ureteroplasty

The connection between the renal pelvis and the ureter, due to a fibrous muscle ring or occasionally the presence of ectopic blood vessels, can cause stenosis and cause hydronephrosis. If the renal parenchyma is normal, the renal function may be restored, and the surgical method is used to relieve the obstruction. If the hydronephrosis is severe and the renal parenchyma has shrunk, and the contralateral renal function is normal, a nephrectomy should be performed. Treatment of diseases: hydronephrosis, renal tuberculosis, contralateral hydronephrosis Indication The connection between the renal pelvis and the ureter, due to a fibrous muscle ring or occasionally the presence of ectopic blood vessels, can cause stenosis and cause hydronephrosis. If the renal parenchyma is normal, the renal function may be restored, and the surgical method is used to relieve the obstruction. If the hydronephrosis is severe and the renal parenchyma has shrunk, and the contralateral renal function is normal, a nephrectomy should be performed. Preoperative preparation 1. Check the vital organs of the body, especially the renal function test (generally including urine routine, blood urea nitrogen determination and phenol red test), to determine whether the Jianbian kidney can compensate for urinary function. 2. Preoperative pyelography must be performed to determine the condition of the two kidneys. At the same time, it should be repeatedly verified where the diseased kidney is. Such as the newly discovered non-functional kidney of venous pyelography, although it can be caused by lesions, but it can also be caused by loss of contrast agent, or temporary renal artery spasm, should be identified. 3. Perform the necessary preoperative treatment. For example, kidney injury combined with shock, must be actively rescued, renal tuberculosis should be treated with anti-tuberculosis for a period of time before surgery (usually 2 weeks), urinary tract infection should be controlled, water and electrolyte disorders should be corrected; anemia and hypertension are also Should try to improve. Surgical procedure (a) renal pelvic ureter junction yv angioplasty (foley) 1. Position, incision: lateral position. Oblique oblique incision (or supine position, abdominal incision). 2. Inject saline test: Separate the renal pelvis and ureter junction. It should be noted that sometimes the appearance of the part is normal and there is still a stenosis. It can be injected into the renal pelvis with normal saline to see if it can be empty. 3. Incision of the upper segment of the ureter: When the renal pelvis cannot be emptied, the upper segment of the ureter below the ureteral junction of the pelvis should be cut longitudinally, and the probe can be probed upwards to block the ureteral ureteral junction. 4. Excision of the stenosis: the incision is extended upward, and the renal pelvis is cut in the y-shape to expose and remove the fibrous muscle ring of the ureteropelvic junction. 5. Renal ureteral anastomosis and renal pelvis: The renal pelvis and the posterior wall of the ureter were sutured with a 4-0 chrome gut. New and small sickle catheters and plastic tubes were introduced into the renal pelvis and ureter through the renal parenchyma incision for renal pelvis. Finally, the tip of the triangular flap is pulled toward the ureter and sutured to form a v-shape. The incision was sutured by layers after the cigarette was drained from the renal pelvis. (two) lingual renal pelvic flap (culp) 1. Position, incision: with yv into a green work. 2. The renal pelvis incision: a slender tongue-shaped renal pelvis flap is made. The majority of the incision is made on the posterior side of the renal pelvis. The cusp is wrapped around the upper part of the pelvis and the anterior side of the incision is located at the posterior medial side of the pelvic ureteral junction. Along the ureter, the urethra is slanted downwards. 3. Flap suture: The tongue-shaped renal pelvis flap was turned down, so that the lingual flap approached the ureter tangential line, and the posterior wall of the two was sutured intermittently with a 3-0 chrome gut. A renal incision is made through which the sacral catheter and the plastic tube are introduced and placed in the renal pelvis and the healthy ureter. Then, the renal pelvis and ureter were sutured with a 3-0 chrome gut. After the external sputum was placed in a cigarette, the incision was sutured layer by layer. (C) oblique trough pyeloplasty (anderson and hynes) 1. Separation of renal pelvis: The ureter is found in the adipose tissue on the inner side of the kidney, covered with a sling, and separated upward along the ureter. About 35% of patients with hydronephrosis have blood vessels traversing and compressing the ureter to supply the lower pole of the kidney, which is also lifted with a sling. Regardless of the blood vessels in the lower extremity, the hydronephrosis should be separated upwards until the renal hilum is exposed to a sufficient extent for pyeloplasty. When separating, the renal pelvis should be placed close to the kidney to push the kidneys to one side to avoid damage. 2. Cutting of the renal pelvis and ureter: The key to the oblique tracheal pyeloplasty is to establish a drooping chute. After cutting under the ureteral stenosis and cutting into a tongue-shaped plate shape, all the mouth should be bent to the renal pelvis at the junction of the pelvis and ureter, and then bent upwards to the upper edge of the renal pelvis, which will produce a chute, and then downward Open, before the lower blood vessels, anastomosis with the ureter. This drooping chute has several advantages: 1 produces a long, oblique anastomosis, 2 relieves the tension of the anastomosis, and 3 produces a normal pelvis ureteral funnel. (1) suture traction line: before cutting the ureter and renal pelvis, first suture three-needle traction line: one needle is pulled inside the ureter under the narrow section, one needle is pulled on the wall of the renal pelvis below the junction of the pelvis and ureter, another needle It is pulled in the upper part of the renal pelvis. (2) Cutting the ureter: The ureter is cut obliquely just below the stenosis, thus making the inner edge slightly longer than the outer edge. Even if there is no stenosis, the ureter should be cut about 2 cm below the junction of the pelvis and ureter (this 2 cm ureter does not transmit peristalsis and should be removed). Remove the sling from the ureter. The ureter was made into a tongue-and-groove shape along the lateral edge of the ureter along the length of the anastomosis (large renal pelvis 3 cm, small renal pelvis 2 cm). The ureteral catheter is inserted into the distal segment of the ureter to exclude distal stenosis. (3) cutting the renal pelvis: the anterior and posterior wall of the renal pelvis is closed, formed at the lateral part of the junction of the ureter and the renal pelvis, and cut at the same time with the curved shear, first at right angles to the lower edge of the renal pelvis, so that when the opening is opened, the tip of the chute is inclined Flat, this will maintain the maximum blood supply to the chute wall. (4) Complete the cutting chute: the cutting should be slowly bent and finally pointed to the renal hilum, so that the chute has the maximum downward movement. The length of the chute should be equal to the upper section of the ureteral tongue depressor. Between the base of the chute and the upper edge of the renal pelvis, a straight line should be formed parallel to the longitudinal axis of the kidney to remove excess renal pelvis. It is better to cut less and not cut more, because once the obstruction is relieved, the renal pelvis will become smaller. 3. Insert the ureteral catheter and the renal pelvic catheter: insert the 8f ureteral catheter into the ureter, the other end through the renal parenchyma and the lower jaw through the renal parenchyma, and another fistula catheter placed in the renal pelvis through the renal pelvis or renal parenchyma. 4. Perform anastomosis: Place the chute in front of the inferior pole of the kidney and remove the sling around the subrenal blood vessel. The upper part of the renal pelvis is sutured continuously with an absorbable intestinal line. It is best to sew only the outer layer and invert the mucosal layer. Use seam stitching before reaching the base of the chute. A traction suture is used to connect the tongue-shaped ureteral end to the base of the chute, and the suture is sutured continuously to the ureteral end and the posterior wall of the base of the chute to begin the anastomosis; and finally to their anterior wall. The stitching distance should be tight and close to the cutting edge to prevent leakage of urine. At the upper end of the ureter, the small triangular space formed between the ureter and the anterior and posterior wall of the renal pelvis should be carefully closed to complete the anastomosis. A continuous suture is used throughout the process. In order to prevent leakage of urine, in addition to the use of the stent, it is a small needle suture for the renal pelvis and ureter, and large needle suture can cause ischemic necrosis. 5. Drainage and suturing: a small incision is made under the skin incision, and a cigarette-type drainage is placed next to the anastomosis. A small incision is made under the incision to draw the drainage tube and sutured. Horseshoe kidneys often have a large number of blood vessels. In patients with hydronephrosis, the junction of the renal pelvis and ureter often lies in these blood vessels. The trough-shaped pyeloplasty should be performed before these vessels in the normal way to solve the obstruction without cutting off the isthmus. .