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Endoscopic-management-of-ureteric-injury

Endoscopic-management-of-ureteric-injury - Endoscopic...

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Unformatted text preview: Endoscopic management of iatrogenic ureteric strictures. iatrogenic Vijayanand.B , Sriram.K , Sunil Shroff. SRMC History History 33 yr female Right loin pain, 4 weeks Fever since, 2 weeks. Fever Difficulty in breathing , 1 week. Reduced urine output, 2 days. Reduced History History No co-morbid associated factors Hysterectomy 4 weeks earlier. Contrast CT thorax 2 days prior to Contrast admission. admission. Hb 10.2 gm% Hb TC 12600 BUN 40 mg/dl S.Creatinine 2.4mg/dl S.Electrolytes -- WNL USG abdomen: Right gross hydrouretero USG nephrosis nephrosis Parenchymal thickness: 2.2 cms. CT KUB CT CT KUB CT CT KUB CT Initial management Initial USG guided PCN Treated for bronchopneumonia Renal parameters reverted to normal Further management Further After 6 weeks , surgery was planned. RGP RGP Antegrade Manipulations Passed a 0.025” Terumo guidewire from the nephrostomy down and slipped it through the strictured area strictured Exchanged with PTFE Exchanged 0.035 over 5 Fr ureteric Catheter Catheter Olive tipped dilators used Olive to dilate the area Grade of ureteral injuries Grade Grade I (haematoma) Grade - Contusion or Haematoma. Grade II (laceration) (laceration - Less than 50% transection. Grade III (laceration) (laceration) - Greater than 50% transection. Grade IV (laceration) Grade - Complete transection with 2 cm of devascularization. Grade V (laceration) (laceration) - Avulsion with greater than 2 cm of devascularization. cm Type of Ureteral injuries Type Crushing by misapplication of the clamps Ligation with a suture Transection ( Partial / complete) Angulation of the ureter with secondary clips. clips. Ischaemia from ureteral stripping electrocoagulation. Resection of a segment of ureter. Combination of the above. Incidence of surgical injury Gynecologic surgery 50 – 66 % General / Colorectal Surgery 15 – 25 % Abdominal vascular surgery 5 – 10 % Ureteroscopy (perforation) 1% - 5 % Sites of ureteral injuries Sites usually involves the lower third Ovarian vascular pedicle at infundibulo-pelvic ligament infundibulo-pelvic Ureteric relation with the Ureteric uterine artery. uterine Cardinal ligament, where the where ureter crosses under the uterine artery. uterine Cardinal ligament tunnel, dorsal to the infundibulo -pelvic ligament near or at the pelvic brim. the Vaginal fornices. Lateral rectal pedicles. Pathological distortion of the Pathological ureteral anatomy. ureteral Treatment depends on Treatment Diagnosis made Immediate - intra-op diagnosis. Delayed - after few days to weeks. If diagnosed intra-op If Grade 1 DJ stenting Grade 2 DJ stenting PCN If diagnosed intra-op Grade 3,4,5:(depending on the level of injury) Grade Short segment loss: – Open or Lap. Ureteric reimplantation. – Open or Lap. Uretero-ureterostomy. – Open or Lap. Psoas hitch. Long segment loss: – Open or Lap. Boari flap. – Open or Lap. Ileal ureter. Mode of presentation Mode Can present post operatively Can - Stricture Stricture - Urinoma Urinoma - Fistula Fistula - Obstructive uropathy. Obstructive Stricture Endo balloon dilatation. DJ stenting. DJ Endoscopic ureterotomy. (using Ho:YAG Laser). (using Post-op. period Urinoma PCN placement. PCN Per-cutaneous drainage of the urinoma (if needed) Wait for edema, induration to settle down. Ante grade nephrostogram, 6 weeks later. Definitive repair on a later date. (depends on the type of ureteral injury). (depends Newer developments Newer Endoscopic Laser luminization Laparoscopic ileal ureter. Lap SIS replacement of ureter. References Endoscopic Management of Ureteral Strictures. Evan Endoscopic Management Ureteral Strictures Evan R. Goldfischer a and Glenn S. Gerber a. The Journal of urology, 1997 – Elsevier. urology, AA Selzman, JP Spirnak - The Journal of urology, 1996 AA Selzman JP - Iatrogenic Ureteral Injuries: A 20-Year Experience Iatrogenic Ureteral Injuries 20 in Treating 165 Injuries. in Urological injuries during obstetric and gynaecological surgical procedures. Shrivastava A, Nandanwar S, Bhattacharya. M .Journal of Postgraduate Medicine, Year 1991, Volume 37, Issue 1. Year Ileal substitution as a Salvage Procedure in the management of iatrogenic ureteric injuries. Gupta NP, Chahal R, Wadhwa. Indian Journal of Urology, Year 1997, Volume 13, Issue 2. 1997, THANK YOU THANK ...
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