Editing Ureteric Stricture Disease (section)

=====Psoas hitch=====
*'''An effective method to bridge a defect of the lower third of the ureter.'''
*'''<span style="color:#ff0000">Bridges ureteral defect of 6-10cm (other source says 5-8cm[https://pubmed.ncbi.nlm.nih.gov/23759011/])</span>'''
**Can provide up to 5 cm of additional length compared to simple ureteroneocystostomy
**May be preferred over ureteroureterostomy in lower ureteral injuries because the tenuous ureteral blood supply might not survive transection.
**'''<span style="color:#ff0000">A ureteral defect extending proximal to the pelvic brim usually requires more than a psoas hitch alone</span>'''
*'''Relative to the Boari flap, the advantages of psoas hitch include:'''
*#'''Increased technical simplicity'''
*#'''Decreased risk of vascular compromise'''
*#'''Decreased risk of voiding difficulties'''

====== Contraindications (1): ======
*'''<span style="color:#ff0000">A small, contracted bladder with limited mobility</span>'''

====== Technique[https://pubmed.ncbi.nlm.nih.gov/23759011/] ======
*'''Identify the ureter.''' The ureter can be identified medial to the medial umbilical ligament (contains obliterated umbilical ligament) or anterior to the bifuctation of the common iliac artery.
*'''Mobilize the ureter.''' Encircle the ureter with a vessel loop to facilitate traction. Mobilize the ureter distally and proximally. Care must be taken to preserve the periureteric adventitial tissue with its inherent blood supply of the ureter. Ligate and transect the ureter distally, and if being performed for ureteric mass or fistula, ligate and transect the ureter proximally above area of concern. For ureteric mass, send frozen section from the cut edge of the proximal ureter. Place a stay suture at 12 o'clock to facilitate orientation.
*'''Mobilize the bladder.''' Fill the bladder with 200-300 mL of saline via the foley catheter. Dissect the peritoneum off the bladder. Depending on the length of the remaining proximal ureter, further bladder mobilization can be obtained by dividing the median umbilical ligament (urachus) and ipsilateral medial umbilical ligament. 
**'''<span style="color:#ff0000">Additional mobility can be achieved by dividing the contralateral superior vesical artery.'''
**'''Aim is to allow a tension-free fixation of the bladder to the psoas muscle at least 2-3cm above the common iliac vessel.'''
*'''Cystotomy:''' Place two stay sutures, 4-5cm apart, in a oblique orientation such that the medial stay suture is more superior. Make a 4-5cm oblique incision between the stay sutures.
*'''Evaluate bladder tension:''' Use index finger inside the open bladder to elevate the ipsilateral most cranial aspect of the bladder. Check if the raised flap easily reaches the intended point of fixation at the psoas muscle. If the bladder cannot be brought to the psoas muscle without tension, the oblique bladder incision is extended to obtain a longer bladder flap.
*'''Fixation of bladder to psoas:''' Use two to three 3-0 absorbable monofilament sutures to take whole detrusor muscle thickness without mucosa and placed preferentially through the tendon of the psoas muscle above the common iliac artery and the femoral branch of the genitofemoral nerve.
**'''Care should be taken to avoid injury to the genitofemoral nerve and the femoral nerve'''
*'''Ureteroneocystotomy.'''
*'''Insert stent.'''
*'''Bladder closure.'''
*'''Insert surgical drain'''

====== Adverse Events ======
*'''Occur uncommonly'''
*'''Early'''
**'''Nerve injury'''
***'''<span style="color:#ff0000">Femoral nerve is most likely to be injured during a psoas hitch</span>'''
**'''Bowel injury'''
**'''Iliac vein injury'''
**'''Urosepsis'''
*'''Late'''
**'''Urinary fistula'''
**'''Ureteral obstruction'''