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1. Intraoprative ureteric injury Mechanism and managemenf

2. Etiology

3. The 6 most common mechanisms of operative ureteral injury are as follows Crushing from misapplication of a clamp Ligation with a suture Transsection (partial or complete) Angulation of the ureter with secondary obstruction Ischemia from ureteral stripping or electrocoagulation Resection of a segment of ureter Any combination of these injuries may occur

4. Risk factors

5. These factors include uterus size larger than 12 weeks' gestation 1- 2-ovarian cysts 4 cm or 3-Endometriosis pelvic inflammatory disease 4- 5- prior intra-abdominal operation 6- radiation therapy advanced state of malignancy 7- 8- and anatomical anomalies of the urinary trac

6. Ureteral injuries can be either expected or unexpected, and they may be the result of carelessness or due to a technically challenging procedure

7. Intraoperative measures (preventions )

8. - The proper surgical approach -The proper exposure of structures -The avoidance of blind clamping of the blood vessels -The dissection with routinely highlight of the ureter and direct visualization - The careful mobilization of the bladder - The cautious use of the electrocautery

9. INTRAOPERATIVE EVALUATION

10. If injury to the ureter is suspected intraoperatively the ureter must be meticulously examined in the area of interest. Direct exploration and visual inspection (including the exploration of retroperitoneal and peri-ureteric haematomas ) are the most common and reliable methods of assessing ureteric integrity]. The bowel should be reflected sufficiently to expose the ureter (s) and an attempt made to trace surgical misadventure or missile path.

11. Intraoperative recognition of ureteric injury can be facilitated b y instilling 5 ml of indigo carmine intravenously or intra- ureteric injection of indigo carmine or methylene blue . Extravasation of blue-tinged urine helps to confirm the injury and location].

12. I f no injury is identified, cystoscopy is the next step Intraoperative IVP may be useful, especially when cystoscopy is unavailable

13. Surgical Therapy

14. Depending on the type, duration, and location of the ureteral injury, surgical treatment may range from simple removal of a ligature to ureteroneocystostomy

15. Observation If a clamp or ligature constricting the ureter is discovered, the clamp or ligature should be removed immediately, and the ureter should be examined. If ureteral peristalsis is preserved and it is believed that minimal damage has occurred, the ureter injury may be managed with observation

16. Ureteral stenting with or without ureterotomy If tissue ischemia or a partial transection of the ureteral wall is suspected, a ureteral stent should be placed. The purpose of the stent , which is typically placed cystoscopically , is to act as a structural backbone onto which the healing ureter may mold

17. Ureteral resection and ureteroureterostomy

18. Indication for Ureteroureterostomy Ureter injury Treatment of short segment (<3 cm) ureteral stricture of the middle and proximal ureter . Distal ureteral strictures are best treated with reimplantation of the ureter . Treatment of retrocaval ureter

19. Contraindications Long ureteral stricture or injuries, which do not allow a tension-free end-to-end anastomosis . Kidneys without sufficent function (<15% of total glomerular filtration rate ) Underlying diseases with excessive surgical risk, if a ureteral stent is an alternative

20. Drains and catheters : Wound drainage 1–2 days Bladder catheter 3 days Ureteral stent 2–4 weeks

21. Complications of Ureteroureterostomy Bleeding. Infection. Urinoma . Recurrence of the ureteral stricture. Injury to adjacent organs (e.g. bowel).

22. Points of Caution Care should be taken to see that the ureter is anastomosed without tension. A soft Silastic indwelling catheter should be placed through the anastomotic area and fed into the bladder caudad and the renal pelvis cephalad . The drain should be placed in the area of the anastomosis and brought out through the right or left lower quadrant and kept in place until all external drainage has ceased  

23. Ureteroneocystostomy

24. If the ureteral injury occurred below the pelvic brim, where visualization of the ureter is difficult and where the vesical pedicles overlie the ureter , ureteroureterostomy is often too difficult to perform. In these cases, 2 types of ureteroneocystostomy procedures are indicated, either a psoas hitch or a Boari flap, in which the bladder is mobilized to reach the easily identifiable ureter proximal to the injury

25. Boari flap

26. Transureteroureterostomy

27. If ureteroureterostomy cannot be performed technically and the defect is too proximal i n the ureter for ureteroneocystostomy , transureteroureterostomy may be performed

28. Postoperative Details

29. Ureteral stent After the patient has recovered from anesthesia and is in suitable condition, the patient may be discharged with instructions to return to the clinic in 14-21 days, when the stent will be removed

30. The patient is discharged with 3 days of antibiotics ( eg , sulfamethoxazole-trimethoprim [ Bactrim ], nitrofurantoin , ciprofloxacin [ Cipro ]) and oral analgesics for potential bouts of discomfort from the stent

31. Ureteroureterostomy , transureteroureterostomy , psoas hitch, and Boari flap

32. Patients who underwent a transperitoneal approach are kept on (NPO) for the first day after surgery All patients receive a 24-hour course of intravenous antibiotics to prevent wound infections.

33. Patients are encouraged to ambulate on the first day after surgery. Once the pain is controlled with oral analgesics and patients are tolerating a regular diet, they are eligible for discharge, with or without their drains