The ureter is handled by grasping its surrounding fat. Direct handling may damage it because of its precarious blood supply.
The type of ureter anastomosis is, in general, independent on whether the transplant is orto or heterotopic.
There are different techniques to sew the ureter. Here below is detailed the end-to-end suture, performed by 4 discontinuous stitches with non-absorbable 11/0 monofilament.
How to do it:
It is important to achieve equal diameters between both ureters. If necessary, the recipient ureter (usually the smaller one) will be cut in bias in order to enlarge its diameter.Care should be taken not to twist the ureters to avoid blocking the urine flow. It is also very important to place the 4 stitches at the same distance from each other.
A. The first stitch is made in the upper side, ventral face, from outside to inside the lumen of the donor ureter. Be sure that you are crossing the muscular wall, not only the surrounding fat.
B. From inside of the recipient ureter to the outside.
C. The stitch nē1 is made by three single knots. At least one long end must be left.
D. Twist the ureter 180ē with the help of the long end of stitch nē 1. The stitch nē 2 is made in the same way as before with nē 1. This second stitch has to remain opposite the first.
E. Tie stitch nē 2 with 3 single knots as before.
F-G-H. Being equidistant to both stitches 1 and 2, the third stitch is made in the same way as the other ones.
I. The last stitch, nē 4, has to be equidistant nē 1 & 2, and opposite nē 3.
J. All four stitches have to be as equidistant as possible one to another. Check the anastomosis for fistula to ensure that there is no urine loss and check also the ureter for peristalsis. |
