**9.2 Principles**

Mobilization should be sufficient to allow a tension-free closure. Tissue interposition is typically recommended. Common sites for ureteral injury are found beneath the uterine vessels near the cardinal ligament and beneath the infundibulopelvic ligament and the tunnel of Wertheim. Successful ureteral repair relies on careful mobilization, wide spatulation, use of fine absorbable suture (4-0, 5-0), and temporary stenting.


### *9.2.1 Injury recognized during surgery*

• Clamp and ligature should be removed immediately (**Figures 8**–**12**).

	- Infant feeding tube No.5
	- J-shaped stent is preferable. (**Figure 6**)
	- Injury to ureter <sup>&</sup>lt; 4-5cm of ureterovesical junction
		- If 3–4 cm proximal to ureterovesical junction ➔ Ureteroureterostomy is needed.
		- If within 2 cm of ureterovesical junction ➔ Ureteroneocystostomy is required.
		- If above two cannot be done without tension ➔ Vesicopsoas hitch is the procedure required.
	- Injury to ureter <sup>&</sup>gt; 4-5cm of ureterovesical junction/at brim
		- Bladder flap (Boari) (**Figure 12**)
		- Uretero-ureteral anastomosis (**Figure 8**)
		- Transperitoneal anastomosis to opposite ureter (**Figure 10**). Rarely done these days
		- Small intestine can be used as a conduit for the lower ureter-ileal conduit (**Figure 9**)
		- Skin ureterostomy

#### *9.2.2 Injuries unrecognized during surgery*

	- Diagnosed within 48-72 hours of surgery- immediate ureteral repair should be done.

If diagnosis is made late or if extensive devascularization and injury are likely to occur e.g., after extensive hysterectomy, or extensive retroperitoneal fibrosis, cellulitis and induration is expected in patients with poor medical condition -PCN (Percutaneous Nephrostomy) preferably under ultrasound is required and definitive surgery can be planned 6-8 weeks later.
