Dr mia oncology conference 1 1-2013

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Dr mia oncology conference 1 1-2013

  1. 1. Dr.Mai Banakhar Assistant Professor Urology Neuromodulation & Pelvic Reconstructive Surgery
  2. 2. o  Introduction o  Applied anatomy o  Types of injury o  Common sites of injury o  Predisposing factors o  Identification of injury o  Prevention o  Management o  Take home message
  3. 3. }  Injury to pelvic ureters is serious operative complications of gynecologic surgery. }  High morbidity. }  Ureterovaginal fistulas . }  Potential loss of kidney function. }  Renal function impairment is greater risk in Ureteric injuries as compared to bladder injuries .
  4. 4. }  Urinary tract operative injuries occur in the course of gynecological procedures due top the close development (embryological) and proximity of the urogenital systems. }  52-82% of operative Ureteric injuries occur during gynecologic surgery. }  30% gynaec-onco surgery
  5. 5. Abdominal 1.  Hysterectomy 2.  Wertheim s hysterectomy 3.  Oophorectomy 4.  Uterine suspension 5.  Vesicovaginal fistulae repair Laparoscopic 1.  Transection of uterosacral ligament 2.  Colposuspension 3.  Treatment of endometriosis 4.  Sterilization (especially Electrocoagulation) Vaginal 1.  Hysterectomy 2.  Anterior colporrhaphy 3.  Cervical biopsy 4.  Culdoplasty 5.  Vesicovaginal fistulae replair
  6. 6. }  Hysterectomy is frequently performed . }  It is associated with a small but significant risk of surgical morbidity and between 2 -10 / 1000 suffer Ureteric injury. Garry, R. The future of Hysterectomy. BJOG Feb 2005; volume 112; PP 133-139
  7. 7. }  1.3-2.2% abdominal hysterectomies }  1.3% laparoscopic hysterectomies }  0.03% vaginal hysterectomies }  As the experience increased with operative laparoscopy ,the incidence of all major complications has declined but Ureteric injuries have stayed constant at 1% Purandare C N. Urological injuries in gynecology. J Obstet Gynecol India 2007; 57 (3); 203-204. Harkki-Siren P, Sjoberg J, Kurki T. Major complication of laparoscopy; A follow up Finnish study. Obstetrics & Gynecology 1999; 94-98
  8. 8. }  The ureter enter the pelvis at the common iliac bifircation, then courses along the lateral side of the uterosacral ligament to enter the base of the broad ligament .Approximately 1.5 cm lateral to the cervix the ureter passes underneath the uterine artery (at the level of internal cervical os).It then passes medially over the anterior vaginal fornix before entering the trigone of the bladder .
  9. 9. The ureters may be injured open and /or laparoscopic hysterectomy due to: Intraoperative: 1.  Crushing injury (clamp) 2.  Ligation (suture) 3.  Transsection ( partial, complete) 4.  Angulation 5.  Ischemia (ureteral stripping, Electrocoagulation) 6.  Resection of ureteral segment. Postoperative 1.  Avascular necrosis 2.  Obstruction: Haematoma, lymphocele
  10. 10. Four anatomical locations: }  Along the lateral border of uterosacral ligament }  At or below the infundibulopelvic ligament }  Base of the broad ligament }  Tunnel of Wertheim in the broad ligament }  Cardinal ligament where the ureter passes under the uterine vessels }  Where the ureter lies in close proximity to the anterior vaginal wall and enters the base of the bladder Gao JS, Leng JH, Lang JH, Liu ZF, Shen K, Sun, DW, Zhu L. Ureteral injury in Gynecologic laparoscopies. Chin Med Sci J, 2007; 22(1); 13-6. Santucci, R A. Ureteral Trauma, http// www.emedicine.com. Feb 2008. Purandare C N. Urological injuries in gynecology. J Obstet Gynecol India 2007; 57 (3); 203-204. Jha S, Coomarasamy A . Chan K K. Ureteric injury in obstetric and gynaecological surgery. The Obstetrician and Gynaecologist 2004; 6; 203-208. Thompson JD. Operative injuries to the ureter: prevention, recognition, and management Te Linde s Operative Gynecology. 8th ed. 1997:1135-73.
  11. 11. Anatomical Risk factors 1.  Ureter attached peritoneum 2.  Close to female genital Tract 3.  Ureter has variable course 4.  Not easily seen or palpated Pathological risk factors 1.  Congenital anomalies of ureter/ kidney 2.  Ureteric displacement: (uterus size ≥12 weeks, prolapse, Tumors (ovarian),cervical or broad ligament swelling. 3.  Adhesions (previous pelvic surgery, Endometriosis, PID) 4.  Distorted pelvic anatomy Technical Risk Factors 1.  Massive intraoperative hemorrhage 2.  Coexisting bladder injury 3.  Technical difficulties 4.  Inexperienced surgeon ½ of ureteric injuries has no identifiable risk factors
  12. 12. }  Most commonly the ureter is injured in the lower third of its pelvic course . }  Two thirds of ureteric injuries are not recognized intra operatively. Intraoperative recognition important to be repaired & renal functional compromise can be avoided Prevention & Intraoperative recognition
  13. 13. General strategies }  Preoperative 1.  To identify ureteral abnormalities IVP ????? Risk of injury 2.  Preoperative stenting }  Intraoperative 1.  Where is the ureter 2.  Adequate exposure 3.  Stay outside the vascular sheath zone of thermal injury 4.  Ureteric dissection and direct visualization Specific strategies Identify the ureter Incise the peritoneal reflection between the uterus and bladder & the bladder is reflected inferiorly with sharp dissection Ureteric stenting aid in the intraoperative detection of Ureter,but NO reduction in risk
  14. 14. Specific preventive strategies
  15. 15. The venial sin is injury to the ureter , the moral sin is failure of recognition Higgins
  16. 16. }  Intraoperative }  Post operative Almost ½ of ureteric injuries can be prevented ,out of these ½ can be detected Intraoperativly
  17. 17. }  Any suspicion… clarified }  Identify the nature and severity of injury }  Look for obstruction/ devascularization }  Dye test: intravenous methyleneblue, indigocarmine, phenazopyridine, Extravasates at the site of injury 3-5 min }  Intraoperative Cystoscopy: RGP }  Non-obstructive, partially obstructive, late injuries ( ischemia, a vascular necrosis can be missed
  18. 18. }  Spontaneous resolution and healing }  Hydronephrosis and gradual loss of renal function }  Urinoma, urinay ascites, infection in transection or necrosis with urinary extravasation }  Fistula formation }  Uretero vaginal, uretero-uterine, uretero cutaneous }  Stenosis with insidious loss of renal function
  19. 19. }  Loin flank pain 0-21 d }  Fever 0-21d }  Peritonitis, paralytic ileus 0-7d }  Fistula 0-30d }  Lower abdominal pain/ pelvic mass 20-40d }  Anuria if bilateral < 24h }  Asymptomatic incidental }  Frank discharge of urine from drain, vagina, or abdominal wound
  20. 20. }  Wbc }  U& electrolyte }  Ivp }  Rgp, }  Ultrasound }  Ct scan }  Fistulogram }  Cystoscopy }  Fluid analysis from drain, ascitic collection
  21. 21. }  Ivp }  Gold standards for post op Dx }  Non visualized }  Dilatation }  Delayed dye spillage }  Peritoneal extravasation }  urinoma
  22. 22. Aim: }  Reservation of renal function }  Anatomical continuity Decision depend on }  Time of detection }  Extend of injury }  Site of injury }  General condition of the patient
  23. 23. Conservative: }  If small injury, no obstruction, patient stable }  Time >5 days }  Ureteral stinting via PCN for 6-8 weeks }  When to operate?
  24. 24. }  If injury detected within 5 days ,operate immediately }  After 5 days tissue edema, inflammation makes repair difficult & definitive therapy is planned after 6 weeks }  To reserve renal function PCN immediately
  25. 25. }  Miticulus dissection, preserving ureteral sheath with the blood supply }  Tension free anastomosis ( ureteral mobilization) }  Water tight closure , absorbable suture. }  Peritonium or omentum to surround the anastomosis }  Drain ( closed, suction) to prevent urine collection }  Stenting the anastomotic site }  Consider proximal diversion with PCN if the ureteric injury is large, completely transected,or the ureter lies in bed of inflammation or fibrosis
  26. 26. }  Distal ureter Ureteric reimplannation
  27. 27. Middle ureters }  Short segment: end to end anastomosis Ø  Long defect: q reimplannation q Psoas hitch q Boari flap
  28. 28. Upper ureter: }  Short segment: end to end anastomosis }  Long segment: }  Transureteroureterostomy }  Ilial replacement }  Auto transplantation }  Nephrectomy
  29. 29. }  Mucosa sparing wall injury, oversewing with absorbable suture }  Ureteral ligation, assessment of viability, stenting }  Partial transaction 1ry repair over stent }  Total transection: Uncomplicated upper and middle: end to end anastomosis over stent }  Complicated: TUU,ilial interposition,nephrectomy }  Lower third reimplantation over stent }  Thermal injury resection & then manage according to the resected part Call Urology team
  30. 30. }  Ureteric stricture formation }  Stent and nephrostomy related problem }  Urinary tract infection }  Wound infection }  leakage from anastomotic site and haematoma formation
  31. 31. }  Most ureteric injuries can be prevented by mastering the knowledge of ureteric anatomy. }  Suspicion and intraoperative detection improves prognosis. }  Any suspicion… clarified }  Early involvement of urologist in decision making during ureteric repair. Skilled postoperative monitoring helps detect ureteric injury before renal compromise.

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