Improved Outcomes in Colon and Rectal Surgery part 42. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | IMPROVED OUTCOMES IN COLON AND RECTAL SURGERY Figure Ureteroureterostomy. A Spatulation of ureteral margins and placement of running locked sutures. Preferred technique. B Oblique anastomosis. can be used to aid in diagnosis of ureteral injury by retrograde injection of methylene blue through the ureteral catheter. They can also be used to place a retrograde wire under fluoroscopic guidance for placement of an indwelling ureteral double-J stent after a ligation crush injury. Types of Injury Laceration A laceration or transection of the ureter can usually be repaired with primary anastamosis ureteroureterostomy with spatulated ends ureteral stent and placement of a closed suction drain in the area of the repair Figure . Ligation If a ligation injury is apparent intraoperativly the clamp or tie can be removed followed by ureteral stent placement for up to one month. The patient should undergo repeat imaging either with a renal ultrasound or intravenous pyelogram IVP at 3 months to ensure a ureteral stricture has not developed. If the injury is not identified until post operatively a retrograde ureterogram and stent placement or percutaneous nephrostomy tube placement may be needed before surgical correction. Devascularization A devascularization injury will not be evident intraoperatively and results from the sacrifice of the segmental ureteral blood supply. Intraoperativley a devascularized ureter may appear discolored lack peristalsis and may not bleed at a transected site. The irradiated ureter is especially susceptible to this type of injury as the normal healthy ureter has numerous collaterals and is very resistant to devascularization even with extensive dissection. The anatomy of the blood supply to the ureter as previously described should be known as the surgeon is carrying his dissection over the pelvic brim. Thermal Thermal injuries will usually present in the early postoperative period with either fistula or stricture formation. These injuries .
