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INTRODUCTION

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Iatrogenic harm to the urinary tract can be caused by any surgeon operating in or around the pelvis and the retroperitoneal abdominal space, with an overall incidence of 0.3% to 1.5%.1 This applies to gynecologists, general surgeons, urologists, vascular surgeons, neurosurgeons, and orthopedic surgeons.

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The anatomy of the lower urinary tract and its close connection with gynecologic organs makes it vulnerable to be affected by gynecologic tumors, adjuvant local treatment such as pelvic radiation, and surgical injuries at the time of dissection. More specifically, gynecologic oncologists have to often deal with a surgical scenario that includes urinary tract involvement by tumor, inflammation and, or fibrosis. It is not rare that, during the resection of a gynecologic tumor, a decision has to be made regarding whether or not to remove a portion of the ureter, bladder, or both. Furthermore, most pelvic exenterative procedures are performed in patients who have received high doses of pelvic radiation. Typically, in such situations, total cystectomy must be performed to accomplish complete tumor removal.

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The goal of this chapter is to explain the general principles and different surgical tools that a trained gynecologic oncologist has to master in order to reconstruct the urinary tract when needed. Continent and incontinent reservoirs are discussed in Chapters 11 and 12 of this book. In this chapter we will discuss the surgical procedures utilized to reconstruct the ureter as well as to enlarge or substitute for the urinary bladder after any surgical injury or after a radical resection.

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URETERAL SUBSTITUTIONAND REPAIR

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Background

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The urinary tract is particularly susceptible to intraoperative injury for a variety of reasons. Operating in difficult situations, such as that encountered with surgery for recurrent malignancy, extensive inflammation and bulky tumors, places the urinary tract at even greater risk. Injuries to the ureter are the most common urinary tract injuries, because the ureter is ­similar in appearance to vascular structures, is difficult to identify as a result of its close adherence to the posterior peritoneum, and can be encountered at virtually any level in the retroperitoneum and upper pelvis. When these facts are studied, along with the intrinsic difficulties with the occasional unforeseen congenital anomalies, such as ureteral duplication or retrocaval ureter, it is easy to understand how easily ureteral injury can occur. Consequently, it is essential that each surgeon operating in this region be familiar with the specific anatomy of this structure.

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Ureteral injury is most commonly iatrogenic in origin. Urological surgeons are the group most frequently causing ureteric injuries particularly with the use of rigid and flexible ureteroscopy. The ureter is at greatest risk for injury from ureteroscopy at the ureterovesical junction, pelviureteric junction, and the pelvic brim. Most injuries are limited to the mucosa and easily managed by the insertion of a ureteral stent.2

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The majority of significant operative ureteric injuries ...

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