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Surgery for wounds or damage to the urinary tract
Wounds or damage to the urinary tract can occur during gynecological and obstetric operations, various injuries. If there is a suspicion of an injury to the urinary tract, appropriate diagnostic methods are required to establish the location, shape and size of the 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 a fait accompli. Tactics when detecting fresh wounds of the urinary tract is reduced to surgery to suture them or perform plastic surgery.
Bladder injuries are extraperitoneal and transperitoneal, with penetration into the cavity (complete) and without damage to the mucosa (incomplete). For non-penetrating wounds of the bladder, two rows of separate sutures are applied to the muscle membrane, without piercing the mucosa with subsequent peritonization.
Technique of execution. With penetrating wounds of the bladder, clamps are applied to the edges of the wound and it stretches, acquiring a slit-like shape. The places of the mouths of the ureters, their relation to the wound hole are determined. Only after that it is sutured with separate sutures, without piercing the mucous membrane of the bladder. The first sutures are lateral, 0.5-1 cm from the edge of the wound. These ligatures are holders. The second row of seams is overlapped so that each ligature is between the two seams of the first row. Closure ends with peritonization.
With extraperitoneal damage to the bladder, a suprapubic section of the abdominal wall and suturing of the bladder from the side of its cavity are made, and with intraperitoneal damage, laparotomy and suturing from the side of the abdominal cavity are performed. In the postoperative period, a permanent catheter is left for 5-7 days.
Damage to the urethra can be observed with blunt injuries of the genitals, sexual 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 sutures is performed. When the urethra ruptures, a section of the bladder is made from the side of the vagina or pubis (with suprapubic cross section) and a catheter is inserted from the side of the bladder, with the help of which the central and peripheral torn ends of the urethra are found and stitched.
Damage to the ureter can be lateral (tangent), as a complete transverse section, chipped, as well as when captured in a ligature. With lateral damage to the ureter, several separate sutures are applied and peritonization is performed due to the nearby peritoneum. If the ureter enters (grabs) into the ligature without wound injuries, it is possible to limit it to release (untying the ligature) if no more than 6-10 hours have passed from the moment of surgery.
However, there is evidence of the restoration of patency of the ureter and the preservation of its integrity when released from the ligature for up to 2 days. With transverse transection of the ureter, surgical intervention is indicated for various options, the choice of which depends on the location of the transection. Stitching of the ends of the ureter can be end-to-end or end-to-side. With anastomosis, end-to-end stitching of the ends of the ureter is performed on the ureteric catheter, which remains for 20-25 days. In the invaginal method of anastomosis (end to side), the vesical end of the ureter is firstly ligated, then a longitudinal incision is made in it (0.5-1 cm), through which, using two ligatures, applied as mattress sutures, the oblique central end of the ureter is inserted. The ligatures are tied and cut, and the hole is sutured with separate sutures. The seam area is peritonized. An invaginal method of suturing the ureter is also possible with anastomosis end to end.
Sewing of the ureter into the bladder is performed if it is transected in the lower sections. The closer the ureter transection occurred to the bladder, 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, the ureter is often mobilized, which is implanted in the bladder, and the latter rises up and is fixed with 3-4 sutures to the walls of the pelvis. There should be good conditions for peritonization of the ureter implantation region in the bladder. The last through the urethra is a metal catheter, which protrudes the wall of the bladder. On the catheter, in the area of protrusion, the bladder wall is dissected. It is necessary that the dissection of the wall of the bladder be 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 dissected longitudinally by 1 cm. Through these created blades of the ureter, they are carried out using the mattress method of ligature, which are then led from the side of the bladder cavity to its outer wall and fixed, tying it on one and the other side. The hole in the bladder is sutured to the walls of the ureter. The ureter implantation area in the bladder is peritonized by the peritoneum. A permanent catheter is left in the bladder for 6-8 days.
Known methods for transplanting the ureter into the colon, temporarily into the skin, etc.
If the ureteric stricture is not eliminated, hydronephrosis and subsequent kidney atrophy develop.
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Surgery for wounds or damage to the urinary tract
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