Ureteroneocystostomy: Reimplantation of the Ureter into the Bladder, Either Using a Psoas Hitch or a Boari Flap
Identify the end of the proximal ureter. If the injury has been recognised intraoperatively, the end will usually be easily identifiable. If, however, there has been a delay in recognising the
The guidewire and stent have c been inserted into the bladder
Figure 5.11. Technique for introducing a stent into the lower ureter. a: The end hole of the JJ stent is passed over the guidewire, which has been placed in the renal pelvis. The guidewire is withdrawn while holding the stent in place. b: Inserting the guidewire into a side hole halfway along the length of the JJ stent makes it easier to disengage. c: The distal end of the guidewire, with the stent, is then passed down the ureter and into the bladder. The guidewire is then removed.
5. TRAUMATIC UROLOGICAL EMERGENCIES 77
injury, the end of the ureter may be encased in a mass of fibrous and oedematous tissue. In such cases, trace the ureter down as far as you can, and transect it as it enters the area of fibrosis. Place a stay suture through the end of the ureter.
The defect between the bladder and the proximal end of the ureter may be bridged using either a psoas hitch or a Boari flap. A Boari flap is generally able to bridge a greater defect than a psoas hitch, and therefore you must decide before you start to make an incision in the bladder whether you are going to employ a psoas hitch or a Boari flap. It is easier to assess the length of bladder flap or hitch that needs to be created by 'inflating' the bladder with a few hundred millilitres of water (we use water because we make the incision in the bladder with diathermy; saline would prevent the diathermy from cutting). use a sterile giving set attached to a 1L bag of water. So you can control the inflow and outflow yourself. Mark out the site of the incision in the distended bladder, using a marker pen if you find this easier, and apply stay sutures around the edges of the incision; these sutures make it easier to manipulate the tissues, and they create less tissue damage than using forceps. Measure the defect and make sure you can bridge it, with a few centimeters to spare, with your proposed method (psoas hitch or Boari flap). Remember, if you prefer to reimplant the ureter in a nonrefluxing fashion, you will need an extra 3 cm or so of length, to allow the ureter to be tunneled into the bladder.