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Ureteric reconstruction following injury

Created: 25/4/2005

 

Ureteric reconstruction following injury

1) Injury due to trauma

  • Ureteric injury <1% of all urinary trauma, due to retroperitoneal position and small x-sectional area
  • Penetrating injuries most common (gunshot>stab)
  • Type of ureteral repair depends on site of injury and viable length of the remaining proximal segment
  • In patients who are haemodynamically unstable ureteral repair is avoided in favour of nephrectomy or staged repair (ureters are tied off and kidney drained percutaneoulsy)

a) URETERAL CONTUSION:

  • Can heal with stricture or break down later if microvascular injury results in ureteral necrosis.

Techniques:

  • Internal stenting (NB. contusions that appeared minor may stricture or break down secondary to unappreciated microvascular damage. If doubt exists, ureter should be dibrided and ureteroureterostomy performed)
  • Severe or large areas of contusion should be treated with excision and ureteroureterostomy (end-to-end repair)
    • Reported success rates as high as 90%
    • Complications: urinary leak (10-24%), abscess, fistula, ureteral stenosis (5-12%)

Principles:

  • Careful mobilisation, spare the adventitia widely to prevent devascularization
  • Debride the ureter liberally until the edges bleed
  • Repair ureters with spatulated, tension-free, stented, watertight anastomosis, placing retroperitoneal drains afterward
  • Consider omental interposition to isolate the repair when possible

b) DISTAL INJURIES

Ureteroneocystostomy

  • Distal ureteral injuries that are so close to the bladder that the bladder does not need to be brought up to the ureteral stump with a psoas hitch or Boari procedure
  • Length of ureteric defect ˜ 4-5cm

Principles:

  • Creation of a submucosal (non-refluxing) tunnel, which will effect a nonrefluxing (3:1 tunnel that is at least three times longer than the ureter is wide)
  • New ureteral orifice is constructed with interrupted 6–0 monofilament absorbable sutures in a watertight and nonobstructing fashion
  • Repair should be stented postoperatively

Psoas bladder hitch (Turner-Warwick and Worth 1969)

  • Mainstay in the treatment of injuries to the lower third of the ureter
  • Preferable to ureteroureterostomy due to tenuous independent blood supply that might not survive transection
  • Length of ureteric defect ˜ 6-10cm
  • Reported success rate 95%

Boari flap (1st described in canine 1894)

  • Injuries to the lower two thirds of the ureter with long ureteral defects (too long to be bridged by bringing the bladder up in the psoas hitch procedure)
  • Pedicle of bladder is swung cephalad and tubularized to bridge the gap to the injured ureter
  • Procedure is time-consuming, may not be appropriate in the acute setting Length of ureteric defect ˜ 12-15cm
  • Not commonly performed but has reported high success rate

c) MID URETERAL INJURIES

Ipsilateral ureteroureterostomy (IUU)

  • Length of ureteric defect ˜ 2-3cm

Crosstransfer of the ureter - transureteroureterostomy (TUU) (Higgins 1934)

  • Involves bringing the injured ureter across the midline and anastomosing it end-to-side to the uninjured ureter
  • Most often performed as a secondary or delayed procedure
  • Can be used in some cases distal ureteral injury, where ureteroureterostomy or bladder flap/hitch repair is impossible (usually because of severe bladder scarring, a congenitally small bladder, or a very long segment of missing ureter)
  • Ureter becomes difficult to intubate or image with ureteroscopy via the bladder
  • Some feel this operation is contraindicated in patients with a history of urothelial cancer or calculi
  • NB. Involves surgery on the uninjured contralateral ureter with the theoretical risk of converting unilateral injury into bilateral (iatrogenic) injury

c) PROXIMAL URETER

Transposition of ileum

  • Is a method used for delayed ureteral repair, especially when a very long segment is destroyed (reported success rates 81%)

Autotransplantation

  • Used after profound ureteral loss or multiple failed attempts at repair
  • Kidney is harvested with max vessel length
  • Iliac vessels used to re-establish vascular integrity
  • Healthy ureter or renal pelvis can be attached to bladder

Reimplantation of the ureter directly into the renal pelvis

  • For ureteral avulsion from the renal pelvis or very proximal ureteral injury
  • Principles (as for UU) are spatulation, tension-free, stenting, postoperative drainage, watertight anastomosis with fine nonreactive absorbable suture

Renal descensus (Popescu 1964)

  • Kidney is mobilised and rotated inferiorly and medially on its pedicle
  • Lower pole secured to retroperitoneal muscle
  • Length of ureteric defect ˜ 5-8cm
  • Also used if additional length is required to bridge a gap, or decrease tension on a ureteral repair

Laparoscopic pyeloplasty (used rarely however likely to become more widespread)

Ureterocalycostomy (also rare)

  • Ureteral stump sewn end-to-side into an exposed renal calyx (used with profound damage to the renal pelvis and ureteropelvic junction)

d) PARTIAL TRANSECTION

Primary repair

Principles:

  • Spatulated, watertight closure, interrupted or running 5–0 or 6–0 absorbable monofilament
  • Injury closed by converting a longitudinal laceration into a transverse one
  • Internal stent and retroperitoneal drain are placed.

2) SURGICAL INJURY

a) Ligation

  • Removal of the ligature or surgical clip and observation
  • Internal ureteral stent is advisable
  • If viability is in question, ureteroureterostomy should be performed

b) Transection

Immediate recognition

  • Nonaortic surgery - as for ureteral injury due to trauma
  • Risk of breakdown of ureteral repair reported to be 8% to 40%

AAA repair

  • Intraoperative management is controversial: nephrectomy (if the patient has a functioning contralateral kidney) versus primary ureteroureterostomy with isolation of the repair with omentum
  • Nephrectomy- although radical avoids the potential for postoperative urinary leakage around a prosthetic vascular graft, which can be fatal
  • However, mortality rate from renal failure for routine AAA repair is 3%, and this climbs to 12% in patients with a ruptured aneurysm

Delayed Recognition

  • Recognized intraoperatively in approx 34% of patients undergoing open operation
  • Majority diagnosed after op with CT, IVU or retrograde
  • Signs and symptoms
  • Fever, ?WCC, peritoneal signs
  • Anuria, urogenital fistula, hydronephrosis, urinary leakage from wound, fever/pain

Repair controversial

  • Immediate attempt at placement of a double-J ureteral stent
  • If stent placement is achieved, open repair is required only in those patients with persistent leakage or ureteral stricture
  • If this fails nephrostomy placed with gentle attempt at antegrade stenting
  • If the ureter ultimately cannot be stented open repair can be attempted after wound healing has occurred
  • Others recommend open repair as soon as possible, citing complication rates as low as those for injuries recognized immediately. However, some reports indicate that delay in diagnosis increases the complication rate significantly

c) Ureteroscopic Injury

  • Treated by ureteral stenting, usually with no complications


ArticleDate:20050425
SiteSection: Article
 
   
    
                                            



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