted 4-0 absorbable sutures using through-and-through stitches. A second layer of 2-0 absorbable sutures should be placed incorporating the serosa and muscle but not the mucosa (Figure 8). Retrograde transurethral filling of the bladder should be performed to ensure a watertight seal. A two-layer running closure of the same layers is also acceptable. The ureteral stents may be removed in 2 weeks if a cystogram or intravenous pyelogram

Figure 6

The ureter is spatulated and stented demonstrates ureteral patency and no leaks. A follow-up intravenous pyelogram is recommended after 1 month to confirm patency, especially in patients who have received prior radiotherapy.

If the ureter and bladder do not approximate easily, then additional measures must be taken. Sufficient mobility of the bladder can often be obtained by developing the space of Retzius and dividing the anterior peritoneum and the lateral bladder attachments. The bladder can then be sutured to the psoas muscle to hold it closer to the ureter and to take up the tension that would otherwise be exerted on the repair. Use 2- 0 permanent suture, taking care to avoid damage to any of the nerves related to the psoas muscle.

In cases where still further mobility is required, an extending bladder flap such as those described by Boari (Figures 9-11) or Demel (Figures 12-14) may be used. The incisions are made and sutured as shown, resulting in the 'lengthening' of the bladder towards the ureter. Once this step is complete, the anastomosis is performed as described above.

Figure 7

The anastomosis is created with interrupted absorbable sutures, full thickness through the ureter and partial thickness through the bladder

Figure 7

The anastomosis is created with interrupted absorbable sutures, full thickness through the ureter and partial thickness through the bladder

Urinary diversion Introduction

Urinary diversion was first described in the mid 1800s. Many different tissues and techniques have been employed, each with their own inherent advantages and disadvantages. The major types now in use in gynecological practice are the intestinal conduits using either small or large bowel, and various versions of the ileocecal continent urinary reservoir.

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