You may be asked to give an intraoperative opinion by your gynaecological, colorectal, or vascular colleagues who suspect that they have damaged the ureter, or they may simply want reas-
5. TRAUMATIC UROLOGICAL EMERGENCIES 67
FIGURE 5.6. Combined JJ stent and nephrostomy drainage of the ureter following perforation of the ureter during ureteroscopy.
surance that they have not. The atmosphere in the operating theatre will be tense and it is important to keep your cool, so that you can go about confirming or excluding a ureteric injury, and repairing it if present, in a systematic and sensible fashion.
Optimise the conditions. Ensure that the area of interest is adequately exposed by packing the bowel out of the way if this
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has not been done. Different surgeons use different retractors. If you are not happy with the type of retractor being used, ask for one that you like (we prefer a Bookwalter retractor). There may be continued bleeding, and the area of interest may be an inch under urine or blood. You cannot adequately examine a ureter or repair it under such conditions. Control any bleeding. It is better to do this now, before a potential repair, than afterward where the presence of the reconstruction may make access to bleeding vessels difficult. Make sure the operating lights provide adequate light. Ask for a headlamp if you are not happy with the light from the overhead operating lights. Ask the anaesthetist to give some intravenous antibiotics, fluids, and blood as required.
The options for examining the ureters are several. Remember, bilateral injuries can occur, particularly following hysterectomy, and therefore you should examine both ureters. You may look directly at the ureters, administer intravenous or intra-ureteric methylene blue and look for extravasation of dye, do an on-table IVU, or perform retrograde ureterography.
Direct Inspection of the Ureter
This is a good way of inspecting the ureter for injury, but a considerable length of ureter may have to be exposed in order to establish that it has not been injured, and for the lower ureter this exposure is more difficult than for the upper ureter.