Advantages of ureteral access sheath?
- Facilitating access to the collecting system, and multiple entry and reentry
- Decreasing intrarenal pressure
- Improving drainage around the scope
- Protecting the scope and
- Avoiding bulking
(From Traxer article)
Diameter of Ureteral access sheath?*)
- 35 cm long
- 12/14Fr diameter
- Diameter of the nonstented ureter - 9 Fr to 10Fr
Several studies have shown that the over distention created by a UAS may compromise ureteral blood flow and subsequently induce ureteral ischemia.7 The reperfusion that occurs after sheath removal may expose the ureteral wall to free radicals and subsequent tissue damage.
(From Traxer article)
Endoscopic classification of ureteral wall injury after RIRS using Ureteric Access Sheath by Olivier Traxer?
- Grade 0 - No lesion found or only mucosal petechiae
- Grade 1 - Ureteral mucosal erosion without smooth muscle injury
- Grade 2 - Ureteral wall injury, including mucosa and smooth muscle, with adventitial preservation (periureteral fat not seen)
- Grade 3 - Ureteral wall injury, including mucosa and smooth muscle, with adventitial perforation (periureteral fat seen)
- Grade 4 - Total ureteral avulsion
Position for eondoureterotomy?
Lower ureteral strictures are incised in an anteromedial direction, taking care to stay away from the iliac vessels.
Upper ureteral strictures are incised laterally or posterolaterally, again away from the great vessels
Bridging Various Ureteral Defect Lengths (in cm) with Different Reconstructive Surgical Techniques
- Ureteroureterostomy 2-3
- Ureteroneocystostomy 4-5
- Psoas hitch 6-10
- Boari flap 12-15
- Renal descensus 5-8
Procedure for Renal Descensus?
- Following entry to the Gerota’s fascia, the kidney is completely mobilized and rotated inferiorly and medially on its vascular pedicle.
- The lower pole of the kidney is then secured to the retroperitoneal muscle using several absorbable sutures.
Length of repair with Boari flap?
A Boari flap can be constructed to bridge a 10- to 15-cm ureteral defect, and a spiraled bladder flap can reach the renal pelvis in some circumstances, especially on the right side.
Blood supply of Boari flap?
Superior vesical artery
Length of Boari flap?
- Base of the flap being at least 4 cm in width and the tip of the flap being at least 3 cm in width.
- The flap length should equal the estimated ureteral defect plus an addition of 3 to 4 cm if a nonrefluxing anastomosis is planned.
- Furthermore, the ratio of flap length to base width should not be greater than 3 : 1 to help minimize flap ischemia.
Procedure of Boari flap?
- A, In Boari flap, the intended flap is first marked on the anterior and lateral aspects of the mobilized bladder.
- B, The flap is created, ensuring good vascular supply.
- C, Ureteroneocystostomy is completed, with the longitudinal bladder tube closure.
Ureteroscope? Diameter? *
6/8.9 Fr semirigid ureteroscope
Part below the ureteropelvic junction to the superior aspect of the sacroiliac joint