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Ureteral Repair
What is
Ureteral Repair?
Ureteral repair is a type of procedure that
involves treatment of injury or trauma to the
ureter.
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Effects
of Ureteral Repair
Ureteral injuries tend to occur in difficult
open surgery or endoscopic procedures. Some
injuries may be unavoidable, and the goal is to
minimize injury.
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Candidates for Ureteral Repair
Ureteral repair is ideal for those who have
injury that may be caused by blunt or
penetrating external violence and from
iatrogenic injury during open and/or endoscopic
surgery
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Your Consultation
The
choice of treatment is based on the location,
type, extent, and timing of presentation, as
well as the patient's medical history, overall
condition, and survival prognosis. Laboratory
evaluation should include urinalysis, urine
culture, complete blood count, and creatinine
determination from the serum and drainage.
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The
Ureteral Repair Procedure
The
choice of repair also is affected by the
presence of cancer, previous radiation,
infection, retroperitoneal fibrosis, and
associated injuries. Most importantly, the
function of the contralateral kidney must be
considered. Regardless of the procedure
performed, the principles of ureteral repair are
the same.
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All
nonviable tissue must be debrided.
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A
well-spatulated, watertight, tension-free
anastomosis is paramount.
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The
repair must be isolated from infection,
retroperitoneal fibrosis, and cancer.
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The
omentum or retroperitoneal fat can be used to
cover the repair and therefore decrease the
risk of fibrosis and increase the blood supply
to the region of the repair.
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Wrapping the repair also allows the ureter to
be mobile and resume peristalsis.
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Special attention is required to avoid
unnecessary mobilization and devascularization
of the ureter.
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Recovery
The
repair should be followed at regular intervals
for the first year to watch for signs of
obstruction or loss of renal function. Follow-up
may be conducted initially with an IVP to
demonstrate the anatomy and then with serial
ultrasounds to evaluate for hydronephrosis.
Nuclear scans also may be of assistance to
determine relative renal function and screen for
signs of obstruction. Serum chemistries should
be monitored to assess for renal function and
acidosis.
The frequency and duration of follow-up is
dependent on the clinical setting and surgeon's
preference.
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Risks
The complications
of repair depend on the type of reconstruction
performed. Complications common to all repairs
may include stricture, extravasation,
hydronephrosis, abscess, fistula formation, and
infection. The key is to diagnose the problem
early and then treat accordingly.
Frequently Asked Questions
Q:
What are the symptoms of ureteral injury?
A:
Patients with undetected ureteral injuries
present with various signs and symptoms, such as
flank pain, CVA tenderness, unexplained fever
and chills, abdominal distention and ileus.
Q:
What are the treatment options for ureteral
injury?
A:
There are essentially three options for ureteral
repair:
1.
end-to-end
reanastomosis
2.
ureteroneocystostomy
3.
transureteroureterostomy
END-TO-END REANASTOMOSIS - If the site of
ureteral injury is above the midpelvis, and the
extent of injury is not extensive, end-to-end
anastomosis of the ureter may be performed.
First, debride the injured portion and then
mobilize the ureter to avoid tension on the
anastomotic site. A double J ureteral catheter
is inserted and extraperitoneal suction
drainage, such as a Jackson-Pratt drain, is
placed close to the anastomotic site. The
bladder is drained with a urethral or suprapubic
catheter.
URETERONEOCYSTOSTOMY - Most ureteral injuries in
difficult laparoscopic pelvic surgeries occur
around the area of either the ureteric canal or
along the site of the cardinal ligament between
the ureteric canal and the base of the bladder.
These injuries are located deep in the pelvis.
After resection of the damaged section of ureter,
continuity of the urinary tract can best be
restored by performing a ureteroneocystostomy
rather than an end-to-end ureteroureterostomy.
To avoid tension on the anastomotic site, the
bladder must be mobilized from the back of the
pubis. An anterior cystostomy is performed and
the ureter is brought through the wall of the
bladder by means of a submucosal tunnel. An
end-to-side mucosa-to-mucosa anastomosis between
the end of the ureter and the side wall of the
bladder is performed. A double J ureteral
catheter is inserted and a Jackson-Pratt drain
is placed retroperitoneally close to the
anastomotic site but not touching it. If
adequate mobilization of the bladder is
difficult, a bladder hitch can be done by simply
displacing the bladder upward and attaching it
to the fascia of the iliopsoas muscle.
Similarly, the upper segment of the ureter can
be further mobilized to reduce the tension on
the anastomotic site.
An advantage of laparoscopic ureteral surgery is
that end to end ureteral re-anastomosis can be
performed, even in cases of injury of the distal
ureter between the ureteric canal and the base
of the bladder. Thus, making the traditional
technique of ureteral re-implantation a rare
procedure. However, the skill of the surgeon is
a critical factor.
TRANSURETEROURETEROSTOMY - If a large segment of
ureter has been damaged and a
ureteroneocystostomy is not possible, a
transureteroureterostomy by an experienced
urologist is advised.
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The following list of Urology procedures are
performed at Beverly Hills Medical Group -
please click the links to find out more:
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