John Mulhall MD, MSc, FECSM, FACS

• Memorial Sloan-Kettering Cancer Center
• New York, USA

Following complete incision allergy medicine while pregnant cetirizine 5 mg order overnight delivery, place a 14/7 Fr endopyelotomy stent over the guidewire in an antegrade fashion allergy treatment therapy purchase 5 mg cetirizine mastercard. Some authors recommend placing a nephrostomy tube for 24­48 hours allergy testing buffalo ny buy cetirizine 10 mg low cost, though tubeless percutaneous endopyelotomies have been reported allergy shots lubbock purchase cetirizine without a prescription. Use a bugbee electrode or Collins knife on a 24 Fr resectoscope to marsupialize the proximal ureter into the renal pelvis allergy testing valdosta ga purchase on line cetirizine. If stones are present, they should be removed prior to the endopyelotomy so that stone fragments do not migrate into the periureteral and pelvic tissues. Then leave the stent for four to six weeks, and the patient must avoid strenuous exercise for eight to ten days. The duration and timing of imaging follow-up is controversial, but two years is a common period. We prefer to do this as a final check for stones and stricture as this can alter the surgery required. The stent can be placed antegrade during the pyeloplasty, but we do it at cystoscopy to be certain of its position and to aid in ureteric identification in difficult cases during the pyeloplasty. The stent is 28 cm, as this allows the J at the renal end to lie well above the anastomosis and not potentially cantilever on it, leading to urine leak and loosening of sutures. It has the advantage of being applicable to high ureteral insertions as well as dependent. Reduction of the redundant pelvis Patient positioning the retroperitoneal approach involves placing the patient in the flank position (lateral decubitus position) with the affected side upwards. Use a flank position with table broken so that lumbar support is raised to maximum height. It is vital to carefully pad soft tissues and bony sites to minimize the risk of neuropraxia, particularly the downside shoulder (axillary roll and posterior back support), hip, knee, and ankle (we prefer a pillow between the legs, buttock support posteriorly, and gel ankle supports). Identify the proximal ureter lying on the psoas muscle and dissect it proximally to the renal pelvis. Care needs to be taken not to strip the periuereteral tissue as this may compromise the ureteric blood supply and a successful outcome. Place a stay suture in the ureter distal to the level of obstruction to aid with the anastomosis and orientation. Two stay sutures are then placed at the medial and lateral aspects of the dependent portions of the pelvis. Bring the apex of the spatulated ureter to the inferior border of the lateral renal pelvis and bring the medial portion of the ureter to the superior edge of the pelvis. Perform the anastomosis with a fine interrupted or running suture such as 4-0 vicryl. Postoperatively, remove the urinary catheter when the drain is dry and the drain 24 hours later if there has been no further drainage. It is wise to outline the flap longer than what is perceived to be needed, as flap shrinkage tends to occur when the pelvis is incised. Continue the medial aspect of the flap incision down the ureter beyhond the obstructed segment. Rotate the apex of the flap down to the apex of the ureterotomy and close the posterior and anterior walls with 4-0 vicryl interrupted sutures. Scardino­Prince vertical flap this has a limited use today for relatively long areas of proximal ureteral narrowing when the ureter is situated at the medial margin of a large box-shaped extrarenal pelvis. The flap is similar to the spiral, except the base is situated more horizontally on the dependent aspect of the renal pelvis. Form the flap from straight incisions, which converge from the base vertically to the apex superiorly on the posterior or anterior aspect of the pelvis. Develop the flap with Potts scissors, rotated down, and sutured with a 4-0 vicryl interrupted to the inferior aspect of the ureterotomy. A variety of pyeloplasty techniques were initially described, although there now appears to be consensus that a dismembered pyeloplasty represents the technique of choice. Laparoscopic pyeloplasty is now an accepted technique, with some authors stating it should be the standard of care in expert hands. It is contraindicated when transposition is required and pelvic reduction is needed. Position the base of the V on the dependent medial aspect of the renal pelvis and the apex at the pelviureteric junction. Carry the incision from the apex of the flap on to the lateral aspect of the ureter and extend distally beyhond the stenosis and several millimetres onto normal calibre ureter. Bring the apex of the pelvic flap to the apex of ureteric incision distally and suture with 4-0 vicryl. Outline the flap with a broad base situated obliquely on the dependent renal pelvis. The cut upper leaflet of Gerota is retracted superiorly using a fan retractor and the perinephric fat is swept superiorly and inferiorly to reveal the kidney. The tissue lying inferior to the lower pole is then dissected carefully by blunt dissection, revealing the renal pelvis and ureter. The same steps as per the transperitoneal approach are followed at this stage with the same postoperative care. Prophylactic heparinization: unfractionated heparin 5,000 international units twice a day or fractionated heparin once a day until discharge. We prefer to do this as a final check for stones and strictures, as this can alter the surgery required. The stent can be placed antegrade during laparoscopy, but we do it at cystoscopy to be certain of its position and aid in ureteric identification in difficult cases during the laparoscopic pyeloplasty. The stent is 28 Fr as this allows the J at the renal end to lie well above the anastomosis and not potentially cantilever on it, leading to urine leak and loosening of sutures. The stent can be placed or changed (if one has been placed previously) during the laparoscopic procedure being placed in an antegrade direction over a guidewire using the superior port Catheterize patient-12­14 Ch catheter Transperitoneal and retroperitoneal approaches: As per laparoscopic simple nephrectomy Outcomes and complications Complication rates are low at 5%. Success rates based on symptoms and renograms postoperatively are around 94%, comparable with open pyeloplasty results. Mean duration of surgery is two and a half hours and mean hospital stay is three days. These results are all comparable with open pyeloplasty and certainly provide a better cosmetic outcome. Transposition adds 30 minutes to the procedure and there appears to be no significant differences related to the approach. This is however a relatively difficult procedure laparoscopically and it is not presently clear how reproducible the initial results from centres of excellence are. Poorly functioning renal units (probably <15%) will be best served with nephrectomy. Pyeloplasty (open/laparoscopic or robotic) has the highest success rates and is considered the gold standard. It is the procedure of choice in patients with gross hydronephrosis, reduced split renal function in the affected kidney, and failed endourological procedures. However, minimally invasive procedures should be offered and have significantly reduced hospital stay and postoperative recovery. Patient positioning Operative technique (i) Transperitoneal: the initial port placement and dissection is the same as for transperitoneal simple nephrectomy, except an 11 cm port replaces the 12 cm port. The proximal ureter is identified lying on psoas with the gonadal vein in close proximity. The proximal ureter is dissected out, being careful not to skin it too much and risk devascularization. If a crossing vessel is seen, it will normally lie on the medial aspect of the pelviureteric junction. We prefer to transpose the pelvis and ureter if a vessel is found, and if this is the case, the crossing vessel needs to be dissected out and freed off the peripelvic tissue. The pelvis and ureter are transposed and an interrupted 3 mg/kg vicryl anastomosis performed intracorporeally. We prefer this to a running suture, which is potentially more ischaemic and if the suture loosens the whole anastomosis can be affected. The operative site is irrigated with normal saline and a tube drain placed to lie close to but not on the anastomosis and brought out via one of the port sites. Wound closure is as per simple nephrectomy and we remove the catheter on day 2 postoperatively. If there is no further significant drainage from the tube drain in the next 24 hours, this is removed on day 3, the day of discharge. The Gerota fascia is Management of ureteric strictures Ureteral strictures are relatively rare and occur in a number of benign and malignant conditions: Congenital Infection. This may improve outcomes, both in terms of initial success but also subsequent surgery if chemotherapy fails. In dealing with ureteral strictures, it is helpful to divide the ureter into proximal, mid, and distal parts. Most strictures occur in the distal ureter due to iatrogenic, malignant, and infective causes. The injury has not been recognized during the pelvic surgery and only becomes evident postoperatively. Nephrostomy tracts can be used therapeutically as part of an antegrade approach to a ureteral stricture. Three endoscopic techniques exist to treat ureteral strictures: catheter dilatation, balloon dilatation, and endoincision. The first end- to- end anastomosis of a divided ureter was described in 1885 by Tauffer. Boree reported cutting the ureteric ends obliquely to reduce the chance of stenosis. Boari described his bladder flap operation in 189468 and ureterointestinal anastomosis was performed by Sir John Simon in 1852. Then place an open-ended ureteral catheter (5 Fr) over the wire and exchange the terumo for a stiffer guidewire, such as a Bentson or Amplatz superstiff. In cases where a suture has been tied around the ureter, if a ureteric stent can be placed this can be definitive treatment and should be left for three months. The disease needs to be treated when inflammation and oedema rather than fibrosis is present. If there is no improvement after four weeks, prednisolone is added to the regimen. If no further improvement is seen in the subsequent four weeks, surgical intervention is required. The distal end of the stent is then placed into the bladder via a percutaneous puncture. The stent needs to be changed every four months using a combined cystoscopic and percutaneous cutdown technique. Similarly, a percutaneous approach to upper or mid-ureteric strictures can be performed following the same description of an antegrade endopyelotomy. The incision in the mid- ureter is made laterally, except over the iliac vessels where it is placed anteromedially. Retroperitoneal fat will be seen usually in the upper, mid, and proximal distal ureter. Retroperitoneal fat may not be seen in marked fibrosis and if the periureteric fat has been seen, no further incision should be made due to the risk of haemorrhage. Then place a stent (14 Fr nephrostent, 7 or 8 Fr double pigtail, or 10 Fr nephrostomy (for antegrade approach)). If a nephrostomy is in place, perform a nephrostogram after 48 hours and cap the nephrostent. If the stricture has caused complete obstruction, it will not be possible to perform a retrograde approach as neither a guidewire or contrast will pass. If the occlusion is <1 cm an endosurgical approach can be tried, but if >1 cm then open surgery is recommended. A purely fluoroscopic or combined fluoroscopy and endoscopic incision can then be followed. In the fluoroscopic approach, introduce a stiff guidewire via the nephrostomy antegrade to the proximal level of the stricture. Use the C-arm to position the guidewire tip, pointing directly at the bladder in both anteroposterior and lateral views. Once the guidewire enters the bladder, grasp it, and bring it out through the urethral meatus. Pass a 4­8 mm balloon dilator antegrade into the stricture and dilate for 10 minutes. Then place either a nephrostent or an indwelling ureteric stent with a nephrostomy. If a nephrostomy is placed, a nephrostogram is performed on day 3 after surgery and removed if no extravasation is seen. The second option is to place an antegrade guidewire to the proximal level of the stricture, followed by a flexible ureteroscope over the wire. Introduce a resectoscope with a Collings knife attached, or an optical urethrotome urethrally. Position the cystoscope so it lies next to the flexible ureteroscope using the C-arm. Turn off the cystoscope light and theatre lights and make the incision to the bright light coming from the ureteroscope. Once the ureteroscope is uncovered, retrieve the guidewire, and place a nephrostent or indwelling stent, plus nephrostomy and a urethral catheter left in situ. If a nephrostomy is placed, a nephrostogram is performed on day 3 after surgery and removed if no extravasation.

Modifiable risk factors need to be addressed with Utero-sacral ligament Cervix Superior central tendon Cardinal ligament Rectovaginal septum Bulbocavernosus M allergy hacks 10 mg cetirizine order visa. Aetiology Injury to the above structures allergy medicine effect on liver generic cetirizine 5 mg online, whether it is the result of an acute episode (pregnancy allergy medicine to take while breastfeeding order cetirizine 10 mg visa, childbirth allergy forecast ontario canada cetirizine 10 mg order with amex, or obstetric injury) allergy x amarillo cetirizine 10 mg order on line, or cumulative as a result of chronic increase of intra-abdominal pressure (chronic obstructive pulmonary disease, obesity, or chronic constipation) or the combination of both, may lead to anatomical prolapse and/or bowel dysfunction. Patients can present with a history of widening of the genital hiatus, perineal laxity/descent, palpable vaginal bulge, and sexual dysfunction. Additionally, patients can describe defecation disorders such as chronic constipation, splinting of the posterior vaginal wall or digitations, stool trapping, and anal incontinence (estimated prevalence of 7% in the adult population). However, it is not uncommon to encounter patients with significant posterior vaginal prolapse in the absence of bowel dysfunction, and vice versa. However, it is currently accepted that the optimal care of any pelvic floor disorder must take into consideration the heterogeneous nature of prolapse. Therefore, pelvic surgeons must not only account for supporting defects in different compartments, but also direct treatment to any associated symptoms. Increases in abdominal pressure result in balanced pressure on anterior and posterior vaginal walls (arrows) so that no net force on support results. Caudally, however, there is no balancing pressure, and force results (dashed arrow), which must be resisted by the fibres of the perineal membrane (shaded area) of perineal body. Increases in rectal pressure are unopposed and force on posterior vaginal wall results (arrow). Reprinted from the American Journal of Obstetrics and Gynecology, Volume 180, Issue 4, John O. Defecating proctography has traditionally been used mainly by the colorectal surgeons to grade rectocoeles anteriorly. It provides a two-dimensional quantification of rectal parameters and dynamic information regarding rectal emptying. Management Conservative treatment the conservative management of a posterior vaginal wall prolapse will be guided by the presence or absence of bowel dysfunction. Whereas conservative therapies play a very limited role in the management of pure anatomical prolapse, this is not the case in bowel dysfunction. In the absence of bowel dysfunction, pelvic floor exercises, and the use of topical oestrogen in the presence of atrophic vaginal changes may provide some degree of symptom relief in cases of mild prolapse. The use of ring pessaries (both supportive and space occupying) is restricted to those with larger prolapse who are not suitable for surgery, or to evaluate symptom improvement prior to surgery. In the presence of bowel dysfunction associated with pelvic outlet symptoms, biofeedback is the first-line treatment option, although there is still controversy over the criteria and testing that should be used when selecting patients. It was not until 1987 that this surgical technique was evaluated for bowel dysfunction,35 with anatomical cure results being reported in the range of 70­90%. Plication of the levator muscle is avoided, as interposition of the levators between the vagina and rectum is perceived as non-anatomical, whereas perineorrhaphy is performed concomitantly in the presence of a deficient perineum. Anatomical success has been reported at 80­90%, with improvement in bowel function and lower rates of de novo dyspareunia. It is designed for low or distal anterior rectocoeles as described by defecography studies and should be avoided in the presence of an enterocoele. The surgical technique involves a U-shaped or T incision made transanally just above the dentate line. One of the main complications of this technique is de novo faecal incontinence, reported as high as 38%, although the aetiology behind it is not clear. The sacrospinous ligament runs from the ischial spine to the lower part of the sacrum/coccyx. Pudendal nerves and vessels lie medial and posterior to the ischial spine, while superiorly and behind the ligament are the inferior gluteal vessels and the hyogastric venous plexus. Similarly, one must take precaution when placing the mesh over the sacrum during sacrocolpopexy. The anatomy in this area must be understood to prevent potentially life-threatening haemorrhage. The left common iliac vein, which lies medial to the artery, as well as the presacral veins and the median sacral artery and vein are at risk during mesh fixation. Further knowledge of the pathway of the ureters-particularly the right ureter-is required. Laparoscopic ventral rectopexy has gained acceptability for the treatment of obstructed defecation/intussusception with or without prolapse. It involves opening the rectovaginal space and dissecting inferiorly to the perineal body. The posterior vaginal fornix is also attached to the mesh, which is fixed beneath the sacral promontory with either sutures, screws, staples, or a tacking device. It facilitates addressing adjuvant problems such as perineal descent, vault prolapse, and enterocoele at the same time, and the patient experiences a more rapid recovery. Complications described include faecal impaction (4%), wound infection (2%), bleeding (2%), leak (1%), and retention (1%). Conclusion Posterior vaginal wall prolapse is an evolving area for pelvic floor surgeons. Predicting those patients who may benefit from conservative and/or surgical treatment remains a challenge for clinicians who require a detailed understanding of the anatomy of the posterior compartment, as well as the differential diagnosis of defecatory and sexual dysfunction. The literature available to date is mainly comprised of retrospective cases and usually with small numbers. Research is needed to assess the pre-and postoperative clinical changes from both anatomical and functional perspectives overall. Apical compartment prolapse this section will discuss uterine prolapse and post-hysterectomy vaginal vault prolapse, in addition to associated descent of the apical compartment of the vagina. It is less common for there to be an isolated apical defect in contrast to multicompartment defects. However, there are several important factors which will influence the type of procedure performed for symptomatic apical prolapse, such as concomitant pathology, age, completion of family, sexual function, patient choice, and hysterectomy risk of early menopause, vaginal access, and previous surgery. Occasionally an obliterative procedure (colpocleisis) can be considered for those patients too fragile to tolerate surgery or with repeated prolapse surgery failure, who are not sexually active. Evaluation Apical or middle compartment prolapse (both uterine and vault prolpase) can represent the most challenging compartment prolapse to identify. For example, it is rare that the anterior vaginal compartment presents as a sole compartment prolapse because it is frequently attached to a degree of prolapse of the middle compartment. Missing this at the time of examination leads to a partial repair of the problem, contributing to the high recurrence rates seen following a single anterior compartment prolapse repair. The apex is best visualized using a Cusco speculum and asking the patient to perform Valsalva while it is slowly removed from the vagina. As previously described with the anterior compartment, an enterocoele (protrusion of the small intestines and peritoneum into the vaginal canal) is not typically treated as a separate disorder, because most patients with enterocoele also have significant prolapse of other compartments. An isolated enterocoele repair rarely corrects all prolapse symptoms and usually additional support procedures are needed. This is a controversial area and preoperative Anatomy and aetiology the anatomy of the supporting structures of the vagina has already been discussed in detail in this chapter. Loss of integrity in level I support, as described by DeLancey, is instrumental in the development of apical compartment prolapse. In the case of vaginal vault prolapse, this is related to attenuation of the cardinal/uterosacral ligament complex following excision during hysterectomy, separation of the pubocervical fascia from the rectovaginal fascia, and separation of these fascia from the cardinal/uterosacral ligament complex. In the absence of the normal support structures to the uterus or the vaginal cuff, the anterior and posterior compartments of the vagina are exposed to intra-abdominal forces that may lead to other compartmental prolapse. Sacrospinous fixation this is the commonest apical suspension procedure performed through the vagina and is typically performed for vault prolapse post-hysterectomy and vaginal enterocoele. However, it can be performed with vaginal hysterectomy, or as a unilateral or bilateral hysteropexy. The procedure involves the placement of two to four sutures through (as opposed to around) the sacrospinous ligament and 3 cm medial to the ischial spine to avoid vessel or nerve injury. The procedure is often accompanied by anterior or posterior compartment repairs and reduction of enterocoele. Anterior recurrence is more common than apical recurrence and success rates in relatively modern series are 69­87%. A variation of this approach is the sacrospinous hysteropexy where following the same approach, the uterus is preserved. Complication rates are similar to the sacrospinous ligament fixation; however, the overall failure rates appear to be higher. The type of pessary used will depend on two main factors: the degree of apical prolapse, and the integrity of the pelvic outlet. However, in those with more significant prolapse or a poorly supported introitus, a space-filling pessary is more suitable such as a Gelhorn or Cube. One of the advantages of the vaginal approach as opposed to the abdominal one is the possibility of performing the surgery under regional anaesthetic block. Indirectly this has made the operation more accessible to women regardless of age and associated medical co-morbidities. The technique itself involves a pericervical incision, access to the peritoneal cavity either through the Pouch of Douglas or through the uterovesical fold, and the division of the different supportive and vascular uterine pedicles in a down-upwards fashion. In order to prevent a future vaginal vault prolapse, the surgeon usually performs a McCall culdoplasty at the same time (see below). Another advantage of the vaginal approach is the possibility to repair any other concomitant vaginal prolapse identified at the time of surgery. The postoperative recovery from surgery is significantly shorter compared to other gynaecological surgeries, with 60% of women reporting normal activities within a week of their operation. Severe intraoperative and postoperative complications are rare (3%) and mainly in the form of intra-abdominal bleed or vaginal vault haematoma. Traditionally it was performed open, but can now be performed using minimally invasive techniques such as laparoscopy or be robotically assisted. Typically, the mesh utilized is polypropylene but biological material has also been used. In addition to the apical prolapse being fixed, the mesh arms can be extended to treat the prolapse of other compartments. There are, of course, significant costs associated with robotic-assisted laparoscopy, and in the absence of randomized controlled trials in this area the benefits and pitfalls need to be carefully weighed up. In a recent update of a Cochrane review, when compared with sacrospinous fixation for the treatment of apical prolapse, open or laparoscopic sacrocolpopexy had less recurrent prolapse and dyspareunia but had longer operating times and was more costly. A further absorbable suture is run in a similar fashion, but through the posterior vaginal wall. When the sutures are tied, it results in a high closure of the peritoneal culde-sac and the associated enterocoele with an attachment of the vaginal apex to the distal endopelvic fascia, which provides apical support and an increase in vaginal length. Complications include haemorrhage, particularly over the sacrum where troublesome bleeding can be encountered either from inadvertent damage to the left common iliac vein or more likely from the presacral venous plexus. Bowel, ureteric, rectal and bladder injury, bowel obstruction, mesh erosion, and infection are other risks. Discitis and osteomyelitis involving the sacrum have been reported but are much rarer. Abdominal/laparoscopic sacrohysteropexy Over the past decade there has been a move towards preservation of the uterus at the time of prolapse repair. Nonetheless, based on the evidence to date, sacrohysteropexy is a safe operation with similar outcomes and risks as seen with the more conventional sacrocolpopexy. Patients still of reproductive age are usually recommended to avoid pregnancy following the surgery. However, there have been cases of successful pregnancies delivered by caesarean section. At the level of the sacrum, the surgical technique is identical to the traditional sacrocolpopexy with the exposure of the anterior ligament of the sacral promontory and retroperitoneal dissection. The novel aspect of this surgery involves the dissection of the uterovesical fold with bilateral piercing of the broad ligament at the level of the uterocervical junction. Once this is performed, a bifurcated (Y shaped) polypropelene flat mesh is inserted bilaterally through the broad ligament posteriorly and secured anteriorly to the uterine cervix using permanent sutures. The uterus is then lifted and tacked to the sacral promontory using titanium staples. Aditional anterior and/or posterior repair may be needed vaginally at the end of the abdominal procedure. Apart from the risk of bladder injury (particularly in women with a previous caesarean section) and broad ligament vessel injury, other intraoperative risks are similar to those described for the colposacropexy. Obliterative procedures these are procedures are generally reserved for the frail elderly, in whom a less invasive procedure is more appropriate and vaginal intercourse is not planned in the future. Partial colpocleisis (for vaginal vault prolapse) or LeFort colpocleisis (for uterine prolapse) involve excision of rectangles of vaginal epithelium from the prolapsed vagina. The vagina is inverted incrementally by purse string sutures and closed with sutured skin edges. In cases with significant uterine prolapse, fenestrations are made in the broad ligament and mesh limbs are placed through them to the sacral promontory. Obliteration of dead space and uterosacral ligament suspension after hysterectomy cannot be overemphasized in the prevention of vault prolapse. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. A comparison between dynamic pelvic magnetic resonance imaging and videoproctography in patients with constipation. Controlled randomised trial of visual biofeedback versus muscle training without a visual display for intractable constipation.

The vessels themselves are not clamped allergy medicine makes me sleepy 10 mg cetirizine order with amex, unless it is essential to do so for major vascular damage allergy testing risks purchase cetirizine line. At this stage the only decision to be made is if the vessels are overtly damaged allergy treatment in dubai cetirizine 5 mg order visa, whether they can be repaired allergy gif generic cetirizine 10 mg mastercard, or whether a nephrectomy will be necessary allergy shots kitchener 10 mg cetirizine with visa. If there are two functioning kidneys and one side has been damaged, then the vascular damage will be repaired with an appropriately fine suture, if possible. If there is only one functioning kidney, every effort should be made to repair the injury. For trauma to the left kidney, an incision is made in the left paracolic gutter along the white line of Toldt. It is sometimes necessary to mobilize not just the colon but also the pancreas, spleen and, with them, the stomach medially to have full access to the left kidney and the major vessels, in which case the incision along the paracolic gutter must be extended upwards and over the spleen on the under surface of the diaphragm. To expose the right kidney, an incision is made in the right paracolic gutter along the white line of Toldt, up and over and hepatic flexure, and then into the lesser sac. Debridement and reconstruction One-third of one kidney is enough for a patient to survive without dialysis. In other words-however bad the kidney might look after injury, it is almost always worth trying to salvage it. Indeed, in the absence of major vascular trauma requiring a nephrectomy, the kidney can almost always be salvaged. It may only be necessary to clamp the artery and not the vein; and if both are clamped, then the artery should be clamped first and the vein released first to reduce the risk of rebleeding. Bleeding points are controlled by suture-ligation using 4/0 or 5/0 absorbable sutures (we use Vicryl) on a round-bodied half-circle needle. When the bleeding is adequately controlled, the collecting system is closed first using the same type of suture material and then the parenchyma is approximated by closing the capsule and as much as is necessary of the underlying parenchyma. It is sometimes helpful to use a haemostatic agent during closure of lacerations in the renal parenchyma and often helpful to wrap the repaired kidney in omentum to help secure haemostasis and restrict extravasation. At the end of the repair, a drain should be left to the operative site and kept there for as long as necessary. In the patient with multiple intra-abdominal injuries, it is surprising how well renal repair works despite the presence of leakage from the bowel, stomach, pancreas, or liver. Repairing these organs provides even more reason for draining of the operative site but the results are usually just as good. Although this is not life-threatening, this always requires surgery to obtain adequate healing. Effectively this is the same as doing a pyeloplasty, but in an emergency situation. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. Renal trauma from recreational accidents manifests different injury patters than urban renal trauma. Detection and significance of microscopic haematuria in patients with blunt renal trauma. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. Single shot intraoperative excretory urography for the immediate management of renal trauma. Revision of current American Association for the Surgery of Renal Injury grading system. Evidence-based validation of the predictive value of the American Association for the Surgery of Trauma kidney injury scale. Predictors of outcome for blunt high grade renal injury treated with conservative intent. Percutaneous emobilsation for the management of grade 5 renal trauma in hemodynamically unstable patients: initial experience. Assessing the usefulness of delayed imaging in routine follow up for renal trauma. Nonoperative management of blunt renal trauma is routine early follow-up imaging necessary Slective transaarterial embolisation for posttraumatic and renal haemorrhage: a second try is worthwhile. The commonest early complications are bleeding and extravasation of urine which may in turn lead to a urinoma, infection, and abscess formation. The best way of handling bleeding is by selective microembolization or surgery if necessary, which is usually only when embolization fails. A urinoma can usually be drained percutaneously through the flank, but may require surgery occasionally. If the kidney is severely traumatized, the preferred option might be to pass the stent cystoscopically up the ureter from below. In a less traumatized kidney, it might be best to perform a percutaneous nephrostomy and stent the ureter from above. Late complications include a persistent urine leak, which again is best treated by percutaneous nephrostomy and stenting. Vascular complications are not commonly seen but include hypertension, arteriovenous fistulae, and pseudoaneurysm formation. Hydronephrosis is a consequence of stricture of the pelviureteric junction, which is encountered occasionally, and is treated in the usual way. There is always concern that renal trauma will lead to loss of renal function and this is certainly a possibility following vascular injury. Aside from patients with significant vascular injury, there is not much evidence of how many patients lose renal function in the long term, because these patients are notoriously difficult to follow up. Renal trauma: kidney preservation through improved vascular control-a refined approach. Evaluation of renal function after major renal injury: correlation with the American Association for the Surgery of Trauma Injury Scale. Andrich Introduction to lower urinary tract trauma the commonest form of lower urinary tract trauma is iatrogenic trauma. This is largely urological iatrogenic trauma as the result of instrumentation and endoscopic surgery. Both are very sensitive for the diagnosis of bladder rupture, as long as the bladder is sufficiently distended to 300­350 mL. Trauma to the bladder the commonest type of bladder trauma is the result of transurethral resection of bladder tumours. In women, gynaecological surgery- specifically, caesarean section, hysterectomy, and sling surgery-is also a common cause. Iatrogenic trauma aside, blunt trauma is the cause of most bladder injuries, particularly road traffic accidents causing pelvic fracture in the presence of a distended bladder. Broadly speaking, bladder trauma can be divided into extraperitoneal and intraperitoneal rupture. The consequences of gynaecological surgery affecting the bladder may be more chronic and present as vesicovaginal fistulation. The clinical features of bladder trauma are usually those of the underlying cause. After a pelvic fracture, gross haematuria is usual; clear urine virtually excludes a ruptured bladder. With a ruptured Management If an extraperitoneal bladder rupture is diagnosed as an isolated injury because of transurethral perforation of the bladder, or after external injury, then it is usually safe to use an indwelling catheter and await spontaneous healing over the next two to three weeks. If the patient requires surgery for any other reason, usually after external trauma, and particularly after pelvic fracture, then the rupture should be repaired with a suprapubic and a urethral catheter and a drain to the site of the repair. Causes would include a bone fragment sticking into the bladder following a fractured pelvis. In the developing world and in children, straddle injuries are about as common as pelvic fracture urethral injuries. The nature of urethral injury Anatomically, the urethra is described as being in three parts-the prostatic, the membranous, and the spongiose. Anatomists do not distinguish between the anterior and posterior urethra nor between the bulbar and penile urethra. The anterior urethra consists of the bulbar and penile components the bulbar being that part of the spongiose urethra surrounded by the bulb of the corpus spongiosum and the bulbospongiosus muscle. At the apex of the prostate, just above the origin of the membranous urethra, the pubo-prostatic ligaments fix it anteriorly. The membranous urethra is fixed posteriorly by the rectourethralis, which runs from the apex of the prostate to the perineal membrane. These relative points and degrees of fixation explain the nature of urethral injury. The membranous urethra is vulnerable as it runs down to the perineal membrane and is particularly vulnerable at that point. The penile urethra is freely mobile and avoids most injuries except those of a sexual nature. Endoluminal injury is particularly common at and just below the perineal membrane where the urethra is fixed in its position, and at the point of curvature of the urethra as it runs up into the pelvis. With intraperitoneal rupture, the standard of care is still to explore the injury and repair the bladder over a suprapubic catheter. This is because of the possibility of bowel prolapse through the rupture site and of urinary peritonitis. In fact, with small ruptures, it is perfectly possible to leave an indwelling catheter and await spontaneous healing, and to explore and repair as above if there is a continuing cause for concern. The management of vesicovaginal fistulation and the complications of sling surgery are beyond the scope of the chapter and are discussed in the section on female urology. It is suffice to say that in the short term, vaginal leakage of urine after gynaecological surgery should be managed by urethral catheterization. In some instances, the leaking will cease in a few days and the fistula will heal without further difficulty. Posterior urethral injury There is a strong association of posterior urethral injury with fractures of the pelvis and specifically with those fractures associated with disruption of the pelvic ring; in other words, associated with fracture or fracture dislocation of the sacroiliac joint as well as fracture of the anterior bony ring of the pelvis. Urological injury does not occur with type A disruptions, and mainly occurs with type B rotational disruptions. The type C injury, with is both vertically and rotationally unstable, is particularly associated with complete disruptions of the urethra and with complicated injuries such as bladder neck injury. The commonest is pelvic fracture urethral injury of the posterior urethra, which is about four times commoner than straddle injuries of the bulbar urethra, which is about five times more common than injuries to the penile urethra, which are generally the result of sexual misadventure. When this occurs, it is usually the bulbar urethra that is affected and a longer and more serious injury results. The commonest cause is a road traffic accident, which account for 65­85% of injuries; falls from a height which account for 20­25% of injuries; or crushing lateral compression injuries, such as a fall from a horse. Interestingly, only 5­10% of ruptures of the pelvic ring are associated with pelvic fracture urethral injuries. It was originally thought that the problem occurred as a result of shearing of the urethra at the junction of the prostatomembranous junction. Nowadays, it is known that these injuries occur at the bulbomembranous junction and contemporary wisdom has it that this is a consequence of the way the pelvic ligaments of the pelvic ring behave, rather than the bone themselves. Ligaments may rupture either mid-substance or they may tear from their attachment at each end-and, in the case of these ligaments, that means at their bony attachment at one end or their visceral attachment to the urethra at the other. When ligaments rupture mid-substance or tear away from their bony attachment there will be no urethral injury. Hence the explanation as to why urethral injury may not occur, as well as to why it may occur. Occasionally, with either open book injuries or with type C injuries, there is a vertical tear of the prostate in addition to a tear of the membranous urethra, and as a secondary consequence of tearing of the prostate, a bladder neck injury occurs. With super-added infection, the normal fascial barriers break down and spread of the infected extravasated blood and urine can occur in any direction regardless of anatomical layers. Anterior urethral injuries the epithelium of the spongiose (anterior) urethra has no suppporting subepithelial layer comparable to the muscularis mucosae in the intestine. Thus, when the epithelium is breached there is immediate exposure of the subepithelial spongy tissue and, because of the pressure of voiding, extravasated urine is forced into the corpus spongiosum under pressure. This ultimately leads to death from sepsis usually coupled with uraemia, because of the failure to excrete urine properly. Other than intraluminal trauma, which may be due to instrumentation or sexual self-gratification, the causes of injury in the penile urethra is usually a penile fracture. The crura may rupture as well or suffer ischaemic necrosis, leading to gangrene, and disruption of the corpus spongiosum or corpora cavernosa at this point. It can be extremely difficult to distinguish between these, particularly between partial and complete injuries, using retrograde urethrography (for radiological reasons described below) or endoscopy-or even at open surgery, because of the distortion produced by the injury. In the absence of retrograde urethrography or when imaging is inconclusive, the only way in which different types of injury can be distinguished is by catheterizability of the urethra. It is very unlikely that it will be possible to pass a catheter through a completely ruptured urethra. Historically, and indeed in most parts of the world today, this is how partial and complete ruptures are distinguished. All clinical features are time-related and, specifically, it commonly takes at least an hour for a ruptured urethra to cause bleeding that is apparent at the external meatus. In situations where a patient may be brought to an emergency department very quickly, there may be no obviously clinical features-certainly when this happens in less than an hour. It is therefore important that a urethral injury is suspected and all patients suspected of having a pelvic ring disruption.

The wire is replaced through the ureteral catheter allergy testing panel generic cetirizine 5 mg buy, and the indwelling stent placed over the wire allergy testing procedure purchase generic cetirizine. Performance of a retrograde pyelogram allergy treatment babies generic 5 mg cetirizine overnight delivery, particularly in the patient with suspected infection or sepsis allergy treatment runny nose cheap 10 mg cetirizine, is controversial allergy shots large local reaction buy cheap cetirizine online. Many surgeons elect not to perform a retrograde pyelogram when infection is suspected, so as not to increase intrarenal pressure and potentially force bacteria or endotoxins into the blood stream through pyelovenous backflow. If a retrograde pyelogram is required in the potentially septic patient, it should be performed with gentle pressure and the minimum amount of contrast necessary to confirm location of the ureteral stent. Risks of retrograde ureteral stent placement include injury to the urethra, bladder or ureter, infection, and bleeding. As with percutaneous nephrostomy placement, instrumentation of the upper urinary tract in the infected or septic patient can result in an acute haemodynamic deterioration, so anaesthesiologists and surgeons should be alert for signs of decompensation. The results of two randomized controlled trials suggest that little difference exists in the efficacy of percutaneous nephrostomy tubes or ureteral stents for achieving urinary drainage. Summary Important indications exist for immediate or urgent intervention to assure urinary drainage or to remove obstructing ureteral calculi. In the case of infection, the consequences of failure to relieve the obstructed ureter can include severe sepsis and death. For both emergent and urgent indications for urinary drainage, a ureteral stent or percutaneous nephrostomy tube may be considered firstline options. For those patients that require intervention to fragment and remove a ureteral stone, ureteroscopy, and shock wave lithotripsy are acceptable options. Appropriate application of these techniques will minimize adverse consequences and maximize quality of life in patients with obstructing ureteral stones. Interventions for stone removal Two primary interventions to remove ureteral stones exist, both of which are covered in detail elsewhere in this textbook (See Chapter 2. For example, the stone-free rate for distal ureteral stones is 94% for ureteroscopy, as compared with 74% following shock wave lithotripsy monotherapy. In addition, ureteral injury and stricture rates (based on historical data) appear to be higher following ureteroscopy. It is unclear if recent advances in ureteroscopic technology have reduced these risks. Relationship between renal blood flow and ureteral pressure during 18 hours of total unilateral uretheral occlusion. Alfuzosin stone expulsion therapy for distal ureteral calculi: a double-blind, placebo controlled study. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. These advances in lithotripsy technologies have generally led to improved safety, and in some cases, the cost-efficiency, of urolithiasis treatment. All lithotripters share four main features: an energy source; a focusing device; a coupling medium; and a stone localization system. The objectives for using different types of energy sources include: maximum efficacy (the overall stone-free rate) and maximum efficiency (cost-effectiveness including need for secondary treatments). The two basic types of energy sources for generating shock waves are point sources (electrohydraulic) and extended sources (including piezoelectric and electromagnetic). Shock waves must be focused in order to concentrate their energy on a target calculus, and the the type of shock wave generation dictates the method of focusing used. Stone localization during lithotripsy is accomplished with either fluoroscopy or ultrasonography. Fluoroscopy provides the urologist with a familiar modality and has the added benefit of effective ureteral stone localization. However, fluoroscopy requires more space, carries the inherent risk of ionizing radiation to both the patient and medical staff, and is not useful, without adjunctive contrast injection, in localizing radiolucent calculi. Sonography-based lithotripters offer the advantages of stone localization with continuous monitoring, and effective identification of even radiolucent stones, without radiation exposure. Anaesthesia requirements Three factors contribute to the need for anaesthesia during shock wave lithotripsy: shock wave pressure (power); area of the shock wave at its skin entry site; and size of the shock wave focal point. The intensity of the shock wave is determined by the type of generator used and the amount of power (usually electrical charge) supplied to the shock wave generator. The original electrohydraulic design delivers the most powerful shock waves, but also causes the greatest amount of discomfort for the patient. Therefore, either general, regional, or local anaesthesia is used in the original spark-gap machines. Recent studies have demonstrated the ability to reduce anaesthesia requirements with the first generation electrohydraulic devices. The increased area of skin entry and diminished focal size has lessened the need for general or regional anaesthesia in patients treated on second or third generation lithotripters. Using the lower power setting, however, causes the overall stone-free rate to decrease, while increasing the number of shocks required per treatment, and the retreatment rate. Therefore, in order to achieve an anaesthesia-free status, one must expect the number of secondary treatments to increase. Rates of Steinstrasse have been reported in 3% patients with ureteral stones <10 mm, and up to 9. Relative contraindications may include large stone size, most cystine stones, active infection, and proximate calcified abdominal aortic or renal artery aneurysms. As the shock wave pressure and focal point area of second and third generation machines have been reduced, so has the requirement for anaesthesia or analgesia. However, the price paid for anaesthesiafree lithotripsy is an increase in the secondary treatment rates, and a subsequent reduction in efficiency. Electromagnetic lithotripsy, usually performed with intravenous or oral sedation, has been found to require a mean of approximately 3,600 shock waves per treatment, with stone-free rates of 69­80% and retreatment rates of 7­21%. In the Nephrolithiasis Guidelines Panel meta-analysis, stones <10 mm demonstrated stone-free rates of 84­90%, while stones >10 mm diameter demonstrated stone-free rates of 68­76%. Conclusions for managing ureteral calculi using shock wave lithotripsy Shock wave lithotripsy has revolutionized the treatment of urinary calculi, and this modality is an acceptable first-line treatment for most ureteral stones. Ureteroscopy the advent of ureteroscopy has significantly impacted the management of ureteral calculi. Semi-rigid ureteroscopy can be used in conjunction with pneumatic, ultrasonic, or laser probes to successfully fragment ureteral calculi. Ureteroscopy is a versatile technique that can be used to treat stones throughout the urinary tract,21­22 though a small working channel often limits the size and usefulness of adjunctive instrumentation which is used for actual stone retrieval. This limitation on available instrumentation has necessitated the use of intracorporeal lithotripsy for the management of most ureteral calculi. Various modalities for intracorporeal stone fragmentation include the holmium laser, and ultrasonic, pneumatic, and electrohydraulic lithotripters. Each class of intracorporeal lithotripter is reviewed in detail elsewhere in this text. Results: According to stone composition As the stone composition varies, so does the efficacy of shock wave lithotripsy. Even at these higher settings however, results with cystine calculi have been Semi-rigid ureteroscopy the technique of rigid transurethral ureteroscopy has undergone significant refinements. Semi- rigid ureteroscopes utilizing fibre- optic image and light bundles were introduced in the late 1980s. These miniureteroscopes were initially designed to use with laser lithotripsy of ureteral calculi. Since the first mini-ureteroscope was introduced, a number of other semi-rigid fibre-optic ureteroscopes have been developed that utilize either one or two working channels. All share the benefits of significantly reduced outer diameter, and increased ease of passage. Flexible deflectable ureteroscopy Innovations in fibre-optic technology have propelled the further development of flexible ureteroscopes. The widespread use of these new instruments has enabled diagnostic and therapeutic procedures to be performed routinely within the upper ureter and kidney. With the addition of active deflection capabilities, these newer endoscopes are often able to access to the entire upper urinary tract, including all of the intrarenal collecting system,30­32 and even lesions or stones located in the lower pole or extremely lateral calyces can now be reached. In addition to the more conventional uses of flexible, deflectable ureteroscopes, many special applications of these instruments have and will be employed to take advantage of their unique capabilities. However, many of the attributes that make flexible ureteroscopy a useful and effective tool can lead to potential complications, as discussed later in this chapter. Semi-rigid ureteroscopy: Indications Semi-rigid mini-scopes are ideally suited for both diagnostic and therapeutic manoeuvres performed in the lower half of the ureter. The semi-rigid mini-scopes are somewhat easier to manipulate in the distal portion of the ureter and therefore allow more rapid ureteroscopic procedures. However, the flexible ureterorenoscope is the ideal instrument to access the proximal half of the ureter, as well as lesions within the renal collecting system. Therefore, a combination approach with both instruments appears to allow easy and safe access to the entire upper urinary tract. Flexible ureteroscopy Introduction of the flexible ureteroscope the most difficult aspect of flexible ureteroscopy is the introduction of the instrument into the distal ureter, because the flexibility of these small instruments, which allows their manipulation throughout the entire upper tract, means they flex when they meet even the slightest resistance in the ureter. Several techniques Semi-rigid ureteroscopy: Technique the standard technique involves passage of a 0. Flexible deflectable ureteroscopy: Current applications the most frequent indication for flexible ureteroscopy is for removal of symptomatic calculi located throughout the ureter or within the intrarenal collecting system. Under direct vision, various intracorporeal lithotripsy devices, stone baskets, grasping forceps or snares can be manipulated to fragment or entrap ureteral or renal calculi, or fragments under direct vision with fluoroscopic monitoring. During withdrawal, distal progression of the scope is monitored fluoroscopically and with visual documentation of the moving ureteral mucosa. This helps assure that the ureter is not entrapped as the stone or fragment is being extracted. The scope can be passed directly over a guidewire that has been placed between the bladder and the renal collecting system. Flexible ureteroscopy: Technique Our current procedure for passage of an actively deflectable, flexible ureteroscope entails initial placement of a 0. Intermittent fluoroscopic monitoring during the entire case is an integral part of the procedure that allows confirmation of ureteroscopic position. After the ureteral catheter has been removed, a second guidewire, or safety guidewire is passed alongside the original (working) guidewire (using, for example, a dual lumen catheter). After removal of the balloon dilator, the flexible ureterorenoscope is passed directly over the working guidewire. Using both direct vision through the ureteroscope and fluoroscopic monitoring, the flexible ureteroscope is passed up to the area of interest either in the ureter or renal collecting system. Once the area of interest has been reached, the working guidewire can be removed and the working port used for either for irrigation or passage of laser fibres, stone baskets, or biopsy forceps. These sheaths can be easily placed over a guidewire, similar to the placement of a nephroscopy sheath during percutaneous endoscopic procedures. Fluoroscopy allows monitoring of the procedure whenever required, and the safety wire provides access to the renal pelvis With the development of flexible deflectable ureteroscopes, ureteral and renal calculi can often be accessed successfully. However, a major limiting factor in using these smaller endoscopes to manage urinary stones is the small size of the working channel, as the currently available flexible deflectable ureteroscopes have working ports ranging from only 3. Current instrumentation to be used through the working ports of these instruments include a wide range of baskets, graspers, electrodes, and laser fibres. The limited size of the working channels of flexible deflectable ureteroscopes not only limits the instrumentation which can be utilized, but also severely restricts irrigant flow, and this will have a negative impact on visualization during the actual therapeutic procedure. Studies have demonstrated that irrigant flow through a flexible, deflectable ureteroscopes with a 3. Two potential ways to augment irrigant flow, and thereby enhance visualization during flexible ureteropyeloscopic procedures, would be to either limit the size of the instrument utilized through the working channel, or to forcefully inject irrigant fluids. Indeed, by reducing the instrument size to approximately 1 Fr (about the size of a laser fibre or small electrohydraulic lithotripsy probe), one can increase irrigant flow to 24 mL/min with gravity irrigation, a 1,200fold increase. However, one should be aware of the potential deleterious effects that can be induced by forceful hand irrigation, as studies have demonstrated that this manoeuvre can raise intrarenal pressures to over 400 mm Hg, and these pressures have been demonstrated to cause rupture of the intrarenal collecting system in animal studies. Percutaneous anterograde ureteroscopy Rupel and Brown used an operatively established nephrostomy tract to extract an obstructing renal calculus in 1941. Several studies have suggested that there are no long-term sequele if a non-infection-related stone has migrated completely through the wall of the ureter. This complication is usually a result of basketing a stone that is too large to be extracted intact. When in doubt, intracorporeal stone fragmentation should obviate the possibility of avulsion. Although endourologic techniques have been used to manage ureteral avulsion, essentially all these significant complications will require ureteral reconstruction. Rates of ureteral stricture or injury were reported in 1­4% and 3­6%, respectively. The exact technique of percutaneous stone extraction used is specific to the size, location, configuration, and presumed composition of the stone. However, the procedure is always performed with the same four sequential steps employed for percutaneous nephrolithotomy: establishing percutaneous access; dilation of the tract; stone manipulation with fragmentation and extraction; and post-extraction drainage and tamponade of the tract. Techniques of percutaneous access are addressed elsewhere in this volume (Chapter 2. Stones <10 mm demonstrated stone-free rates of 80­97%, while stones >10 mm demonstrated stone-free rates of 79­93%. When stratified by stone location, stones <10 mm demonstrated stone-free rates of 97%, 91%, and 80% the distal, mid, and proximal ureter, respectively. Stone-free rates were 93%, 78%, and 79% in the distal, mid, and proximal ureter, respectively, for stones >10 mm.

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