Endoscopic management of iatrogenic ureteric strictures
Download
1 / 25

Endoscopic management of iatrogenic ureteric strictures. - PowerPoint PPT Presentation


  • 189 Views
  • Uploaded on

Endoscopic management of iatrogenic ureteric strictures. Vijayanand.B , Sriram.K , Sunil Shroff. SRMC. History. 33 yr female Right loin pain, 4 weeks Fever since, 2 weeks. Difficulty in breathing , 1 week. Reduced urine output, 2 days. History. No co-morbid associated factors

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Endoscopic management of iatrogenic ureteric strictures.' - graceland


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Endoscopic management of iatrogenic ureteric strictures

Endoscopic management of iatrogenic ureteric strictures.

Vijayanand.B , Sriram.K , Sunil Shroff.

SRMC


History
History

  • 33 yr female

  • Right loin pain, 4 weeks

  • Fever since, 2 weeks.

  • Difficulty in breathing , 1 week.

  • Reduced urine output, 2 days.


History1
History

  • No co-morbid associated factors

  • Hysterectomy 4 weeks earlier.

  • Contrast CT thorax 2 days prior to admission.


  • Hb 10.2 gm%

  • TC 12600

  • BUN 40 mg/dl

  • S.Creatinine 2.4mg/dl

  • S.Electrolytes -- WNL

  • USG abdomen: Right gross hydrouretero nephrosis

  • Parenchymal thickness: 2.2 cms.





Initial management
Initial management

  • USG guided PCN

  • Treated for bronchopneumonia

  • Renal parameters reverted to normal


Further management
Further management

After 6 weeks , surgery was planned.



Antegrade manipulations
Antegrade Manipulations

  • Passed a 0.025” Terumo guidewire from the nephrostomy down and slipped it through the strictured area

  • Exchanged with PTFE 0.035 over 5 Fr ureteric Catheter

  • Olive tipped dilators used to dilate the area


Grade of ureteral injuries
Grade of ureteral injuries

Grade I (haematoma) - Contusion or Haematoma.

Grade II (laceration) - Less than 50% transection.

Grade III (laceration) - Greater than 50% transection.

Grade IV (laceration) - Complete transection with 2 cm of devascularization.

Grade V (laceration) - Avulsion with greater than 2 cm of devascularization.


Type of ureteral injuries
Type of Ureteral injuries

  • Crushing by misapplication of the clamps

  • Ligation with a suture

  • Transection ( Partial / complete)

  • Angulation of the ureter with secondary clips.

  • Ischaemia from ureteral stripping electro-coagulation.

  • Resection of a segment of ureter.

  • Combination of the above.


Incidence of surgical injury
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 of ureteral injuries

usually involves the lower third

Ovarian vascular pedicle at infundibulo-pelvic ligament

Ureteric relation with the uterine artery.

Cardinal ligament, where the ureter crosses under the uterine artery.

Cardinal ligament tunnel, dorsal to the infundibulo -pelvic ligament near or at the pelvic brim.

Vaginal fornices.

Lateral rectal pedicles.

Pathological distortion of the ureteral anatomy.


Treatment depends on
Treatment depends on

Diagnosis made

Immediate - intra-op diagnosis.

Delayed - after few days to weeks.


If diagnosed intra op
If diagnosed intra-op

Grade 1

DJ stenting

Grade 2

DJ stenting

PCN


If diagnosed intra op1
If diagnosed intra-op

Grade 3,4,5:(depending on the level of injury)

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 of presentation

  • Can present post operatively

    - Stricture

    - Urinoma

    - Fistula

    - Obstructive uropathy.


Stricture

  • Endo balloon dilatation.

  • DJ stenting.

  • Endoscopic ureterotomy.

    (using Ho:YAG Laser).


Post op period urinoma
Post-op. periodUrinoma

  • PCN placement.

  • 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).


Newer developments
Newer developments

  • Endoscopic Laser luminization

  • Laparoscopic ileal ureter.

  • Lap SIS replacement of ureter.


References
References

  • EndoscopicManagement ofUreteralStrictures. Evan R. Goldfischer a and Glenn S. Gerber a. The Journal of urology, 1997 – Elsevier.

  • AA Selzman, JP Spirnak - The Journal of urology, 1996 - IatrogenicUreteralInjuries: A20-YearExperience in Treating 165 Injuries.

  • Urological injuries during obstetric and gynaecological surgical procedures. Shrivastava A, Nandanwar S, Bhattacharya. M .Journal of Postgraduate Medicine, Year 1991, Volume 37, Issue 1.

  • 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.



ad