Causes and management of long ureteral defect

1. By
Nader Adel Abdelsattar
Assistant lecturer at Al-Azhar University

3. Length: 25-30 cm.
Parts:
1) Abdominal Part
The ureter start as a continuance to the renal pelvis, which is a
funnel-shaped organ, to the medial margin of the lower end of
the kidney.
It runs medially on the psoas major and then it enters
downwards. Lateral to process of the traverse of the lumbar
vertebrae.
It enter the pelvic cavity by crossing in front of the bifurcation
of the common iliac artery in the pelvic brim in front of the
sacroiliac joint.

4. • Psoas major & fascia
• Genito-femoral nerve
• Tips of transverse process

5. Rt side:
Parietal peritoneum
Rt gonadal vessels
2nd & 3rd partof Duedenum
Rt colic & Ileocolic vessels
Root of mesentry
Terminal part of ileum
Lt side:
Parietal peritoneum
Lt gonadal vessels
Lt colic & sigmoid Vessels
Apex of sigmoid mesocolon

6. Pelvic Part:
It run backward, and
laterally along the anterior
margin of the greater sciatic
notch.
Opposite to the ischial
spine, it turns forwards and
medially to get to the base of
the urinary bladder, where it
enters the bladder trigone as
ureteric orifice

7. Mucosa
• Transitional epithelium
• No submucosa
Muscle
• Outer longitudinal
• Middle circular
• Inner longitudinal
Adventitia

10. External trauma
 Blunt trauma ; e.g. fractured lumbar processes and
thora-columbar dislocation
 Penetrating trauma(e.g. gunshot injuries): the
mechanism by direct transection and by disruption of
blood supply and subsequent necrosis
o Associated visceral injury e.g. small or large bowl
perforation is common
o Associated renal injuries 10-28%
o Associated bladder injuries 5%
1) Ureteral injuries:

11. Iatrogenic trauma:
o the commonest cause of ureteral injury
o Most injuries involve the pelvic part of ureter
Open surgeries:
Pelvic surgeries; such as hysterectomy, colorectal surgery or open
urological procedures
Vascular surgeries; such as aortoiliac and aortofemoral bypass
surgery
Laparoscopic surgeries
Laparoscopic hysterectomy also may occur during
electrosurgical or laser-assisted lysis of endometriosis
Endourologic e.g.Ureteroscopy
1) Ureteral injuries:

12. Chronic inflammatory disease:
oTB
oBilharziazis
Retroperitoneal Fibrosis
Iatrogenic Injuries
Neoplasm
Rediation Damage
2) Ureteral stricture:

13. • Americal Association for the Surgery of Trauma (AAST)
Ureteral injury grading scale:

15. 1)Extravasation of urine is diagnostic for ureteral injury
2)Methods help to diagnose ureteral injury intraoperative:
Ureteral inspection: contusion and laceration is often
visible. The viability of the ureter may be compromised when
the ureter is dusky, discolored, lacking capillary refill or when
there is no bleeding from cut edge of the ureter.
Dye test: colored dye(indigo carmine, phynazopyridine HCL
or methylene blue) can be administer by intravenous infusion,
by direct injection into renal pelvis, or by retrograde injection
during cystoscopic ureteral catheterization
Pyelogram: Contrast can be administered by intravenous
infusion(on the table IVU), by direct injection into the renal
pelvis or by retrograde injection during cystoscopic ureteral
catheterization

16. One shot IVU is unreliable for diagnosing
ureteral injury. However intraoperative IVU
may be helpful when give IV bolus of contrast
(2ml/kg maximum 150 ml) followed by serial
KUBs over next 2-15 minutes

17. Presentation:
Persistent flank or abdominal pain
Postoperative fever
Flank or abdominal mass
Prolonged ileus
Anoria (if bilateral)
Prolonged high output from surgical drains:
The drain can sent for spot creatinine. It usually be 25-
450 mg/dl when fluid is urine, but is will be similar to serum
creatinine when its not urine
Cutaneus fistula in neglected cases

18. Routine laboratory investigations:
oLeukocytosis
oTransient elevation of serum creatinine
Spot creatinine from surgical drains
IVP-
 Mainstay of diagnosis
 Extravasation, hydro- ureter/ nephrosis, delayed function, stricture
• CT contrast-
 Hydronephrosis, extravasation, stricture, urinoma, ascites, post-op
surrounding anatomy
• USG-
 Hydro-ureter/ nephrosis and urinoma.
Retrograde pyelogram
Antigrade pyelogram
Fistulogram

22.  Aim of treatment:
 Preservation of renal function.
 Restoration of anatomical continuity.
Decision depends on:
 General condition of the patient
Time of detection
Site of the defect
Extent of the defect

23. • Debridement of necrotic tissue.
• Ureteric dissection preserving adventitial sheath and its blood
supply.
• Spatulation of ureteral ends.
• Tension-free, watertight mucosa-to-mucosa anastomosis with
absorbable sutures.
• Internal stenting.
• External drain.
• Isolation of injury with peritoneum or omentum

24. Upper third
Uretero-calycostomy
Trans-ureteroureterostomy
Middle third
Trans-ureteroureterostomy
Boari flab ± psoas hitch
Lower third
Psoas hitch
psoas hitch ± Boari flab
Complete
Ileal interposition
Autotransplantation
Nephrectomy (rare cases)

25. Ureteral injury in unstable patients needs temporary
urinary drainage followed by delayed definitive
management
ligate the ureter, with a non absorbable suture just
above the injury aid in visualization at the time of
the second operation.
Ureteric catheterization: ureteral catheter placed
into the ureter, sutured and brought out through the
skin
Nephrectomy Gordon et al., 2014

26. Up to 1 week
Gordon et al., 2014
Need exploration of the ureter
After 1 week Tissue edema and inflammation makes
repair difficult so PCN for 3 months
and then evaluate

27. Amputation of lower pole to expose infundibulum and
calyces
Distal ureter debrided and spatulated
Insertion of stent
Anastmosis to calyx using interrupted 4/0 vicryl

30. Described By Boari 1894
Seldom used as 1st choice
Tunneling the donor ureter
through the sigmoid colon
mesentery. superior to the
inferior mesenteric artery to
avoid kinking
(Paick et al, 2006)

32. Indications:
When primary reanastomosis
to a distal segment is not
feasible,
Or if a ureteroneocystostomy
is precluded i.e.
Rectal injury
Major vascular injury
Extensive bladder injury
Contraindications:
Inadequate donor ureter
length
Disease of the recipient
ureter such as:
Urothelial carcinoma.
Urolithiasis.
Retroperitoneal fibrosis
Pelvic tumors with ureteral
involvement
Iwaszko et al, 2010

33. First described by Zimmerman and colleagues (Zimmerman et
al, 1960)
Tension free Fixation to psoas muscle.
Avoid injury to genitofemoral nerve (superficial the psoas
muscle).
Good results replacing the lower ½ of the ureter.
(Ordoroca R. et al ,2014)

34. Procedure:
The contralateral superior vascular pedicle is ligated and
divided (to permit mobilization to the affected site)
The bladder dome is pulled and sutured to the ipsilateral psoas
tendon
The ureter is re-implanted to the bladder dome
Avoid injury to genito-femoral nerve
Contraindication:
Psoas hitch is contraindicated when bladder is too small to
permit sufficient mobilization

36. Universally Good results.
Could bridge significant defect.
 Done with psoas hitch.
Anti-reflux measure is feasible.

37. Anterior flap is created beginning 2 cm
from the bladder neck and extending to
the bladder dome, its base about 4 cm

40. Glass tube (Boari, 1895)
Vitallium (Metal) (Lord, 1942)
Tantium (Lubach, 1947)
Polyethylene (Scher, 1955)
Teflon (Ulm, 1963)
Silicon (Plum, 1963)
Dacron (Griffith, 1973)

41. Nephro-Vesical
Stents
Alternative to a
permanent nephrostomy
Uses only in patients with
metastatic disease, where
internal ureteral stenting
proved to be impossible.
JoergSchmidbauer et al, 2006

42. Infection.
Dislodgment.
Leakage.
Non-peristaltic.
Encrustation.

43. (Using gastro-intestinal tract)
Stomach
Ileum
Ilio-colonic
Colonic

45. Available
Wide surgical versatility
Peristalsis
Long mesentric supply
Assure the viability of the graft

47. 4 5 6
Figure 1
The patient is
placed supine
position and a
median
laparotomy
performed.

48. Figure 2
The paracolic gutter is
incised and the descending
colon reflected medially to
expose the
retroperitoneum.
The ureter is exposed
proximal to and away from
the strictured segment
A loop is passed beneath
the ureter and held up for
traction, to facilitate its
dissection.

49. Figure 3
The ureter is
transected at a
healthy well
vascularized segment
A stay suture is
applied which helps
later in proper
orientation

50. Figure 4
Buttonhole is
created in the left
mesocolon near its
base; the ureter is
pulled through this
window and laid
intraperitoneally.

51. Figure 5
The intestinal substitute is
derived from the terminal
ileum; a segment 6–7 cm long
is usually sufficient.
The main operating room
lights are switched off. With
back transillumination, the
arborization of the blood
vessels within the mesentry is
clearly visible.
The selected segment is
further subdivided into three
equal parts, with preservation
of the individual bloodsupply.

52. Figure 6
The isolated
segments are then
separated and the
continuity of bowel
re-established.
The pedicles of
the isolated ileal
rings are
temporarily
controlled by a soft
bulldog clamp.

53. Figure 7
Each ring is then
incised along its
longitudinal axis
the incisions of the
most proximal and
distal segments are
close to the mesenteric
attachments.
The intermediate ring
incised at the
antimesenteric border

54. Figure 8
The incised segments
are unfolded and their
adjacent ends sutured
together using 4/0
absorbable material.
The result is the
creation of an intestinal
plate of ª2 cm wide
and 16–18 cm long.

55. Figure 9
This plate is then
tubularized around a 16
F Nelaton catheter
using a continuous 4/0
absorbable material.
The ends of this tube
are devoid of any
mesenteric
attachments, to
facilitate anastomosis
of the tube to the
ureter proximally and
its antirefluxive
implantation in the
bladder distally.

56. Figure 10
An end-to-end-
anastomosis made
between the proximal
end of the ileal tube
and the spatulated
proximal ureter using
interrupted 4/0
absorbable sutures
The distal end
implanted using the
Lich-Gregoir
principle.

58. Hardy 1963.
Can overcome any defect.
When other treatment options
are not feasible
Patient shouldn’t have aorto-
iliac atherosclerosis or renal
disease.
Need a special experience
(Gordon et al 2014)

59. Nephrectomy is rarely necessary, it may
be indicated in cases of severe injury to the
ipsilateral kidney, or ureteral injury with
non functioning or poor functioning kidney
Gellhaus et al., 2014

60. Ureteral injuries are recently repaired laparoscopically with
particular rise in robotic use of ureteral reconstruction.
There are reports of laparoscopic Boari flap, psoas hitch, and
ureteroureterostomy repairs are promising.
The advantages:
less postoperative pain,
less blood loss,
shorter convalescence,
and minimal disfigurement.
Initially; operative times were longer but have decreased as
experience has increased.
Gordon et al., 2014

61. Laparoscopic Boari flap First described by Fugita and
colleagues (2001)
involving only three patients
Mean operative time of 220 minutes
all patients had resolution of obstruction.
Castillo and colleagues (2005) reported a slightly larger series
of laparoscopic Boari flap in eight patients.
Operative times (mean 157 minutes),
blood loss (mean 124 mL),
hospital stay (mean 3 days
Two complications occurred including one pulmonary
embolism and one patient with urinary leakage
The robotic-assisted laparoscopic approach was first reported
several years later (Schimpf et al, 2008).

62. An anterior
flap is created
beginning
2 cm from the
bladder neck
and
extending to
the bladder
dome

63. The spatulated
ureter is
anastomosed
to the apex of
the flap with
interrupted 4-0
absorbable
suture.

64. The flap is then
closed in a
running
fashion.

66. Open
Labaroscopic
Endourologic
Gun Shot
Decelerating Injury
TB
Bilhaziazis
Retroperitoneal
Fibrosis
Iatrogenic Injuries
Neoplasm
Rediation Damage