Benign Urinary Tract Surgeries

Ureter reimplant

Cohen Crosstrigonal technique

  1. Position supine, arms tucked, prep abdomen and genitals
  2. Pfannenstiel incision along Langer lines, incise down to fascia
  3. Separate fascia off underlying muscle
  4. Separate rectus muscles at linea alba almost to pubis, retract laterally with Denis Browne ring
  5. Place stitch on either side of midline incision, then make vertical cystotomy
  6. Pack bladder dome with moist raytec x3, retract edges superiorly and laterally
  7. Identify ureters at trigone, beware of ureteral duplication
  8. Place holding stitch past distal portion of ureteral orifice
  9. Incise mucosa with cautery (cut), ensure enough room around orifice for suturing
  10. Dissect away underlying tissue from ureter, obtain enough length that the ureter can reach the skin without tension
  11. Create the cross-trigonal tunnel with a right-angle retractor, grasp the ureteral retraction stitch and pull through the neohiatus
  12. Stitch the ureteral apex with 4-0 vicryl x1, then stitch in the rest of the ureter with 6-0 vicryl
  13. Close the mucosa over the dissection site with ***
  14. Remove the raytecs, close the bladder in two layers, start towards bladder neck, close one layer, then continue the same stitch on the outer layer
  15. Close the fascia with ***, scarpas with vicryl interrupted x3, and skin with subcuticular stitch, then apply dermabond

Ureteral trauma

Open repair technique

  1. Identify ends of ureter
  2. Debride injured tissue
  3. Place 2-0 stitch on each end for traction
  4. Spatulate to widen anastomosis
  5. Place wire through midpoint hole of stent, and place stent into proximal and distal ends
  6. Use 4-0 monocryl x2 to close in running fashion circumferentially

Postop care

Bladder Augmentation

Ileocecoplasty technique

  1. Place patient supine with arms out, place in trendelenberg, do not need to hyperextend bed, give cefazolin + metronidazole for bowel coverage
  2. Tip: can place foley prior to prep/drape, but need accessible to fill bladder during case
  3. Make midline incision from pubic symphysis to slightly above umbilicus to access hepatic flexure, divide layers and enter peritoneal cavity
  4. Free up ascending colon from retroperitoneal attachments, can see kidney/duodenum underneath, free up to hepatic flexure
  5. Mark 10-15cm terminal ileum and 10-15cm cecum/ascending colon, identify mesenteric blood supply to ensure presence, can perform doppler and IC green before stapling
  6. Create mesenteric window with tonsil/bovie, then divide mesentery up to bowel with ligasure, then staple bowel
  7. Take bowel ends, create opening and staple together (ensure new conduit is inferior), then close the hole either with new staple load or 2-0 vicryl interrupted, can oversew with 2-0 silks
  8. Fill bladder with 200mL water, then open bladder at dome transversely, place traction 2-0 vicryl stitches on flaps for access
  9. Ensure cecum lays comfortably on bladder, then open antimesenteric end of cecum
  10. Open end of ileum, place 12Fr catheter, grasp redundant tissue with allis clamps, and staple off excess ileum (taper off towards ileocecal valve)
  11. Switch for 16Fr catheter, place plication (imbricating) sutures with 2-0 vicryl on antimesenteric side, checking that catheter pops in/out after tying each one down
  12. Secure cecum to bladder with 2-0 vicryl - place 3 stitches and run each one, try to have knots on outside of bladder
  13. Place drain - make separate stab incision, then push tonsil clamp from skin into abdomen, grasp drain and pull through, secure with nylon stitch
  14. Cut out circle on skin at ideal channel site, remove underlying subcutaneous fat (expose with army/navy retractors), create small cruciate incision on fascia, should be large enough to allow one finger through
  15. Insert babcock clamp through channel incision into abdomen, grasp channel and bring out through skin, stitch to skin with 3-0 vicryl (do not stitch mesentery), make sure balloon is inflated, should have either separate suprapubic or urethral foley as safety valve
  16. Closure - #1 PDS x2 (meet in middle) for fascia, then 3-0 vicryl to bring subcutaneous tissue together and staples for skin

Cystotomy repair

Repair steps

  1. Identify cystotomy - can make anterior cystotomy to find posterior cystotomy
  2. Can place full-thickness traction sutures to help with visualization
  3. Run mucosal 2-0 vicryl to close bladder
  4. Run serosal/detrusor 2-0 vicryl to close outer bladder layer
  5. Leak test via catheter with 120mL (or more) to ensure no leaks
  6. Can consider placing drain at repair site

Postop care