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the edges of the bowel using a series of interrupted
Vicryl sutures. The conduit base is now attached to the
posterior abdominal wall peritoneum with two or three
individual sutures of Vicryl. This is important so there
is no tension on the ureters themselves, and the conduit
does not prolapse into the pelvis.
Formation of the stoma
A circle is cut in the skin at the site marked by the stoma
therapist. This incision is carried down to the aponeurosis, which is cut and the edges clipped. The surgeon
Suturing the ileal segment to the ureters
The staples on each side of the ileal segment are now
removed or, as in modern practice, the isolated ileal
segment can now be lifted up. The long arm of the T
tube is threaded through the segment. This is ideally
done by passing a soft bowel clamp down the length of
the segment, grasping the tube and drawing it gently
through. It is important to make sure that the tube
passes in the direction of peristaltic flow, and as the T
tube is threaded through the segment (Fig. 28.9) the
edges of the platform can then be carefully sutured to
BONNEY’S GYNAECOLOGICAL SURGERY
290
Fig. 28.4 Reconstituting bowel
continuity using the GIA
stapling device.
Fig. 28.5 TA55 stapler (this artwork
was originally prepared for the United
States Surgical Corporation’s General
Atlas and for publications by
Professors Mark Ravitch MD and
Felicien Steichen MD, ©USSC 1981).
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FORMATION OF A URINARY DIVERSION
291
Fig. 28.6 Completing the side-to-side anastomosis using the
TA55 stapler and removing redundant tissue.
Fig. 28.7 Showing the isolated loop of bowel and the
completed reanastomosed small bowel.
Fig. 28.8 Joining the splayed out ends
of the ureter and inserting a T tube.
now places his left hand in the abdomen and elevates
the abdominal wall under this incision. With his right
hand he continues to cut down through the peritoneum, producing a hole through which the index
finger can be easily passed.
A Babcock forcep is now passed through the hole and
the distal end of the conduit with the T tube is gently
drawn through. The conduit should be inspected to
make sure that it is lying comfortably without undue
tension or torsion. The edges of the peritoneum and the
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this is usually removed within 24 h of the end of the
procedure.
Variations in technique
Recently, the authors have performed all the stapling
with the GIA stapling device. This simplifies the operation, allows one instrument with replaceable cartridges
to be used throughout, and improves the speed and
cleanliness of the procedure.
Postoperative care
It has been the authors’ practice to maintain the nasogastric tube for 3–4 days. It is then removed and the patient allowed free fluids and light diet by mouth. Many
surgeons now do not use nasogastric tubes but the evidence base appears to be low. The T tube is kept in place
for approximately 10 days and is then gently pulled to
see if it can be removed. If it does not easily release, further attempts should be made on the next 2 days, but
then the patient can be allowed home with the T tube in
place, and it is usually found after a short period of time
that the conduit naturally discharges the T tube into the
ileostomy bag. The patient will require intensive training in the maintenance of the ileostomy appliance. This
is performed by the stoma therapist once the patient is
mobile and confidence is developed at this time. It has
been the authors’ practice to maintain prophylactic
antibiotics, not only during the operation but for some
aponeurosis in the stoma hole are now sutured to the
bowel to fix it in position. The position and fixity of the
bowel should be at a short distance from the open end
of the conduit. The Babcock forcep is now inserted a
short distance into the stoma and used to grasp the
mucosa (Fig. 28.10). This process everts the end of the
bowel, and the edge of the bowel which is now rolled
back on itself is sutured first to the serosa and then to
the skin edge so that a rosebud stoma is formed. The
stoma appliance is put in place feeding the shortened T
tube down into the back.
Closing the abdomen
This is carried out as described in Chapter 6. It is prudent to place a drain close to the anastomosis site, but
BONNEY’S GYNAECOLOGICAL SURGERY
292
Fig. 28.9 Drawing the long arm of the T
tube down the segment of bowel.
Fig. 28.10 Forming the ‘rose bud’ stoma.
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298–301), demonstrates another way in which stapling techniques can be used for the formation of conduit and reanastomosing bowel segments.
Buchsbaum and Schmidt’s Gynecologic and Obstetric
Urology, 2nd edition, published by W.B. Saunders, Philadelphia, in 1982, pp. 168–188, contains a complete review of the
major techniques for urinary diversion. They clearly cover
the indications and the wide variety of methods available to
the surgeon for making a diversion.
days after the procedure, until good urinary flow is
developed.
It is important to maintain good hydration so that a
fast flow of urine can be maintained in the postoperative period. This will reduce the risk of clot formation
blocking the ureters or the conduit itself.
Further reading
Textbooks
Stapling in Surgery by Felicien Steichen and Mark Ravitch,
published by Year Book Medical Publishing, Chicago (pp.
FORMATION OF A URINARY DIVERSION
293
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294
Damage recognized at the time
of operation
Bladder injuries
The most common circumstance for damage to the
bladder is when the bladder is being separated from the
anterior surface of the lower uterus and cervix during
hysterectomy or caesarean section. If the surgeon is
unsure about the possibility of an injury he should
insert diluted methylene blue into the bladder through
a urethral catheter and look for any leakage into the
peritoneal cavity.
Damage to the muscularis
If the bladder is not entered but a ‘bubble’ of mucosa
can be seen pushing through from the muscularis, all
that is required is that the area should be oversewn with
an interrupted or continuous Vicryl suture and as a precaution the bladder drained with a Foley catheter for 7
days following the procedure.
Breaching of the bladder wall
If the bladder has obviously been entered, the area
should be clearly identified by placing Allis’s tissue forceps on the edge of the defect. The mucosa and muscularis can be sutured separately in two layers with a
continuous suture followed by an interrupted layer
using a Vicryl suture. However, if trauma is minimal,
the repair can be in a single layer to the muscularis coat
with a continuous or interrupted suture technique.
It is vital to identify the ureteric orifices if the damage
has occurred close to the trigone or the site of entry
of the ureters into the bladder wall. In these
The management of injuries to the
urinary tract
29
There has been little need for major changes to this
chapter since the last edition. Although injury to the
urinary tract is one of the major concerns of the gynaecological surgeon during routine gynaecological procedures, actual injury is rare. The surgeon should know
the whereabouts of the ureters and bladder during any
procedure to avoid being ‘a urinary tract neurotic’ and
taking ridiculous precautions to avoid the ureters and
bladder. These structures should be treated with care
but not with the type of respect which results in never
handling them.
Anatomical relationship
The source of the gynaecologist’s concern is the close
relationship of the ureters to the cervix and the uterine
arteries, and the retroperitoneal course of the ureter in
the pelvis and its close contiguity with the infundibulopelvic ligament at the pelvic brim. The attachment of
the bladder to the anterior part of the uterus and the
necessity to separate the two structures often places the
bladder in considerable danger of damage.
Predisposing factors
These are summarized in Table 29.1.
Traditionally, injuries to the urinary tract have been
classified into those recognized at the time of operation
and those which manifest themselves later in the postoperative period.
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Incision of the ureter
It is rare to partially resect the ureter; more commonly,
it is completely resected. In these circumstances the
management is to anastomose the cleanly divided ends
of the ureter, having first made the ends spatulate (Fig.
29.1).
The operation
Identifying the site of damage The area affected is
exposed and the damaged area resected.
Making the anastomosis The clean ends of the ureter
are spatulated (see Fig. 29.1), and sutured using 4.0
Vicryl over a ureteric stent.
Management of the stent The commonest stent used is
the ‘pigtail’ Silastic stent (Fig. 29.2), which can remain
in the ureter for considerable periods of time. The
upper end of the stent is inserted into the renal pelvis
and the lower end into the bladder. If a pigtail is used, no
fixation is required as the ‘memory’ of the catheter will
circumstances, the gynaecologist would do well to call
upon the assistance of a urological colleague to perform
the repair.
If it is necessary to carry out a repair without assistance, the gynaecologist should open the bladder at its
upper part, identify the ureteric orifices, catheterize
them and proceed with the repair under direct vision.
Where the damage to the bladder has occurred following irradiation, there is a significant risk of failure of
healing and subsequent fistula formation. The interposition of an omental flap may improve the blood supply
to the area and reduce the risk of necrosis.
Ureteric injuries
Where it is suspected that the ureter has been damaged
at operation, whether this be by cutting, crushing or inclusion in a suture, then the ureter should be widely exposed so that a full inspection can be carried out. This is
best done by separating the pelvic peritoneum from the
pelvic side wall and exposing the full length of the pelvic
part of the ureter. It is not necessary to separate the
ureter from the peritoneum for its full length as this
would merely jeopardize its blood supply. An immediate repair of the damaged ureter gives a very good
prospect of complete recovery without the need for
further surgery.
Injuries to the pelvic ureter
Crushing injuries
These may be caused by crushing or nipping by tissue
forceps or by inadvertent ligation. The management
should be to resect the crushed area and anastomose the
two ends (Fig. 29.1).
INJURIES TO THE URINARY TRACT
295
Table 29.1 Predisposing factors leading to urinary tract
injury in gynaecological procedures
Congenital anomalies, including duplex ureters and ectopic
kidneys
Endometriosis
Chronic pelvic inflammatory disease
Retroperitoneal masses such as broad ligament fibroids and
large ovarian cysts
Previous pelvic surgery
Radiotherapy with scarring and compromised blood supply
Fig. 29.1 Anastomosis of the ureter after either transection
or resection of a short length of damaged ureter.
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The operation
Preparation of the ureter The damaged distal end of
the ureter must be ‘freshened’ by removing any
necrosed or traumatized tissue. A short length of ureter
is mobilized and the distal end drawn towards the
bladder.
Assessing ureteric tension and bladder mobilization If
there is any tension, then the bladder should be
mobilized by separating it from the symphysis pubis,
gently lifting the bladder towards the ureter (the psoas
hitch), or by developing a ‘Boari–Ockerblad flap’.
The psoas hitch This simple technique involves
suturing the bladder wall to the iliopsoas muscle on
the pelvic side wall, thus elevating the bladder and
shortening the distance between the bladder and the
ureter to be anastomosed (Fig. 29.3).
The Boari–Ockerblad flap Where there has been significant loss of the distal ureter, this technique allows
the gap to be bridged by bladder tissue and a satisfactory anastomosis to be achieved without tension.
unwind the terminal few centimetres and provide adequate fixation (see Fig. 29.2).
Extraperitoneal drainage The operative area should
be drained to monitor for leakage of urine during the
first few days.
Injuries to the distal ureter
This type of injury tends to occur in association with
gynaecological surgery. It differs from injuries higher
up the ureter in that it is often difficult to mobilize the
ureter sufficiently to anastomose it without tension. In
this situation the method most used to deal with this
problem is to produce a new point of entry into the
bladder; the damaged distal portion remaining can be
either ligated or resected. The ureter should be implanted using an antireflux mechanism which will
require the bladder to be opened.
BONNEY’S GYNAECOLOGICAL SURGERY
296
Fig. 29.2 The Bard coil stent, showing the Silastic stent and
the coiled introduction wire. Photograph kindly supplied by
Bard Urology Division, Bard Limited, Sunderland, Tyne and
Wear, UK.
Fig. 29.3 The psoas hitch.
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Bladder closure and drainage The bladder is drained
with an indwelling catheter and the extraperitoneal
space is drained with a suction drain.
The most important point to be considered when fashioning the flap (Fig. 29.4), is to be careful not to make
the flap too narrow. It is extraordinarily easy to forget
the relationship between the width of the flap and the
tube which it must become. The flap is more readily performed with a full bladder and it may be worth filling
the bladder before the incision. An oblique U-shaped
incision is then made in the bladder wall and the distal
end of the ureter is either sutured directly to the end or
is tunnelled submucosally. Figures 29.4 and 29.5 show
the technique for producing a flap with an antireflux
anastomosis.
Direct implantation of the ureter into the bladder
Once the end of the ureter is clean and it has been
decided that it is possible to implant it into the bladder,
the first step is to open the bladder and confirm the site
of anastomosis. Again, this is more readily performed
with a full bladder. An oblique opening is then made in
the bladder and the distal end of the ureter is drawn
through it using two stay-sutures attached to its edges
(Fig. 29.6). The edges are then sutured to the mucosa
and two further stitches are placed to fasten the side of
the ureter to the outer surface of the bladder in order to
anchor it and counter any tendency to retraction. The
ureter is stented and the coiled end left to lie in the
bladder to be retrieved later using a cystoscope.
INJURIES TO THE URINARY TRACT
297
Fig. 29.4 The Boari–Ockerblad flap: developing the flap
from the bladder wall.
Fig. 29.5 The Boari–Ockerbald flap: suturing the flap to
form a tube over the antireflux anastomosis.
Fig. 29.6 Implantation of the ureter into the bladder wall.
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Frequently, it is not possible to bridge the obstructed or
damaged length of ureter and more extensive procedures are necessary. These are entirely in the province of
the urologist and will merely be listed here.
(a) Ureteroileoneocystostomy, or the use of an isolated segment of ileum to bridge the damaged length of
ureter to the bladder.
(b) Transureteroureterostomy may be used if it is
not possible to reanastomose the damaged ureter with
the bladder or the urologist feels that the long-term
problems of using a segment of intestine are not
justified.
(c) Nephrectomy may be necessary if renal function
is markedly impaired.
Radiotherapy damage
Where the patient has had irradiation to the ureter
which is damaged, great care and skill is called for when
deciding on the optimal method of repair. It is also important to remember that the irradiation may have also
compromised the blood supply of organs close to the
ureter, particularly bowel; consequently, if conduits are
to be produced, a segment of bowel outside the irradiation field should be chosen.
The gynaecologist must not be slow or too proud to
ask for advice and assistance from his urological colleagues; early recognition and management of damage
to the urinary tract is in the patient’s best interests.
Further reading
Textbooks
Buchsbaum and Schmidt’s Gynecologic and Obstetric
Urology, 2nd edn, published by W.B. Saunders, Philadelphia,
in 1982, is a valuable source of information on many urological problems found in obstetrics and gynaecology. The sections on the various traumas to the urinary tract are well
hidden in the text but are worth searching for, drawing the
reader’s attention to many valuable diagnostic and management principles.
References
WF Hendry, in a review in Progress in Obstetrics and Gynaecology, vol. V, John Studd (ed.), published by Churchill
Livingstone, has summarized many thoughts on the subject.
Postoperative care
Prophylactic antibiotics specific for bacteria affecting
the urinary tract should be used. The ureteric catheter
should be maintained for at least 7 days, preferably
longer.
An intravenous urogram with special views of
the lower ureter will confirm the security of the
anastomosis.
Ureteroureteral anastomosis This may be necessary if
it is impossible to bridge the gap between the end of the
damaged ureter and the bladder. The damaged ureter is
cleaned and mobilized; it is then brought across the
mid-line without tension and directly anastomosed
into the side of the remaining ureter. Ureteric stents
should be used to support the anastomosis until healing
has occurred.
Ileal conduit In the rare circumstances where both
ureters are damaged and reimplantation into the
bladder cannot be achieved, it is preferable to produce
a urinary diversion such as an ileal conduit rather than
make a skin ureterostomy.
Management of the delayed diagnosis of
urinary tract damage
The management of the late diagnosed urinary tract
damage is mainly the area of expertise of the experienced urologist; the gynaecologist should not delay in
calling for his colleague’s advice as further delay will
seriously risk the function of the kidney.
The diagnosis of urinary tract damage may be made
following the development of symptoms such as urine
leakage if a fistula has occurred or loin or ureteric pain
where obstruction to the outflow develops.
The management of urinary fistulae is dealt with in
Chapter 15.
The management of obstructive damage to the
ureters can be divided into two phases: drainage and
repair. Drainage of the obstructed renal tract is best
performed by radiologically guided percutaneous
nephrostomy. Ureteric catheters can sometimes be
passed beyond the point of obstruction, especially
when the blockage is due to extrinsic pressure.
Repair of the damage to the ureter needs to be carried
out if the obstruction could not be relieved by a stent.
BONNEY’S GYNAECOLOGICAL SURGERY
298
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The 2nd edition of Atlas of Urologic Surgery, by Frank
Hinman, published by W.B. Saunders (1998) is an excellent
book with full descriptions and useful illustrations of the
relevant urological procedures.
He has also used his own wide experience to demonstrate
the methods of diagnosis and management of a variety of obstructive problems of the ureter in patients with gynaecological disease.
INJURIES TO THE URINARY TRACT
299
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