This document discusses ureteric injuries during gynecologic surgery, including diagnosis, management, and preventative strategies. Some key points:
Ureteric injuries have an incidence of 1-2% during gynecologic surgery and are most common during hysterectomy near the pelvic brim. Injuries can be diagnosed intraoperatively using dye tests or cystoscopy, or postoperatively based on symptoms like flank pain appearing 0-21 days later. Investigations include IVP, CT scan, and cystoscopy. Management involves ureteral stenting or nephrostomy if stenting is not possible. Preventive strategies for surgeons include fully exposing and visualizing the ureter,
Ureters are retroperitoneal structues which run anterior to psoas muscle and cross lateral to medial.4sites are prone where ureter can be injured and its management
Ureteric injury in Gyenec Surgery, Serious complication of gynecologic surgery
Significant morbidity and long-term sequelae
Uncommon in benign gynecologic surgery
Vaginal hysterectomy has the lowest rate of ureteral injury
Laparoscopic hysterectomy has the highestThe 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.The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.
First part –Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.
Ureters are retroperitoneal structues which run anterior to psoas muscle and cross lateral to medial.4sites are prone where ureter can be injured and its management
Ureteric injury in Gyenec Surgery, Serious complication of gynecologic surgery
Significant morbidity and long-term sequelae
Uncommon in benign gynecologic surgery
Vaginal hysterectomy has the lowest rate of ureteral injury
Laparoscopic hysterectomy has the highestThe 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.The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.
First part –Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.Cervicopexy is fertility conserving surgical management of prolapse.
LSCS is the most common obstetric procedure but it can be very difficult to manage in cases of previous LSCS, low lying placenta, and PPH. please check out the youtube links to the videos embedded in this PPT.
ADHESIOLYSIS DURING LSCS https://youtu.be/2Hv80v3yu20
BLADDER DISSECTION https://youtu.be/6qsaTJ1yRUY
RECTUS SHEATH ADHESIOLYSIS https://youtu.be/SryJHjuGsME
VECTIS IN FLOATING HEAD DURING LSCS https://youtu.be/3PECperU8Cw
BREECH DELIVERY https://youtu.be/i-LcmTNNVvU
TRANSVERSE LIE WITH IUFD https://youtu.be/hG28uqpkdpU
CONJOINT TWINS https://youtu.be/KLR7D6wkf38
LSCS IN PLACENTA PREVIA https://youtu.be/dNKQwt4KhVY
SYSTEMATIC PELVIC DEVASCULARISATION https://youtu.be/UwSH6V6GBVw
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.Cervicopexy is fertility conserving surgical management of prolapse.
LSCS is the most common obstetric procedure but it can be very difficult to manage in cases of previous LSCS, low lying placenta, and PPH. please check out the youtube links to the videos embedded in this PPT.
ADHESIOLYSIS DURING LSCS https://youtu.be/2Hv80v3yu20
BLADDER DISSECTION https://youtu.be/6qsaTJ1yRUY
RECTUS SHEATH ADHESIOLYSIS https://youtu.be/SryJHjuGsME
VECTIS IN FLOATING HEAD DURING LSCS https://youtu.be/3PECperU8Cw
BREECH DELIVERY https://youtu.be/i-LcmTNNVvU
TRANSVERSE LIE WITH IUFD https://youtu.be/hG28uqpkdpU
CONJOINT TWINS https://youtu.be/KLR7D6wkf38
LSCS IN PLACENTA PREVIA https://youtu.be/dNKQwt4KhVY
SYSTEMATIC PELVIC DEVASCULARISATION https://youtu.be/UwSH6V6GBVw
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
3. INTRODUCTION
‘ THE VENIAL SIN IS INJURY TO THE URETER , THE MORTAL SIN IS
FAILURE OF RECOGNITION’
- Ureteric injuries – potential complication of gynaecologic
surgery.
- Over the years, unique surgical modifications of procedures have
been made to probability of ureteric injuries. Despite that,
ureteric injuries remains a very real complication .
- Incidence – 1%-2%
- It varies with the nature of surgery , skill of the surgeon,
complexity of patient’s anatomy.
4. GOALS:
A)Anatomy of ureter & to illustrate how it is prone to get injured
during gynaecologic surgery.
B)Review unique issues surrounding ureteric injury during
performance of specific groups of gynaecologic surgeries.
C)Recognition and management of ureteric injury.
D)Basic principles of avoiding injury.
5. ANATOMY OF URETER
• Retroperitoneal structure
• Length in adults – 25-30cm (10 in.) from renal pelvis to trigone of
the bladder ;3 mm in dm .
• Pelvic brim divides it into:
a) abdominal segment (12-15cm)
b) pelvic segment (12-15cm)
• Slightly constricted at 3places
a) At pelvi ureteric junction
b) At brim of true pelvis
c) At its opening in the lateral angle of trigone
6.
7. Histology: Has 3 distinct layers
1)mucosa with transitional epithelium
2)muscular layer – longitudinal,
circular, spiral ,smooth muscle fibres
3) adventitia which contains
intercommunicating network
of blood vessels
8.
9. COURSE OF THE URETER:
• Abdominal ureter runs ventral to psoas
muscle posterior to ovarian vessels to
the pelvic brim.
• Right ureter lies slightly lateral to IVC –
decends into pelvis—over common iliac
artery bifurcation
( rarely , it can be over IVC ,hence , during
para aortic node sampling before removing
nodes ureter must be identified)
• Left ureter runs lateral to aorta
,posterior to IMA, ovarian
vessels&colon. Its obscured by sigmoid
colon at pelvic brim.
• It mirrors right ureter at pelvic brim ,
entering pelvis over left common iliac
artery bifurcation
10.
11. • There is little variance between positions taken by pelvic
ureters.
• They decend into posterior lateral pelvis –lateral to
sacrum – ventral to internal iliac artery --medial to
internal iliac artery & its anterior branches
• Ureters pass beneath the uterine artery – WATER UNDER
THE BRIDGE.It lies 1.5cm lateral to cervix where it enters
paracervical tissues.
• Passes through paracervical tissue –THE TUNNEL OF THE
CARDINAL LIGAMENT / ANTERIOR BLADDER PILLAR ( also
referred as WEB OR TUNNEL OF WERTHEIM.
12.
13.
14.
15.
16.
17.
18. BLOOD SUPPLY:
• 3 sets of long arteries:
a) Upper part – branch from renal artery, gonadal / colic vessels
b)Mid part – branch from aorta ,gonadal / iliac vessels
c)Pelvic part – branch from vesical / middle rectal / uterine
vessels
• Arteries to ureter lie closely attached to peritoneum
• They divide into ascending and decending branches which
form plexus on surface of ureter and then supply it.
• Ureter is perfused by rich network with anastomoses within
adventitial sheath( relatively resistant to devascularisation)
,however such injuries occur & difficult to diagnose , as the
sequelae becomes apparent only in postop period.
19.
20. NERVE SUPPLY:
Sympathetic – T10- L1
Parasympathetic – S2-S4
All nerves – sensory in function.
They reach ureter through renal/aortic/hypogastric plexus.
EMBRYOLOGY:
Ureter develops from ureteric bud which is an outgrowth of
mesonephric duct.
21. • Above the pelvic brim, blood supply is derived from medial vessels,
distally blood supply originates laterally
• Hence , dissection and mobilisation to be done from the lateral
aspect above the pelvic brim & from the medial aspect below the
brim.
• In 10% cases, middle part of ureter is supplied only by minute twigs
From peritoneal vessels.
• In 2 % cases, although there are long arteries to the middle part ,
upper and lower parts are supplied by short vessels.
22. Risk factors
ANATOMICAL
• Has close attachment to peritoneum
• Closely related to FGT
• Variable course
• Not easily seen/palpated
PATHOLOGICAL
• Congenital anomalies of ureter/kidney
• ureteric displacement – uterine size > 12 weeks,
prolapse, tumor, cervical and broad ligament swellings
• Adhesions ( previous surgeries, endometriosis, PID)
• Distorted pelvic anatomy
23. TECHNICAL
• Massive intra op hemorrhage
• Co existent bladder injury
• Technical difficulties in view of pelvic pathology
• Technical fallacies –a) inadequate incision
b) improper abdominal packing
24. TYPES OF INJURY
INTRA OP:
a) Crushing (misapplication of clamp)
b) Ligation ( with a suture)
c) Transection ( partial / complete)
d) Angulation of ureter with secondary obstruction
e) Ischaemia from ureteral stripping /laser/electro coagulation
f) Resection of the segment
POST OP:
a) Avascular necrosis
b) Kinking
c) Subsequent obstruction due to overlying hematoma/
lymphocele.
25. URETERAL INJURY ASSOCIATED WITH
GYNAECOLOGIC SURGERY
• Most common site : Pelvic brim near the infundibulopelvic
ligament
• Most common procedure: Simple abdominal hysterectomy
• Most common type of injury: Obstruction
• Most common ‘activity’ leading to injury : Attempts to
obtain hemostasis
• Most common time of diagnosis : None -50-50 split
between intraoperative and postoperative.
26.
27. SITES OF URETERAL INJURIES:
1) Dorsal to infundibulopelvic
ligament near or at pelvic brim
2)Cardinal ligament where ureter
crosses under uterine artery
3) Tunnel of wertheim
4) Lateral pelvic sidewall above
uterosacral ligament
5) Intramural portion of ureter
34. VISUALISATION OF URETER DURING
SURGERY
• There is significant degree of interpatient variability in the anatomy
of ureter.
• Pale glistening appearance
• If inflammatory / adhesive changes are not present, ureter can be
seen from pelvic brim to parametrial tissue ,once it enters into tunnel of
wertheim ,they cant be seen / palpated ,they should be mobilised out of
the tissue.
• Ureteric peristalsis – helps in identification but following any degree of
trauma , it will have transient paralysis.
• Therefore , skill of accurately identifying the ureter is based on
understanding its anatomy and not its motion.
35. • Snap feeling when passed between fingers during laparotomy, will permit
one to follow ureter to tunnel without actually exposing it.
• In laparoscopic / robotic assisted procedures , camera magnification is
necessary to identify its course.
• Opening of parietal peritoneum is necessary to allow for accurate
inspection or to mobilise & separate from the site of operative
interest.Important in inflammatory comditions,-infection , neoplasia ,
post surgical changes
36. INTRAOP:
1) Any suspicion should be clarified – visualising peristalsis is
inadequate to exclude occlusion or extravasation
2) Dye test – IV phenazopyridine / indigo carmine/ methylene
blue (5ml) – extravasates at the site of injury in 3-5min(
abdominal )
3) Intra ureteric dye test- Identify ureter over common iliac artery,
stretch it, insert 21 G IV cannula into the lumen,5- 10 cc
methylene blue is injected.
Intact ureter – Dye comes into foley’s catheter
Ureteric leak- blue staining of pelvis
Obstruction- swelling+, no leakage
37. 4)Intra op cystoscopy –confirmation of urine efflux from ureteral
orifices . Non obstructive / partially obstructive / late injuries
due to ischaemia and avascular necrosis can be missed.
• Acute ureteral injuries are best recognised & managed
intraoperatively.
• Collaborative assistance from urology or urogynaecology
• Decisions regarding nature of repair and to proceed with intra
corporeal repair versus conversion to laparotomy in setting of
laparoscopic/ robot assisted procedures.
• Intraoperative repair reduces sequelae – stricture, fistulae,
loss of renal function, need for subsequent reoperation
38. • Cautery devices must be used with care.
Diffusion of thermal energy leads to occult ureteral injury
resulting in delayed stricture or urine leak presenting days to
weeks postoperatively.
39. POST OP:
SYMPTOMS TIME OF PRESENTATION
Anuria <24 hours
Adynamic ileus/peritonitis 0-7 days
Loin/ flank pain 0-21 days
Fever 0-21 days
Dribbling of urine from vagina, oliguria 0-30 days
Lower abdominal/ pelvis mass (urinoma) 20-40 days
Asymptomatic (incidental finding)
40. INVESTIGATIONS:
• WBC Count – Leucocytosis
• RFT , Electrolytes – Transient rise in Serum
Creatinine –should prompt further investigations.
• IVP – GOLD STANDARD FOR POST OP DIAGNOSIS-
Hydroureteronephrosis,stricture
• USG- Abdomen & Pelvis – HUN
• CT Scan - Hydroureteronephrosis /
ascites/urinoma/stricture/extravasation
• Cystoscopy – affected ureter- no urine spurt from the
ureteric orifice
41. • Retrograde ureteropyelography – diagnosis & initial therapy of
ureteral injury
• Contrast injection & opacification of ureter – defines site &
severity of leakage or obstruction & facilitates ureteral
stenting.
• Allows resorption of urinoma & spontaneous healing of ureter.
• If stenting is not possible, nephrostomy tube is placed – urine
drainage & prevent renal injury.
• Double dye test – with oral phenazopyridine Hcl + vesical
methylene blue & 3 swab test – fistula identification
• Fluid analysis from drains / ascitic collection –urine has
creatinine
> 10 mg/dL.
42. PREVENTIVE STRATEGIES TO REDUCE
THE RISK OF URETERIC INJURIES
1) General 2 ) specific
a) Pre op
b) Intra op
GENERAL PREVENTIVE STRATEGIES :PRE OP :
• IV Urogram
• USG
• Pre op stenting – There is no reduction in incidence ,
May aid in intra op reduction of ureteric injury
-But there’s no proof that pre-op IVP/CECT reduces the risk of
injury.
-Endometriosis ,PID, UV prolapse ,previous intra abdominal
surgery not associated with increased prevalence of abnormal
IVP findings
43. PREOPERATIVE STENT PLACEMENT:
• Facilitates identification of injury
rather than prevention
• Complications: perforation,stent
malposition,extravasation,hemat
uria,stricture
• Should be considered in
complex cases
44. • INTRA OP:
DICTUM – SURGEON SHOULD CONSTANTLY AND
EQUIVOCALLY KNOW WHERE THE URETER IS AT
ALL THE TIMES.
1)Adequate exposure of operative field
2)Avoid blind clamping of blood vessels
3) Mobilise bladder away from operative site
4) Stay outside vascular sheath of ureter
5) Cautious about thermal injury
6)Ureteric direct visualisation & mobilisation
45. SPECIFIC PREVENTIVE STRATEGIES
TAH :
• Upward traction on uterus during placement of clamps
• Apply second clamp always medial to first clamp
• Clamp infundibulopelvic ligament near the ovary after
dissection and palpation
• Skeletonise ,clamp and ligate uterine vessels close to uterus
– clamping immediately along the cervix
• Clamp cardinal and uterosacral ligaments close to uterus
• Never to 0pen vagina unless bladder is dissected
downwards and laterally
( careful dissection of the bladder off the cervix)
• Use of intrafascial technique
46.
47.
48. VH :
• Remarkably uncommon as VH is not performed for
conditions which distort ureteral anatomy ( endometriosis ,
malignancy)
• Compared to abdominal hysterectomy ,risk of ureteral
injury is reduced in VH – traction on the cervix pulls the
uterus farther from the ureter.
• Tension on the cervix is therefore critical during clamping
the pedicles.
• Adequate development of vesicouterine space
• All the clamps – apply close to uterus .
• Avoid double clamping of uterosacral ligaments
• Vaginal oopherectomy should be avoided / done cautiously
• During anterior colporraphy – avoid too lateral dissection
and deep sutures.
49.
50.
51. LAPAROSCOPIC HYSTERECTOMY :
• Its imperative to know the location of the ureter
• Bleeding points at Uterosacral ligaments should be secured
with sutures /clips instead of electro coagulation
• In LAVH, place stapler/suture across uterine vessels & cardinal
ligaments instead of electro coagulation.
• Use of harmonic scalpel.
52.
53.
54. SPECIFIC HIGH RISK PROCEDURES FOR
URETERAL INJURY
• LAPAROSCOPY ASSOCIATED URETERAL INJURIES:
-0.3-0.4%
-Thermal spread (extreme caution with use of cautery )– occult
injury
-Delayed diagnosis the probability of successful immediate
primary repair
-MC during laparoscopic hysterectomy , when uterine vessels are
stapled/ electro coagulated & IP ligament is transected
55. COMPLEX ADNEXECTOMY:
• Retroperitoneal approach( continues deep into pelvis as
pararectal space)
a)to access pelvic vessels to establish hemostasis
b)It’s adhesion and pathology free space
• Ureter lies on the medial leaf of broad ligament
• If adnexal mass is adherent to the peritoneum overlying ureter,
ureter can be safely dissected from peritoneum.
• After mobilisation of ureter, resection of mass can be performed.
• Rarely, its impossible to mobilise ureter from the pathology-
surgeon’s decision whether to leave residual tissue on ureter(
ureteral obstruction) or to resect segment of ureter & repair.
56.
57. TAH-HIGH RISK SITUATIONS:
• Cervical/ broad ligament fibroid can be challenging – ureter
can be anterior/lateral/posterior to fibroid.
• Clamping pedicles around the fibroid- Risk of ureteral injury
• Myomectomy – by incision adjacent to uterus or cervix(
staying within myometrial capsule of fibroid)
• Bleeding may occur- clamping adjacent to uterus.
• Rarely, if this is impossible, entire course of ureter must be
identified without clamping /cutting.
• Vigilant when there is bleeding from pedicles especially at vaginal
angles controlled by superificial 3-0 sutures so as not to incorporate
the ureter.
• Intrafascial hysterectomy technique is used
58. • CAESAREAN HYSTERECTOMY:
• Supracervical hysterectomy
• Placement of finger into endocervico-vaginal canal
• Simple to identify where to place a clamp adjacent to cervix
VAGINAL: CULDOPLASTY:
• Ureter is at risk.
• Can be prevented by identification of uterosacral ligaments by
palpation in paravesical space.
59. BLADDER NECK SUSPENSION:
• Injury during retropubic repair affects distal ureter
PREDISPOSING CONDITIONS:
• Vigorous dissection of space of retzius & periurethral tissue
• High elevation of burch colposuspension sutures
• Paravaginal defect repair with burch procedure
• Excessive lateral traction of bladder brings ureter into field of
operation
60. SURGERY FOR PELVIC ORGAN PROLAPSE :
• Ureter is damaged by direct ligation / kinking from plication of
redundant tissue
• In Mc Calls Culdoplasty , identification of uterosacral
ligaments & traction by Allis reduces chance of injury
• Cystoscopy with IV indigo carmine to check for ureter integrity
61. RADICAL PELVIC SURGERY:
Accidental
• Ureteral injury Intentional
• Intentional in MD Anderson type 4 radical hysterectomy,
anterior or total pelvic exenteration, resection of fixed
pelvic side wall mass involving ureter – ureteral resection
& reconstruction.
• Radical resection following radiation increases risk by
30%
• Increased rates during vaginal trachelectomy as fertility
sparing treatment for Ca Cervix FIGO 1A1 & 1B1.
62. MANAGEMENT
AIM:
a) preservation of renal function
b)restoration of anatomical continuity
DECISION DEPENDS ON:
a) Time of detection
b)Type of injury
c) Length of injury
d)Site of injury
d)General condition of patient
63. If ureteric injury goes unrecognised
POSSIBLE SEQUELAE :
1)When injury is minimal – spontaneous resolution & healing
2)Complete obstruction- Hydronephrosis & gradual loss of renal
function
3)Transection – Urinoma/ Urinary ascites/necrosis
4)Fistula formation
5)Stenosis
64. General principles of ureteric repair
• Ureteric dissection preserving adventitial sheath & its blood
supply
• Tension free anastomosis by ureteric mobilisation
• Spatulation ≥ 1 cm to create a wide caliber lumen
• Use of fine absorbable suture(4-0,5-0)to minimise
inflammatory response & subsequent stricture.
65. • Use of omentum to surround anastomosis
• Ureter must be stented at the time of reconstruction &left in
place for atleast 14 days
• Suction drain placed near but not in contact with the repair.
66. WHEN TO OPERATE:
• If detection of injuries is within 5 days ,operate
immediately
• After 5 days – tissue edema & inflammation makes
repair difficult &definitive surgery is to be planned after
6-8 weeks.
• To preserve renal function , PCN to be carried out.
67.
68.
69. PARTIAL TRANSECTION
• Closed loosely with fine (5-0) absorbable suture &
stented.
• Placement of stent – over a flexible guidewire using
intraoperative cystoscopy or directly through small
anterior cystotomy.
• Bladder drained 7-10days following repair
77. SEQUELAE:
• Stricture
• Stent and nephrostomy related problems
• UTI
• Ureteric obstruction / reflux
• Boari flap complication
• Hematoma
• Wound infection
78. • Sound knowledge of ureteral anatomy – to avoid injury
• If ureter is damaged during gynaecologic surgery, intraoperative
diagnosis allows for immediate repair in most cases.
• For this reason, INTRAOPERATIVE CONFIRMATION OF URETERAL
INTEGRITY SHOULD BE ROUTINE, whether the surgical approach
is transvaginal or transabdominal through open / laparoscopic/
robot assisted approach.
• Ureter may be assessed visually, by palpation, cystoscopically.
• Identification of mechanism of injury & its location guides
immediate / delayed repair.
• WITH PROPER RECOGNITION & THERAPY , URETERAL FUNCTION
CAN BE RESTORED & RENAL FUNCTION MAINTAINED.
TAKE HOME MESSAGE :