IN SUSPECTED URETERIC INJURY AT PELVIC SURGERY

WHAT IS THE BEST RATIONAL STEP????

1)do an IVP on the OT-table
2)entire length of pelvic-ureter is to be exposed to assess
3)inject dye into bladder
4)carry out retrograde stenting of ureter



[DOUBT:the Q-source has given the ans as (3)!!!!but have no clue to support this ans......what about (2) ]

FRNZ, PLZ somebody have a say on this Q --------perhaps this also remained unnoticed

best rational step wud b on table ivp..ther is no point in exposing the whole of ureter as injury occur at the site of surgery, also visually inspecting ureter cn detect injury to ureter???..injecting dye into bladder will perhaps identify bladder or urethral injury.unless the pt has gross vesicoureteric reflex the dye wont reach ureter to any significant amount...to carry out retrogade stenting 1 mite need to kno the site of injury. otherwise wer to stent?? these r my logics neednt b rite..

www.eMedicine.com (PAPER-ureteral injury during gynecological procedures)-


* If the ureteral injury is noted intraoperatively and additional imaging is necessary to localize the lesion, the best imaging study is retrograde ureteropyelography. By placing a cystoscope in the bladder and cannulating the affected ureteral orifice with a ureteral catheter, dilute Cystografin is injected into the ureter under fluoroscopy or when taking a kidneys, ureters, bladder (KUB) image. If the dye is seen in the renal pelvis without any ureteral extravasation or significant narrowing along the ureter, the ureter is in continuity and may be managed conservatively, with either observation or stent placement.

* If ureteral injury is suspected postoperatively, imaging studies evaluating for hydronephrosis, ipsilateral renal function, and continuity of the ureter are necessary. These imaging studies may include an intravenous urogram (IVU), an abdominal and pelvic CT scan with IV contrast, a renal ultrasound, and/or retrograde ureteropyelography. While the IVU largely has fallen out of favor in the evaluation of stone disease, many urologists believe that an IVU is the best imaging study to evaluate for continuity of the ureter in cases of ureteral injury. Unlike a renal sonogram and a retrograde ureteropyelogram, the IVU assesses for function of the ipsilateral kidney and the drainage of the ureter in a series of sagittal images. Hydronephrosis, ureteral integrity, and any extravasation usually can be seen readily through an IVU.

*l A CT scan aso can assess for both function of the ipsilateral kidney and drainage of the ureter. Because CT images are a series of cross sections, visualizing ureteral integrity and continuity often is more difficult than with an IVU. CT scanning has the advantage of imaging for concomitant conditions at the same time.

* Renal ultrasound is perhaps the best noninvasive method to visualize the kidney and shows hydronephrosis with great sensitivity. Renal ultrasound does not assess for kidney function, nor does it assess the continuity of the ureter. Therefore, if renal ultrasonography is performed, retrograde ureteropyelography often is necessary to evaluate the course of the ureter.

Other Tests:

* If one is unsure whether a ureteral injury has occurred intraoperatively, IV administration of 10 mL of indigo carmine or methylene blue with 20 mg of furosemide may help to localize a ureteral injury. Extravasation of blue dye indicates ureteral discontinuity.

* Postoperatively, if any drainage is noted from the vagina, an attempt should be made to diagnose a ureterovaginal or vesicovaginal fistula. This may be accomplished with a bedside test. In this test, a tablet of oral Pyridium is administered. The bladder is instilled via a catheter with saline that is colored with methylene blue. A vaginal tampon is inserted. Since Pyridium turns the urine orange, if an orange liquid is observed on the end of the tampon, a presumptive diagnosis of a ureterovaginal fistula can be made. Alternatively, if the tampon absorbs a blue liquid, the diagnosis of vesicovaginal fistula can be made. However, since both types of fistulas may be present simultaneously, this test may not be completely reliable.


thus, answer is-3. inject dye into bladder through cystoscope..

post op evaluation- IVU, USG,CT.

SO, ANSWER IS 3 AS MENTIONED ABOVE.

SOME ADDITIONAL POINTS-

Etiology: The 6 most common mechanisms of operative ureteral injury are as follows:

* Crushing from misapplication of a clamp

* Ligation with a suture

* Transsection (partial or complete)

* Angulation of the ureter with secondary obstruction

* Ischemia from ureteral stripping or electrocoagulation

* Resection of a segment of ureter

Any combination of these injuries may occur.

Several predisposing factors have been identified in iatrogenic urologic injury. These factors include uterus size larger than 12 weeks' gestation, ovarian cysts 4 cm or larger, endometriosis, pelvic inflammatory disease, prior intra-abdominal operation, radiation therapy, advanced state of malignancy, and anatomical anomalies of the urinary tract. Ureteral injuries can be either expected or unexpected, and they may be the result of carelessness or due to a technically challenging procedure.

WELL-GIVEN EXPLANATORY ANS WITH AUTHENTIC REFERENCE---------THESE ARE REALLY HELPFUL