Download If the surgeon decided to identified the ureter

DR EMAMI
UROLOGIST
In female Anatomic relationship between
REPRODUCTIVE SYSTEM
&
GUT
predispose the GUT to involment by gynecologic
disorders and places it at risk
Injury to the bladder or ureter occur
Appproximately %1 -%2 of all major
gynecologic procedure


Between 50% ad 90 of all lower urinary
truct injury occure during gynecologyic
surgery.
Some of these injures can not be
avoided. but the majority are avoidable.
Review of the surgical literature
reveal two fact:
Most injury occur during benign
procedure
Most injury are not recognized
During procedure

Preoprative assessment:
patient history,physical examination and
preoperative laboratory evaluation may
sugest abnormal function of GUT.
If any abnormality is revealed
Further evaluation shoud be performed
Bladder Continous drainage
almost allways
Foley catheter(triple lumen)
Ureteral stent
dose not reduce incidence of surgical injury to ureter.
Ureteral stent predispose the ureter to damage
As a result of immobility it imparts to the ureter
During all surgical procedure :
Sharp dissection
blunt dissection
Small pedicles
large pedicles
(Many ureters are damaged by application
Of clamp in a frantic effort to control pelvic
hemorrhage)
Complicated case
Abdominal _vaginal _perineal _preparaition
Foley _catheter_three_way continous drainage
Identify the ureter
Abdominal
ureter
Pelvic ureter
If the surgeon decided to identified the
ureter
Identification without dissection
Follow ureter under posterior peritoneum
Over hydrate /lasix injection(peristaltism)
Identification with dissection
Open retro peritoneom/preserve vascular sheat
Pelvic ureter biforcation
common iliac arterie
Posterior boundary of ovarian
fossae
Beneath the uterine arteries
Ant and lat cervix and vagina
Pelvic cavity &ureter truma
Oblitration of cul_de_sac
Plication of utero sacral ligament
Suspentation of vaginal apex
Patial truma/viable tissue
Complete truma /non viable
End to end anastomsis
Uretero
neocystostomy
Don’t try to identified the ureter
Good plan between uterine &bladder
(vesicoperitoneal fold)
The surgeon should be aware:
The bladder may be pull up beneath the anterior
abdominal wall :


Incomplate emptying
Previous surgery
(cesarean)
Bladder trauma
Bladder trauma
Good drainage
Tissue hydrodistention
Intra operative repair of bladder injur
Extra peritoneal laceration
Closed with one or two layers of NO3/o
Absorbable suture
Trans peritoneal laceration of bladder&
Base of bladder
Repaired in two layer usingNO3/o
Absorbable suture
Covered with omental or peritoneal flap
For better healing
Continous drainage for at least 7days
Anti spasmodic drug
Antibiotic therapy
Urinary tract injury occur in %1- %2 of patients
undergoing major laparoscopic surgery.
Bladder injury result from dissection with or
without cautery.
For prevention of ureteral injury ureteral
catheter is recommended.
Intera operative
Seeing the cath through an incision
Repaired over a trans urethral cath in layers
using NO 3 /o or 4/o
Absorbable suture
(bulbocavernous fat pab may be requried)
THANKS FOR
ATTENTION