5. TRAUMATIC UROLOGICAL EMERGENCIES 73
delay in recognition of a ligature injury to the ureter, it is probably safer to remove the affected segment of ureter and perform a ureteroureterostomy (Assimos et al. 1994). Generally speaking the stent is maintained in position for somewhere between 3 to 6 weeks. At the time of stent removal a retrograde ureterogram can be done to confirm that there is no persistent leakage of contrast from the original site of injury, and to see if there is evidence of ureteric stricturing (Fig. 5.9).
For other injuries, in general terms, the type of treatment depends on the level of ureteric injury. It has been traditional teaching that the blood supply to the distal ureter is somewhat tenous, and for injuries at this level (below the takeoff of the internal iliac artery) reimplantation directly into the bladder via a psoas hitch or Boari flap is recommended. The approach to repair at different levels of ureteric injury is summarised in Figure 5.10.
FIGURE 5.9. A retrograde ureterogram post-stent removal.
74 J. REYNARD
Figure 5.10. Surgical techniques for repair of ureteric injuries at different levels of the ureter.
Factors other than the level of injury are important in determining the type of repair. Blast injuries characteristically cause considerable collateral damage to the ureter and surrounding tissues, which may not be apparent at the time of surgery. Delayed necrosis can occur in such apparently normal looking ureters. Simple ureterostomy may therefore be inappropriate in such cases, and debridement of a considerable length of ureter, followed by reimplantation into a Boari flap may be necessary
General Principles of Ureteric Repair
■ The ends of the ureter should be ddDrid^ so that the edges to be anastomosed are bleeding freely.
■ The anastomosis should be tension free.
■ For complete transection the ends of the ureter should be spatulated, to allow a wide anastomosis to be done.
■ A stent should be placed across the repair.