Ureteral Operations
Kenneth D. Hatch
GENERAL PRINCIPLES
Definition
Injury to the ureter may result from surgery, cancer, radiation, or infection.
Gynecologic surgery is the most common cause of ureteral injury and will be the subject of this chapter.
The injury may be from partial or complete transection, ligation, kinking, crushing, or thermal injury from the energy used to dissect the ureter.
Partial and complete transection injuries may be recognized during surgery.
The other injuries may not be apparent until the postoperative period.
A complete ligation will often be apparent in 48 hours as the patient may have flank pain with a small rise in creatinine. This is followed by a fever and worsening flank pain.
Kinking injuries may be diagnosed several days after surgery as postoperative edema intensifies the kink, leading to more complete obstruction.
Thermal injuries may be diagnosed 7 to 14 days postoperatively. The urine usually leaks into the pelvis, causing a urinoma with fever and ileus. The urine may then make its way out through the vaginal cuff, leading to a ureteral vaginal fistula.
Crushing injuries may present the same as thermal injuries if the ureteral wall has been devascularized enough for leakage to occur. If no leakage occurs, the ureter may scar and cause stenosis.
Anatomic Considerations
The ureter has five main sources of blood supply.
The distal ureter receives circulation from vessels at the base of the bladder.
A branch from the uterine vessel supplies blood to the lower pelvic ureter.
A branch from the internal iliac artery nourishes the mid and upper pelvic ureters.
A branch from the common iliac artery supplies the mid abdomen ureter.
Branches from kidney supply the upper ureter.
These vessels all contribute to the vascular network.
Nonoperative Management
All of these ureteral injuries will need intervention.
Incomplete ureteral obstruction and nonobstructive ureterovaginal fistula may be amenable to cystoscopy and an attempt to pass a ureteral stent.
If this fails, then percutaneous nephrostomy with antegrade passage of a stent should be attempted.
If a stent cannot be placed, then the percutaneous nephrostomy will be left in place to drain the urine.
IMAGING AND OTHER DIAGNOSTICS
The best image is a CT urogram. It will identify the site of injury and determine if there is a complex fistula involving the ureter and the bladder.
PREOPERATIVE PLANNING
If conservative treatment as outlined above is unsuccessful, then surgical repair of the injury will be necessary. The type of operation will depend on the level of the ureteral injury (vide infra).
The traditional management was to wait for 3 months before attempting a corrective surgical procedure. This was based on the premise that associated inflammation would need to regress. Today the waiting period is based on the location of the injury and the associated disease process.
If there is significant urinoma and subsequent inflammatory reaction, a period of waiting up to 6 weeks with percutaneous drainage of the urine and antibiotics for 10 days will make the surgery more successful.
If this is an acute obstructive injury without associated inflammation, then an early operation within a few days is recommended.
If the patient has had a hysterectomy at the time the injury occurred and it is detected more than 1 week postoperatively, then a waiting period of up to 4 weeks to allow for the acute postoperative inflammation to subside should be considered.
SURGICAL MANAGEMENT
The site of injury will determine the type of operation.
Ureteral injuries in the mid and lower pelvis will be able to have a simple ureteroneocystostomy (see Tech Fig. 32.1 and Video 32.1
).
Injuries near the pelvic brim may require a psoas hitch to ensure a tension-free anastomosis (see Video 32.2
).
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