pelvic ureteral anastomosis

Pelvic ureteral anastomosis includes ureteral end-to-end anastomosis, ureteral bladder transplantation, and ureteral bladder wall anastomosis. Each method corresponds to different symptoms: ureteral end-to-end anastomosis is suitable for ureteral injury and short pelvic surgery. Ureteral stenosis at 2 cm. Ureteral bladder transplantation is suitable for the removal of the lower ureter due to stenosis, injury or tumor in the lower ureter, but the remaining ureter must be of sufficient length so that there is no tension in the anastomosis. The ureteral bladder wall anastomosis is suitable for patients with a small residual ureter. The wall flap of the top of the bladder can be used to make up the resection of the ureter. Treatment of diseases: ureteral tumor ureteral injury Indication 1. Ureteral end-to-end anastomosis is suitable for ureteral injury during pelvic surgery and ureteral stricture shorter than 2cm. 2. Ureteral bladder transplantation is suitable for the lower segment of the ureter due to stenosis, injury or tumor of the lower ureter, but the remaining ureter must have sufficient length so that there is no tension in the anastomosis. 3. The ureteral bladder wall flap anastomosis is suitable for patients with short residual ureter. The wall flap of the top of the bladder can be used to make up the resection of the ureter. Preoperative preparation Epidural anesthesia or spinal anesthesia. Surgical procedure 1. Position: supine position, the side of the sick side is slightly higher. 2. Incision: An oblique or curved incision is made from the medial parallel inguinal ligament of the anterior superior iliac spine to the pubic symphysis. Cut the skin, subcutaneous tissue and the external oblique muscle aponeurosis, and cut the intra-abdominal oblique muscle and the transverse abdominis muscle. If necessary, the anterior rectus sheath can be opened to enlarge the incision. Here, the blood vessels under the abdominal wall are inclined from the outside to the inside. If they cannot be avoided, they can be ligated and cut. Then, the peritoneum is separated from the abdominal wall muscle layer and pulled inward. 3. Exposing ureteral lesions: Separate and expose the ureter that follows the retroperitoneum and the ureter at the junction with the bladder. Care should be taken to protect the ureteral fibrous membrane during separation so as not to damage the abundant vascular anastomosis below the fibrous membrane layer and affect blood supply. 4. Match: According to different situations, the following three methods of matching can be used: (1) ureteral end-to-end anastomosis: firstly separate the two broken ends or separate the two broken ends after the lesion is removed, so that the two broken ends are not tense when they are combined. If possible, chamfer the two sections to increase their circumference. Then, the thicker ureteral catheter is inserted into the renal pelvis through the proximal end, the other end is inserted into the bladder through the distal end, and a small opening is taken out on the anterior and lateral wall of the bladder, and then extracted through another skin incision in the middle of the lower abdomen. The two ends were sutured intermittently with a 3-0 gut. The suture passes through the fibrous membrane layer and the muscular layer without passing through the mucosal layer. The anastomosis is covered with loose tissue in the vicinity. The cigarette was drained from the anastomosis and pulled out from the original incision. (2) ureteral bladder transplantation: the position of the ureteral bladder anastomosis is best selected near the original ureteral orifice, but also at the top of the bladder. The anterior wall of the bladder was cut in the median. After the exploration, the lesion was excised, the distal end of the ureter was ligated, and the proximal segment of the ureter was inserted into the bladder by 1.5 cm (or a 0.8 cm long bladder incision). The bladder muscle layer and the ureteral pulp muscle layer were sutured intermittently with the gut in the periphery of the bladder outside the bladder. The non-supply vessel in front of the ureter was longitudinally opened 0.5 cm, and then the full-thickness ureteral orifice was sleeved, the edge and The mucosa of the small incision of the bladder is anastomosed to the mucosa, forming a papillary opening that protrudes into the bladder. A newly formed ureteral orifice was inserted into the ureteral catheter, a fistula catheter was placed in the bladder for bladder fistula, and a ureteral catheter was passed through the fistula catheter, both of which were drawn through the anterior bladder incision. The anterior bladder incision was sutured in two layers In the middle of the lower abdomen, another drainage port is taken, and the two tubes are taken out. Cigarette drainage was taken from the original incision outside the anastomosis and behind the pubis. (3) ureteral bladder wall flap anastomosis: the wall wall of the anterior wall of the bladder, the width of the valve should be determined according to the thickness of the ureter, generally 3 ~ 6cm, the length can reach more than 10cm, the base of the wall should be wider than the top. The method is to first fill the bladder with saline, and mark the wall wall to be formed on the bladder wall with methylene blue. The inner side of the base starts from the midpoint of the bottom of the bladder and extends downward to reach the lower bladder corner of the healthy side; From the midpoint of the lateral edge of the bladder, it extends downward and stops at a point behind the contralateral pubic symphysis, whereby the point is cut to the point of the lower bladder, which is the top of the wall. The wall flap is turned up, and the physiological saline is injected submucosally at the midpoint of the top edge to separate the mucosa from the muscle layer. A tunnel is made between the two layers with scissors, and the mucosa at the end of the tunnel is cut into a small opening, which will be cut off. The proximal end of the ureter is passed through the tunnel through the small opening. This proximal end is also made into a nipple according to the previous method to prevent stenosis. The sarcoplasmic layer of the ureter is fixedly sutured to the sarcoplasmic layer of the rim of the bladder at the top edge of the wall flap. Ligation of the distal ureter. The ureteral catheter is inserted into the renal pelvis through the new ureteral orifice, and the distal end is drawn through the external urethra. The bladder flap was sutured around the proximal end of the ureter and the bladder incision was sutured. The first layer was sutured continuously with a 2-0 chrome gut. The second layer was sutured or sutured with a silk suture. Inverted suture. Then the pubis on the bladder is ostomy. The abdominal wall incision was sutured layer by layer after the cigarette was drained outside the anastomosis and behind the pubis.

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