Psoas Hitch (Turner-Warwick and Worth 1969) A psoas hitch is fashioned by making an incision in the bladder that lies at right angles to the long axis of the ureter, and this incision is opened out in the same axis as the ureter (Fig. 5.12a). This essentially lengthens the bladder, allowing it to reach the ureter, which can be anastomsed to the bladder without tension. Place two stay sutures on either side of the planned incision (Fig. 5.12b). As the incision is made, intermittently pull the stay suture apart until you have produced an incision that is long enough to breach the defect. Alternatively, place two fingers inside the bladder and elevate the bladder toward the cut ureter. To achieve an adequate length of bladder, you may well have to divide the contralateral superior vesical vessels. The psoas hitch will need to reach well above the iliac vessels so that it can be anchored to the psoas minor tendon (or psoas major tendon if the former is absent) and to achieve this length the incision in the bladder may have to comprise as much as 50% of the circumference of the bladder.
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Figure 5.12. a: Oblique incision, which is opened at right angles to the line of incision. b: Creating the psoas hitch. c: Placing the hitch stitches.
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Hitch stitches are used to anchor the bladder to the psoas minor tendon (Fig. 5.12c). They take tension off of the ureterovesical anastomosis and also prevent tension at this site developing as the bladder fills and empties. We place the hitch stitches (2/0 Vicryl) that will anchor the bladder to the tendon of psoas minor at this time, first so that we can be sure we have achieved an adequate length of bladder for tension-free ureter-to-bladder anastomosis, and second so that we can perform the anastomosis in a position that will avoid kinking the ureter. We clip, but do not tie, the stitches yet, because as Turner-Warwick and Worth (1969) suggested, 'Having sited the position of the hitch-sutures, it is often easier to create the ureteric tunnel before actually anchoring the bladder.' When placing the hitch stitches be careful not to place the sutures too deeply, as it is possible to hit the genitofemoral nerve (which lies on psoas major) and even the femoral nerve (which exits laterally from the psoas major).