of Suprapubic Catheter
and Burch Operations
With Bladder Flap
Injury to the ureter is occasionally high enough in
the pelvis for a primary ureteroureterostomy to be performed without
having to resort to a ureteroneocystostomy. In these cases, the ureter
has been damaged at or near the pelvic brim while clamping, incising,
and ligating the infundibulopelvic ligament or while excising an extensive
ovarian carcinoma that has distorted the pelvic anatomy at or near
the pelvic brim. Although less common than procedures for correcting
lower injuries to the ureter, a ureteroureterostomy is preferable to
a ureteroneocystostomy when it can be performed without tension on
the anastomosis producing the stenosis.
The essential features of the
procedure are the adequate mobilization of the cut ends of the ureter
to prevent tension on the anastomosis, the use of a spatulated anastomosis,
and the use of delicate suture, meticulous hemostasis, and drainage
of the anastomosis site via a closed suction drain through the lower
The purpose of the ureteroureterostomy
is to anastomose the transected ureter.
Physiologic Changes. After
a damaged or diseased portion of the ureter has been removed, the
ureter is anastomosed. The sequelae of ureteral obstruction and/or
laceration are relieved.
Points of Caution. Care should be taken to see that
the ureter is anastomosed without tension.
A soft Silastic indwelling catheter should be placed through the anastomotic
area and fed into the bladder caudad and the renal pelvis cephalad.
The drain should be placed in the area of the anastomosis
and brought out through the right or left lower quadrant and kept in
place until all external drainage has ceased.
The patient is placed in the dorsal position,
and the abdomen is opened through a lower midline incision.
The pelvis is cleared of adhesions and intestinal
contents. Exposure of the pelvic structures is essential at all
times. The pathologic site in the ureter is identified, and the
peritoneum overlying the ureter at its junction with the common
iliac artery is incised. Dissection of the ureter is carried
down to the site of damage and/or stenosis.
An appropriate segment of ureter is dissected
out of its bed and mobilized between soft Silastic drains. Care
is taken not to damage the ureteral sheath or the delicate network
of vessels beneath the sheath that are vital to the vascularity
of the ureter. The pathologic portion of ureter is excised with
A Silastic ureteral catheter is inserted
up to the renal pelvis and down into the bladder. Interrupted
4-0 synthetic absorbable sutures are placed through the entire
wall of the ureter.
The anastomosis has been completed over a
Silastic ureteral catheter. Vessel loops are shown elevating
A closed suction drain site
in the lower quadrant of the abdomen is selected. A Kelly clamp
is passed retroperitoneally, and a soft closed suction drain
is brought out through the lower quadrant and is left adjacent
to the anastomosis. The drain is used to prevent the collection
of urine in the area of the anastomosis and should be left in
place until all urinary drainage through it has ceased.
The peritoneum is closed with interrupted
3-0 synthetic absorbable sutures over the ureteroureterostomy
so that the ureter remains retroperitoneal.
The Silastic ureteral catheter
is removed at the time of water cystoscopy 10-12 days postoperatively.
A urologic workup should be performed 6 weeks following anastomosis
and 3 months thereafter to ensure against stenosis and hydronephrosis.