Ureter anatomy injury & diversion


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  • These stents have a J memory curve on each end to prevent their migration in the postoperative period. After 3–4 weeks of healing, stents can be endoscopically removed from the bladder.
  • Ureter anatomy injury & diversion

    1. 1. URETERIC INJURY IN OBST ETRICS AND GYNAECOLOGICAL SURGERY AND URINARY DIVERSIONS Prof. M.C. Bansal. Founder Principal & Controller ; Jhalawar Medical College And Hospital Jhalawar Ex Principal & Controller ; Mahatma Gandhi Medical College and Hospital Sitapura, Jaipur.
    5. 5. • The ureters are the muscular ,thick walled narrow tubes(Right and Left) • Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.
    6. 6. PELVIC URETER • The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder. • The abdominal segment lies on the psoas muscle and enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel.
    7. 7. • At the level of ischial spines it runs in the broad ligament and enter the ureteric canal formed by the cardinal ligament, crossed by the uterine vessels running anterior to ureter. • Here, It is 1.5 cm lateral to cervix. • The ureter runs medially and enter the bladder close to the anterior vaginal wall . On left side it even can cross the vaginal angle . Ureters while running at base of broad ligament ,are also very close to utero sacral ligament.
    8. 8. • The ureter is supplied by : Renal , Gonadal, Common iliac , Internal iliac, vescical Uterine arteries and the Abdominal aorta. • The venous drainage generally follows the arterial supply. BLOOD SUPPLY
    9. 9. LYMPHATIC DRAINAGE • Lymph drains into sub mucosal ,intramuscular and adventitial plexuses ,which all communicates. INNERVATION • The ureter is supplied from the lower three thoracic , first lumber and second to fourth sacral segment of spinal cord by branches from the renal and aortic plexuses and the superior and inferior hypogastric plexuses.
    10. 10. INCIDENCE • 75% ureteric injuries take place during gynaecological procedures. • Abdominal Hysterectomy is the most common procedure. • 30% chance of injury during gynaec-oncosurgery. • 0.5-1% ―Abdominal Hysterectomy. • 0.1 % —Vaginal Hysterectomy. • 9-10%-Wertheim's Hysterectomy
    11. 11. Common sites of ureteric injury • At the pelvic brim during clamping of infundibulopelvic ligament. • At the bifurcation of common iliac artery during internal iliac artery ligation. • Lateral pelvic wall above the uterosacral ligament. • Base of broad ligament , ureter passes under the uterine artery. • Ureteric canal-During Wertheim hysterectomy. • Intramural portion near the insertion into the trigon when base of bladder is injured or repaired. • Upper vagina during clamping of vaginal angle.
    13. 13. 1.ANATOMICAL RISK FACTORS: A)THE URETER: • Has close attachment to the peritoneum. • Closely related to female genital tract. • Has variable course. • Not easily seen or palpated.
    14. 14. 2.PATHOLOGICAL RISK FACTORS: 1. Congenital anomalies of ureter or Kidney. 2. Ureteric displacement by: Uterine size ≥12 weeks. Prolapse. Tumour{ovarian neoplasm}. Cervical fibroid/Ca. broad ligament swellings(fibroids , incarcirated ovarian tumours or hematomas) 3.Adhesions: Previous pelvic surgery. Endometriosis. PID. Extention of carcinomatous indurations in broad ligaments , post irradiation. 4.Distorted pelvic anatomy.
    15. 15. 3.TECHNICAL RISK FACTORS • Massive intraoperative haemorrhage. • Coexistent bladder injury. • Technical difficulties. • Inexperienced surgeon.
    16. 16. TYPES{CAUSES}OF INJURY INTRAOPERATIVE • Crushing from misapplication of a clamp. • Ligation with a suture. • Transection{partial or complete} • Angulation of the ureter with secondary obstruction. • Ischemia from ureteral stripping , LASER or electrocoagulation. • Resection of a segment of ureter. • Any combination of these injuries may also occur. POSTOPERATIVE • Avascular necrosis following werthiem. • Kinking-peritonisation of vaginal stump after hysterectomy. • Subsequent obstruction over: -Haematoma or -Lymphocele
    17. 17. In ½ OF THE cases URETERIC INJURy is not identified at the time of primary injury during surgery
    18. 18. ABDOMINAL • Hysterectomy. • Wertheim’s hysterectomy. • Oophorectomy. • Uterine suspension. • Burch colposuspension. • Vesicovaginal fistula repair. LAPROSCOPIC • Division of adhesions. • Electrocoagulative injury while uterine arteries are coagulated or ligated. • Transection of uterosacral ligament. • Colposuspension • Treatment of endometriosis. • Sterilisation (electrocoagulation) PROCEDURE ASSOCIATED WITH URETERIC INJURIES VAGINAL • Hysterectomy. • Anterior colporrhaphy • Cervical biopsy. • Vesicovaginal fistula repair. • Culdoplasty
    19. 19. Prevention strategies to reduce the risk of ureteric injuries • General preventive strategies: Preoperative Intraoperative • Specific Preventive strategies:
    20. 20. GENERAL PREVENTIVE STRATEGIES A .Preoperative measure: • Intravenous urogram(IVU). • Ultrasound scan. • Previous investigations ,can identify ureteric dilatation and disclose anatomical variations. • Preoperative stenting in conditions of anatomical distortion.
    21. 21. INTRAOPERATIVE PREVENTION • Surgeon is to constantly and equivocally know where ureter is all times. • Appropriate operative approach. • Adequate exposure. • Avoid blind clamping and ligature of blood vessels. • Mobilise bladder away from operative site • Stay outside vascular sheath . • Limit the zone of coagulation to avoid thermal injury. • Ureteric dissection and direct visualisation.
    22. 22. IDENTIFICATION OF URETER • The peritoneal reflection anterior to the uterus is incised and the bladder is pushed down with blunt or sharp dissection. • Pelvic ureter is identified on the medial aspect of the broad ligament during the opening of perivescical and perirectal spaces while performing extended hysterectomy or removing broad ligament tumors.
    23. 23. IMAGING • No proof that preoperative IVU or CE-CT reduces risk of injury. • Endometriosis , PID uterovaginal prolapse and previous intra - abdominal surgery are associated with increased prevalence of abnormal IVU finding.
    24. 24. SPECIFIC PREVENTIVE STRATEGIES A}During Abdominal hysterectomy:- Clamp infundibulopelvic ligament after lifting up the ligament dissection and palpation ,clamp near to the ovary. -Always clamp{cardinal , Uterosacral} ligaments close to the uterus. -Never to open vagina unless urinary bladder is dissected down properly and sufficiently. -Use of intrafacial technique.
    25. 25. SPECIFIC PREVENTIVE STRATEGIES B}During Vaginal surgery : 1. Prevention of ureteric injuries can be achieved by adequate development of vescico-uterine space , by: -Downward traction on the cervix. -Counter traction upward by Sim’s speculum below the bladder. 2. All clamp:-Small bites. -Close to the uterus. 3. Avoid double clamping of uterosacral ligament. 4. Vaginal Oophorectomy should be avoided or done cautiously. 5. During anterior colporrhaphy: -Avoid too lateral dissection . -Avoid deep suture :as the distance between needle and ureter in upper vagina ≤0.9 cm.
    26. 26. • C)During laparoscopy:can be achieved by: • -Moving the fallopian tubes away from pelvic side walls before coagulation. • -The bleeding points at uterosacral ligaments should be secured with sutures or clips instead of electrocoagulation. • -In LAVH place stapler or suture across uterine vessels and cardinal ligaments instead of electrocoagulation.
    28. 28. MANAGEMENT
    29. 29. AIM OF MANAGEMENT • Preservation of function. • Anatomical continuity. • Decision depends on- Time of detection Extent of injury Site of injury General condition of patient
    30. 30. Upper ureteric injuries • Primary ureteroureterostomy • If there is extensive loss of the ureter, autotransplantat ion of the kidney can be done as well as bowel replacement of the ureter.
    31. 31. STENTING  Insert a silicone internal stent through the anastomosis before closure. Advantages : 1. Maintenance of a straight ureter with a constant caliber during early healing, 2. The presence of a conduit for urine during healing, 3. Prevention of urinary extravasation, 4. Maintenance of urinary diversion, 5. Easy removal
    32. 32. Ureteric Injury Repair • Depends on cause, location, and extent – Minor trauma (ligature or crush) may be managed with stent and drainage – Partial transection corrected with suture repair or resection • Lower third – Primary ureteroureterostomy (ligation) – Bladder tube flap (Boari flap) – Transureteroureterostomy (extensive urinoma or pelvic infection – Procedure of choice: Psoas Hitch
    33. 33. Psoas Hitch Procedure
    34. 34. Upper, Middle, Lower Segments
    35. 35. Laboratory findings  Retrograde Urethrogram  Rule out urethral injury ▪ Insert catheter ▪ Inflate balloon ▪ Inject dye (20 ml, water soluble) ▪ Visualize (X-ray)
    36. 36. Laboratory findings  Catheterization  Hematuria  Culture initial catheterization ▪ Infection  Contra indication ▪ bloody urethral discharge
    37. 37. Laboratory findings CT Scan / Cystogram  Check bladder integrity ▪ Catheterize ▪ Inject dye ▪ Radiograph imaging ▪ X-ray ▪ CTS ▪ Drainage Film
    38. 38. 86 Urinary diversion • to divert urine from the bladder to a new exit site. • Usually through a surgically created opening (stoma) in the skin.
    39. 39. Introduction • Diversion of urinary pathway from its natural path • Types: –Temporary –Permanent
    40. 40. Indications of permanent urinary diversion • When the bladder has to be removed • When the sphincters of the bladder & the detrusor muscle have been damaged or have lost their normal neurological control • When there is irremovable obstruction in the bladder & distal to that • Ectopic vescicae • Incurable vescico- vagina fistula
    41. 41. 89 Indications • Tumour necessitating removal of entire bladder • Pelvic malignancy • Birth defects • Strictures • Trauma to ureters and urethra • Neurogenic bladder • Chronic infection causing severe uretral and renal damage • Intractable interstitial cystitis and • Incontinence
    42. 42. Temporary urinary diversion • Suprapubic cystostomy • Pyelostomy or nephrostomy or urethrostomy (with indwelling catheters)
    43. 43. Illustration of suprapubic tube placed to aid bladder drainage Suprapubic Cystostomy
    44. 44. A nephrostomy is a surgical procedure by which a tube, stent, or catheter is inserted through the skin and into the kidney.
    45. 45. Permanent urinary diversion • Uretero - sigmoidostomy • Ileal conduit • Colon conduit • Ileocaecaecal segment • Lowsley’s operation
    46. 46. 94 Types of urinary diversions Cutaneous urinary diversions •Ileal conduit (ileal loop) •A 12 cm loop of ileum led out through abdominal wall •Stents used •The space at cystectomy site drained by a drainage system •After surgery a skin barrier and a transparent disposable urinary drainage bag •Constantly drains
    47. 47. 96 Complications of ileal conduit • Wound infection • Wound dehiscence • Urinary leakage • Ureteric obstruction • Small bowel obstruction • Ileus • Stomal gangrene • Narrowing of the stoma • Pyelonephritis • Renal calculi
    48. 48. 97 Cutaneous Ureterostomy…
    49. 49. 98 Vescicostomy
    50. 50. 99 Nephrostomy…
    51. 51. Uretero- sigmoidostomy • Complications: – Reflux of urine – Hyperchloraemic acidosis – Renal infection – Stricture formation
    52. 52. 101 Continent Urinary Diversions • Continent Ileal Urinary Reservoir Indiana Pouch • Most common continent urinary diversion • Periodically catheterized Koch Pouch Charleston Pouch Ureterosigmoidostomy • Voiding occurs from rectum
    53. 53. 102
    54. 54. 103
    55. 55. 104 Koch Pouch II
    56. 56. 105 ureterosigmoi dostomy
    57. 57. 106 Potential complications • Peritonitis due to disruption of anastomosis • Stomal ischaemia and necrosis due to compromised blood supply to stoma • Stoma retraction and separation of mucocutaneous border due to tension or trauma
    58. 58. Bladder reconstruction
    59. 59. Recto sigmoid pouch
    60. 60. 110 Nursing process : The patient undergoing urinary diversion surgery Preoperative assessment : • Cardiopulmonary assessment • Nutritional assessment • Learning capacity assessment Preoperative nursing diagnosis • Anxiety • Knowledge deficit Preoperative planning and goals • Relief of anxiety • Ensuring adequate nutrition • Explaining surgery and its effects
    61. 61. 111 Nursing Management • In the immediate postoperative period urine volumes are monitored hourly • An output below 30 ml/h dehydration or obstruction • Promote urine output – a catheter may be inserted through urinary conduit • Provide stoma and skin care – consult with enterostomal therapist • Skin care specialist consulted • Stoma looked for color – dark purplish –blood supply compromised • Skin inspected for irritation • Bleeding • Wound infections
    62. 62. 112 Postoperative nursing interventions • Monitor urinary function • Prevent complications infection, sepsis, respiratory, complications, fluid and electrolyte imbalances, fistula formation. • Ryle’s tube aspiration • Ambulate quickly • Maintain peristomal integrity • Relieve pain • Improve body image • Exploring sexuality issues • Treat peritonitis • Look for stomal ischaemia and necrosis • Look for stomal retraction and separation
    63. 63. 113 • Neomycin, kanamycin • Immediately after operation – catheter in rectum – to prevent reflux into ureters and infection of the newly formed ureteric opening into the intestines • Monitoring fluid and electrolytes : intestinal mucosa absorb urine water and electrolytes; diarrhoea due to potassium and magnesium; maintain the balance. Pt advised to empty the rectum every 2 hours to ↓ build up of pressure and thereby the absorption of urinary salts • Retrain the rectum – special sphincteric exercises – learn the differentiate between the need to defaecate and the need to urinate
    64. 64. 114 • Promoting dietary measures – avoid chewing gum, smoking. • Salt intake restricted to prevent hyperchloremic acidosis. Potassium increased to make up for potassium lost in acidosis • Monitoring and managing potential complications : - pyelonephritis due to reflux of bacteria from rectum – long term antibiotics – late complication due to irritation - adenocarcinoma
    65. 65. 115 Managing ostomy appliance • Empty the pouch when 1/3 full to prevent weight pulling down • A small amount of urine is left to prevent collapse of the bag against itself • The collecting bottle and tubing is rinsed with cold water daily and once in a week with a 3:1 solution of water and white vinegar • Continuing care – look for metastases
    66. 66. 116 • Look for leakage of urine from the appliance • Urine pH is kept below 6.5 by administration of ascorbic acid • Appliance to be fitted properly to prevent skin from getting irritated by urine • If the urine is foul smelling C&S done • Ileal conduit – mucosa – mucus produced – urine gets mixed with mucus – patient encouraged to take lot of fluid to wash out the mucus. • Appliances : reusable or disposable • Skin barrier used to protect skin from urine
    67. 67. 117 Promoting home and community care • Teach patients self care • Control odour : food that gives odour to urine avoided e.g. Cheese, eggs • Deodorizers or dilute white vinegar introduced into the drainage bag • Ascorbic – acidifies – suppresses odour • Aspirin introduced into bag to deodorize may cause ulceration of the stoma
    68. 68. 118 • Home and community care • Teaching self care • Continuing care
    69. 69. Future aspects 1. More than 40 variants of continent diversion, no single best technique 2. Which bowel segment ? 3. Which continent technique ? 4. Which anti-reflux technique ? Only long term follow up can answer these questions