Ureteric Stricture Disease: Difference between revisions

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**'''Cystotomy:''' Use cautery to make 1-1.5 cm vertical incision on anterior surface of bladder. Use 4-0 chromic to take inside out bites at 4 quadrants of the cystotomy. Apply snaps to these.

**'''Spatulate ureter'''. Use scissors to spatulate the ureter for 1-1.5 cm at 6 o'clock.

**'''Cephalad vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) to take an outside-in bite on the bladder at the ~~cephalad~~ aspect of the cystotomy and then inside-out on one side of 6 o'clock apex of distal ureter. Use another 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and repeat on contralateral side of ~~cephalad~~ aspect of cystotomy. Tie these down, cut end without needle, place needle end on shod.

**'''Cephalad vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) to take an outside-in bite on the bladder at the lower aspect of the vertical cystotomy and then inside-out on one side of 6 o'clock apex of distal ureter. Use another 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and repeat on contralateral side of lower aspect of cystotomy. Tie these down, cut end without needle, place needle end on shod.

**'''Insert double J stent'''. Advance guidewire through ureter into renal pelvis. Advance double J stent over this, remove guidewire , and allow distal curl to fall into bladder.

**'''Caudal vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and place a U stitch at 12 o'clock of ureter to ~~caudal~~ aspect of cystotomy: take an outside-in bite at 12 o'clock on the ureter followed by inside-out bite on caudal aspect of the cystotomy, then outside-in bite on ~~caudal aspect~~ of the cystotomy just opposite to previous bite, then inside-out on the opposite side at 12 o'clock on the ureter. Tie this down, cut needle off, and leave suture side long.

**'''Caudal vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and place a U stitch at 12 o'clock of ureter to upper aspect of cystotomy: take an outside-in bite at 12 o'clock on the ureter followed by inside-out bite on caudal aspect of the cystotomy, then outside-in bite on upperaspect of the cystotomy just opposite to previous bite, then inside-out on the opposite side at 12 o'clock on the ureter. Tie this down, cut needle off, and leave suture side long.

**'''Complete vesicoureteric anastomosis'''. Use previous 3-0 absorbable monofilament sutures at apex and run each stitch distally. First bite is outside-in on ureter, second bite is backhand inside-out on bladder. Then subsequent bites are forehand outside-in on ureter, inside out on bladder. Once at the caudal end of anastomosis, tie to previous long 3-0 vicryl U sutures. Cut sutures.

**'''Insert surgical drain'''

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*'''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. Additional mobility can be achieved by dividing the contralateral superior vesical artery.

*'''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.

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*'''Rates of ureteroenteric anastomotic stricture after continent diversion is 3-25%, majority occur within the first 2 years'''

==== ~~'''~~Risk factors~~'''~~ ====

==== Risk factors ====

#Technique used for ureteral dissection

#Segment of bowel used for the diversion

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===Retrocaval ureter===

*'''See Pediatrics Ureter Anomalies Chapter Notes'''

*'''See [https://test.urologyschool.com/index.php/Pediatrics:_Ectopic_ureter,_Ureterocele,_and_Ureteral_Anomalies#Retrocaval_Ureter_(Circumcaval_Ureter,_Preureteral_Vena_Cava) Retrocaval Ureter Section] in Pediatrics Ureter Anomalies Chapter Notes'''

==Questions==

#What are the causes of ureteral stricture disease?

@@ Line 159: / Line 159: @@
 **'''Cystotomy:''' Use cautery to make 1-1.5 cm vertical incision on anterior surface of bladder. Use 4-0 chromic to take inside out bites at 4 quadrants of the cystotomy. Apply snaps to these.
 **'''Spatulate ureter'''. Use scissors to spatulate the ureter for 1-1.5 cm at 6 o'clock.
-**'''Cephalad vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) to take an outside-in bite on the bladder at the cephalad aspect of the cystotomy and then inside-out on one side of 6 o'clock apex of distal ureter. Use another 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and repeat on contralateral side of cephalad aspect of cystotomy. Tie these down, cut end without needle, place needle end on shod.
+**'''Cephalad vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) to take an outside-in bite on the bladder at the lower aspect of the vertical cystotomy and then inside-out on one side of 6 o'clock apex of distal ureter. Use another 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and repeat on contralateral side of lower aspect of cystotomy. Tie these down, cut end without needle, place needle end on shod.
 **'''Insert double J stent'''. Advance guidewire through ureter into renal pelvis. Advance double J stent over this, remove guidewire , and allow distal curl to fall into bladder.
-**'''Caudal vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and place a U stitch at 12 o'clock of ureter to caudal aspect of cystotomy: take an outside-in bite at 12 o'clock on the ureter followed by inside-out bite on caudal aspect of the cystotomy, then outside-in bite on caudal aspect of the cystotomy just opposite to previous bite, then inside-out on the opposite side at 12 o'clock on the ureter. Tie this down, cut needle off, and leave suture side long.
+**'''Caudal vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and place a U stitch at 12 o'clock of ureter to upper aspect of cystotomy: take an outside-in bite at 12 o'clock on the ureter followed by inside-out bite on caudal aspect of the cystotomy, then outside-in bite on upperaspect of the cystotomy just opposite to previous bite, then inside-out on the opposite side at 12 o'clock on the ureter. Tie this down, cut needle off, and leave suture side long.
 **'''Complete vesicoureteric anastomosis'''. Use previous 3-0 absorbable monofilament sutures at apex and run each stitch distally. First bite is outside-in on ureter, second bite is backhand inside-out on bladder. Then subsequent bites are forehand outside-in on ureter, inside out on bladder. Once at the caudal end of anastomosis, tie to previous long 3-0 vicryl U sutures. Cut sutures.
 **'''Insert surgical drain'''
@@ Line 181: / Line 181: @@
 *'''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. Additional mobility can be achieved by dividing the contralateral superior vesical artery.
+*'''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.
@@ Line 277: / Line 278: @@
 *'''Rates of ureteroenteric anastomotic stricture after continent diversion is 3-25%, majority occur within the first 2 years'''
-==== '''Risk factors''' ====
+==== Risk factors ====
 #Technique used for ureteral dissection
 #Segment of bowel used for the diversion
@@ Line 306: / Line 307: @@
 ===Retrocaval ureter===
-*'''See Pediatrics Ureter Anomalies Chapter Notes'''
+*'''See [https://test.urologyschool.com/index.php/Pediatrics:_Ectopic_ureter,_Ureterocele,_and_Ureteral_Anomalies#Retrocaval_Ureter_(Circumcaval_Ureter,_Preureteral_Vena_Cava) Retrocaval Ureter Section] in Pediatrics Ureter Anomalies Chapter Notes'''
 ==Questions==
 #What are the causes of ureteral stricture disease?