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HPV na Prática Clínica

Conheça a clínica
Corpo clínico
Fale Conosco

Doenças e Disfunções
.Infertilidade
.Disfunção erétil
.Infecção urinária
.DST
.Próstata
.Rim
.Bexiga
.Testículos
.Pênis
.Cálculos urinários
.Vasectomia
.Reversão de Vasectomia

Compre o livro
HPV na Prática Clínica

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Managing Ureteral Injuries
Once an injury to the ureter is recognized intraoperatively, it is imperative to evaluate the extent of injury. If a suture or surgical clamp is involved, these must be removed so that the injured site may be thoroughly inspected. Hemostasis and exposure are crucial to allow adequate visualization of the injury site. Indigo carmine dye can be infused intravenously in order to look for extravasation at the suspected site of injury.
Management of ureteral injury is based on the type of injury (crushing versus transection), extent of injury (partial or complete), and its location within the pelvis. In injuries in which the ureter has been crushed (incorrect placement of a clamp), the integrity of the crushed segment must be questioned and a stent should be placed for 7 to 10 days while revascularization occurs.(7) Most of these injuries require a stent to prevent stricture formation. If the crushed segment appears necrotic or ischemic, the segment must be excised and repaired as if the ureter had been transected. Partial or complete transection of the ureter requires surgical repair. If a ureter has a small partial transection, it is possible to repair it directly unless the injury is very distal and difficult to assess. In those instances, it is easier to reimplant the ureter directly into the bladder. In cases of larger partial injuries, the ureter should be completely divided, spatulated, and repaired primarily with an end-to-end anastomosis.
Complete transections are managed based on the level of injury. If the ureter is injured more than 5 cm from the ureterovesical junction, a ureteroureteral anastomosis should be performed. If the injury is less than 5 cm from the ureterovesical junction, a ureteroneocystotomy should be performed.(4) When repairing a ureteral injury, a few basic principles should be remembered: 1. The ureter should be handled gently with atraumatic forceps. 2. The ends of the damaged segment are freshened prior to reanastomosis. 3. Unnecessary dissection should always be avoided. 4. The anastomosis must be tension free. 5. A retroperitoneal drain should be placed next to the area of repair and a ureteral stent should be placed to prevent stricture formation.(3)
New growth of transitional epithelium occurs in approximately 2 weeks followed by peristalsis across the repair in approximately 4 weeks.(7) When the diagnosis of the ureteral injury is delayed, it may not be feasible to reoperate at the time of diagnosis. Most surgeons will reoperate if the diagnosis is made within 72 hours of the original surgery. Others may choose to reoperate within 1 to 2 weeks if there are no contraindications. If more than 2 weeks have elapsed since the initial insult, most surgeons agree that it is best to place a percutaneous nephrostomy tube to drain the ipsilateral kidney. Reoperation should then be considered after 8 to 12 weeks.(4) In several studies it has been reported that 70% to 80% of injuries resolve with percutaneous nephrostomy tube placement.(14,15) Therefore, it is important to perform an IVP or retrograde ureterography prior to reoperating to assess the integrity of the ureter. Contraindications to immediate reoperation include a delay of more than 2 weeks postoperatively, poor surgical candidacy, recent radical pelvic dissection, or postoperative infection.(7)
Managing patients after ureteral repair involves catheter drainage of the bladder. The Foley catheter should be left in place until the drainage from the Jackson Pratt (JP) drain is less than 25 to 30 cc/day. Typically, 2 to 3 days is adequate if there was no cystotomy and 7 to 10 days if a cystotomy had been performed. If the JP drainage increases after the Foley is removed, the Foley catheter should be replaced. If no increase in JP drainage is noted, the JP drain may be removed. Ureteral catheters are generally removed in 10 to 14 days unless the ureter has been completely transected. In cases of complete transection, the ureteral catheters should be left in for 3 to 6 weeks. An IVP should be performed 1 month after all drains and catheters are removed. If the initial study is normal, a follow-up ultrasound should be performed at 3 and 6 months postoperatively. Any abnormal study should be repeated in 4- to 6-week intervals until stabilization or resolution of the problem is clear.(4)

Summary
In summary, the location and type of injury will determine the type of surgical repair. A thorough knowledge of pelvic anatomy, including the course of the ureter and its blood supply, is critical in preventing injury to the ureter. Of equal importance is recognizing an injury if it does occur and knowing the basic steps to take to both avoid further harm and facilitate repair in an expeditious fashion.