Methodological Approaches to the Development of Laparoscopic Correction of Iatrogenic Ureteral Injuries
The objective: systematization of tactical methods of laparoscopic correction of iatrogenic ureteral injuries in teaching of doctors under training. Materials and Methods. During 2002–2012, 61 patients aged 21 to 72 years with ureteral injury have been operated at the clinic of urology of the faculty of postgraduate education of Donetsk national medical university. 24 patients (39 %) had damage of the right ureter, 36 patients (59 %) — of the left ureter, and 1 patient (2 bilateral ureteral injury. Laparoscopic correction of ureteral injury was carried out in 36 (59 %) patients, direct uretheroneocystostoanastomosis — in 26 (72 %) patients; direct uretheroneocystostoanastomosis in combination with the method Psoas-hitch — in 7 (20 %) patients; Boari surgery —in 3 (8 %) patients. All patients underwent ultrasound examination, excretory urography and computer tomography. Cystoscopy and vaginoscopy were used to confirm the diagnosis and to identify possible associated vesicovaginal fistula. Immediately before the operation ureteroscopy was carried out to clarify the nature and location of the injury. Correction of damage was carried out immediately after the diagnosis. If there were significant hydronephrosis, extravasation of urine, sepsis, the patient was previously imposed puncture nephrostomy, аnd surgery was postponed to a later date, after the correction of existing damage. Results. Principles of laparoscopic ureteral reconstruction are in full excision of non-viable tissue of the ureter; maintaining an adequate blood supply to the ureter, exclusion of its skeletonization; adequate mobilization of the ureter to avoid tension of tissue of anastomosis; forming tight anastomosis using fine absorbable sutures, full contact of mucous membranes; JJ-stent installation; adequate external passive drainage to avoid the formation of a hematoma and uroplania; exclusion of anastomosis zone using peritoneum and omentum; bladder catheterization to avoid reflux of urine. The average duration of laparoscopic operations of uretheroneocystostomy was 180 (78–12) min, the averageblood loss was 80 (45–150) mL. Early complications occurred in 8 (22.2 %) patients, including: in 4 (11.1 %) — urination on drainage during 5–8 days, in 2 (5.5 %) — necrosis of the anastomosis zone with the development of urinary peritonitis, in 2 (5.5 %) purulent pyelonephritis detected. All patients were under regular medical supervision, every 6 months, they underwent ultrasound of the urinary system, the control of blood tests, urine tests and biochemical parameters. None of the patients showed no signs of upper tract dilation, or the active pyelonephritis. Results. Iatrogenic ureteral injuries are rare but severe complication of pelvic surgery. Timely diagnosis and adequate correction of ureteral injury can preserve the function of the kidneys and eliminate negative effects. Laparoscopic uretheroneocystostomy is a highly effective method of surgical correction of the injury of the lower third of the ureter. Compliance with the established rules of the operation, based on our own experience and the experience of foreign colleagues, will allow to perform the operation effectively, and reduce the number of complications.