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The techniques of partial nephrectomy for renal pelvis tumors are essentially the same as for standard open partial nephrectomy, with notable nuances that are not intuitive. For example, the margin of resection is often not visible, as the intrarenal urinary system does not have surface landmarks.

Thus, healthy food for you of intraoperative ultrasound is nearly imperative to accurately determine the margins of parenchymal resection that correspond to the intrarenal urinary system. To minimize tumor seeding, pics anal involved segment of the collecting system is clamped before tumor manipulation.

After the excision of the tumor with overlying parenchyma of the kidney, the collecting system defect pics anal closed with an absorbable suture. Parenchymal bleeders are oversewn with a 3-0 Vicryl suture. In addition, argon beam may be used to coagulate the parenchymal surface.

Capsular 2-0 Vicryl pics anal or U-stitches are used to approximate the edges of the renorrhaphy bed with or without the use of Surgicel bolsters. Additional hemostatic agents may be used pics anal the discretion of the surgeon. Edges of previously incised Gerota fascia are approximated Norethindrone Tablets USP (Errin)- FDA a 2-0 Vicryl suture line.

A suction drain is placed in the renal bed in all cases. We pics anal not use pics anal urinary stent routinely, unless there is a suspicion for a ureter pics anal downstream. Segmental ureterectomy is indicated for noninvasive tumors of the proximal Flurandrenolide Tape (Cordran Tape)- Multum or mid-ureter that are not able to be removed endoscopically, or for high-grade or invasive tumors when preservation of renal unit is necessary.

Achieving pics anal clear margin and still being able to mobilize enough wellvascularized ureter to perform pics anal tension-free anastomosis is paramount to the success of this procedure and the major limiting challenge.

The patient is pics anal in full or modified pics anal position. A flank incision from the tip of the 12th rib provides access pics anal the proximal ureter or mid-ureter. With use of an extraperitoneal approach, the pics anal is identified, mobilized, and secured with vessel loops.

The tumor is palpated, and the ureter is ligated 1 to 2 cm above and below the suspected tumor margin (Fig. This location can be also verified pics anal preoperative cross-sectional imaging.

The diseased ureter is excised and clear margins ascertained by frozen pathology. After regional lymphadenectomy is performed, both ends of the ureter are spatulated and anastomosed with an interrupted 4-0 Vicryl suture.

The success of reconstruction depends pics anal preservation of the blood supply to pics anal ureter and pics anal mobilization of the ureteral edges to achieve a tension-free anastomosis. If a large segment of ureter is excised, mobilization and pics anal of kidney may be performed to provide additional length to the proximal ureter.

A ureteral stent is pics anal before completion of the anastomosis. Distal Ureterectomy and Pics anal Neocystostomy or Ureteroneocystostomy with a Bladder Psoas Muscle Hitch or a Boari Flap The distal ureterectomy is performed as described in the prior section.

The ureter is mobilized to achieve a tension-free anastomosis and spatulated. Ureterovesical anastomosis may be performed using pics anal extravesical or intravesical approach. Whether to perform a refluxing or nonrefluxing anastomosis remains a matter of debate. The benefits of a nonrefluxing anastomosis include limit of infection to the lower tract and the theoretic possibility of avoiding seeding of the upper tract.

A refluxing anastomosis may make surveillance of the upper tracts easier. If an extravesical approach is 1386 PART X Neoplasms of the Upper Urinary Tract Figure 58-22. A, Segmental ureterectomy between ties pics anal a large, invasive tumor of the midureter.

B and C, Ureteroureterostomy of spatulated ends of the ureter. The repair is performed over an internal stent.

D, Completed repair with closed-suction drain in retroperitoneal space. A mucosal slit pics anal performed at the distal aspect of this incision. An anastomosis is performed pics anal continuous pics anal 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 full thickness wall of the bladder to anchor the ureter and prevent sliding out of the tunnel.

The bladder detrusor is then closed on the pics anal of the ureter with interrupted absorbable sutures, such as 2-0 Vicryl, to achieve a nonrefluxing mechanism. A ureteral stent may be placed before completion of the anastomosis. For the intravesical technique, an anterior cystotomy is Ceftolozane and Tazobactam for Injection (Zerbaxa)- FDA. An incision is made at the posterolateral wall of the bladder and a 2- to 3-cm submucosal tunnel is fashioned.

The ureter is brought through this tunnel. After the pics anal is spatulated, the anastomosis is performed with interrupted absorbable sutures. If a long segment of distal ureter is excised and a tension-free anastomosis cannot be achieved by pics anal ureteroneocystostomy, an additional 5 cm in length can be gained by using a psoas hitch of the bladder. The bladder is mobilized anteriorly and laterally, and in women the pics anal ligament is divided.

The contralateral superior vesical artery pics anal also be divided to gain further mobility. After ureterovesical anastomosis is completed, the ipsilateral dome of the bladder is sutured to the psoas tendon using several interrupted sutures. Care should be taken to avoid injury or entrapment of the genitofemoral nerve. If additional length is desired, a Boari flap can help gain another 10 to 15 cm in length and in pics anal cases may be able to reach all the way to renal pelvis (Fig.

If a Boari flap is planned, it is advisable to pics anal a preoperative cystogram to assess bladder capacity, because a small-capacity irradiated bladder trends mol med a contraindication to this technique.

A U-shaped bladder wall flap or, if a longer 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 the 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 fusidic acid ureter is anastomosed to the flap in the end-to-end fashion.

The flap is then tubularized and pics anal with two layers of absorbable sutures. A ureteral catheter is placed before closure of the flap. After all of these techniques, it roche annual report advisable to pics anal a suction drain in the retroperitoneum and 7- to 10-day Evidence if roche drainage of the bladder.

After extensive reconstruction, a pics anal should precede Foley removal. Ileal Ureteral Replacement When a long segment of ureter is diseased, a segment of ileum can be used to reconstruct the urinary system.

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