Features of installation and removal of the ureteral stent. Clinical picture of pathology

Due to the location, size and mobility of injuries and damage to the ureters under the influence of external forces are relatively rare. In particular, this is due to the fact that this body elastic, easily displaced and protected by powerful muscles, ribs, iliac bones. Of particular interest from a practical point of view are iatrogenic injuries of the ureter that occur during medical diagnostic procedures (for example, ureteral catheterization, contact ureterolithotripsy), as well as during operations (more often on pelvic organs).

ICD-10 code

S37.1. Injury to the ureter.

ICD-10 code

S37 Injury of pelvic organs

What causes ureteral injury?

Least often the ureter is damaged by external trauma. Isolated gunshot injuries of the ureters are rare: there are only 8 isolated injuries per 100 such injuries. As a rule, they are combined with injuries of other organs (with closed injuries of the ureters - up to 33%, with open ones - up to 95% of all cases). According to various sources, ureteral injuries account for only 1-4% of injuries to the genitourinary organs.

Gunshot injuries of the ureters account for 3.3-3.5% of all combat injuries of the genitourinary system during modern military operations. Injuries of the lower third of the ureters predominate, which is associated with the use individual means protection.

In modern local military conflicts, ureteral injuries occur in 5.8% of the wounded. Injuries of the ureters during the Great Patriotic War occurred in about 10%, and during the local conflict in Afghanistan - in 32% of all injuries of the genitourinary organs.

Damage to the ureters can be caused both directly (damage to the mucous membrane, compression of the ureter with a suture, complete Z partial dissection, crushing, avulsion or avulsion), and indirectly (devascularization during electrocoagulation or too thorough dissection, late necrosis of the ureter after radiation exposure, etc.). ) impact. Open injuries of the ureter almost always occur with gunshot wounds and in all cases are in the nature of a concomitant injury.

The biggest statistical study damage to the ureter was carried out by Z. Dobrowolski et al. in Poland in 1995-1999. According to this study, 75% of ureteral injuries are iatrogenic, 18% are due to blunt trauma, and 7% are due to penetrating trauma. In turn, iatrogenic injuries of the ureters in 73% of cases occur during gynecological, and in 14% - urological and general surgical operations. According to Dobrowolski and Dorairajan, damage to the ureter during gynecological operations occurs in 0.12-0.16% of cases.

In laparoscopic operations (mainly laparoscopically assisted transvaginal hysterectomy), the probability of damage to the ureter is less than 2%. In this case, electrocoagulation acts as a damaging factor leading to damage to the ureters.

Endoscopic technologies for the diagnosis and treatment of ureteral stones, obliterations and strictures of the urethra, urothelial tumors can be complicated by iatrogenic injuries of the ureters (2-20% of cases). Damage to the ureters during ureteroscopy covers mainly only the mucous membrane or may be minor damage to its wall. Potential complications of endoscopic surgery include perforation, ureteral stricture, ureteral false passage, ureteral avulsion leading to bleeding of varying intensity, infectious and inflammatory complications, up to sepsis.

Perforation and false course of the ureter may occur during the insertion of a ureteral stent or guidewire, especially if it is obstructed, for example by a stone, or if the course of the ureter is tortuous.

Basically, iatrogenic injuries of the ureters are associated with non-compliance with certain rules for endoscopic manipulations. If resistance is insurmountable during insertion of a stent or guidewire, retrograde pyelography should be performed to clarify the anatomy of the ureter. When using small-caliber ureteroscopes (less than 10 Fr), flexible ureteroscopes and temporary ureteral stents, ureteral perforation occurs in 1.7%, strictures - 0.7% of cases.

Rupture of the dilator balloon during endoscopic dilatation of the ureteral stricture as a result of a sharp build-up of pressure in the balloon can also lead to its iatrogenic damage.

Ureter avulsion is rare (0.6%) but most serious complication ureteroscopy. This usually occurs in the proximal third of the ureter when a large calculus is removed with a basket without first fragmenting it. If the detachment of the ureter has occurred, then drainage of the urinary tract (percutaneous nephrostomy) is indicated with further restoration of the integrity of the ureter.

The main causes of iatrogenic damage to the middle third of the ureter, in addition to endoscopic manipulations, are surgical interventions on the external iliac vessels, lymphadenectomy, and suturing the posterior leaf of the parietal peritoneum.

Penetrating noniatrogenic ureteral injury occurs mainly in young ( average age 28 years), are usually unilateral and are always accompanied by damage to other organs.

In 95% of cases, they occur as a result of gunshot wounds, are much less likely to be caused by edged weapons, and most rarely occur during car accidents. In case of damage to the ureters, resulting from the impact of an external force, its upper third is more often damaged, the distal part - much less often.

In general, injuries to the lower third of the ureter account for 74%, while the upper and middle thirds account for 13% each. It should be noted that such damage to the ureter is also often accompanied by damage to the visceral organs: the small intestine - in 39-65%, the large intestine - in 28-33%, the kidneys - 10-28%. bladder- in 5% of observations. Mortality with such combinations of injuries is up to 33%.

Symptoms of an injury to the ureters

Symptoms of injuries and injuries of the ureter are extremely scarce, and there are no pathognomonic symptoms. The patient may be disturbed by pain localized in the lumbar, iliac regions or hypochondrium. An important symptom that allows suspecting damage to the ureter is hematuria. According to various sources, when the ureter is damaged, hematuria occurs only in 53-70% of cases.

The severity of the victim's condition and the absence of a characteristic clinical picture leads to the fact that in 80% of the wounded early stages rendering prompt assistance, damage to the ureter is not diagnosed, and in the future it is detected only at the stage of complications. Both after a combined and after an isolated injury to the ureters, a ureterocutaneous fistula develops. Leakage of urine into the periureteral tissue leads to the development of infiltrate and suppuration, which ultimately leads to the formation of scar fibrous tissue in the wall of the ureter and around it.

In severe combined injuries, accompanied by damage to sources, the clinical picture is dominated by symptoms of damage to the abdominal organs, kidneys, as well as symptoms of shock, internal bleeding, an increasing retroperitoneal urohematoma is accompanied by symptoms of peritoneal irritation, intestinal paresis.

Symptoms of closed injuries of the ureter

Closed injuries of the ureter, as a rule, occur with iatrogenic trauma during instrumental interventions on the ureter, as well as surgical and gynecological operations on the pelvic organs and retroperitoneal space (according to literary sources, from 5 to 30% of surgical interventions in the pelvic area are accompanied by trauma to the ureters), to closed injury ureter also includes damage to the intramural ureter during TUR of the bladder.

Damage to the ureters with rupture of the wall or its complete interruption causes urine to enter the periureteral tissue. With minor tears of the wall of the ureter, the urine entering the retroperitoneal space gradually and in small quantities impregnates the fiber and contributes to the development of urinary stagnation and urinary infiltration. Retroperitoneal soaked in urine and blood adipose tissue subsequently, it often suppurates, which leads to the development of isolated purulent foci or, with significant necrosis and melting of fatty tissue, to urinary phlegmon, secondary peritonitis, but more often to urosepsis.

Symptoms of open injuries (wounds) of the ureters

In the absolute majority of cases, ureteral injuries occur in severe concomitant trauma of the chest, abdominal cavity and pelvis. The degree and nature of damage is determined by the kinetic energy and shape of the wounding projectile, the localization of the wound and the hydrodynamic effect. In a number of observations, bruises and tissue ruptures occur due to the side effect of the shock wave of a projectile flying nearby.

The general condition of the victims is grave, most of them are in shock. This is due to both an injury to the ureter and combined injuries of the kidneys, organs of the abdomen, pelvis, chest and spine.

Gunshot and stab-cut injuries of the ureters may not manifest themselves clinically at first. The main symptoms of damage to the ureter are pain in the wound, retroperitoneal hematoma or urohematoma, hematuria. The most important symptom of damage to the ureter is the discharge of urine from the wound.

Moderate hematuria, which occurs once with a complete rupture of the ureter, is observed in approximately half of the wounded. Urine outflow from the wound canal (urinary fistula) usually does not occur in the first days, it usually begins on the 4th-12th day after the injury of the ureters. With a tangential injury to the ureter, the urinary fistula is intermittent, which is explained by the temporary restoration of the patency of the ureter. If the peritoneum is damaged, urine enters the abdominal cavity, and the leading clinical manifestations in this case are symptoms of peritoneal irritation; peritonitis develops. If the outflow of urine is difficult and it does not enter the abdominal cavity, it becomes impregnated with fatty tissue, urohematoma, urinary streaks, urinary intoxication, urinary phlegmon and urosepsis develop.

Classification of injury to the ureters

Mechanical damage to the ureters by type are divided into two groups: closed (subcutaneous) and open injuries ureters. Among the open ones, bullet, shrapnel, piercing, cutting and other wounds stand out. Depending on the nature of the damage, they can be isolated or combined, and on the number of damage - single or multiple.

Ureter - paired organ, therefore, in case of injury, it is necessary to single out the side of damage: left-sided, right-sided and bilateral.

The classification of closed and open injuries of the ureter, used in Russia to date, subdivides them as follows:

By localization (upper, middle or lower third of the ureter).

By type of damage:

injury;
have an incomplete rupture of the mucous membrane;
incomplete rupture of the outer layers of the ureter;
complete rupture (wound) of the wall of the ureter;
interruption of the ureter with a divergence of its edges;
accidental ligation of the ureter during surgery.

Closed injuries of the ureters are rare. The small diameter, good mobility, elasticity and depth of the ureters make them inaccessible for this type of injury. IN rare cases there may be a complete or partial destruction of the wall of the ureter or its crushing, leading to necrosis of the wall and urinary streaks or the formation of ureteral stricture.

Closed injuries of the ureters are divided into bruises, incomplete ruptures of the ureter wall (its lumen does not communicate with surrounding tissues), complete ruptures of the ureter wall (its lumen communicates with surrounding tissues); interruption of the ureter (with a divergence of its ends).

Open injuries of the ureter are divided into bruises, tangential injuries of the ureters without damage to all layers of the ureter wall; interruption of the ureter; accidental injury or ligation of the ureter during instrumental studies or laparoscopic surgery.

At present, the American Urological Association has proposed a classification scheme for ureteral injuries, which has not yet received wide distribution in the domestic special literature, but they believe that its use is important for choosing the right method of treatment and for unifying the standards of clinical observation.

Classification of injuries of the ureter American Association urologists

Diagnosis of trauma to the ureters

Diagnosis of injuries and injuries of the ureters is based on an analysis of the circumstances and mechanism of injury, clinical manifestations and data special methods research.

Diagnosis of ureteral injury includes three stages: clinical, radiological and operational.

Clinical diagnosis of ureteral injury

Clinical diagnosis of ureteral injury is based on the presence of appropriate suspicions (eg, wound location and direction of the wound channel, assessment of urine and wound discharge). Such suspicions arise first of all with penetrating, more often gunshot, wounds of the abdomen, if the projection of the wound channel corresponds to the placement of the ureter, or if after a hysterectomy there are back pain, urine output from the vagina, and other relevant symptoms. To clarify the localization and nature of injuries and the choice of therapeutic tactics, the study of urine collected during the first urination after an injury is of great importance.

Although early diagnosis of ureteral injuries is considered the basis for obtaining good treatment results, nevertheless, as statistics show, this is more an exception than a pattern. Even during iatrogenic injuries of the ureter, the diagnosis is established intraoperatively only in 20-30% of cases.

Isolated iatrogenic injury to the ureter can be easily missed. After gynecological operations, accompanied by an injury to the ureter, patients develop back pain, urine output from the vagina, and a septic condition develops. If an injury to the ureters is suspected during surgery, intravenous indigo carmine or methylene blue solution is recommended to detect the damaged area of the ureter, which is especially important for detecting partial damage to it. As a method of prevention and for intraoperative diagnosis of ureteral injuries, its catheterization has also been proposed.

With a closed injury, the rupture of the LMS, which is more typical for children, is always associated with the mechanism of sharp inhibition. Such injuries may not be recognized, since even during operations performed for other indications, they are almost impossible to detect by transabdominal palpation of the ureteral area. In this regard, high-volume excretory urography with a single shot (one shot IVP) is indicated for injuries that have arisen by the mechanism of sudden inhibition, and for stable hemodynamic parameters, CT with a bolus injection of RVC. The absence of contrast enhancement of the distal ureter indicates its complete detachment. Unusual findings such as a fracture of the transverse or spinous processes of the lumbar vertebrae can target probable damage to the ureters from an external force.

Based on the victim's complaints, history and clinical signs, the fact of damage to the ureter is usually established. At the same time, a more in-depth instrumental examination is necessary to determine the type and nature of the ureter injury. Depending on indications and specific possibilities medical institution various methods examinations of the victim are used in each case.

Instrumental diagnosis of ureter injury

Examination of the victim begins with an ultrasound of the abdominal cavity and abdominal cavity. Special studies usually begin with the performance of a plain radiography of the kidneys and urinary tract and excretory urography. and if indicated, infusion urography with delayed radiographs (after 1, 3, 6 hours or more), CT. Chromocystoscopy and ureteral catheterization with retrograde uretero- and pyelography have a high diagnostic value. TO instrumental methods most often resorted to at the final stage of diagnosis and in case of severe injuries immediately before surgery.

If damage to the ureter is suspected, including iatrogenic ones that occur during instrumental manipulations, the introduction of a contrast agent through the ureteral catheter, stent or catheter loop helps to determine the location of the injury and the prevalence of streaks, which contributes to the timely diagnosis of such injuries and the correct provision of adequate assistance.

The general principles for examining a victim with suspected ureter injury are the same as for closed injuries of this organ.

It is important to remember that the severity of the condition of the wounded does not allow the use of many diagnostic methods. So, intravenous urography in all its variants, chromocystoscopy. radioisotope methods are uninformative in the wounded in a state of shock. Any transurethral diagnostics is generally contraindicated for a wounded person in this condition. If the state of the wounded allows, then the results of ultrasound and CT are the most informative.

The definition of a liquid formation in the retroperitoneal tissue (urohematoma) by ultrasound makes it possible to suspect damage to the urinary tract.

Recognition of fresh injuries of the ureter (gunshot, stab-cut) can be especially difficult. Severe associated injuries usually attract the attention of surgeons first, as a result of which trauma to the ureter is often visible. An analysis of such observations shows that, almost as a rule, an injury to the ureter is not diagnosed even during the primary surgical treatment of the wound and is detected only a few days after it.

For the diagnosis of damage to the ureter, excretory urography can be successfully used, which, with sufficient kidney function, shows the condition and degree of patency of the ureter, the level of its damage and leakage of the contrast agent into the surrounding tissues. Chromocystoscopy, in addition to assessing the condition of the bladder, provides information about the patency of the ureter; intravenously administered indigo carmine can also be detected in the urine excreted from the wound channel.

If indicated, ureteral catheterization and retrograde pyeloureterography are performed, supplemented if necessary by fistulography.

The foregoing applies entirely to the diagnosis of iatrogenic (artificial) injuries of the ureters.

Diagnostic capabilities of radiation diagnostic methods

In most clinical situations, a panoramic x-ray of the abdominal organs and excretory urography allow you to assess the degree of damage and outline medical tactics. Indications for urography are hematuria and urohematoma. In shock or life-threatening bleeding, urography should be performed after stabilization of the condition or during surgery.

In unclear situations, retrograde ureteropyelography or CT is performed, which is the most informative study. If the condition of the victim is unstable, the examination is reduced to performing infusion or high-volume urography, and the final diagnosis is carried out during surgery.

Injuries to the ureters can be manifested by obstruction of the upper urinary tract, however, the most reliable radiological symptom of their damage is leakage of the RVC beyond its limits.

To detect this, excretory urography is performed with intravenous administration of RKV in an amount of 2 ml / kg. Currently, instead of excretory urography, CT with a bolus injection of RVC is more often performed, which makes it possible to detect concomitant lesions. If these studies are not informative, a survey radiography is indicated. urinary system 30 minutes after the injection of a double dose of contrast agent. If even after this it is impossible to completely exclude damage to the ureters, and the suspicion persists, retrograde ureteropyelography is performed, which in such situations is considered the "gold standard" of diagnosis.

Intraoperative diagnosis of ureteral injury

The most effective method for diagnosing damage to the ureters is direct visualization of the damaged area, since with the help of both pre- and intraoperative studies, this usually succeeds in 20% of cases! That is why during the revision of the abdominal cavity, at the slightest suspicion of an injury to the ureters, a revision of the retroperitoneal space should also be made, especially if there is a hematoma.

Distinguish between absolute and relative readings for revision of the retroperitoneal space.

Absolute indications: ongoing bleeding or pulsating perirenal hematoma, indicating significant damage.
Relative indications: urinary extravasation and the inability to determine the degree of damage due to the need to perform urgent intervention for associated injuries of the abdominal organs (this approach avoids unnecessary revision of the retroperitoneal space).

Differential diagnosis of ureteral injury

For the purpose of differential diagnosis between injuries of the ureter and the bladder, the method of filling the bladder with a colored liquid (methylene blue, indigo carmine) is used. If the bladder is damaged, a colored liquid is released from the urinary fistula; in cases of damage to the ureter, unstained urine is still excreted from the fistula.

Treatment of injury to the ureters

Indications for hospitalization

Suspicion of ureteral injury is an indication for emergency hospitalization patient.

Treatment of injury to the ureters: general principles

The choice of method for treating ureteral injuries depends both on its nature and on the timing of diagnosis. With late diagnosis of iatrogenic injuries of the ureters due to urological and non-urological operations, the need for additional interventions is 1.8 and 1.6, respectively, while in intraoperative diagnosis this figure is only 1.2 additional interventions per patient.

First health care in military field conditions in case of injury to the ureter, it provides anesthesia with trimeperidine (promedol) from a syringe tube or its analogue, carrying out the simplest anti-shock measures, giving antibiotics inside a wide range actions, immobilization in case of suspected fracture of the spine or pelvic bones, in case of injuries - imposition aseptic dressing and evacuation on a stretcher in the prone position.

The first medical aid consists in the repeated use of painkillers, elimination of deficiencies transport immobilization, the introduction of antibiotics and tetanus toxoid in open injuries, bladder catheterization according to indications. In case of injuries of the ureters, the bandage is controlled with bandaging, and if indicated, temporary or final stop external bleeding (clamping, ligation of the vessel in the wound), anti-shock measures.

According to vital indications, victims with penetrating abdominal wounds, as well as those who have signs of ongoing internal bleeding, are operated on.

Specialized care is provided in the urological departments. When it is provided, the victims are taken out of shock, further treatment wounds according to generally accepted principles in urology, perform repeated surgical treatments or surgical interventions on the ureter with elements of reconstructive surgery. It includes the implementation of delayed surgical interventions in case of damage to the ureter, the treatment of complications (suppuration, fistula, pyelonephritis, narrowing of the urinary tract), the performance of roconstructive and restorative operations.

Surgical treatment of ureteral injury

In case of mild injuries of the ureters (the maximum is a partial rupture of its wall), one can limit oneself to nephrostomy or stenting of the ureter (preferably the latter). Stenting can be performed both retrograde and antegrade under X-ray television control and contrast ureteropyelography using a flexible wire. In addition to stenting, bladder catheterization is also performed to prevent reflux. The stent is removed on average after 3 weeks. In order to clarify the conductivity of the ureter, excretory urography or dynamic nephroscintigraphy is performed after 3-6 months.

Treatment of injuries of the ureter is mainly surgical. Any surgical intervention for damage to the ureter should be completed with drainage of the retroperitoneal space, the imposition of a nephrostomy, or drainage of the PCS by internal or external drainage with stent-type catheters.

If damage to the ureters occurred during surgery, then first of all it is recommended to restore the integrity of the ureter using a ureteral stent and external inactive drainage of the surgical area.

Operational accesses are determined by the nature of the damage. In case of isolated damage to the ureter, it is preferable to perform a lumbotomy, a lumbar extraperitoneal incision in the eleventh intercostal space or a pararectal incision, and if the lower third of the ureter is damaged or if there are signs of combined damage to the abdominal organs, a laparotomy, usually median.

At complete break ureter the only acceptable treatment seems to be prompt recovery its integrity.

The principles of ureteral reconstruction do not differ from the principles of other reconstructive interventions of the urinary tract. To achieve success, it is necessary to ensure good vascular nutrition, complete excision of the affected tissues, extensive mobilization of the ureter to ensure the imposition of a tight (watertight) anastomosis without tension, and good wound drainage. It is also desirable to cover the anastomosis with a nutritional pedicle omentum.

Depending on the level of the reconstruction of the ureter, various operations are performed.

upper third - ureteroureterostomy, transureteroureterostomy, ureterocalicostomy;
middle third ureteroureterostomy, transureteroureterostomy, Boari operation;
lower third different kinds ureterocystoneostomy;
whole ureter ureteral replacement ileum, kidney autotransplantation.

In case of damage to the ureter above the pelvic ring, it is necessary to economically resect its edges and sew the ends on the endotracheal tube, perform nephrostomy and drain the retroperitoneal tissue.

With a larger defect in the ureter, they resort to moving and fixing the kidney below the usual place. If the lower third of the ureter is damaged, it is ligated and a nephrostomy is applied. Reconstructive and restorative operations (operations Boari, Demel) are performed after the inflammatory process subsides.

There is only one situation in which immediate nephrectomy is indicated when ureteral injury is accompanied by an aortic aneurysm or major vascular injury requiring prosthetics. This helps to avoid extravasation of urine, urinoma formation and infection of the prosthesis.

Treatment of closed injuries of the ureter

Conservative treatment for damage to the ureters during instrumental manipulations and subcutaneous trauma is permissible only in cases of bruises and tears of the ureter wall without violating the integrity of all its layers. Treatment is with anti-inflammatory medicines, thermal procedures, according to indications of bougienage of the ureter and treatment aimed at preventing the development of periureteritis and strictures.

Clinical practice convinces of that. that with a closed injury of the ureters, it is possible to use surgical treatment as an emergency. The main indications are an increase in internal bleeding, a rapid increase in periureteral urohematoma, intense and prolonged hematuria with a deterioration in the general condition of the victim, as well as signs of a combination of ureter injury with damage to other internal organs. Anesthesia is preferably general.

Iatrogenic injuries of the ureters occur not so much due to technical reasons, but as a result of topographic and anatomical changes in the surgical field, anomalies in the development of the urinary organs and the desire of urologists for maximum radicalness in operations on the pelvic organs.

When iatrogenic damage to the ureter during endoureteral manipulations (for example, ureteroscopy, ureterolithotripsy, stone extraction, endoureteral removal of tumors), when all layers are broken and there are streaks in the periureteral tissue, and also when there is a suspicion of damage to the parietal peritoneum, surgical treatment is always indicated. The main measure Prevention of possible iatrogenic damage to the ureters during surgical interventions for various diseases of the abdominal cavity and pelvis is the study of the state of the upper urinary tract in the postoperative period. A rather promising method for preventing intraoperative injuries is fluorescent visualization of the ureters during surgery, which is performed using intravenous administration of sodium fluorescein. As a result, a luminescent glow of the ureter occurs, which allows visual control of their position without skeletonization. Effective method prevention of iatrogenic damage to the ureters - the use of conventional or special luminous catheters. allowing to control the position of the ureters during the operation.

The damaged ureter, identified during the operation, after economical excision of the edges, is sutured according to one of the generally accepted methods, trying to turn the transverse gap into an oblique one. The damaged ureter is intubated with a stent or drainage tube.

operating wound in lumbar region regardless of the nature of the surgical intervention on the ureter, they are carefully checked for hemostasis and foreign bodies, drained and sutured. If surgery on the damaged ureter was performed through the abdominal cavity, in the lumbar or iliac region a counter-opening is applied, the posterior peritoneum in the projection of the damaged ureter is sutured, and the abdominal cavity is tightly sutured. In the immediate postoperative period, the whole complex of conservative measures aimed at preventing complications is continued.

Treatment of open injuries of the ureter

With open injuries (wounds) of the ureters, surgical treatment is predominantly performed (up to 95%).

Conservative treatment of ureteral injury is permissible only in some cases, with isolated wounds with knives, without significant tissue destruction, with moderate and short-term hematuria and a satisfactory condition of the wounded. Treatment in these cases is carried out according to the same plan as with closed injuries of the ureters.

In case of isolated injuries of the ureters, one of the types of lumbar incisions or pararectal access is used, in case of combined injuries, the access is determined by the nature of injuries to the organs of the abdomen, chest and pelvis, but at the same time, typical thoraco-, lumbo- and laparotomy in their various combinations are used. Most urologists with combined injuries of the ureters and abdominal organs prefer median laparotomy. When intervening on wounded organs, it is advisable to follow a certain sequence: first, all measures are taken to stop heavy bleeding, the source of which is often the parenchymal organs and vessels of the mesentery; then perform the necessary interventions on hollow organs (stomach, small and large intestine): last turn treat wounds of the urinary tract (ureter, bladder). If the ureter is destroyed over a large area, a nephrostomy is placed and the ureter is intubated.

In case of injuries of the ureters, the stitching of its ends after excision is permissible with a diastasis of no more than 5-6 cm; it is first necessary to mobilize its distal and proximal ends. To prevent subsequent narrowing at the anastomosis site, the following intervention options are possible: when resecting the damaged area of the ureter, the proximal and distal ends of the ureter are crossed obliquely and anastomosed with U-shaped sutures: end-to-side anastomosis is performed after ligation of the distal end; carry out the anastomosis of the type "side to side" after ligation of the distal and proximal ends. This is possible only with sufficient length of the ureter. After suturing the wound of the ureter or its resection followed by anastomosis, ureteropyelonephrostomy is performed (if the ureter is damaged in the upper third) or ureterocystomy (if the ureter is damaged in the middle or lower thirds).

A great contribution to the development of plastic surgeries on the upper urinary tract, aimed at sensing the function of the kidney, was made by both domestic and foreign urologists. Significant technical difficulties arise in the diagnosis of recurrent hydronephrosis, specific lesions of the upper urinary tract. consequences of traumatic, including iatrogenic, injuries, ureterocutaneous fistulas with extended, complicated strictures of the proximal ureter. Of the many proposed technical solutions in clinical practice in such cases, operations are applied according to the methods of H.A. Lopatkin. Calp de Virda, Neivert, replacement of the ureters with the intestine and kidney autotransplantation. Intestinal ureteroplasty is indicated for bilateral ureterohydronephrosis, hydronephrosis of a single kidney, ureteral fistulas, long and recurrent ureteral strictures, including post-traumatic and post-traumatic genesis, and can be considered as an alternative to nephroureterectomy.

These surgical interventions belong to the category of increased complexity and do not always end successfully, and therefore they often decide on lifelong nephrostomy drainage or in favor of nephrectomy. With a single kidney, such a tactic dooms the patient to a lifelong existence with nephrostomy drainage. B.K. Komyakov and B.G. Guliyev (2003) with extended defects of the proximal ureter suggested original way surgical intervention - upward displacement of the pelvic ureter by cutting out a flap from the bladder along with the corresponding half of the Lieto triangle and the mouth.

Operation technique

By pararectal access from the costal arch to the womb, the retroperitoneal space is widely opened and the pathologically altered part of the ureter is resected. Then, the peripheral end of the resected ureter (up to the mouth) and the side wall of the bladder are mobilized without damaging the peritoneum and upper cystic vessels. With an oval incision, capturing the corresponding half of the triangle of the bladder, a wide flap is cut out from its lateral wall along with the mouth, which is displaced in the cranial direction. The integrity of the mouth and ureter in this area is not violated, thereby maintaining their blood supply due to the vessels of the bladder. The distal ureter moved in this way is sutured to its pelvic region or pelvis.

stitched with its prilokhanochny department or pelvis. The resulting defect in the bladder is sutured with an interrupted vicryl suture, urethra a Foley catheter is placed. Retain or form a nephrostomy. An intubator is inserted into the proximal ureter or installed through the nephrostomy and anastomosis. The pararenal and paravesical spaces are drained with silicone tubes, the wound is sutured.

With extended gunshot defects of the ureter, with necrosis of the ureter in patients with a transplanted kidney, with iatrogenic extended injuries of the ureter, multiple fistulas of the ureter, one of the methods of treatment is drainage of the kidney by percutaneous puncture nephrostomy or kidney autotransplantation. With a sufficient length of the ureter, it is possible to perform the operation of imposing a new anastomosis of the ureter with the bladder. A difficult problem is the treatment of patients with a complete defect of the ureter. In the absence of a full-fledged ureter, the main method of treatment is the imposition of an anastomosis between the flap from the bladder (Boari-type operation) in patients after transplantation of an auto- or donor kidney. D.V. Perlin et al. (2003). R.H. Galeev et al. (2003) clinical observation proves the possibility of complete replacement of the ureter by pyelocystoanastomosis.

According to the data of a complex study, including X-ray radiological, it is possible to judge the details of morphological changes in the wall of the ureter only presumably. Visual revision of the ureter during surgery is subjective. Identification of structural changes and their extent in the wall of the ureter during the operation does not create a clear idea. According to visual assessment, the borders of the contracting part of the ureter are 10-20 mm smaller than according to the EMG performed during surgery on the exposed ureter. Only at a distance of 40-60 mm are electric potentials in the wall of the ureter close to normal. This means that direct ureterocystoneostomy can be performed with altered tissues. As a result, the patency of the urinary tract is not sufficiently restored, and the surgery itself cannot be classified as radical.

An obligatory element of operational assistance for open (especially gunshot) injuries of the ureters is the surgical treatment of the wound (wounds), including, in addition to stopping bleeding, excision of non-viable tissues, dissection of the wound channel, removal foreign bodies, cleaning the wound from dirt, introducing antibiotic solutions into it and around it.

After intervention on the damaged ureter and surgical treatment of the wound (wounds), reliable drainage of the periureteral space is provided, including by applying counter-openings.

According to Z. Dobrowolski et al. different types of operations for injuries of the ureters are performed with different frequencies: ureteroneocystostomy - 47%, Boari operation - 25%, end-to-end anastomosis - 20%, replacement of the ureter with the ileum - 7% and kidney autotransplantation - 1%. D. Medina et al. in 12 out of 17 patients with early diagnosed ureteral injuries, they were restored with stenting, in one - without stenting, in four - by ureterocystoneostomy.

Concerning possible outcomes late diagnosis injuries of the ureters, different authors report completely contradictory data. Yes, D.M. McGinty et al. 9 patients with late diagnosis of ureteral injuries had a mostly poor outcome with a high rate of nephrectomies, while D. Medina et al. 3 similar patients underwent recovery with a favorable outcome.

The search is currently ongoing alternative methods treatment of ureteral injuries that could reduce the invasiveness of interventions and/or improve quality of life. Among such interventions is an endoscopic method of dissection of strictures of the lower third of the ureter up to 1 cm using the cut-to-the-light technique and an alkaline titanyl phosphate laser, which leads to a long-term stable result. Complications

There are early and late complications of ureteral injuries. Among early complications secrete urinary streaks, the development of urohematoma and various infectious and inflammatory complications (pyelonephritis, phlegmon of the retroperitoneal space, urinary peritonitis, sepsis). Late complications include stricture and obliteration of the ureter, ureterohydronephrosis, and urinary fistulas.

Prediction of ureter injury

The prognosis for open and closed injuries of the ureters depends on the degree of injury, the nature and type of damage to this organ, complications, damage to other organs with combined injuries, on the timeliness and volume of assistance provided. Patients who have suffered trauma to the ureter remain at a high risk of late complications.

The experience of many urologists in performing various options reconstructive operations on the urinary tract, including those accompanied by a significant injury to the ureter, forces an individual approach to restoring the patency of the ureter in each specific observation.

In conclusion, it should be noted that all publications on the treatment and diagnostic tactics for injuries of the ureters are retrospective. This means that their reliability reaches only grade III or lower. Naturally, this fact implies the need for serious research in order to obtain more reliable results, but even so, some theses can already be outlined at the present time.

Most of the damage to the ureters is iatrogenic in nature and is due to gynecological operations. Such injuries often affect the lower third of the ureter. An effective diagnostic method in this case is intraoperative, the preferred method of treatment is reimplantation of the ureter into the bladder.
Damage to the ureters caused by an external force mainly affects the upper third of the ureters. They are almost always accompanied associated injuries other organs. The main cause is penetrating gunshot trauma to the ureters. Under conditions of stable hemodynamics, the preferred diagnostic method is contrast-enhanced CT. In case of gunshot wounds, they can occur due to reactive concussion and devascularization of the adventitious layer, therefore, during surgical treatment, a wide refreshment of its edges is necessary before recovery.
Closed injuries of the ureters are mainly found in children, cover the LMS and are associated with the mechanism of sudden inhibition.

When are organ pathologies diagnosed? urinary system, sometimes the patient undergoes removal of the ureter in order to normalize the operation of the entire system. Operations on this internal organ are carried out in cases where it is necessary to restore anatomical structure ureter or if there are pathologies in development, as a result of which the organ is bent or twisted. Surgery is often prescribed after traumatic injury, inflammatory process or previous surgery on the organs of the genitourinary system. Surgical intervention is performed when urine cannot be excreted normally and accumulates in the bladder and kidneys. Depending on the disease and the degree of pathology, various types of operations are prescribed.

Intervention preparation

In medicine, operations on the ureter are not uncommon and widespread. In most cases, only with the help of plastic surgery it is possible to restore the normal function of the urinary system and return a person to a normal life. Given the existing disease, the site of damage and the degree, the individual characteristics of the patient, there are many types of surgical intervention.

The appropriate variant of surgical intervention is selected by the attending physician after complex diagnostics and making an accurate diagnosis.

Before surgery, the patient should prepare the body. First of all, eliminate the signs of kidney failure in chronic form and stabilize the patient. With blockage of the ureter, pyelonephritis is often observed, which needs treatment with antibacterial drugs. If the patient is indicated for intestinal plastic surgery, then two weeks before the operation, he must comply strict diet which limits fiber intake.

Before surgery, it is necessary to clean the intestines, conduct preventive actions to eliminate the inflammatory process. For this, the patient undergoes a course of antibiotic therapy. These drugs affect the unfavorable microflora of the internal organ. A couple of days before surgery, a patient is shown parenteral nutrition, in which nutrients are administered intravenously, bypassing the gastrointestinal tract.

Operation on the ureteropelvic segment

There are many types of operations in the ureter in the area of the ureteropelvic segment. Depending on the degree of damage, the patient's condition, location and other factors, surgical intervention is prescribed. suitable type. Physicians perform extramucosal ureterotomy, which is indicated for mild hydronephrosis, which has arisen due to impaired function of the opening of the pyeloureteral sphincter. Medicine knows other types of operations in this area of \u200b\u200bthe internal organs:

Intubation ureterotomy is aimed at eliminating strictures in the pelvic region of the internal organ.
Surgical intervention by Marion involves dissection of the narrowed section of the organ. Excision is made along all layers of the ureter, then an endotracheal tube is inserted, which passes through the pelvis.
External pyeloureteroplasty is aimed at expanding this segment by longitudinal excision of the organ wall in the area of the stricture.
Ureterolysis is performed when there are periureteral adhesions that compress the ureter. The operation is performed with tweezers or a scalpel, which remove adhesions.
Denervation of the kidney pedicle, which is performed using a lumbar incision. The renal pedicle is isolated from fat tissue and the surrounding nerve fibers are isolated.

In medicine, there is a Fenger operation, which involves dissection of the stricture along the pelvic wall to the ureter. A drainage tube is inserted into the incision and the resulting wound is sutured. Stewart's surgical intervention is indicated for adhesive disease. Schwitzer and Foley operations are performed, which involve an incision of the pelvis and ureter with their subsequent plastic surgery.

Removal of stones from the ureter

IN Lately it is possible to remove stones from the ureter with painless methods that reduce the risk of recurrence. Popular methods of stone removal are ureteroscopy, lithotripsy, and open surgery. Ureteroscopy is indicated for patients whose stone size does not exceed 1 cm. The procedure is carried out using a ureteroscope and a camera that displays what is happening on the screen. Before the operation, the patient is given a local or general anesthesia because the process is painful.

Lithotripsy

Lithotripsy is performed using waves that have a destructive effect on the formed stones. Depending on the type and structure of the stone, there are different types of lithotripsy. This method is painless, but is used for small stones that have a relatively loose structure. In medicine, remote, contact, laser, ultrasonic and pneumatic lithotripsy are distinguished. This method of removing stones is not suitable for everyone and is contraindicated for women in position, patients who weigh more than 130 kg, those who have impaired blood clotting.

Open operation

Open surgery on the ureter is used extremely rarely, in especially severe cases. It is carried out in case of relapse, with large stones or in case of suppuration. Surgical intervention is carried out using general anesthesia, since it involves cutting the patient's abdominal cavity. Last time this method displaces laparoscopic surgery, which involves several small incisions. This type of surgery is less painful and the rehabilitation time is simplified.

Reconstructive surgery

Ureterolysis

With ureterolysis, surgery is performed, in which both or one ureter is released from the resulting fibrous tissue, since it compresses the channels and leads to obstruction. This procedure is robotic and is carried out using a camera and small instruments that are inserted into the patient through incisions in the abdominal cavity. The scar tissue is cut out, followed by the release of the ureter. The surgeon then wraps the organ in fatty tissue to increase blood flow and restore normal ureteral function. If new tissue scarring occurs, the fat flap will protect the ureter from recurrence.

Ureteroureteroanastomosis

This surgical intervention is indicated in case of stenosis or trauma to the ureter, in which damage occurred. During the operation, an oblique incision is made at the ends of the internal organ, and then they are sewn together on a catheter, which is inserted into the ureter. An oblique section is used to provide a larger diameter anastomosis. This type of incision prevents strictures from occurring. After a week, the patient's catheter is removed and the patient recovers. normal function ureter.

Ureterocystoanastomosis

Ureterocystoneostomy or ureterocystoanastomosis is performed in case of trauma to the middle part of the ureter. Surgery is carried out in several ways. Most often, the surgeon extends the renal end of the internal organ to the bladder, and then fixes it with dissolving threads. During the operation, a small splint is used, which is removed a week after the operation. In women, this surgery is performed through the vagina.

Such an operation is also carried out through the abdominal cavity (by the abdominal route) in cases where the patient has previously undergone an operation to eliminate a gynecological disease. With any type of surgical intervention, the task of the surgeon is to create a strong anastomosis that will cope well with the function of excreting urine.

Intestinal plastic

In the process of intestinal plastics, an operative intervention is performed, in which the urethral area is replaced with a tube. This tube is made from the walls of the intestine. Such an operation is performed in patients with a tumor or damage to the ureter in a long area. During the operation, a small part of the intestine is cut off and a tube is made from it, which is then attached to the ureter. This surgical intervention is possible only with the help of a good specialist because the procedure is complicated.

Operation Boari

Treatment with this surgical method is indicated for damage to the entire part of the urinary canal. Boari surgery is not recommended for patients who have a wrinkled bladder or have significant damage to the middle part of the urethra. During the operation, reimplantation of the urinary canal is performed. The surgeon cuts a small part of the tissue of the bladder, and then forms an artificial urinary canal from it.

Transplantation of ureters into the intestine

Doctors have developed such an atypical method of transplanting ureters into the intestines. This surgical intervention is used in extremely rare cases, when it is not possible to eliminate the problem of urine excretion in other ways. There are several types of surgery in which the ureters are transplanted into different departments intestines. During surgery, the bladder is usually removed. This method of treatment is indicated for cancer or in case of excision of a large part of the ureter, which is injured. cancer cells. This type of surgery is risky and harms the kidneys and upper urinary tract.

Postoperative period and consequences in men and women

It is sometimes difficult to predict the consequences of ureteral surgery, since many factors must be taken into account. If the pathology was identified in a timely manner and a proper operation was performed, then the outcome for the patient is quite favorable. In the postoperative period, it is recommended to follow a special diet, especially if there were stones in the ureter. The patient should comply with the daily fluid intake.

In the first days after surgery, the patient should be provided with bed rest. After some operations, it is recommended to save horizontal position for 2-3 weeks. If there was a vesical fistula in men, then you should remain calm for 3 weeks until the drainage tube is removed from the urethra. The patient needs to monitor the abdominal cavity and bowel function, especially after intestinal plastic surgery, since there is a possibility of developing peritonitis.

It is an indication for surgical treatment. The bougienage of the narrowed ureter, which is still sometimes used, does not give a lasting effect, and besides, like any forced introduction of instruments into, it is fraught with serious dangers (perforation, followed by swelling, impaired urine outflow and).

Contraindications to surgical treatment for ureteral strictures can be either general, that is, depending on the severity of intercurrent diseases, or determined by far-reaching changes in the upper urinary tract above the stricture and (with bilateral strictures or stricture of the ureter alone). In such cases, nephrostomy (open or percutaneous puncture) is performed as the first stage of surgical treatment.

Methods of surgical treatment. The method of surgical treatment depends on the extent and level of stenosis. For single strictures in the juxtavesical ureter, direct ureterocystoanastomosis is used, and for more extensive, but not exceeding 10-12 cm in length, strictures of the pelvic ureter, indirect strictures are used. With stenoses of great length, Boari's operation is rarely successful. According to D. V. Kahn (1967), in case of stenosis of the entire pelvic ureter, in which the Boari operation is impossible, Demel's operation is advisable, which consists in cutting out the upper half of the bladder, retracting it upward and laterally and implanting the intact part of the ureter into it. However, this operation makes it possible to replace the pelvic region of only one of the ureters and, therefore, is applicable for high pelvic strictures of the ureter of tuberculous etiology, but is not applicable for postradiation stenosis, which usually affects both ureters. Bilateral indirect ureterocystoanastomosis according to Boari is not always feasible for strictures and radiation etiology, as they are often accompanied by a lesion with a significant decrease in its capacity (tuberculous microcystitis). Special meaning in such cases, the proposed and first performed by N. A. Lopatkin in 1965, the operation of replacing the pelvic sections of both ureters with one median flap of the bladder acquires. This operation is indicated for high and extensive strictures of the pelvic sections of both ureters, when the length of the flaps that could be cut from both anterolateral walls of the bladder is not enough to replace each ureter separately.

Peculiarities preoperative preparation may be associated with concomitant strictures of both ureters or the ureter of a single kidney of a far advanced kidney (infusion detoxification therapy, puncture percutaneous nephrostomy, hemodialysis) and with antibiotic therapy about which, as a rule, accompanies strictures of the ureters.

Technique of surgical interventions. Resection of the ureter with end-to-end ureteroureteroanastomosis with isolated and limited stricture of the ureter does not present significant technical difficulties. The ureter is mobilized 2-3 cm up and down from the stricture; the affected area is excised within healthy tissues; an intubation tube made of polyethylene or other plastic material is inserted into both ends of the ureter, and the ends of the ureter are connected on it with 4-6 nodal catgut (preferably chrome-plated catgut on an atraumatic needle) sutures. The injection is done from the outside inward, the injection is done from the inside outward, through all layers of the ureter wall; ligatures are tied outside, outside the lumen of the ureter. Mobilization of the ureter and the possibility of contact between its intact ends is facilitated by the fact that it is usually stretched not only in width but also in length above the stricture, and forms bends. This, after the isolation of the upper ureter from adhesions, gives a sufficient margin of its length.

The tube-tire is carried out in renal pelvis and taken out of it through a nephro- or pyelostomy along with a tube draining the pelvis. There are modern tubes for drainage of the pelvis, at the end of which there is a thinner tube for insertion into the ureter. Such a tube serves both as a drain and as a splint, which is especially advisable in case of a small intrarenal pelvis, which makes it difficult to remove 2 tubes through it. In women, in the absence of additional indications for drainage pelvicalyceal system(acute purulent pyelonephritis, bleeding, necrosis of the renal papillae, etc.), the intubation tube can be brought out through the bladder and.

Similarly, in case of stricture of the pelvis-ureteral segment, its resection with pyeloureteroanastomosis is performed.

Ureterocystoanastomosis for strictures of the perivesical or intramural ureter.

With extensive stenosis of the ureter, extending beyond its pelvic region or highly located, the only way restoring the evacuation of urine from the kidney to the bladder is the partial or complete replacement of the ureter with a segment of the small intestine. If only 20-25 years ago even single and low-lying tuberculous strictures of the ureter served as an indication for nephrectomy [Epshtein I. M., 1959], then organ-preserving reconstructive operations are currently being performed. Intestinal plastics of the ureter in the clinic was first used in the USSR by A.P. Frumkin (1954). Depending on the unilateral or bilateral nature of the ureteral stenosis and its length, unilateral and bilateral complete or partial replacement of the ureter with a segment of the intestine is used.

With strictures of the ureter of any origin, complicated by far advanced destruction renal tissue(, pyelonephritic wrinkling of the kidney,), produce a nephroureterectomy.

Features of postoperative management depend on the nature of the transaction. common feature, characteristic of all reconstructive operations on the urinary tract, is the need to comply bed rest in the immediate postoperative period (on average within 2 to 3 weeks).

After ureterocystoanastomosis (direct or Boari), bed rest is recommended for 2 weeks; the drainage tube from the ureter is removed on average 3 weeks after the operation, and a few days after that, the urethral drainage tube is removed (in women) or the suprapubic vesical fistula is healed (in men). After intestinal plastics of the ureter, the terms of bed rest are approximately the same; the main attention is paid to the condition of the abdominal cavity and intestinal function, since the most formidable complication is peritonitis.

Possible complications and their prevention. The most likely complication characteristic of operations for ureteral strictures is anastomotic leakage, which, when using the tissues of the urinary tract itself, can lead to retroperitoneal urinary leakage with subsequent development of urinary phlegmon, and after replacement of the ureter with a gut, to peritonitis, if the leakage concerns enteroenteroanastomosis or anastomoses of the intestine with the pelvis and bladder when they are applied intraperitoneally.

Measures to prevent these complications are the impeccably correct technical performance of all reconstructive operations on the urinary tract, adequate drainage of both the urinary tract itself (nephro-, pyelo-, epicystostomy) and the surrounding tissues of the retroperitoneal space (“insurance” drainage tubes), strict control of drainage systems in the postoperative period, in case of blockage of "functional" tubes - washing them with small portions (2 - 3 ml) of sterile liquid with preliminary suction of their contents, in case of non-functioning "insurance" drainage tubes - checking their patency by suction or washing with hydrogen peroxide, the use of permanent suction systems.

Results of surgical treatment and prognosis. The results of the above plastic surgeries for ureteral strictures are usually favorable. The prognosis depends mainly on the state of renal function, since with strictures of the ureter, especially bilateral or with a single kidney, chronic renal failure often develops, including advanced ones. So, the prognosis after replacement of the ureter with the intestine, undertaken in the late stages of CRF, can be very unfavorable, because in conditions of azotemichesky intoxication this operation fraught with exacerbation of chronic renal failure, anastomotic failure. Therefore, replacement of the ureter with the intestine, as well as other reconstructive plastic surgeries for ureter strictures, should be undertaken in a timely manner, in the early (latent or compensated) stages of chronic renal failure.

"Operative Urology" - edited by Academician of the USSR Academy of Medical Sciences N. A. LOPATKIN and Professor I. P. SHEVTSOV

To restore the full functionality and conductivity of the urinary tract, ureteroplasty is prescribed. There are several options for surgical intervention, which is prescribed taking into account the localization of the pathology, the degree of damage to the ureter, and also based on the individual characteristics of the patient's body.

Ureteroplasty is a modern technique for eliminating defects and restoring normal canal patency.

Indications

Plastic surgery of the ureteropelvic segment is prescribed for pathologies of the urinary tract, when conservative treatment cannot restore the functional activity of the ureters. The pelvis-ureteral region is operated on with a local examination of the affected area. More often, the procedure is prescribed for hydronephrosis (increased pressure in the kidney). Other reasons for rhinoplasty include:

damage to the urinary tract during surgery;
obstruction (obstruction of outflow) of the ureter;
obstruction after complications during childbirth;
previously performed procedures for the removal of fibroids or other neoplasms in the genitourinary system;
hydroureteronephrosis caused by stricture.

Contraindications

To determine possible complications during the treatment, as well as the type of surgical procedure performed, you should seek the advice of your doctor. Diagnostic procedures and symptoms will help eliminate a number of possible reasons why such a procedure cannot be prescribed. In addition to the fact that the intervention is not prescribed for pregnancy and diabetes, it also cannot be performed if the patient has:

blood clotting disorders;
chronic diseases and sharp forms infectious diseases;
pathology of the cardiovascular system.

Before plastic surgery of the ureter, the patient undergoes an examination and tests.

Before the operation, a complete diagnostic examination is prescribed. This will reveal not only the nature and level, but also assess the patient's individual intolerance to a number of drugs used and exclude the presence of concomitant pathological processes. The absence of factors preventing surgical intervention allows the attending physician to set a date for plastic surgery.

Operation types

The intervention is performed under general anesthesia after determining the dose of anesthesia (during the diagnostic procedures). A catheter is installed to facilitate the outflow of urine during plastic surgery during the rehabilitation period. Treatment is carried out through:

segmental replacement of the ureter with tissues of the bladder or intestines (intestinal plasty);
by stitching the urinary tract with the removal of the affected segment (possibly when operating on a small segment) - ureteroureteroanastomosis;

Intestinal plastic

Partial and complete replacement of the ureters involves the replacement of organ tissues with intestinal tissues. A portion of the bowel (isolated) is formed with a catheter and sutured to the renal calyx to form a new portion of the ureter. With segmental plasty, suturing occurs with a healthy segment of the urinary tract with the catheter being brought out. This will serve as the ureter until the functions of the restored segment are fully restored. Partial plasty is used to eliminate tumors and large lesions.

Operation Boari

The procedure is characterized by the formation of a tube of the ureter from the tissue of the bladder. An area larger than the affected area is excised from the walls of the bladder (to avoid compression in the ureter), with a plastic tube inserted. The Boari operation is prescribed when there are violations of the ureters on both sides. At the same time, tubes are formed from the tissues of the urea, the operated area of which is sutured during the procedure. Drainage is installed in the urea at the site of the excised area.

Endoplasty of the mouth of the ureter

The procedure can be prescribed if a patient has vesicoureteral reflux. During the operation, there is less organ damage with a reduced risk of developing pathologies and complications after the procedure. Plastic surgery is carried out by introducing a volume-forming gel under the mucosa through a needle. This dilates the orifice of the ureter, after which a catheter is inserted for 12 hours during the postoperative period.

The ureters are most susceptible to trauma during gynecological operations.. There is a high risk of damage to the ureters during extended extirpation of the uterus with appendages for cervical cancer; during operations for the removal of intraligamentary cysts, when the topography of the ureters is changed; during operations for endometriosis involving the urinary tract (with vaginal access, the examination of the surgical field is very limited); with supravaginal amputation of the uterus for fibroids emanating from the cervical region and extending to the bladder. Currently, during extensive gynecological operations, in order to avoid damage to the ureters, they are isolated over a length of 5-6 cm. At the same time, it is difficult to exclude damage to the adventitia of the ureters, they seem to skeletonize, especially in cases of their involvement in an inflammatory or tumor process. Complete intersection of both ureters is rare, one ureter - in 1.5-8% of cases. Often there is parietal (incomplete) damage to the ureters. In addition, the ureters may become ligated when ligating bleeding vessels and may be mistaken for adhesions and ligated.

Crossing the ureters. When crossing both ureters in the next few hours or for 2-3 days, there is no urination and excretion of urine. Anuria, pain in the lower abdomen are observed. Palpation in suprapubic region it is possible to detect signs of urinary infiltration in the pelvis. A picture of ascending pyelonephritis develops (hectic temperature appears, blood leukocytosis rises to 24,000-30,000). Patients with the intersection of one ureter unnoticed during the operation complain of dull aching pain in the kidney area on the side of the lesion and in the suprapubic region. There is an increase in body temperature. The clinical picture of unilateral pyelonephritis develops. After 2-3 weeks, patients note the release of urine from the vagina, that is, a ureterovaginal fistula is formed. The described phenomena do not develop so quickly with parietal injuries of the ureters. But in both cases, the process ends with the formation of ureterovaginal fistulas. Violation of the outflow of urine from the kidneys in case of damage to the ureters, cicatricial-sclerotic changes in the area of damage create prerequisites for the development of hydroureteronephrosis and, ultimately, renal failure.

Complete intersection or parietal damage to the ureters during surgery is rarely detected, since the doctor's attention is directed to combating bleeding. Subsequent diagnosis is based on data from special urological studies. With chromocystoscopy, if there is an intersection of the ureters, their mouths do not contract, indigo carmine does not enter the bladder. With unilateral intersection of the ureter on the side of the injury, the mouth does not contract, indigo carmine is not released from it, on the opposite side, indigo carmine is released from the mouth. With parietal damage to the ureters, the orifices contract rarely and weakly, indigo carmine is released in a sluggish stream. Valuable information can be obtained with the help of excretory urography: the flow of contrasted urine into the pelvic tissue indicates the side of the damage and its level.

Diagnosis of ureterovaginal fistulas also requires the use of special urological research methods. So, staining of the vaginal tampon with chromocystoscopy allows you to establish the presence of the ureterovaginal fistula and sometimes the side of the injury. Detection of excretion of indigo-stained urine administered intravenously when examining the vagina in the mirrors also helps to determine the ureterovaginal fistula and, in some cases, the side of the lesion. If you suspect the so-called incomplete ureterovaginal fistulas, which are formed with parietal damage to the ureters, we recommend the following diagnostic procedure. The vagina is tightly plugged, one of the ureters is catheterized, and 1-2 ml of indigo carmine is retrogradely injected into the pelvis. The ureteral catheter is immediately removed. By staining the tampon with indigo carmine, the presence of a ureterovaginal fistula and the side of the injury are determined. The same manipulation must be repeated on the other side.

Vaginography has a high diagnostic value in detecting ureterovaginal fistulas. Enter the colpeirinter. After the balloon is inflated or filled with liquid, a contrast agent is injected into the vagina through a catheter built into it, which penetrates the ureter through the fistula and fills the pyelocaliceal system, and urography is performed. On x-rays on the side of the lesion, the same picture is obtained as with retrograde ureteropyelography, which allows you to establish the side of the damage.

If the intersection of the ureter is noticed during the operation or on the 1st day after it, immediately restore its integrity by stitching end to end, end to side or side to side on a plastic tube or catheter. Parietal injuries of the ureter, not noticed during surgery, can be treated conservatively by catheterization for 8-10 days. With formed ureterovaginal fistulas, the principle of organ preservation is followed. Due to the technical difficulties of plastic surgery in early dates and poor conditions (urinary infiltration, suppuration), some urologists at the first stage are limited to the imposition of a pyelo- or pefrostomy and drainage of the pelvic tissue, and then ureterocystoneostomy is performed 2-3 months after the operation. With large defects in the ureter, when ureterocystoneostomy is not possible due to its high tension, operations such as Boari are performed. Thus, the normal activity of the kidneys is restored.

Ligation of the ureters. In the case of ligation of both ureters, patients in the first 2-3 days notice the most severe paroxysmal pain in the kidney area. Anuria is observed, a picture of acute kidney failure and bilateral pyelonephritis. With unilateral dressing due to compensatory function contralateral kidney acute renal failure does not develop, but patients experience severe attacks, renal colic on the side of the injury. If not accepted Urgent measures may develop acute pyelonephritis and ureterohydronephrosis.

Anuria in the next hours after surgery and in the next 24-48 hours, an increase in the phenomena of acute renal failure (azotemia, dyselectrolytemia), metabolic acidosis, hyperhydration, an increase in ESR, ECG data (signs of toxic myocarditis), edema indicate that both ureters are tied . On excretory urograms made in the first hours after the operation, when the excretory function of the kidneys is still preserved, there is an expansion of the pelvicalyceal system, the contrast agent does not enter the bladder due to an obstacle in the distal ureters, the ureters are dilated above the obstacles. In the case of ligation of one of the ureters, the described radiological changes found on the side of the injury. With chromocystoscopy in case of bilateral damage, the bladder is empty, urine does not enter the bladder, the mouths of the ureters are strongly and rapidly reduced in vain. Indigo carmine is not excreted from the mouths. When one ureter is ligated, a similar picture is found on the side of the injury, from the contralateral mouth there are powerful throws of urine, intensely stained with indigo carmine. When trying to catheterize the ureters, there is an insurmountable obstacle at the level of 5-6 cm on both sides (in cases of bilateral damage) or on one side (in case of unilateral damage). On a retrograde ureterogram, the ureter is filled only in the lower third.

With anuria, the development of acute renal failure, that is, when the diagnosis of ligation of both ureters is established, the operation should be performed no later than 48 hours. The wound is sutured, the ureters are isolated, and ligatures are removed. Restore the patency of the ureters and the normal passage of urine. In case of unilateral damage, the ligature is also removed from the damaged ureter in the next 48 hours, if this is done later, then the damaged part of the ureter will have to be resected and its ends anastomosed, otherwise a stricture will form in the area of damage.

Skeletonization of the ureter. This type of damage manifests itself in a more distant period than those described above. 4-6 months after gynecological surgery, patients complain of the appearance of a dull aching pain in the area of one or both kidneys. Celebrated in the evenings subfebrile temperature. Periodically, the pain worsens, becomes paroxysmal. When examining such patients, attention is drawn to the pallor of the skin, coated tongue, moderate arterial hypertension. Enlarged both or one kidney are palpated, while the degree of pain is different. Pasternatsky's symptom is weakly positive on one or both sides. Dysuric phenomena and cloudy urine visible to the eye are possible.

An increase in one or both kidneys, determined by palpation, suggests the presence of hydroureteronephrosis on one or both sides. The data of excretory urography, retrograde pyelography make it possible to establish the diagnosis of hydroureteronephrosis, which has arisen on the basis of the formation of ureteral strictures in the distal sections due to their skeletonization during gynecological surgery. Similar changes in the ureters can also be observed without their skeletonization during gynecological surgery. The development of cicatricial-sclerotic processes in the pelvic tissue, especially after radiation therapy, can also contribute to the formation of ureteral strictures.

In most cases, after skeletalization of the ureters, their strictures are quite significant in length (up to 8-10 cm), therefore, the most common surgical treatment is to anastomose the ureter with the bladder using Boari-type operations.

For better orientation during gynecological surgery, we recommend pre-catheterization of both ureters. In order to detect trauma to the ureters during the operation, we consider it appropriate to administer intravenous indigo carmine at the stage of ureter isolation. This technique, according to our data, is reliable for detecting violations of the integrity of the ureters. When isolating the ureters, you need to be very careful, try, if possible, not to disturb its trophism.