The left ureter is at risk for injury during hysterectomy, hemicolectomy, and any procedure performed in the pelvis. Recognition and repair of the injury limits post-operative morbidity. Once the injury is recognized, a number of repairs are possible. In all repairs, a water-tight closure and mucosa-to-mucosa apposition of the anastomosis is necessary. The location of the injury often determines the type of repair utilized.
More commonly, injuries occur outside the pelvis. In these cases, a ureteroureterostomy can be performed to restore continuity of the urinary tract. For injuries in the pelvis, commonly a simple ureteral reimplantation into the bladder is the most effective option. The ureter is spatulated and a new opening created in the bladder wall. The ureter is anastomosed to the bladder mucosa with 4-0 or 5-0 absorbable suture, and potential tension on the anastomoses is lessened with a psoas hitch.
Injuries in the middle to proximal third of the ureter are often repaired with ureteroureterostomy (figure 1). The proximal ureter around the injury is mobilized for a short segment. This can often be performed with blunt dissection that preserves the periureteral vascular supply. The same is then completed for the distal segment. The two ends should meet, excluding the injured portion, without tension. A healthy portion of the ureter needs to be identified and used for the anastomosis on each end. The injured portion of the ureter can often be removed. Once the two ends are able to reach without tension, spatulation longitudinally is performed to widen the region of anastomosis (figure 2a and b). This will allow minor contraction without narrowing the lumen. A stay stitch may be used in each end to minimize tissue handling. The mucosa should not be manipulated with forceps. Using a 4-0 or 5-0 synthetic absorbable suture, the apex of one end is anastomosed to the spatulated portion of the other (figure 2c). A full thickness suture is placed with the knot on the outside of the mucosal apposition. Interrupted sutures are placed approximately every 2 to 3 mm to ensure a water tight closure. Once half the anastomosis is completed, a ureteral stent may be placed to facilitate drainage while the injury heals. The ureteral anastomosis is then completed. Post-operatively, a closed suction drain should not be left adjacent to the repair as this may promote further urine leak and fistula formation. If a ureteral stent is placed, it should be removed in 4 to 6 weeks (figure 3).
Injuries occurring in the lower third of the ureter can be repaired with primary ureteral reimplantation with or without a psoas hitch. To prepare the proximal ureteral segment, gentle mobilization of the peritoneum medially is accomplished using a vessel loop around the ureter and bluntly dissecting proximally. The ureteral segment is transected at 90 degrees, followed by ...