Features of installation and removal of the ureteral stent. Instrumental diagnosis of ureter injury

SURGICAL ACCESS TO THE URETER

All surgical approaches to the ureter can be divided into three groups: extraperitoneal, transabdominal and combined. Choice online access to the ureter depends on the location of the pathological process and the extent of the proposed surgical intervention (Fig. 12-333). For surgical intervention on the lumbar and iliac ureter, incisions are usually used Fedorova And Israel and to expose the lower ureter - incisions Pirogova, Tsulukidze And Keya.

Access Fedorova begins under the XII rib,

goes first closer to the edge of the iliocostal muscle (i.e. iliocostalis), and then at the level of the anterior axillary line passes to the anterior wall of the abdomen parallel to the inguinal (pupartova) bundle. Then, the outer third of the rectus abdominis muscle is cut across and a cut is made along it longitudinally to pubic bone. This incision gives wide access to the lumbar, iliac and pelvic ureters (Fig. 12-333, 1).

Incision Pirogov starting from the level of the anterior

superior iliac spine and lead 4 cm above inguinal fold parallel to it through the oblique and transverse muscles to the outside

Rice. 12-333. Incisions to expose the ureters. 1 -

incision Fedorova, 2 - cut Israel 3 - cut Pirogov, 4 - cut Tsulukidze, 5 - cut Keya.(From: Chukhrienko D.P., Lyulko A.V. Atlas of operations on the organs of the genitourinary system. - M., 1972.)

foot edge of the rectus muscle. After that, the transverse fascia of the abdomen is dissected, the peritoneum is pushed up and inwards, and the ureter is exposed. With this access, the ureter can be mobilized to the very place of its confluence with the bladder (Fig. 12-333, 3).

Incision Tsulukidze start on two transverse

finger below the level of the navel from a point located one transverse finger outward from the lateral edge of the rectus abdominis muscle. From top to bottom, the incision gradually approaches the rectus muscle and along the lateral edge of the latter reaches the pubic tubercle of the corresponding side. The upper part of the incision is led with a bulge inward, and the lower part is led outward. Having cut the skin with subcutaneous tissue, the aponeurosis of the external oblique, internal oblique and transverse abdominal muscles is dissected and penetrated into the retroperitoneal tissue. The outer edge of the incision with wide muscles pulled outwards with blunt hooks. In a blunt way, the parietal sheet of the peritoneum is peeled inward, after which it penetrates into the iliac fossa, and then into the subperitoneal part of the small pelvis (Fig. 12-333, 4).

Incision Keya 10-12 cm long is carried out along the midline above the symphysis. After dissection of the skin, subcutaneous tissue and aponeurosis, the rectus abdominis muscles are bred with blunt hooks and the transverse fascia is dissected. The peritoneum is peeled upward in a blunt way to the bifurcation of the common iliac artery, where the ureter is found and mobilized (Fig. 12-333, 5).

If during the operation it is planned to perform a revision of the kidney, Derevianko recommends using an incision along the outer edge of the rectus abdominis muscle from the costal arch to the pubic tubercle (Fig. 12-334).

To expose the pelvic ureter

ka wide use got access Hovnatanyan, similar to access Pfannenstiel(access by Hovnatanyan carried out 1 cm above the womb, and access along Pfannenstiel - along the natural transverse skin fold 3-4 cm above the womb). An arcuate incision 15-18 cm long above the pubic joint is used to dissect the skin and subcutaneous tissue. According to the skin incision, the aponeurosis is dissected and its upper flap is peeled upwards from the rectus muscles. Further stupidly separate the rectus and pyramidal muscles. The peritoneum is exfoliated

Rice. 12-334. Incisions to expose the pelvic ureters. 1 - with revision of the kidney Derevyanko, 2 - access Hovnatanyan.(From: Chukhrienko D.P., Lyulko A.V.

yut up and to the midline (Fig. 12-335). The advantages of this incision are low trauma and the ability to manipulate both ureters. IN Lately to approach the upper and lower parts of the ureter, less traumatic oblique variable incisions without crossing the muscles began to be used.

RESECTION AND SUTURE OF THE URETER

Technique. Previously, a ureteral catheter is inserted into the corresponding ureter. One of the accesses described above exposes

yut retroperitoneal space. Using the catheter, the ureter is easily found and its narrowed section is isolated from the surrounding tissues. If the narrowed area is small, it is cut along the front wall in the longitudinal direction and stitched in the transverse direction (see Fig. 12-335).

In cases where there are cicatricial changes, the affected area is resected. It is preliminarily checked whether it is possible to connect the distal and proximal ends of the ureter without tension. A soft clamp is applied to the proximal end of the ureter and the narrowed area is excised within healthy tissues. After that, proceed to the suture of the ureter. Before stitching into the proximal end of the ureter, a previously introduced endoscopically ureteral catheter is inserted. The ureter is laid in place, its ends are brought closer to each other and sutured end to end through the adventitia and the muscular membrane (Fig. 12-336, a). In the area of ​​such a suture, with a normal lumen of the ureter, narrowing may develop in the future, therefore, to stitch the ends of the ureter end-to-end, the ureter can be dissected not transversely, but in an oblique direction (Fig. 12-336, b).

You can suture with the introduction of the proximal end of the ureter into the distal. In such cases, the end of the distal segment of the ureter along its anterior wall is dissected 1 cm in the longitudinal direction. The anterior and posterior walls of the proximal segment of the ureter, stepping back from the edge by 1-1.2 cm, are stitched with U-shaped sutures. Their free ends are passed through the side walls of the distal segment of the ureter (Fig. 12-337, a).

Rice. 12-335. Expansion of the narrowed portion of the ureter, a - dissection of the narrowing in the longitudinal direction, b - suturing of the dissected area in the transverse direction. (From: Chukhrienko D.P., Lyulko A.V. Atlas of operations on organs genitourinary system. - M., 1972.)

Rice. 12-336. Expansion of the narrowed portion of the ureter, a - end-to-end suturing of segments of the ureter, b - to increase the lumen, the ureter is excised in an oblique direction. (From: Chukhrienko D.P., Lyulko A.V. Atlas of operations on the organs of the genitourinary system. - M., 1972.)

The sutures are tightened, introducing the central end of the ureter into the peripheral one. Impose additional interrupted sutures on the anastomosis.

For stitching the ureter end to side, the end of the lower segment of the ureter is tied up, its front wall is dissected in the longitudinal direction. The end of the upper segment is stitched with U-shaped sutures, the free ends of which are stitched through the incision through the walls of the distal segment of the ureter (Fig. 12-337b). The threads are tightened and tied, immersing the central segment of the ureter into the distal one. The edges of the incision are sutured to the wall of the invaginated segment.

During side-to-side anastomosis, the ends of both segments of the ureter are tied up, their side walls are cut in the longitudinal direction by 1 cm. With interrupted sutures, the edges of the incision of the proximal segment of the ureter are sutured to the edges of the wound of the distal one (Fig. 12-337, c).

The choice of the method of suturing the segments of the ureter is associated with the localization of damage, its extent, the condition of the kidney, and the conditions for performing the operation. The operation is completed by bringing a drainage tube to the suture site and suturing the wound. A number of authors recommend that urine be diverted by pyelonephrostomy until the wound of the ureter heals.

holders above and below the stone. Two provisional sutures are placed on the sides of the proposed incision, and the wall of the ureter is cut longitudinally between them. Since ureteral stones are almost always accompanied by periureteritis, the incision is made not above the stone, but above or below it (Fig. 12-338). After removing the stone, the patency of the ureter is checked. After making sure of its patency, nodal sutures are placed on the edges of the incision. without affecting the mucous membrane. After suturing, the ureter is placed in place. A drainage tube is brought to the site of operation and the wound is sutured. In order to avoid bedsores and perforation of the iliac vessels, the drainage tube is isolated from them with a gauze graduate.

In case of poor patency of the terminal ureter, a lower intubation ureterotomy is performed.

Technique. Before surgery, if possible, catheterization of the ureter is performed. After ureterolithotomy, the end of the catheter is brought out into the ureterotomy incision and a polyethylene tube is passed antegradely. The proximal end of the tube is passed up the ureter) "above the site of its incision. The distal end is removed through the external opening of the urethra and left for 5-6 days.

URETEROTOMY

Technique. According to one of the accesses described above, the retroperitoneal space is opened. They find the ureter, isolate it from the fiber, bring gauze or rubber

Rice. 12-337. suture of the ureter, a - seam of the ureter with the introduction of the proximal segment into the distal one according to the type of drainpipe, b - anastomosis of the ureter end to side; c - side-to-side anastomosis of the ureter. (From: Chukhrienko D.P., Lyulko A.V. Atlas of operations on the organs of the genitourinary system. - M., 1972.)

Rice. 12-338. Ureterotomy. The ureter was taken on holders and opened longitudinally. (From: Chukhrienko D.P., Lyulko A.V. Atlas of operations on the organs of the genitourinary system. - M., 1972.)

URETOROSTOMY Method Matizena

Technique. cut Fedorova the retroperitoneal space is opened and the upper part of the ureter is isolated. After that, the wall of the ureter is dissected and the edges of its wound are sutured to the lumbar muscles and skin (Fig. 12-339). Through the wound of the ureter, a catheter is inserted into the pelvis and the wound is sutured. When applying a temporary fistula of the ureter, the edges of its wound are not sutured to the skin.

URETERAL TRANSFER OPERATION

Ureteral transplantation (ureterocystoneostomy) can be performed in the skin, bladder, and intestines. touching various methods ureterocystoneostomy, it must be indicated that when suturing the ureter with the mucous membrane Bladder strictures are often formed. To avoid this complication, it is necessary that the distal end of the ureter should stand in the bladder cavity by 1.5-2 cm, or it should be cut obliquely or split like a fish mouth.

The essence of the operation Matizena is to cut out rectangular shape a flap from the wall of the bladder, which is folded into the cavity of the bladder and the ureter is placed in it. The central end of the ureter along its anterior wall is incised and fixed with rare sutures to the formed flap. The defect in the bladder is sutured, creating the mouth of the ureter in the form of a nipple (Fig. 12-340). Urine is drained through the suprapubic fistula.

Way Hilla

hill modified the technique Matizena.

After crossing the ureter, a ureteral catheter is inserted into its central end (Fig. 12-341. a), the adventitia and the muscular membrane are excised for 1-2 cm (Fig. 12-341b). The remaining mucous membrane is everted, forming a nipple (Fig. 12-341, c). The nipple through the hole made in the bladder is passed into the bladder and sewn to the inner surface of its wall (Fig. 12-341, d). To divert urine into the bladder, a permanent catheter is inserted or a cystostomy is applied.

Way Boari

Technique. After mobilization of the corresponding half of the bladder and the pelvic ureter, the latter is transected within healthy tissues. Its distal end is tied up. A thin drainage tube is inserted into the central end, which

Rice. 12-340. Ureterocystoneostomy by Matizen. 1 -

the line of cutting out the flap from the bladder, 2 - the end of the central segment of the ureter is laid in the flap of the bladder and fixed, 3 - formed nipple in the cavity of the bladder. (From: Chukhrienko D.P., Lyulko A.V. Atlas of operations on the organs of the genitourinary system. - M., 1972.)

Rice. 12-341. Ureterocystoneostmia according to Hill(explanation in the text).

fixed to the ureter with interrupted sutures at its very edge (Fig. 12-342, a). Then along the anterolateral surface of the corresponding half of the bladder throughout 2,5-3 cm in the transverse direction, a flap is cut out, the leg of which lies on the posterolateral wall of the bladder. The flap is turned upwards, its length is adjusted, and the ureter is placed and fixed on its edge. Then the flap is folded into a tube and sutured with interrupted catgut sutures (Fig. 12-342, b). The bladder defect is sutured with interrupted catgut sutures in the longitudinal direction through all layers of the bladder wall. The drainage tube is left in the ureter for 10-12 days. Its distal end in women is removed through the urethra, in men - through an additional incision on the anterior wall of the bladder.

With plastic Boari can be replaced with a bladder flap up to 6-7 see terminal ureter. The disadvantages of this operation is that when the ureter is sutured into the cystic flap, dissimilar tissues come into contact with each other: the mucous membrane of the bladder and the adventitia of the ureter. Based on this, a number of authors (Frumkin, Kan and others) recommend removing the mucosa of the free end of the flap for 1-1.5 cm. The ureter is placed on a demucosated bed and its edge is sutured to the bladder mucosa so that the ureter mucosa coincides with the bladder mucosa.

Operation Demel

Technique. The pelvic section of the corresponding ureter is exposed and transected within healthy tissues. After that, according to one of the methods described below, the bladder is extraperitonized and dissected in the transverse direction (Fig. 12-343a). The end of the central segment of the ureter is split and implanted in upper part bladder. The incision of the bladder is sutured in the longitudinal direction (Fig. 12-343, b). Urine is drained from the bladder through an additional opening on the anterior wall of the bladder. The defect of the anterior wall is closed in the usual way.

Surgery has long been effective methodology to restore integrity and functionality internal organs. Ureteroplasty is one of those operations when it is possible to return the proper functioning of the urinary system. What intervention methods are available, how to prepare and how to undergo a rehabilitation course?

Indications and contraindications

To date, plastic surgery has several important indications:

• plastic is performed in case of obstruction (obstacles) for the outflow of urine from the kidney;
• damage to the ureters during surgical interventions;
• damage after oncological diseases genitourinary system and their treatment.

Damage is most commonly observed in women during disorders labor activity, removal of uterine fibroids. Doctors also consider hydronephrosis and hydroureteronephrosis to be an absolute indicator for plastic surgery. With hydronephrosis, the pressure inside the kidney increases. Plastic surgery of the ureteropelvic segment is performed. If the ureteropelvic segment is operated on, then the intervention involves examining the entire area and crushing the stones.

Hydroureteronephrosis is an indication for plastic surgery.

Hydroureteronephrosis is characterized by an obstruction to the outflow of urine in the pelvicalyceal system and in the ureter itself. Pathology (stricture) occurs when the ureter is blocked. Fistulas are another indication for plastic surgery. They occur when the ureters are injured during abdominal interventions.

Contraindications for any intervention are the following pathologies and diseases:

• blood clotting disorder;
• untreated infections;
• pregnancy;
• diabetes;
• diseases of the cardiovascular system.

In addition to the listed contraindications, the procedure may be rejected for other indicators. Therefore, it is important to undergo an examination and properly prepare for it. During this period, the doctor takes into account all the factors, takes into account the results of the research and makes a decision. If the decision is positive, then the preparation period begins.

Surgical intervention

The procedure is the replacement of part of the excretory tube with an autograft. It is carried out only in case of serious, when other methods of treatment have not brought the expected results. The choice of the method of intervention is selected in accordance with the individual indicators of the patient, which are identified during the preparation.

Preparing for plastic surgery

Deciphering the analysis for blood clotting is necessary for diagnosing the disease and performing ureteroplasty.

Operation on the ureters requires the doctor to perform thorough examination the patient's health status. Including infections of the genitourinary system are detected. When they are detected, the doctor prescribes the appropriate treatment. In addition, the patient must take a blood test for clotting and other indicators. An important milestone examination is to identify allergic reactions to certain drugs that can be used during the intervention and during the rehabilitation period. Another stage is bacteriological research. If the tests and examinations are successful, the infections are cured, the doctor sets the date for the surgical intervention.

Operation and methods of its implementation

The intervention is performed under general anesthesia, so the anesthesiologist examines the patient and selects the dose of anesthesia, checks the patient's response to certain drugs. Doctors also install a catheter that will help to remove urine during the intervention and for several days after it. And only after that the doctor starts working with the ureter.

Today intervention is carried out in several ways:

• the ureter is replaced by intestinal tissues;
• tissues for replacement are taken from the bladder;

A stitching technique is also possible urinary tract after removal of the affected part. This method is only possible by removing a small part of the damaged urinary tract. If the damage is in the lower part, then the doctor connects the healthy tissue of the ureter to the bladder.

Intestinal plasty (partial and complete replacement) of the ureter

Surgical intervention is indicated if it is necessary to completely replace the damaged area.

Intestinal plasty is a front line of work on the formation of a part of the urinary tract from an isolated segment of the intestine, in particular, it is used small intestine. In the course of work, the surgeon, using a catheter, forms the ureter from the segment of the intestine. right size and stitches it with pelvicalyceal system kidneys and bladder. This technique used when it is necessary to completely replace the damaged area.

With partial plasty, the same segment of the isolated intestine is used and sutured to the remaining healthy parts of the ureter. In this case, the catheter used during the procedure is brought out. It will serve as a temporary ureter until all tissues have completely healed. Partial plasty allows you to eliminate tumors or adhesions in small areas. Also, this intervention is used to eliminate large areas of damage to the ureter. Boari surgery consists of reconstructing the ureter with a bladder flap.

This intervention technique is used to restore the integrity of the ureters. The essence of the intervention is that the ureteral tube is formed from tissue from the stalk of the bladder. A plastic tube is inserted into the ureter and fixed. After that, a piece of tissue with a width of 2–2.5 mm is excised from the wall of the bladder. The length of this segment should be greater than the length of the affected area of ​​the ureter. This is necessary in order to avoid subsequent compression of the ureter.

The Boari operation suggests the possibility of plasty of both ureters in case of bilateral lesions. To do this, immediately cut out 2 segments or 1 wide. Of these, the doctor forms tubes and sews instead of the affected areas. The area of ​​the bladder, where the tissues were taken, is sutured tightly by the surgeon. The catheter or tube is passed through the urethra to the outside. During the intervention, the surgeon additionally puts a drain into the bladder.

Pulling the bladder to the psoas muscle is preferable to reconstruction of the ureter with a bladder flap. Only in rare cases the defect of the ureter is so large that pulling up the bladder is not enough to form a ureteroneocystoanastomosis. Alternative interventions in such cases are the imposition of a ureteroureteroanastomosis, bringing down the kidney and kidney autotransplantation. Relative contraindication to the reconstruction of the ureter with a flap of the bladder - its small volume, especially with neurogenic dysfunction.

When both ureters are affected, transureteroureterostomy is combined with pulling up the bladder and fixing it to the psoas muscle or with reconstruction of the ureter with a bladder flap. Lack of length of the ureter can be filled appendix. Replacement of the ureter ileum rarely used.

Fig.1. A urethral catheter is placed and connected to a container containing fluid and wrapped in a sterile diaper

A. The position of the patient - on the back. A urethral catheter is placed and connected to a container containing fluid and wrapped in a sterile diaper.

The incision is made taking into account the localization of scars after previous operations on the urinary tract. More often they resort to a median incision or a transverse incision in the lower abdomen.

B. Displace the peritoneum along with spermatic cord or round ligament of the uterus medially, exposing the unchanged ureter above the defect, usually at the level of the bifurcation of the common iliac artery or higher. The ureter is taken on a rubber holder and isolated in the direction of the bladder for the required length.

With a second operation, when the ureter is surrounded by scar tissue and there is a high risk of damage iliac vein when retracting the peritoneum, it is preferable to approach the ureter by transperitoneal access through the lower median incision. blind or sigmoid colon it is retracted medially, the posterior peritoneum is opened along the lateral canal and the ureter is exposed above the iliac vessels in the distal direction to the bladder.

When cutting out a flap of the bladder, it is advisable to resort to hydropreparation in order to facilitate the separation of the peritoneum from the posterolateral walls of the bladder. Allocate and cross the remains of the urachus.

Fig.2. If necessary, excise the affected part of the ureter

If necessary, the affected part of the ureter is excised, and a suture-holder is applied to the proximal, unchanged end. The distal end is tied up.

The bladder is completely mobilized, on the side opposite to the flap to be cut out, the upper and, if necessary, the lower neurovascular bundles are ligated. The unopened bladder in the form of a tube is displaced upward to assess the possibility of pulling it up and suturing it to the psoas muscle. If it is not possible to pull the bladder up to the unchanged ureter, a flap is cut out from the wall of the bladder. The bladder is filled with liquid and, using a measuring tape, determine the length of the flap necessary to compensate for the defect of the ureter - the distance from rear wall bladder to the proximal end of the transected ureter.

The tip of the flap should be 2 cm wide, or 3 times the diameter of the ureter, to avoid compression of the ureter in the tube formed from the flap. The width of the flap at the base is at least 4 cm. The ratio of the width and length of the flap should be 2:3. The flap is placed transversely; if it is necessary to compensate for a significant length of the ureter, an oblique or S-shaped incision of the bladder wall is made. The contours of the proposed flap are marked with a special marker.

Impose 2 seam-holders at a distance of 4 cm from each other at the intended base of the flap. The longer the flap, the wider its base should be. The flap should not include scar tissue the walls of the bladder. At the intended top of the flap, measured with a measuring tape, 2 more sutures are applied. Then the contours of the flap are marked with an electrocautery, which makes it possible to coagulate the superficial vessels of the bladder wall. Fluid from the bladder is evacuated.

The bladder wall is dissected with an electric knife along the distal contour of the flap medially from the sutures-holders. 2 additional sutures-holders are applied to the corners of the flap and the wall of the bladder is cut to the base of the flap. Small bleeding vessels are coagulated, large ones are tied with a thin catgut thread. Areas with questionable blood supply are cut off. A thin PVC tube is inserted into the contralateral ureter. The bladder wall is sutured distally to the base of the flap with 3-0 synthetic absorbable suture, pulling the bladder toward the psoas tendon.

Fig.3. To form a submucosal tunnel of sufficient length, it is necessary that the bladder flap and the ureter overlap each other by at least 3 cm.

For the formation of a submucosal tunnel of sufficient length, it is necessary that the bladder flap and the ureter find each other by at least 3 cm. blood vessels from renal pelvis. If the length of the ureter is insufficient, the tunnel is not formed and the end of the ureter is sutured to the edge of the bladder flap. If the length of the ureter is insufficient for this, the kidney is mobilized inside Gerota's fascia and moved 4-5 cm down. In all cases, tension on the ureter should be avoided.

Laheya scissors form a submucosal tunnel for 3 cm, then the end of the scissors perforates the mucous membrane. Submucosal infiltration saline facilitates the formation of the tunnel. At the end of the scissors put on the wide end of a thin 8F vinyl chloride tube and pass it through the tunnel up.

Fig.4. The ends of the suture placed on the ureter are tied to the tube and the ureter is passed down the tunnel.

The ends of the suture-holder applied to the ureter are tied to the tube and the ureter is passed down the tunnel. The end of the ureter is cut obliquely and dissected along.

Fig.5. The end of the flap is fixed to the psoas minor muscle and its tendon with a synthetic absorbable thread.

A. The end of the flap is fixed to the psoas minor and its tendon with a 3-0 synthetic absorbable suture so as not to capture the ilioinguinal and genitofemoral nerves in the suture.
B. The end of the ureter is fixed to the bladder wall with a 4-0 synthetic absorbable suture, capturing the submucosa and muscle layer the walls of the bladder. An anastomosis is formed by applying an additional 3-4 interrupted sutures to the mucous membrane.

Fig.6. A thin PVC tube is inserted through the ureter to the renal pelvis.

A thin vinyl chloride tube is inserted through the ureter to the renal pelvis, which is fixed with a 3-0 catgut thread to the mucous membrane of the flap distal to the anastomosis. The free end of the tube is brought out through the counter-opening in the wall of the bladder and anterior abdominal wall, fixed to the skin with a 2-0 silk thread. A suprapubic Maleko or Foley catheter is passed through an additional counter-opening in the abdominal wall and the wall of the bladder, which is sutured to the skin.

The flap is sutured in the form of a tube with a continuous suture with a 4-0 catgut thread, without capturing the mucous membrane, the bladder wall defect is sutured in the same way. The adventitia and the muscle layer of the bladder wall are sutured with a second row of interrupted sutures with a 4-0 synthetic absorbable suture. Several additional sutures connect the end of the bladder flap with the adventitia of the ureter. It must be ensured that the bladder at the base of the tube is firmly attached to the psoas tendon. A drainage tube is inserted into the retroperitoneal space through an additional counter-opening. If a laparotomy approach was used, the peritoneum is sutured, but the drainage tubes are removed extraperitoneally. The ureteral stent is removed on the 8th day after the operation, and after another 2 days, in the absence of discharge from the wound, the suprapubic catheter is removed.

POSTOPERATIVE COMPLICATIONS

Damage to the opposite ureter can be suspected when pain and subfebrile temperature. To clarify the diagnosis, perform excretory urography and ultrasound.

Infection may develop after removal of the ureteral stent urinary tract With high temperature. In such cases, antibiotics are prescribed. With persistent infection, which indicates obstruction of the anastomosis, ultrasound and percutaneous puncture nephrostomy are performed. Urine leakage usually comes from a leaking bladder wound rather than from the anastomosis. In this case, the suprapubic catheter is not removed until the leakage stops. If it still continues, cystography and excretory urography are performed to determine the site of the leak and the cause. If the sutures of the anastomosis fail, the ureter is intubated under the control of a cystoscope; the ureteral stent is left for 5-10 days. In some cases, a nephrectomy may be required. Due to the cicatricial process, late stricture is possible, in which surgical revision is indicated, and in case of late diagnosis, nephrectomy.

Operative access to the kidneys. Operative accesses to the organs of the retroperitoneal space (kidneys, ureters) are divided into transperitoneal and extraperitoneal.

Transperitoneal accesses include median and pararectal laparotomy.

All extraperitoneal accesses are divided into vertical (Simon's incision), horizontal (Pean's incision) and oblique (Fedorov's, Bergmann-Israel's incision, etc.). Vertical and horizontal incisions are rarely used, as they do not provide wide access (Fig. 25).

For gunshot wounds and closed injuries of the kidney, the Nagamatsu dorsolumbar incision, thoracoabdominal incision, and Frumkin incision can be used.

Rice. 25. Operative access to the kidney and ureter.

1 – Simon section; 2 – Pean section; 3 – Bergmann-Israel section; 4 – Fedorov section.

Simon cut is carried out along the outer edge of the muscle that straightens the spine, from the XII rib to the wing of the ilium. Pean's incision is carried out in the transverse direction in front of the outer edge of the rectus abdominis muscle to the outer edge of the muscle that straightens the spine.

Bergmann–Israel section start slightly higher and the medial angle formed by the outer edge of the erector spinae muscle and the XII rib, and lead along the bisector of this angle obliquely down and forward, passing 3-4 cm above the anterior superior iliac spine, reaching the middle or even medial third of the inguinal ligament . Access allows you to approach the ureter along its entire length and to the common iliac artery.

Section according to Fedorov combines the possibilities of intraperitoneal and extraperitoneal access. It starts at the outer edge of the muscle that straightens the spine, at the level of the 12th rib, and leads in an oblique direction to the front wall of the abdomen to the outer edge of the rectus muscle, ending at the level of the navel or above it. Access is indicated for kidney tumors, extensive kidney injuries and combined injuries of the abdominal organs.

Nagamatsu Access is a transverse incision passing almost at a right angle paravertebral to the level of the X rib. With this access, a partial resection (up to 3 cm) of the X, XI, XII ribs is performed closer to the place of their attachment (Fig. 26). This opens up great opportunities for approaching the high-lying upper pole of the kidney, but the risk of damage to the pleura is high.

Rice. 26. Access to the kidney according to Nagamatsu.

After an incision in the skin, subcutaneous tissue and fascia, three layers of muscles are crossed. The first layer consists of two muscles: at the top - the latissimus dorsi, at the bottom - the external oblique muscle of the abdomen. The second layer is the serratus posterior inferior muscle and the internal oblique muscle of the abdomen. The third layer is one muscle - the transverse abdominal muscle. After dissection of the muscles and fascia (thoracolumbar fascia, square muscle of the lower back), the parietal peritoneum, together with the fatty retroperitoneal tissue, is bluntly peeled off medially and anteriorly. After this, a shiny retroperitoneal fascia becomes visible. Through it, the kidney is palpated, surrounded by fatty tissue and a capsule. The retroperitoneal fascia is dissected. Allocate a kidney to the gate, and dislocate it into the wound.

Operative access to the ureter. All surgical approaches to the ureter can be divided into three groups: extraperitoneal, transabdominal and combined. The choice of operative access to the ureter depends on the location of the pathological process and the extent of the proposed surgical intervention. For surgical intervention on the lumbar and iliac ureter, the Fedorov and Israel incisions are usually used, and for the exposure of the lower ureter, the Pirogov, Tsulukidze and Keya incisions are used (Fig. 27).

Rice. 27. Incisions to expose the ureters.

1 – Fedorov section; 2 – Israel section; 3 – Pirogov section; 4 – Tsulukidze section; 5 – Keya section.

Fedorov's access begins under the XII rib, first goes closer to the edge of the iliocostal muscle, and then, at the level of the anterior axillary line, passes to the anterior wall of the abdomen parallel to the inguinal (pupart) ligament. Then, the outer third of the rectus abdominis muscle is cut across and a cut is made along it longitudinally to the pubic bone. This incision gives wide access to the lumbar, iliac, and pelvic ureters.

Pirogov's incision starts from the level of the anterior superior iliac spine and leads 4 cm above the inguinal fold parallel to it through the oblique and transverse muscles to the outer edge of the rectus muscle. After that, the transverse fascia of the abdomen is dissected, the peritoneum is pushed up and inwards, and the ureter is exposed. With this access, the ureter can be mobilized to the very point of its confluence with the bladder.

The Tsulukidze incision begins two transverse fingers below the level of the navel from a point located one transverse finger outward from the lateral edge of the rectus abdominis muscle. From top to bottom, the incision gradually approaches the rectus muscle and along the lateral edge of the latter reaches the pubic tubercle of the corresponding side. The upper part of the incision is led with a bulge inward, and the lower part is led outward. Having cut the skin with subcutaneous tissue, the aponeurosis of the external oblique, internal oblique and transverse abdominal muscles is dissected and penetrated into the retroperitoneal tissue. The outer edge of the incision, together with the broad muscles, is pulled outward with blunt hooks. In a blunt way, the parietal sheet of the peritoneum is peeled inward, after which it penetrates into the iliac fossa, and then into the subperitoneal part of the small pelvis.

A Keya incision 10–12 cm long is made along the midline above the symphysis. After dissection of the skin, subcutaneous tissue and aponeurosis, the rectus abdominis muscles are bred with blunt hooks and the transverse fascia is dissected. The peritoneum is peeled upward in a blunt way to the bifurcation of the common iliac artery, where the ureter is found and mobilized.

If during the operation it is supposed to revise the kidney, Derevyanko recommends using an incision along the outer edge of the rectus abdominis muscle from the costal arch to the pubic tubercle.

To expose the pelvic ureter, Ovnatanyan's access, similar to Pfannenstiel's access, is widely used (Ovnatanyan's access is carried out 1 cm above the womb, and Pfannenstiel's access is carried out along the natural transverse skin fold 3–4 cm above the womb). An arcuate incision 15–18 cm long above the pubic joint is cut into the skin and subcutaneous tissue. According to the skin incision, the aponeurosis is dissected and its upper flap is peeled upwards from the rectus muscles. Further stupidly separate the rectus and pyramidal muscles. The peritoneum is peeled upward and towards the midline. The advantages of this incision are low trauma and the ability to manipulate both ureters. Recently, less traumatic oblique variable incisions without muscle transection have been used to approach the upper and lower parts of the ureter (Fig. 28).

Rice. 28. Incisions to expose the pelvic ureter.

1 - with a kidney revision according to Derevyanko; 2 - Hovtanyan's access.

Nephrectomy. Indications: kidney crush, tumors, severe pyonephrosis.

Position of the patient: on the side of the healthy side with a roller placed under the lower back, the arm is placed behind the head, the leg on the healthy side is bent, on the diseased side it is fixed in a straightened position.

Anesthesia: anesthesia.

An approach should be chosen that provides the best approach to the kidney or ureter, in which muscles, vessels and nerves are less damaged. In this regard, the best approaches are Pirogov-Bergmann-Israel oblique cuts. If it is necessary to expose the ureter, the incision is continued to the middle or even medial third of the inguinal ligament (L.Israel) or provides access to the lower part of the ureter (N.I. Pirogov). In this case, the incision is continued 4 cm above the inguinal ligament and parallel to it, through both oblique and transverse abdominal muscles to the rectus muscle.

Operational reception. Separately allocate the elements of the gate of the kidney (ureter, artery and vein).

The ureter is isolated as low as possible from the renal pelvis. Under each of the renal vessels, two ligatures are placed on a Deschamps needle or using a curved Fedorov-type clamp. First ligate the artery, then the vein. Ligatures located closer to the spine are tied first. Then, at a distance of 1 cm from the first ligatures, the second ligatures are tied (ensuring reliability) on both vessels. At a distance of 1 cm from the second ligatures, a Fedorov clamp is applied. Vessels cross between Fedorov's forceps and kidney gates. Opening Fedorov's clamp, check if there is any bleeding. In the absence of bleeding, the clamp is removed and the treatment of the ureter is started. A clamp is applied 2–3 cm distal to the orifice of the ureter. Below the clamp, the ureter is ligated. Under the clamp between it and the ligature, the kidney is cut off and removed. The ureter stump is treated with an alcoholic solution of iodine, the ligature is cut off, and it is immersed in soft tissues.

Careful hemostasis is carried out in the area of ​​the kidney bed, tubular drainage and a swab are brought in. The wound is sutured in layers to drains.

Nephrotomy. Indications: foreign bodies, stones.

Position of the patient: as in nephrectomy.

Kidney access. A Bergmann-type incision is used.

Operational reception. After the kidney is exposed 1 cm posteriorly from the middle of its convex edge, a small incision (malovascular zone) is made along its long axis, focusing on the position foreign body. A narrow forceps is inserted through the incision and the foreign body is removed (Fig. 29). At the end of the manipulation, hemostatic closing sutures from absorbable sutures are applied. The fascial capsule is sutured. Produce hemostasis. The lumbotomy wound is sutured in layers.

Rice. 29. Nephrotomy with removal of a stone from the renal calyx.

Operations for kidney injuries. Indications: injuries and ruptures of the kidneys.

Operational access. In case of isolated damage to the kidney, the optimal approach is an oblique lumbar incision according to Bergmann-Israel, in case of a combination of damage to the abdominal organs, a median laparotomy.

Operational reception. With superficial ruptures of the kidney, interrupted sutures are applied, the threads are passed through the parenchyma so that they do not cut through. When a kidney is ruptured near the pelvis, sutures are applied through the deepest point of the wound and a significant part of the parenchyma, capturing the area on the opposite side of the rupture of the organ.

If the pelvis and cup are damaged, a nephrostomy is applied using a Foley catheter. To do this, a separate incision is made through the middle and lower cups outside the area of ​​the parenchyma sutures and a curved forceps or dissector is inserted into the pelvis. The parenchyma is perforated, having found the "nose" of the instrument under the fibrous capsule of the kidney, the capsule is dissected above it. The catheter is pulled, its tip is placed in the middle of the renal pelvis. The catheter is fixed to the kidney capsule with two purse-string sutures. The incision of the pelvis is hermetically sutured.

If the pole of the kidney is crushed without damage to its gate, the pole of the kidney is resected. In this case, a rubber tourniquet or soft vascular clamp is applied to the renal pedicle. Above the resection line, the kidney capsule is dissected, and it is shifted down (Fig. 30). The kidney parenchyma is resected wedge-shaped. Temporarily relaxing the tourniquet, profusely bleeding vessels are found and ligated. Seal the cavitary system of the kidney by placing interrupted sutures on its parenchyma near the opened cup so that the threads do not penetrate into the lumen cavity system. The wound of the parenchyma of the kidney is sutured with interrupted U-shaped sutures tightly one to the other. The displaced fibrous capsule is shifted to the newly formed pole of the kidney, and its edges are sutured with interrupted sutures (Fig. 30c).

Rice. 30. Kidney resection.

When the rupture of the kidney spreads to its hilum or when total destruction kidneys produce nephrectomy. The hilum of the kidney is exposed. A Fedorov-type clamp is applied to the kidney vessels as close as possible to the renal parenchyma. The renal artery and renal vein are transected 0.5 cm distal to the clamp. An additional clamp is applied distally to the renal artery and a clamp to the renal vein. Tied up separately renal artery and vein, remove the distal clamps. The entire renal pedicle is re-bandaged, Fedorov's clamp is removed. Pulling the kidney, allocate the ureter throughout. The ureter is ligated and cut off at the point of entry into the bladder. The kidney is removed.

Completion of the operation. The lumbotomy incision is closed tightly.

During organ-preserving operations, the perirenal space is drained, the nephrostomy catheter is removed through a separate incision.

Errors and dangers:

1) massive blood loss during resection of the pole of the kidney (to prevent it, a tourniquet is first applied to the renal pedicle);

2) rupture of the urethra (catheterization in this case is dangerous by aggravating damage and infection of the paraurethral tissue; the bladder is emptied by suprapubic puncture or an epicystostomy is applied).

Operations for paranephritis. Retroperitoneal phlegmon in the kidney area is called paranephritis. Pus can accumulate directly in the fatty tissue around the kidney. It can be localized both in front of the kidney and behind it. A relative obstacle to its spread may be the corresponding leaves of the perirenal fascia. Abscesses in the subperitoneal tissue can be located along the lumbar and iliac muscle and in the colon.

For reliable drainage of the abscess cavity, surgical intervention is performed. For diagnosis and temporary drainage, endovideo surgery can be undertaken. A port is inserted into the cavity of the abscess, through which, in turn, a tube is inserted for temporary or permanent drainage, according to appropriate indications, to eliminate acute inflammation.

Operational intervention. Position of the patient: on a healthy side with a large roller in the lumbar region.

Anesthesia: anesthesia.

Access: Bergmann-Israel incision, which starts from the end of the XII rib, retreating 4-5 cm from the line of spinous processes.

When the abscesses are located along the ureter or along the lumboiliac muscle, the incision is continued down, as with access along N.I. Pirogov. In the process of dissection and separation of the muscles, they approach the focus of inflammation. The abscess is opened (safer - with the blunt end of the instrument), pus is released. The incision is expanded downwards, the cavity is cleaned and examined so as not to leave pockets or streaks unemptied. ( Attention! The bridges in the cavity are not torn, as severe bleeding may occur). The cavity is drained with one or two thick tubes and loose gauze swabs. Rubber drains are fixed with strong threads to the skin wound. The edges of the wound in some places are narrowed with several sutures. Put on a bandage.

Resection and suture of the ureter. Technique. Previously, a ureteral catheter is inserted into the corresponding ureter. One of the approaches described above exposes the retroperitoneal space. Using the catheter, the ureter is easily found and its narrowed section is isolated from the surrounding tissues. If the narrowed area is small, it is cut along the front wall in the longitudinal direction and stitched in the transverse direction (Fig. 31).

Rice. 31. Stages of suturing in the narrowing of the ureter.

In cases where there are cicatricial changes at the site of narrowing of the ureter, the affected area is resected. It is preliminarily checked whether it is possible to connect the distal and proximal ends of the ureter without tension. A soft clamp is applied to the proximal end of the ureter and the narrowed area is excised within healthy tissues. After that, proceed to the suture of the ureter. Before suturing, a ureteral catheter previously inserted endoscopically is inserted into the proximal end of the ureter. The ureter is laid in place, its ends are brought closer to each other and end-to-end is sutured through the adventitia and the muscular membrane. In the area of ​​such a suture, with a normal lumen of the ureter, a narrowing may develop in the future, therefore, to stitch the ends of the ureter end-to-end, the ureter can be dissected not transversely, but in an oblique direction.

You can suture with the introduction of the proximal end of the ureter into the distal. In such cases, the end of the distal segment of the ureter along its anterior wall is dissected 1 cm in the longitudinal direction. The anterior and posterior walls of the proximal segment of the ureter, stepping back from the edge by 1-1.2 cm, are stitched with U-shaped sutures. Their free ends are passed through the side walls of the distal segment of the ureter (Fig. 32).

Operations for phimosis and paraphimosis. phimosis – impossibility of displacement foreskin for the head of the penis.

Patient position: supine.

Anesthesia: local infiltration anesthesia in the midline of the dorsal surface of the penis.

Operation technique. A grooved probe is inserted under the foreskin on the back of the penis. Both sheets of the foreskin are cut along the probe, going beyond the head of the penis. In the upper part of the incision, a triangular patch according to Roser is cut out and sewn in the upper corner of the skin wound (Fig. 32). The edges of both sheets of the dissected foreskin are sutured with interrupted sutures. Put on a bandage.

Rice. 32. Roser operation for phimosis.

paraphimosis- strangulation of the glans penis, often a complication of phimosis resulting from the forcible displacement of the narrowed foreskin behind the glans penis.

An attempt is made to reposition the head under anesthesia and against the background of muscle relaxation. If non-operative methods do not lead to success, then an urgent operation is necessary.

The infringing ring is cut on the back of the penis (Fig. 33), and its head is repositioned. As the inflammatory process subsides, a circular circumcision of the foreskin is performed.

Rice. 33. Hayek-Roshal operation for paraphimosis.

Operations for hydrocele. Indication: Increasing hydrocele.

Anesthesia: local or general.

Operation technique according to Winkelmann. Access. A skin incision 6–8 cm long is made along the outer edge of the scrotum above the site of fluid accumulation. The incision starts from the edge of the scrotum. The spermatic cord is exposed in layers, by pulling the cord, the testicle is dislocated into the surgical wound.

Longitudinally over the bulge, all the shells are dissected up to their own. An incision is made in the latter, the edges are grasped with clamps, and the liquid is released. The shell is cut longitudinally (Fig. 34). The excess part of the shell is removed. The remaining part of it is turned outward with a serous surface, and the opposite edges of the membrane are sutured behind the spermatic cord.

The testicle is dipped back into the scrotum. Perform meticulous hemostasis. The wound is sutured tightly in layers.

To prevent swelling of the scrotum, a suspension is prescribed for several days.

Stricture of the ureter (ureter) is a pathological narrowing of its lumen, in one way or another causing violation outflow of urine from the pelvis. This narrowing may be congenital or acquired.

Ureteral strictures may be asymptomatic and lead to severe renal dysfunction. Most often, the narrowing of the ureter is complicated by secondary infection (recurrent pyelonephritis, pyelitis, etc.), the formation of stones.

With small strictures, it is possible to place a stent in the ureter, balloon dilatation, endoureterotomy. Let us consider in more detail the causes of ureteral strictures and the types of operations used to treat this pathology.

• Show all

  1. Classification of strictures

  Classification criterion	Types of strictures	Description
  By time of occurrence	Congenital
  	Acquired
  due to obstruction	External
  	Internal
  By nature	benign
  	Malignant
  By etiology	iatrogenic	Ureteroscopy. Irradiation. Kidney transplant.
  	Non-iatrogenic
  Depending on localization	Proximal
  	Medium
  	Distal

  Table 1 - Classification of ureteral strictures

  2. Epidemiology

  Wide application endoscopic studies upper division ureter led to an increase in the number of iatrogenic strictures.

  The likelihood of ureteral obstruction after endoscopic treatment about calculi is 3-11%. According to latest research, when used in the treatment of urolithiasis, fibroendoscopes of a smaller diameter, laser lithotripsy, and smaller instruments, the frequency of ureteral strictures decreases and is less than 1%.

  Risk factors for the formation of strictures are also the time of stone penetration into the wall of the ureter and perforation of the ureter during endoscopic treatment.

  Factors that increase the likelihood of narrowing of the ureter after ureteroscopy:

  1. 1 Large diameter fiber endoscope.
  2. 2 Long-term persistence of a stone in the lumen of the ureter.
  3. 3 Wedging of a stone.
  4. 4 Large stone size.
  5. 5 Proximal localization of the calculus.
  6. 6 Perforation of the ureter during ureteroscopy.
  7. 7 Use of intracorporeal lithotripsy.

  Narrowing can be a complication of external and internal drainage of the ureter. The frequency of ureterointestinal anastomosis stricture formation is 3-5%.

  Damage to the ureter can occur with any surgical intervention on the organs of the pelvis or retroperitoneal space. To share gynecological operations accounts for 75% of iatrogenic ureteral injuries.

  3.

  The ureter (ureter) is a muscular tube lined internally with transitional epithelium that connects the renal pelvis to the bladder. Throughout the ureter is located in the retroperitoneal space.

  Its length is 20-30 cm and often depends on the height of the person. The diameter of the lumen of a normal ureter is 4-10 mm and varies throughout (physiological narrowing).

  Two narrowings of the ureter are most important: ureterotazic and ureterovesical. The narrowest part of the ureter is located at the point of its transition into the small pelvis (uretero-pelvic junction): in this place, the ureter is thrown over the bifurcation of the common iliac artery.

  In men and women, the ureter passes behind the gonadal vessels and in front of m. iliopsoas, crosses the common iliac vessels (artery and vein) and below passes into the pelvic cavity.

  In males, the vas deferens wraps around the ureter anteriorly before it enters the bladder. In women, the ureter is located behind the vessels of the uterus close to its neck, passing lower into the intramural section in the wall of the bladder.

  

  Figure 1 - Anatomy of the ureter. Illustration source -

  The blood supply to the ureter is provided from several sources. In the upper third, the ureter is supplied with blood by branches extending from the renal and gonadal arteries. IN middle third blood supply is provided by small branches from the aorta. In the pelvic region, the ureteral wall is nourished by branches of the iliac, cystic, uterine, and hemorrhoidal arteries.

  4. Pathophysiology

  The process of stricture formation most often occurs against the background of ischemia, as a result of which there is an overgrowth connective tissue in the wall of the ureter.

  overgrowth fibrous tissue may occur in response to trauma (eg, stone passage) or chronic inflammation(chronic tuberculosis, local inflammatory response on suture material).

  Histopathological analysis of ureteral strictures reveals irregular deposition of collagen fibers, fibrosis, different stages of inflammation (depending on the etiological factor and the time since the onset of the inflammatory response).

  The resulting obstruction of the ureter can be mild, with asymptomatic course, proximal ureteral dilatation and hydronephrosis, or it can be severe, causing complete obstruction with loss of function of one of the kidneys.

  5. Clinical picture of pathology

  In some patients, strictures are not accompanied by any symptoms. Often the clinic appears only at the time of urination or when renal colic occurs.

  The severity of symptoms does not correlate well with the degree of obstruction of the lumen of the ureter. At times, even the most severe obstruction is not accompanied by a clinic.

  With localization of strictures on both sides (with retroperitoneal fibrosis, retroperitoneal lymphadenopathy), chronic kidney failure, azotemia. The ability to restore kidney function depends on the time elapsed since the obstruction, and its degree.

  The most characteristic symptoms:

  • Pain in the lower back (pain can be dull, pulling, with colic, the pain is paroxysmal, sharp, gives along the ureter to the groin).
  • Fever.
  • Increased/reduced urination.
  • Admixture of blood in the urine.

  6. Examination of the patient

  6.1. Laboratory research

  1. 2 with the determination of the sensitivity of the infectious agent.
  2. 3 Biochemical blood test (assessment of kidney function according to the level of electrolytes, urea, creatinine).

  6.2. Instrumental Research

  • Ultrasonography. Ultrasound is often the first instrumental examination, which allows you to identify changes in the lumen of the ureter, signs of hydronephrosis.

  The study is non-invasive, has no contraindications and does not require the introduction of contrast agents. The main limitation of the use of ultrasonography is the poor visualization of the ureter throughout, especially in obese patients.

  Also, ultrasound can only assess the anatomical state of the ureter and does not give a conclusion about the functional state of the kidney, the degree of obstruction.

  • CT scan. CT can be used in patients with acute pain in the lumbar region and is often used in patients with a history of urolithiasis.

  CT results have high sensitivity and specificity in the establishment of hydroureteronephrosis and the place of expansion of the ureter, the assessment of the thickness of the wall of the ureter.

  According to CT data, it is possible to judge the presence of impacted, wedged calculi, to suspect extravasation of urine.

  The use of intravenous contrast allows assessing the degree of obstruction and obtaining information about the relationship of adjacent anatomical structures.

  The use of contrast must be countered by its nephrotoxicity. CT with contrast injection is best method estimates external causes stricture, oncological process and its metastasis.

  • Intravenous pyelography. Until recently, intravenous pyelography was the method of choice in assessing the degree of obstruction. Since the introduction of contrast-enhanced CT, intravenous pyelography has become rare.

  

  Figure 2 - Severe stricture of the distal right ureter. Intravenous pyelography performed on a patient 4 weeks after hysterectomy for endometriosis. Damage to the ureter was identified during surgery and repaired. Illustration source -

  

  Figure 3 - Intravenous pyelography in the same patient. Condition after combined ante- and retrograde laser endoureterotomy of the stricture followed by balloon catheter dilatation and stenting. The patient shows resolution of symptoms, disappearance of signs of obstruction 3 months after endoureterotomy and stent placement. Illustration source -

  • Retrograde pyelography. The study is of high value, as it allows assessing the condition of the ureter without systemic administration of nephrotoxic contrast. Retrograde pyelography allows you to decide on the choice of treatment method.

  

  Figure 4 - Retrograde pyelography. On the right, in the middle part of the ureter, a stricture is determined. The patient has a history of surgical treatment (3 years ago) - aortobifemoral shunting for obliterating atherosclerosis. When examining a patient, an increase in the level of urea in a biochemical blood test was determined, according to ultrasonography - bilateral hydronephrosis. Illustration source -

  • Intraluminal ultrasonography. The main advantages of the method include the ability to assess the degree of ureter obstruction, the state of adjacent structures. The main disadvantage is the invasiveness of the study, as well as the impossibility of assessing with complete obstruction of the lumen of the ureter.
  • Scintigraphy. The method allows assessing the functional state of the kidneys, measuring the clearance of the radiopharmaceutical and calculating the renal blood flow.

  6.3. Histological characteristics

  If there is doubt about the nature of the stricture, ureteroscopy with a biopsy from the site of obstruction is performed before surgical treatment.

  • The histology of benign strictures is nonspecific: the formation of a scar with the deposition of collagen fibers, the stricture is surrounded by an inflammatory infiltrate.
  • Strictures formed during radiation therapy differ low content cellular elements at the site of narrowing, hypertrophy of vessels with acellular matrix.
  • Malignant strictures contain cellular elements characteristic of tumors (loss/decrease in cell differentiation, atypia of nuclei, invasion of the tumor into the underlying layers). Most often, the ureter is recorded transitional cell carcinoma.

  7. Surgical treatment

  There are currently no experts common opinion regarding the choice of the main method of treatment of patients with ureteral strictures. Surgical interventions for stricture include:

  1. 1 Balloon dilatation.
  2. 2 Endoureterotomy.
  3. 3 Stenting (intraluminal stent in the ureter).
  4. 4 Open operations.
  5. 5 Minimally invasive laparoscopic and robotic operations (replacing open methods treatment).

  

  Figure 5 - Options for endoscopic correction of ureteral strictures. Image source - www.nature.com

  7.1. Indications and contraindications for surgical treatment

  Indications for intervention in patients with stricture may include:

  1. 1 pain syndrome.
  2. 2 Chronic recurrent pyelonephritis.
  3. 3 Severe ureteral obstruction, which can lead to irreversible damage kidney function.
  4. 4 Hematuria.
  5. 5 Stone formation proximal to the obstruction site.

  Contraindications for surgical treatment:

  1. 1 The main contraindication to surgical treatment (both open and endoscopic) is active phase infectious process.
  2. 2 Severe disorders of the coagulation system that cannot be corrected.

  When planning surgical treatment, many factors are taken into account. At the terminal stage of oncology, decompensation chronic diseases, elderly patients have a significant risk of complications of surgical treatment.

  In this situation, it is necessary to consider placing a stent in the ureter for a long time. According to Chung, in 41% of cases after stenting, obstruction symptoms return within a year.

  In 30% of patients, an external nephrostomy was required within 40 days from the moment of installation of the ureteral stent. Predictors of poor results of stenting: strictures due to the oncological process, creatinine level above 13 mg/l.

  When saving less than 25% of normal function kidney balloon dilatation and endoureterotomy with a high probability will not have the desired therapeutic effect.

  In this case, an open operation (up to a nephrectomy) will be required. The functional state of the kidney can significantly improve after the elimination of obstruction (the less time has passed since the obstruction, the higher the effect of the operation).

  If less than 10% of the normal functional capacity of the kidney is preserved, nephrectomy is considered, since full recovery kidney function on the side of the obstruction should not be expected.

  7.2. Before the operation

  1. 1 rating anatomical features strictures according to CT with contrast, retrograde pyelography.
  2. 2 Assessment of the degree of obstruction and kidney function (scintigraphy is used to assess the functional state of the kidneys).
  3. 3 In patients with malignant pathology in history before surgery, it is necessary to obtain a biopsy from the site of narrowing.
  4. 4 To reduce the risk of postoperative infection, the patient should have sterile urine specimens before surgery.
  5. 5 When planning intestinal interposition, the patient undergoes mechanical and antibacterial preparation of the intestine the day before the intervention.
  6. 6 Antibacterial prophylaxis (administration of II generation cephalosporin 1.0 - 1.5 g 1-2 hours before the operation).
  7. 7 Anesthesia: In most cases, endotracheal anesthesia is the choice.

  8. Balloon dilatation

  Typically, balloon dilatation is the first step in resolving the obstruction, followed by placement of a temporary ureteral stent over the stricture for 4 to 6 weeks.

  The probability of final success from this combination is 55%. Best Results from balloon dilatation can be obtained with non-ischemic transient obstruction.

  The prognosis is influenced by the following factors: the duration of the stricture (optimally up to 3 months), the small length of the narrowing.

  Complications of balloon dilatation are:

  • 1 infection.
  • Lack of effect from the intervention.

  9. Endoureterotomy

  The operation is usually performed for benign strictures and has a better treatment outcome compared to balloon dilatation.

  The proper effect of the operation can be achieved in 78-82% of patients with ureteral strictures. A weak effect of the operation may be with a reduced functional ability of the kidneys (below 25% of the norm), a stricture length of more than 1 cm, a pronounced narrowing of the lumen of the ureter (less than 1 mm in diameter).

  There are two options for the operation:

  1. 1 Antegrade endoureterotomy.
  2. 2 Retrograde endoureterotomy.

  Retrograde endoureterotomy does not require a skin incision and is less invasive than antegrade.

  In excision of the stricture, the technique of a cold knife (cold knife), electrocoagulation or laser is used.

  An incision is made at the site of narrowing to the entire depth of the wall, the instrument reaches the tissue surrounding the ureter. The incision should begin 1–2 cm distally and end proximal to the constriction.

  The dissection of the wall is performed under the control of an endoscope inserted into the ureter through the urethra and bladder. After the procedure, a temporary stent with a diameter of 7F-14F is placed for 4-6 weeks.

  Possible complications:

  1. 1 infection.
  2. 2 Damage to adjacent structures (vessels, intestines).

  10. Placement of a stent in the ureter

  Intraluminal stents are more often used in the treatment of malignant stricture, in patients not subject to open / minimally invasive surgical treatment (with severe concomitant pathology, decompensation of chronic pathology).

  Removing a stent from the ureter can be difficult. Sometimes spontaneous migration of the stent occurs.

  According to Liatsikos, ureteral patency was restored in 66% of cases. After 1 year, lumen patency was observed in 37.8% of patients, after 4 years - in 22.7% of patients. Stents can be replaced every 6-12 months.

  11. Open operations

  Open surgeries performed to restore the lumen of the ureter:

  1. 1 Psoas hitch.
  2. 2 Boari flaps.
  3. 3 Ureteroneocystostomy - excision of the stricture and reimplantation of the proximal part of the ureter into the bladder.
  4. 4 Ureteroureterostomy - the formation of an anastomosis between the unchanged parts of the ureter (the operation is feasible with a small length of the stricture, mobility of the ureter).
  5. 5 Ureteropyelostomy - anastomosis between the unchanged part of the ureter and the pelvis of the kidney (the operation is feasible with proximal strictures of small extent). With cicatricial deformities of the pelvis, it is possible to perform an ureterocalicostomy (anastomosis between the ureter and the pelvis calyx).
  6. 6 Intestinal interposition.

  The probability of stable resolution of obstruction in open surgery is 90%.

  Possible complications:

  1. 1 Dynamic intestinal obstruction.
  2. 2 Formation of urinoma (pararenal urinary pseudocyst).
  3. 3 Leakage of urine from the anastomosis site.
  4. 4 Iatrogenic damage to the intestinal wall.
  5. 5 Violation of the functional state of the bladder (with the methods of psoas hitch, Boari flap).

  The choice of variant of the operation is determined by the location and extent of the stricture. Terminal ureter strictures can be treated with ureteroneocystostomy, psoas hitch.

  With proximal localization of the stricture, it is possible to use the Boari technique, which allows prosthetic replacement of the distal 10-15 cm of the ureter.

  For strictures of the middle part of the ureter with a small extent, it is possible to perform ureteroureterostomy. For the success of this operation, it is important to form an anastomosis with minimal tension, which requires adequate mobilization of the ureter throughout.

  

  Figure 6 - Formation of ureteroureteroanastomosis. Image source - Medscape.com

  Proximal strictures can be repaired with a ureteropyelostomy (if the length of the ureter allows). To reduce tension in the area of ​​the anastomosis, the operation can be supplemented by mobilization of the kidney.

  With cicatricial deformity of the pelvis, it is possible to form an anastomosis with the ureteral stump and the kidney calyx (ureterocalicostomy). Operations on strictures of the proximal ureter can be performed from different approaches (laparotomy, lumbotomy).

  11.1. Psoas hitch

  The method is used in the treatment of strictures of the distal ureter (the last 3-4 cm of the ureter).

  

  Figure 7 - Scheme of the psoas hitch operation. Illustration source - http://cursoenarm.net

  Operation steps:

  1. 1 Skin incision (transverse Pfannenstiel incision or lower median vertical incision).
  2. 2 Bladder mobilization
  3. 3 Fixation of the bladder to the psoas muscle with non-absorbable sutures.
  4. 4 Excision of the stricture and replantation of the ureter into the dome of the bladder.
  5. 6 Installation of a cystostomy outside the dome of the bladder (the figure shows a sutured cystostomy).

  11.2. Boari flap

  Indications:

  1. 1 Extended stricture of the ureter.
  2. 2 Failure to mobilize the ureter sufficiently to form a tension-free ureterovesical anastomosis.

  

  Figure 8 - Scheme of the Boari flap operation. Image source - www.researchgate.net

  Operation steps:

  1. 1 Access (median laparotomy).
  2. 2 Excision of the narrowed portion of the ureter.
  3. 3 Cutting out a flap from the wall of the bladder.
  4. 4 The cut flap is brought to the stump of the ureter to create an anastomosis.
  5. 5 This method allows you to create a flap 12-15 cm long and impose a tension-free ureterovesical anastomosis.
  6. 5 Placement of a temporary stent for the time of anastomosis healing (10-21 days).
  7. 7 Placement of drains to the area of ​​anastomosis.

  Contraindications for performing psoas hitch and Boari flap:

  1. 1 Wrinkled bladder with reduced distensibility.
  2. 2 Limited bladder mobility.
  3. 3 Ureteral strictures above the pelvic inlet.

  11.3. Intestinal interposition

  The principle of the operation is to replace the site of the affected ureter with a loop of the small intestine.

  The operation is performed when:

  1. 1 Extended strictures of the ureter.
  2. 2 Proximal localization of the stricture.
  3. 3 Failure to adequately mobilize the ureter and bladder.

  Contraindications:

  1. 1 Chronic renal failure (plasma creatinine more than 20 mg/l).
  2. 2 Obstruction in the way of outflow of urine from the bladder.
  3. 3 Chronic inflammatory diseases intestines ( ulcerative colitis, Crohn's disease).
  4. 4 Enteritis against the background of radiation exposure.

  

  Figure 9 - Scheme of intestinal interposition. Image source - www.icurology.org

  Operation steps:

  1. 1 Access (median, lower median laparotomy).
  2. 2 Resection of the ureter with stricture.
  3. 3 Mobilization of the loop of the small intestine (it is extremely important to maintain adequate blood supply to the loop during mobilization) and its cutting off with two linear staplers.
  4. 4 Interposition of the mobilized loop (the bowel loop serves as a conductor of urine from the proximal ureteral stump to the bladder): formation of ureterointestinal and vesicointestinal anastomoses.
  5. 7 Placement of drains to the area of ​​anastomosis.

  11.4. Laparoscopy and robotic surgeries

  Increasingly, minimally invasive techniques are used in the treatment of strictures. Laparoscopy is replacing open surgery.

  The main advantages of laparoscopy and robotic operations (Da Vinci system):

  • Minimally invasive.
  • Improved visualization of the surgical field due to multiple magnification.
  • Less chance of postoperative complications.
  • Early mobilization of the patient after surgery.
  • Less hospital stay and more short term rehabilitation.

  12. Postoperative period

  1. 1 Antibacterial therapy continues until the removal of postoperative drains.
  2. 2 Drainages are removed with a small amount of discharge (less than 30 ml / day), in the absence of urine output through the drainage (assessment of the creatinine level in the discharge, with urine output, the creatinine level will be several times higher than normal level creatinine in blood plasma).
  3. 3 In patients after endoureterotomy, stents are left for 4-6 weeks.
  4. 4 In patients with newly formed anastomoses, stents are left for 2-3 weeks.
  5. 5 Depending on the method of treatment, the rehabilitation period may vary. In case of open surgeries and uncomplicated course of the postoperative period, the patient stays in the hospital for 4-10 days. With minimally invasive interventions (laparoscopy, endoureterotomy), the length of stay in the hospital is reduced to several days.

  Article Highlights