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After the site of obstruction or trauma is identified, nonviable
tissue is debrided, and the ureter is mobilized proximally and
distally to allow for a tension-free anastomosis Ureteral
injury caused high-velocity gunshot wounds (>2000 ft/sec;
mostly hunting and assault rifles) may be associated with a larger
zone of devitalized tissue. In these instances, the ureter should be
generously debrided before repair. Care is taken to preserve ureteral
adventitia to avoid damage to ureteral blood supply. If there
is still tension, the surgeon should be prepared to perform a psoas
hitch or a bladder flap (or both) to relieve tension. Ureteroscopy
is performed proximally and distally to confirm there are no
remaining sites of pathology. Each end of the ureter is widely
spatulated (1.5 cm), and an end-to-end anastomosis is completed
using a fine absorbable suture. Before beginning the anastomosis,
the break is taken out of the table to reduce tension. The authors
prefer braided polyglactin or an equivalent suture because of its
easy handling and relatively quick dissolution. The specific details
of the repair are less important than the basic principle of wide
spatulation and anastomosis of the unspatulated end of one ureter
to the spatulated end of the other ureter. The anastomosis may
be performed in a running or an interrupted fashion
If the tissue quality is tenuous, an interrupted anastomosis allows
a more precise closure and ensures that the entire repair is not in
jeopardy if a single area becomes compromised because of poor
tissue quality, delayed ischemia, or an inadequate bite during the
suturing. Knots may be placed intraluminally or extraluminally
at the preference of the surgeon. After the posterior anastomosis
is complete, a ureteral stent is placed, and then the anterior anastomosis
is completed. Tissue sealant is applied, and tissue wrap
(omental or peritoneal) is used if readily available. A closedsuction
drain is placed adjacent to the anastomosis. The nephrostomy
tube is left in place and capped.


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