Complications after unrecognized injuries of the urinary system in obstetric and gynecological practice. Anterior colporrhaphy or anterior plasty

What is a narrowing of the ureter? What causes ureteral stricture? What is ureteroplasty? There are different types of operations on the ureter: ureteral transplantation, intestinal ureteroplasty, even buccal ureteroplasty. What does a patient need to know about these ureteral treatments? What are the advantages of Oncourology NCG in the treatment of ureteral stricture?

What is ureteral narrowing and how does it manifest itself?

Narrowing of the ureter or its stricture ... On the one hand, everything is simple: for one reason or another, the lumen of the ureter narrows or closes altogether and urine from the kidney cannot enter the bladder. For the patient, this is a nightmare. The threat of kidney death, often - pain and inflammation, almost always - a nephrostomy - a tube removed from the kidney and constantly connected to a bag - a urinal ... For a doctor, this is the hardest choice: to remove a kidney due to constant bouts of purulent pyelonephritis or to try to perform a risky intervention according to restoration of the patency of the ureter.

What are the causes of ureteral stricture?

Unfortunately, there are many. Of the benign diseases, the most common cause is urolithiasis. The passage of a stone through the ureter leads to injury and scarring of the mucosa. There is an independent disease - the so-called. Ormond's disease, leading to a total narrowing of the ureter. Basically, any injury to the ureter can lead to a stricture or narrowing of the ureter. Such injuries can occur during oncological operations, for example, when the surgeon detects the germination of colon cancer or uterine cancer in the ureter and is forced to remove part of the ureter.

Well, let's imagine a situation where a patient has a narrowing of the ureter. Basically, the ureter is a thin tube that periodically contracts to force urine out of the kidney and into the bladder. An analogy can be made with a conventional rubber hose. As long as it's intact, all is well. But try warming this hose over a fire - and that's all, please, the stricture is ready. In everyday situations, it is always easier for us to completely replace almost any tube - it is expensive and unreliable to repair it. Ureteroplasty is, in a broad sense, the restoration of the patency of the ureter at the expense of some other tissue. The most common option - the Boari operation - is performed when the bladder is healthy, and the ureter is damaged in the lower third (sometimes in the middle). We take a flap from the bladder and model the ureter (Fig. 1). To restore the right ureter, you can take the appendix - the appendix. (Fig. 2). Worse when the whole ureter is affected, i.e. There is a total stricture of the ureter. Then we are forced to take an isolated section of the ileum (Fig. 3) and replace the ureter with this section. Recently, plastic surgery of the ureter of the buccal mucosa is gaining popularity in the world. The ureter at the site of narrowing is dissected longitudinally and a flap from the buccal mucosa is sutured there as a substitute material. Thus, plastic surgery of the ureter is its partial or complete replacement, or restoration of its patency due to various tissues.

What should the patient know about the treatment of ureteral narrowing?

It is necessary to know and understand one thing. Ureteral surgery, like all reconstructive plastic surgery, is perhaps the most difficult part of our work. It is always much easier to remove any organ than to restore anything. An important feature: no more than 4% of urologists are involved in reconstructive plastic urology, as a rule, in specialized centers. In itself, the choice of a method for restoring the ureter is an extremely crucial moment - it is necessary to take into account a lot of factors - trauma or radiation, the need for further chemoradiotherapy.

— What are the advantages of Urology Oncology GCG in the treatment of ureteral stricture?

Perhaps I will not be mistaken if I say that we have organized a specialized center with an interdisciplinary team of experienced surgeons. This allows us to provide people with high-quality assistance in the most difficult situations. If the cause of the disease of the ureter is oncological, then we will definitely organize a consultation to resolve the issue of further treatment so that our operation does not negatively affect the quality of life of the patient. With all this, I consider our attitude towards the patient to be a much more important achievement. We just know how to be around.

On the ureters produced with stones, cicatricial narrowing, traumatic injuries.

The position of the patient to expose the upper two-thirds of the ureter, as in operations on the kidney; if the lower and, in particular, the intrapelvic section are exposed, the position is on the back.

The exposure of the upper and middle sections for surgery on the ureter is performed by an oblique extraperitoneal lumbar incision according to Fedorov or Bergman-Israel, leading it to the level of the iliac spine. After dissection of the muscular-fascial layers and the transverse fascia of the abdomen, the parietal peritoneum is widely exfoliated to the medial side and on its posterior surface, at the level of the inner edge of the psoas muscle, the ureter is found.

For operations on the ureter in the lower third and its intrapelvic part, an incision of the abdominal wall according to Pirogov is used. The incision starts at the level of the iliac spine and leads four centimeters above the inguinal ligament, parallel to it, through the oblique muscles and the transverse muscle up to the rectus muscle. After dissection of the transverse fascia of the abdomen in the medial section of the incision, the lower epigastric vessels are found and crossed between the ligatures. The peritoneum is widely exfoliated and pushed up and inwards. At the level of the posterior third of the innominate line of the pelvis, the ureter is found, which usually departs with the peritoneum, if the operation is performed on the intrapelvic section in men, the peritoneum is peeled off from the walls of the small pelvis to the base of the bladder, and in women, along with the peritoneum, the broad ligament with appendages is pushed back. The ureter is exposed to the place where it flows into the bladder.

For operations on the ureter in the pelvic region, the Kay approach is also used. The bladder is emptied. The incision is carried out as with a high section. On the diseased side, the lateral surface of the bladder is exposed from the fiber and pushed back in the opposite direction; the peritoneum on this side is exfoliated back until the place of the inflection of the ureter through the linea terminalis is found and it is isolated to the place where it flows into the bladder.

Removal of a stone from the ureter

For an operation on the ureter to remove a stone localized in the juxtavesical (paravesical) area, the ureter is exposed using the Pirogov approach described above and a rubber flagellum is placed under it, which serves as a holder. A longitudinal section is cut through the wall above the location of the stone and removed. Interrupted sutures are applied to the edges of the incision from the thinnest catgut on a traumatic needle. The sutures capture only the adcentia and the muscular membrane, without penetrating through the mucous membrane. After suturing the organ, a rubber drainage is brought to the operation site. The abdominal wall is sutured in layers, bringing it extraperitoneally through the posterior corner of the wound.

After removing the stone, the longitudinal incision of the ureteral wall can be left unsutured, a catheter is inserted into it, and drainage is brought to the operation site. In the future, regenerative restoration of the integrity of the wall occurs.

Resection and suture of the ureter

Resection of the ureter with subsequent suturing of the ends is indicated for cicatricial narrowing. A suture is applied for his injuries, including accidental ones during operations (extirpation of the uterus). After excision of the cicatricial area of ​​the ureter, it is sutured end to end. To facilitate this operation, a ureteral catheter is first inserted into the ureter.

The ends of the transected organ are brought together and sutured over the catheter with rare interrupted thin catgut sutures through the adventitia, the muscular membrane. When stitching the edges, they are only brought into contact so as not to get a narrowing shaft.

In some cases, dissection of the ureter is advantageous to produce not strictly transversely, but obliquely. The operation on the ureter is completed, as with the removal of a stone.

When extirpations of the bladder, the ureters are implanted into the sigmoid colon according to the method of S. R. Mirotvortsev or Coffey.

Ureteroplasty

One of the important, hitherto unresolved problems of plastic surgery are operations on the ureter to restore its defects.

The first plastic surgery on the ureter - replacing it with a segment of the small intestine - was performed in 1900 by Urso and de Fabi. In the future, to replace the missing segment, they began to use segments of blood vessels, a fallopian tube, a flap from the bladder wall sewn in the form of a tube (Boari), and, finally, recently, plastic materials (teflon, plexiglass, dacron). However, all these methods, as well as experiments on homoplastic transplantation of lyophilized grafts, do not give satisfactory results. The difficulties are that fistulas often form at the site of the sutures, hydronephrosis occurs due to stenosis in the area of ​​the sutures, pyelonephritis as a result of an ascending infection. Recently, a fundamentally new method has been experimentally developed - transferring the kidney itself to the pelvis (fossa iliaca); the remaining whole area is implanted into the bladder, and the renal vessels are connected by a vasoconstrictor apparatus to the nearest highways - the external iliac vessels. The results obtained allow us to hope for the possibility of applying the method in

Complication of surgical interventions on the abdominal cavity and pelvic organs by trauma to the ureter is a rather unpleasant phenomenon.

Most experienced obstetrician-gynecologists in practice have encountered damage to the ureter of varying degrees, and in most cases the latter was diagnosed in the postoperative period. The greatest risk exists in radical, extended operations for malignant diseases of the cervix. According to various authors, iatrogenic injury of the ureter during operations to remove the uterus for neoplasms and / or for inflammatory diseases ranges from 0.5 to 46% and from 0.1 to 17% of cases, respectively.

In addition to large oncogynecological operations, there is a risk of damage in the following cases:

• The imposition of obstetric forceps.
• Craniotomy.
• Cesarean section with dissection of the cervix in the lower segment in the transverse direction, and with extirpation of the uterus due to profuse bleeding after cesarean section.
• During an abortion.
• Operations on the vagina and uterus, especially in radical operations for cervical cancer.
• Removal of intraligamentous tumors.
• With hysterectomy by vaginal access.
• Cases of spontaneous necrosis of the distal ureter due to a very tight fit of the fetal head to the pelvic bones are described.

Damage is caused by a violation of the topographic and anatomical relationships of the urinary and genital organs during their prolapse, a change in topographic relationships caused by tumor and inflammatory processes, in which the broad ligaments of the uterus are infiltrated, shortened, and the ureters are involved in the process. Therefore, the operating surgeon must thoroughly know not only the anatomy, but also changes in the urinary tract in various pathological processes, without which it is impossible to count on a decrease in the number of the above complications.
The commonality of embryogenesis causes close anatomical connections between the urinary and female genital organs, which leads to a high probability of damage to the bladder and ureters during obstetric and gynecological operations. The ureters cross the common iliac vessels near their bifurcation and then travel along the pelvic wall to the bladder. In these places, the ureters are located at the bases of the broad ligaments of the uterus, behind the ovaries and fallopian tubes, then they pass under the vessels of the uterus and are 1.5-2 cm away from the cervix. At first, they are located parallel to the uterine arteries, then they cross them and go anteriorly and upwards between the sheets of broad ligaments. For a short distance, the ureters lie on the anterior wall of the vagina. The entire length of the pelvic ureter is surrounded by a fascial sheath and fiber.

The ureters are relatively more fixed in the pelvic cavity, especially distal to the internal iliac artery. In the pelvis, the ureters can move laterally (uterine fibromyoma) or medially. In obstetric practice, mainly the juxtavesical and intramural parts are damaged, in gynecological practice, the pelvic part of the ureter is damaged. And if bladder damage, as a rule, is recognized intraoperatively, relatively easily corrected and does not require repeated reconstructive operations, then ureteral injuries are not always diagnosed in a timely manner, and therefore the restoration of a woman's health is delayed for a long time, requires repeated surgical interventions and in a number of cases. cases can lead to kidney loss. These patients are more likely to develop urosepsis. Every gynecologist knows about this danger, but not always before an obstetric or gynecological operation, the doctor assesses the condition of the urinary system.

About 30% of ureteral injuries are diagnosed intraoperatively, which allows immediate surgical correction. In this case, the postoperative period is somewhat lengthened, which is caused by the need for a urologist to control the restoration of ureteral patency, but repeated operations, as a rule, are not required.

Intraoperative signs of damage are:

1. Filling the wound with urine. In doubtful cases, an indigo carmine test is performed (introduction of 5 ml of a 4% solution of indigo carmine). The appearance of blue dye in the wound confirms the fact of damage and helps to establish its localization.
2. Intraoperative expansion of the ureter above the site of surgery. In this case, revision and visualization of the ureter to the bladder is required to determine the cause of the obstruction.

The main task of the doctor in case of acute injury of the ureter is to preserve the kidney. Detection of damage during the operation dictates the need for the following options for intraoperative reconstruction: In case of complete intersection of the ureter, the imposition of uretero-uretero or ureteroneocystoanastomosis. The operation is indicated when the ureter is injured in the upper pelvic region: at the upper part of the broad ligament of the uterus, at the place of intersection with the iliac vessels. This is a simple operation and in most cases ensures the normal function of the ureter. The main points of this operation are as follows: the ends of the ureters are cut obliquely, which provides a large area of ​​the anastomosis and reduces the possibility of subsequent stricture formation. Their convergence is carried out without tension. Anastomosis is best performed on a thin catheter, which is left for 7-8 days. The catheter promotes the formation of an anastomosis and ensures the outflow of urine from the kidney. Normal contractions of the ureter are restored 2-3 weeks after plastic surgery. When connecting the ends of the ureters, atraumatic needles with chrome-plated catgut No. 3/0 or No. 4/0 and sutures that do not capture the mucous membrane should be preferred. The operation of choice for trauma to the intramural or juxtavesical ureter is ureterocystoanastomosis. Ureterocystoanastomosis anatomically and physiologically quite justified, since the epithelial cover of the ureter and bladder is similar in structure. This operation is performed mainly by transabdominal, rarely transvaginal access.

Regardless of which access the operation is performed on, the main condition is the creation of a strong, well-functioning anastomosis between the ureter and the bladder. For this purpose, the free end of the ureter must maintain a good blood supply and be implanted at the base of the bladder. This possibility appears after partial extraperitonization of the bladder. Two provisional ligatures are applied to the anterior wall of the bladder and the wall is cut between them better in the transverse direction. Then, with the help of a thin instrument, a submucosal tunnel is made directly above Lieutau's triangle, where the renal end of the ureter is pulled. Several dozen different methods for connecting the ureter to the bladder have been proposed. The most successful methods were proposed by Fritsch (1916), N.A. Lopatkin (1968) and others. More effective results are obtained when the ureters are carried into the bladder through the submucosal tunnel. Ureterocystoanastomosis has significant advantages over other plastic surgeries. It restores the integrity of the injured ureter and creates a new functioning fistula with the bladder.

Operation Boari (Demel, Gregoire). With lesions of the pelvic ureter, when it is impossible to carry out direct reimplantation into the bladder, as well as uretero-ureteroanastomosis, then the Boari operation is used. It was proposed at the end of the 19th century by Van Hook (1893) and Boari (1894). However, for many years it did not find clinical application. There are only a few reports in the literature about the use of this operation in acute ureteral trauma, but it is used quite often in elective surgery.

Ureterocutaneostomy. Indications for it arise in cases of acute injury to the ureter, when the patient's condition is severe or the team of surgeons is not ready to perform a reconstructive operation. This operation is technically very simple and does not take much time to complete. The renal segment of the ureter is sutured into the skin of the ilio-inguinal region, and its free end must stand 2-2.5 cm above the skin surface. This technical detail facilitates the care of operated patients in the future. Of course, the indications for palliative urinary diversion operations are currently significantly narrowed. Nevertheless, they have an undoubted advantage over nephrectomy, as they allow one to perform plastic surgery on the ureter over time and preserve a functioning kidney. When the ureter is punctured with a needle, a soft rubber tube is brought to the damaged section. Its opposite end is brought out through the skin counter-opening. It is removed 3-4 days after the cessation of urine excretion through it.

In case of incomplete dissection of the wall of the ureter, several thin catgut threads are applied to it and a rubber tube is brought in, which should not come into contact with the sutures. It is brought out through the skin counter-opening and removed after the restoration of the passage of urine in a natural way. Leaving the surgical wound without drainage can lead to the development of urinary streaks, followed by the formation of a ureteral fistula or urinary peritonitis. Thus, a puncture or parietal wound of the ureter does not require reconstructive surgery. It is enough to suture the defect of the ureter with a thin catgut, but it is necessary to drain the retroperitoneal space in order to prevent the development of urinary peritonitis or phlegmon.

If ligation of the ureter or compression by the clamp is detected, the ligature is removed and, if necessary, catheterization. With massive bleeding, the ureter is often ligated along with the uterine arteries. The ligature must be removed very carefully to avoid re-bleeding. As a rule, after a short-term ligation of the ureters, severe complications do not occur, although structures may subsequently develop. To avoid such complications, catheters are inserted into the ureters, which are left on average for 4-5 days. If the ureter was squeezed with a soft clamp for no more than 10 minutes, it should be inserted into the lumen of its catheter using a catheterization cystoscope and left for 4-5 days. With a longer compression of the ureter, the injured area is subject to resection, followed by the connection of the disconnected ends.

You can decide on a nephrectomy when an irreparable injury has been caused to the ureter, and the somatic condition of the patients or some other reason does not allow subsequent plastic surgery. However, in such cases, the surgeon must be sure that the remaining kidney will provide the function assigned to it. To resolve this issue, immediately after damage to the ureter, an indigo carmine test can be performed according to the following method: a catheter is placed in the bladder, and a clamp is applied to the central end of the damaged ureter and 5 ml of a 0.4% solution of indigo carmine is injected intravenously. The release of paint through the catheter from the bladder after 3-6 minutes indicates the presence and preservation of the function of the contralateral kidney. More reliable information about the latter is given by excretory urography, if it is possible to perform it on the operating table. These studies also make it possible to exclude a congenitally single or only functioning kidney, when there can be no talk of a organ-removal operation.

Clinical manifestations of ureteral injuries not recognized during surgery depend on the nature of the injury (tied or transected) and may appear as early as the first day after surgery. Unfortunately, but it often happens that there are signs of damage, but the doctor at first does not attach importance to them or cannot correctly interpret them. There are cases when an injury to the ureter was recognized a month or more after the onset. In this regard, in a number of patients, complications associated with ureteral obstruction and infection (acute pyelonephritis) or with urinary leakage come to the fore. In both cases, the issue of reconstruction fades into the background.

When ligating the ureters, the most common signs are anuria, renal colic, back pain, back pain in combination with hyperthermia. The appearance of high fever, pain in the lower abdomen, lower back, mild symptoms of peritoneal irritation should alert the doctor.

When crossing the ureters, the clinical manifestations are usually the following: the formation of urinary infiltrates with their subsequent drainage through the vagina, the formation of a ureterovaginal fistula, the occurrence of peritonitis, the appearance of anuria in combination with peritonitis, the appearance of hematuria.

The appearance of the above signs requires clarification of the diagnosis using ultrasound examination of the kidneys and retroperitoneal space, excretory urography, retrograde ureteropyelography. With ultrasound of the kidneys, as a rule, retention changes of varying degrees of severity are determined, which depends on the nature of the injury. When ligating the ureter, they are obvious, when they are transected, they are minimal, and therefore they are not always correctly evaluated by the doctor.

On the excretory urogram, retention changes in the pelvis are determined in combination with extravasation of urine or without the latter, on ascending ureteropyelography - extravasation of urine or obstruction. There are different points of view on the issue of tactics of treatment of this contingent of patients in the literature. There are supporters of two-stage surgical treatment with preliminary nephrostomy, but in most cases of intraoperative ureteral injuries detected in the immediate postoperative period, single-stage, or primary, reconstructive operations are appropriate. This allows you to significantly reduce the duration of treatment and the rehabilitation period. Unfortunately, in our country, treatment is more often carried out in two stages, which is associated not only with the late recognition of the injury, but also in some cases with insufficient qualifications of the urologist who provides assistance.

If an injury is detected after more than 5 days, when an infection is attached, the flow of urine into the abdominal cavity and retroperitoneal space is primarily eliminated. This is achieved by imposing a nephrostomy (open) or puncture, if there is a certainty that there is no need for drainage of the retroperitoneal space, since with occlusion of the ureter, urine through reflux can penetrate into the perirenal tissue through the kidney gate, leading to the development of abscesses and sepsis. With a simple ligation of the ureter, this is enough, since the resorption of catgut threads in some cases restores the passage of urine. At the same time, the pelvic tissue is widely drained. After the patient's condition improves, conditions are created for plastic surgery on the urinary tract.

When the ureter is transected, urinary leakage extends into the paravesical, parauteral, and even pararenal space or down towards the vagina. The more time urine has no outlet, the more extensive the urinary infiltrates. Diagnosis of urinary infiltration does not cause difficulties, but the more time passes before the breakthrough of urine through the abdominal wound or vagina, or until the drainage of streaks, the greater the likelihood of dystrophic and purulent-inflammatory processes in the urinary system and surrounding tissues and the worse the conditions for subsequent plastic surgery .

In the area of ​​the infiltrate, it is necessary to dissect the tissues and drain the pelvic tissue through the obturator foramen according to Buyalsky-McWorter. To do this, from the side of the small pelvis perforate the obturator membrane closer to the descending branch of the pubic bone. At the same time, the beak of the cortsang protrudes outward on the inner surface of the thigh. A skin incision is made above it and a tube is pulled through it into the pelvic cavity. Drainage is also effective through the ischiorectal fossa. If the ureter is injured, urine may leak into the periureteral space and encapsulate to form a urinoma. Clinically, urinoma is manifested by malaise, gross hematuria, abdominal pain. X-ray at the same time, retention changes in the kidney are visible, with an ultrasound examination, a urinoma is visible. The urinoma must be emptied during the lumbotomy.

If the ureters are damaged, urinary peritonitis may occur. Early symptoms of peritonitis are tachycardia, high body temperature, tension of the abdominal wall. Against the background of peritonitis, acute renal failure may occur. With an ultrasound examination, retention changes will be determined, with an X-ray - signs of extravasation of urine.

Success is ensured by early diagnosis and timely operation. The operation consists in closing the defect of the urinary organs. The parietal defect can be sutured on a splint that is brought into the bladder. If the ureter is completely transected or resected, a ureterocutaneostomy can be performed. If peritonitis is not expressed, a uretero-ureteroanastomosis may be applied. The abdominal wall is sutured leaving drains. After the elimination of the threat to the life of the patient, the following reconstructive operations can subsequently be performed:

• uretero-ureteroanastomosis;
• ureterocystoanastomosis;
• operation of Boari, Demel, Gregoire;
• intestinal plastic of the ureter;
• transplantation of the ureter into the intestine;
• reoperation and removal of ligatures.

To prevent damage to the ureter during surgery, the following measures are necessary:

1. ureteral catheterization before surgery;
2. wide surgical access, providing the possibility of free manipulations in the wound;
3. separation of the bladder from the cervix and vagina by a longitudinal dissection of the peritoneum along the round ligament;
4. assessment of the ureter from the intersection with the uterine artery to the confluence with the bladder during the restoration of the posterior fornix of the vagina after extirpation of the uterus;
5. identification of the pelvic ureters during surgery with orientation to the iliac vessels;
6. separation of the ureter from the posterior leaf of the broad uterine ligament during hysterectomy;
7. careful cutting off of the sacro-uterine ligaments during extirpation of the uterus;
8. ligation of the vessels of the uterus after a wide opening of the vesicouterine and perivesical space and separation of the posterior peritoneum;
9. examination of the ureters should be taken as a rule in cases where during the operation there was a reason for their injury. This allows timely recognition of the injury and corrective surgery, which can save many patients from serious consequences.

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 acute forms of 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.

Surgical intervention has long been an effective technique for restoring the integrity and functionality of 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;
• injuries after oncological diseases of the genitourinary system and their treatment.

Damage is most often observed in women during violations of labor, 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 to 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.

Surgery on the ureters requires the doctor to conduct a thorough examination of the patient's health. 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 stage of the examination is the identification of 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 technique for stitching the urinary tract after removal of the affected part is also possible. 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, the small intestine is used. In the course of work, the surgeon, using a catheter, forms an ureter of the required size from a segment of the intestine and sews it with the pyelocaliceal system of the kidney and the bladder. This technique is 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.