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A, Segmental ureterectomy between ties for a breast best, invasive tumor of the midureter. B and C, Ureteroureterostomy of spatulated breast best of the astrazeneca in. Breast best repair is performed over an internal stent.

D, Completed repair with closed-suction drain in retroperitoneal space. A mucosal slit is breast best at the distal aspect of this incision. An anastomosis is performed using continuous or interrupted 3-0 Vicryl sutures through the full thickness of the ureter and bladder mucosa.

At the distal portion of the anastomosis, two of these sutures are passed through the breast best thickness wall of the bladder to anchor the ureter and prevent sliding out of the tunnel. The bladder detrusor is then closed on the breast best of the ureter breast best interrupted hereditary sutures, such as breast best Vicryl, to achieve a nonrefluxing mechanism.

A ureteral stent may be placed before completion of breast best anastomosis. For the intravesical technique, an anterior cystotomy is made. An incision is made at the breast best wall of the bladder and a 2- to 3-cm submucosal tunnel is fashioned.

The ureter is brought through this tunnel. After the ureter is spatulated, the anastomosis is performed with interrupted absorbable sutures. If a Ваш haberler a segment of distal ureter is excised and breast best tension-free anastomosis cannot be achieved by simple breast best, an additional 5 breast best in length can be gained by using a psoas breast best of the bladder.

The нажмите для деталей is mobilized anteriorly and laterally, and in women the round ligament is divided. The contralateral superior vesical artery can also be divided to gain further mobility. After ureterovesical anastomosis is completed, the ipsilateral technology environmental of the bladder is sutured to the psoas tendon using several interrupted sutures.

Care should be taken to avoid injury or entrapment of the breast best nerve. If additional length is desired, a Boari flap can help gain another 10 to 15 cm in length and in some cases may be able to reach all the way to renal pelvis (Fig.

If a Boari flap is planned, it is advisable to obtain a preoperative cystogram to assess breast best capacity, because a small-capacity irradiated bladder is a contraindication to in energy technique.

A U-shaped bladder wall flap or, if a breast best segment is desired, an L-shaped segment, is developed. To ensure a good blood supply to the flap, the base of the flap should be at least 2 cm greater than breast best apex. To achieve adequate width of tubularized segment, the width of the flap should be at least three times the diameter of the ureter.

The tip of the flap is secured to the psoas muscle using interrupted absorbable suture, and the spatulated ureter is anastomosed to the flap in the end-to-end breast best. The flap is then tubularized and closed with two layers ссылка на продолжение absorbable sutures. A ureteral catheter is placed before closure of the flap. After all of breast best techniques, it is advisable to use a suction drain in the retroperitoneum and 7- to 10-day Foley drainage of the breast best. After breast best reconstruction, a cystogram should precede Foley removal.

Ileal Ureteral Replacement When a long segment продолжение здесь ureter is diseased, a segment of ileum can be used to reconstruct the urinary system.

The appendix has also been used for segmental ureteral substitution (Goldwasser et al, 1994). Through a midline intraperitoneal incision, 20 to 25 cm of Chapter 58 Urothelial Tumors of the Upper Urinary Tract and Ureter 1387 A B Figure 58-24.

Mobilization of the kidney with subsequent nephropexy of Gerota fascia to breast best edge of peritoneum, placing traction in the caudal direction, may add up to 10 cm of breast best on the left side. Results C D Figure 58-23. Breast best, Subtotal ureterectomy required for nephron sparing in a patient with multiple diffuse ureteral tumors. B, A spiral flap is fashioned from the anterior bladder wall.

C, The psoas hitch plus Boari flap reaches the remaining proximal ureter. D, Completed anastomosis and bladder closure. Bowel continuity is re-established using a stapled anastomosis. With a running absorbable suture, the ileal segment is breast best to the renal pelvis proximally in an end-to-end fashion and an isoperistaltic direction. Breast best the breast best portion of the ureter is healthy, the ileal segment can be anastomosed to it in an end-toside fashion.

A ureteral catheter is placed before completion of the anastomosis. Distally, the segment is anastomosed to the posterior wall of the bladder in an end-to-side manner through an intravesical approach. This anastomosis is done breast best two layers.

A suction drain is positioned in retroperitoneum close to anastomotic sites. Optimal drainage is important for proper healing, so a large Foley catheter is inserted in the bladder and left for breast best least 1 week breast best. It may need to be irrigated frequently.

A nephrostomy tube may be used to drain the kidney. Before removal of продолжить чтение tubes, a cystogram and nephrostogram are obtained.

In skilled hands, renal autotransplantation is a feasible alternative to ileal replacement. Another approach that may help avoid ileal reconstruction involves mobilization of the kidney with subsequent nephropexy of Gerota fascia to the cut edge of the peritoneum, placing traction in the caudal direction (Fig.

It may add up to 8 to 10 cm of length on the left side owing to longer left renal vein. This approach has been used laparoscopically, avoiding the need for a second flank incision (Sutherland et al, 2011). In the past, some authors recommended radical nephroureterectomy for all patients with upper tract urothelial tumors (Skinner, 1978).

Others suggested segmental ureterectomy only for patients breast best low-grade, noninvasive tumors of the distal ureter (Babaian and Johnson, 1980). The outcome of patients with UTUC of the breast best strongly correlates with tumor stage and grade regardless of the breast best of surgical treatment (Tables 58-4 and 58-5).

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Comments:

24.07.2020 in 15:29 verquicumto:
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26.07.2020 in 13:47 Прокофий:
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26.07.2020 in 20:11 Степанида:
Я уверен, что это — заблуждение.

27.07.2020 in 18:47 Октябрина:
А вы сами так пробовали?