■ Mucosa-to-mucosa anastomosis should be done, to achieve a watertight closure.
■ A drain should be placed aroimd the site of anastomosis
5. TRAUMATIC UROLOGICAL EMERGENCIES 75
Primary Closure of Partial Transection of the Ureter
A partial transection of the ureter may be repaired over a JJ stent, as long as the injury has not been caused by a gunshot wound (in which case there may well be a blast effect causing more extensive necrosis than is immediately apparent at the time of surgery; such injuries are better managed by excising the affected segment of ureter and performing a primary ureteroureteros-tomy). Mobilise the ends of the ureter to allow a tension free anastomosis to be done. Pass a guidewire into the renal pelvis and pass the stent up into the renal pelvis. To introduce the stent into the lower ureter, remove the guidewire and place it in a side hole of the stent, so as to straighten the end of the stent so that it may be introduced into the distal end of the ureter (Fig. 5.11). We find it easier to place the guidewire through a side hole in the middle of the stent, because this makes it easier to disengage the wire from the stent. The stent may be pulled out of the bladder as the guidewire is withdrawn if the latter has been placed through a side hole near the end of the stent. Thread the stent and guidewire down the ureter and into the bladder. We instill some diluted methylene blue into the bladder via catheter and fill the bladder with saline, clamping the catheter so that the bladder can be distended. When the JJ stent reaches the bladder and the guidewire is withdrawn, blue fluid refluxes up the stent and this confirms that the distal end of the stent is in the bladder. We use 4/0 Vicryl (i.e., absorbable suture material) to close the hole in the ureter. Place a drain down to the site of the repair.
This is anastomosis of one end of the ureter to the other end. The essential factor for successful anastomosis is the absence of tension. If the defect between the ends of the ureter is of a length where a tension-free anastomosis would not be possible, then reimplantation into the bladder via a psoas hitch or Boari flap will be needed. The technique for anastomosis of the two ends of the ureter is the same as for partial transections, other than the fact that the two ends of the ureter should be spatulated to allow a wide-bore anastomosis.