Urological Emergencies in Clinical Practice стр.55


iatrogenic ureteric injuries in 43 patients, 28 (65%) of whom underwent definitive repair within 6 weeks of injury.

Delayed Treatment—Temporizing Procedures

Temporary urine drainage may be achieved by placement of a percutaneous nephrostomy, and if there is a significant urinoma demonstrated by CT or ultrasound, this can be drained percuta-neously by a radiologist. If the patient is too unstable for definitive repair, you may insert a nephrostomy on the operating table (by opening the renal pelvis and inserting it from inside out). However, this can take a considerable amount of time, which you may not have in a shocked patient. In such cases, tie the ureter off at the site of the leakage with a long, nonabsorbable suture. This allows dilatation of the ureter so your interventional radiologist can subsequently place a nephrostomy tube under x-ray control a day or so later. The nonabsorbable suture allows easier identification of the ureter when you later come back for definitive repair.

Definitive Treatment

The options include:

■ JJ stenting

■ Primary closure of partial transection of the ureter

■ Direct ureter to ureter anastomosis (primary ureteroureteros-tomy)

■ Reimplantation of the ureter into the bladder (ureteroneocys-tostomy), either using a psoas hitch or a Boari flap

■ Transureteroureterostomy

■ Autotransplantation of the kidney into the pelvis

■ Replacement of the ureter with ileum

■ Permanent cutaneous ureterostomy

■ Nephrectomy

JJ Stenting

For some injuries, JJ stenting may be adequate for definitive treatment, particularly where the injury does not involve the entire circumference of the ureter and continuity, therefore, is maintained across the region of the ureteric injury. In situations where a ligature has been applied around the ureter, and this has been immediately recognised such that viability of the ureter has probably not been compromised, the ligature should be removed and a JJ stent should be placed (cystoscopically if this is feasible or, if not, by opening the bladder). If, however, there has been a

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