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Surgery for injuries or damage to the urinary tract
Wounds or damage to the urinary tract can occur during gynecological and obstetric operations, various injuries. If urinary tract injury is suspected, appropriate diagnostic techniques are required to establish the location, shape and size of damage. In most cases, injuries of the urinary tract are detected immediately, during surgery or other manipulations. And only in certain situations, injuries or damage to the urinary tract are detected some time after the fact. Tactics in detecting fresh wounds of the urinary tract is reduced to surgical intervention for their suturing or plastic surgery.
Wounds of the bladder are extraperitoneal and transperitoneal, with penetration into the cavity (complete) and without damage to the mucous membrane (incomplete). In case of non-penetrating injuries of the bladder, two rows of separate sutures are placed on the muscle membrane, without piercing the mucous membrane with subsequent peritonization.
Technique performance. When penetrating wounds of the bladder at the edges of the wound clamps are superimposed and it stretches, acquiring a slit-like shape. The locations of the mouths of the ureters, their relationship to the wound hole are determined. Only after that it is sutured with separate sutures without piercing the bladder mucosa. First impose side seams, retreating 0.5-1 cm from the edge of the wound. These ligatures are taped. The second row of stitches is superimposed so that each ligature is between the two stitches of the first row. Closure by peritonization is ending.
In case of extraperitoneal damage to the bladder, a suprapubic incision of the abdominal wall and suturing of the bladder are made from the side of the bladder, and in the case of intraperitoneal bladder - a laparotomy and closure from the side of the abdominal cavity. In the postoperative period, a permanent catheter is left for 5-7 days.
Damage to the urethra can occur with blunt trauma to the genitals, intercourse and gynecological operations. There may be a longitudinal tear or incision of the urethra, as well as its transverse rupture. Sewing with a thin needle and thin stitches. At a rupture of the urethra, a section of the bladder is made from the side of the vagina or pubis (with suprapubic transverse section) and a catheter is inserted from the side of the bladder, by means of which the central and peripheral ruptured ends of the urethra are searched and stitched.
Damage to the ureter can be lateral (tangential), as a complete cross section, stabbed, as well as when seized into a ligature. In case of lateral damage to the ureter, several separate sutures are applied and peritonization is performed due to the peritoneum located nearby. If the ureter gets into the ligature without wound injuries, it can be limited to its release (loosening of the ligature), if no more than 6-10 hours have passed since the moment of operation.
However, there is evidence of the restoration of the patency of the ureter and the preservation of its integrity upon release from the ligature for up to 2 days. For transverse transection of the ureter, surgical intervention is indicated for various options, the choice of which depends on the location of the transection. Stapling of the ends of the ureter can be end-to-end or end-to-side. With an anastomosis end to end, the ends of the ureter are stitched together on the ureteral catheter, which is left for 20-25 days. With the invaginal anastomosis method (end to side), the vesicular end of the ureter is first tied, then a longitudinal incision is made (0.5-1 cm), through which, using two ligatures, applied as a mattress suture, a cut-off oblique central end of the ureter is inserted. The ligatures are tied and cut, and the hole is sutured with separate seams. The suture area is peritonized. An invaginal method of ureteral stitching is also possible with an end-to-end anastomosis.
The ureter is inserted into the bladder in case of its transection in the lower sections. The closer to the bladder ureter transection occurred, the more successful this operation. Its effectiveness is still determined by the degree of mobility and displacement of the ureter down and the bladder up. For this, mobilization of that part of the ureter that is implanted into the bladder is often performed, and the latter is lifted upwards and fixed with 3-4 stitches to the walls of the pelvis. There must be good conditions for peritonealization of the area of implantation of the ureter into the bladder. In the last through the urethra is a metal catheter, which bulges the wall of the bladder. On the catheter, in the area of protrusion, dissection of the bladder wall is performed. It is necessary that the dissection of the bladder wall is made closer to the implantable end of the ureter, as well as to its mouth in the bladder. The renal segment of the ureter is cut longitudinally by 1 cm. Through these created blades, the ureter is carried out using the mattress method of ligature, which is then taken from the side of the bladder cavity to its outer wall and fixed, tying it on one side and the other. The hole in the bladder is sutured to the walls of the ureter. The area of implantation of the ureter into the bladder is peritonized by the peritoneum. A permanent catheter is left in the bladder for 6-8 days.
Known methods of ureteral transplantation into the colon, temporarily in the skin, etc.
If the ureteral stricture is not removed, hydronephrosis and subsequent kidney atrophy develop.
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Surgery for injuries or damage to the urinary tract
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