A ureteral stent open ureteroureterostomy hand assisted lapa

A ureteral stent, open ureteroureterostomy, hand-assisted laparoscopic ureteroureterostomy, renal autotransplantation, ileal ureteral reposition, and nephrectomy are among the approaches adopted for the management of the damaged or disrupted ureter. A prolonged delay in the repair of a damaged or injured ureter may lead to local matrix metalloproteinases and fibrosis, which can ultimately cause the atrophy and shrinkage of the ureter. Some authors approved immediate repair of all iatrogenic ureteral injury upon confirmative diagnosis irrespective of the interval between injury and diagnosis. Such handling would reduce the incidence of subsequent complications such as ureteral stricture, fistula, and urinoma formation. Moreover, it is reported that the delay between diagnosis and management would significantly elevate the rate of complications from 10% to 40%. Although the optimal management approach for the proximal ureteral injury remains inconclusive, it is our opinion that immediate repair upon confirmation of the diagnosis is the best course of action. The simplicity of surgical management and the shortened interval between injury and repair would benefit the patients significantly. When performing the end-to-end ureteral anastomosis, certain principles should be followed. First, as the vessels supplying the ureter are tenuous, it is advised to perform careful dissection of the periureteral soft tissue that preserves the integrity of the adventitia prior to connecting the interrupted ureter. Second, it is advised that the connection of the ureteral ends by spatulated anastomosis should include a luminal stent, while the newly created connection should be water tight and tension free. Finally, an omental wrap may be performed on the repaired ureter to increase the possibility of its survival. Some additional advantages could also be gained while performing all the aforementioned procedures by pure laparoscopy. The patient does not need to go through yet another open surgery, thus shortening the recovery duration. In the aforementioned case, all the negative findings in the 6-month follow-up would confirm the effectiveness of such a managing strategy. In recent years, minimal access posterior lumbar surgery is gradually gaining popularity among neurosurgeons. The surgical field of such a procedure is generally deep and narrow, and because of less than ideal visibility associated with this approach, the chance of inadvertent injury to the retroperitoneal ureters and vessels at the L4–5 intervertebral space will be considerably increased. However, a fundamental knowledge of regional anatomy, the proper use of suitable surgical instruments, and careful surgical maneuvering will significantly reduce the risk of iatrogenic damage to the ureter. In the unforeseen circumstance where ureteral injury has occurred, prompt and direct surgical management upon confirmation of the diagnosis is recommended. Repair of the minimal invasive TLIF-damaged ureter with a pure laparoscopic approach as reported earlier may prove an option with added benefit to the patients.