如何降低输尿管扭曲的风险

                               
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The McCall culdoplasty operation is currently done to treat enterocele and provides a good uterosacral suspension of vaginal vault. Nevertheless, published data describe ureteral kinking in 5-10% of cases (1). Attempt to reduce this complication by prophylactic placement of ureteral stent is not convincing, as ureteral kinking occur in 7% of cases even if a ureteral stent is placed compared to 9% without stent.(2)
The video shows a modified McCall culdeplasty, described by D. Nichols, which reduce significantly the incidence of ureteral complications. In this technique, the sutures concern ONLY the utero-sacral ligament high inside the peritoneum and near the sacrum, without taking the cardinal ligament, nor the peritoneum on the lateral side of the pelvis
A non absorbable suture, Prolene° 0, is used to do a purse-string, taking first the left uterosacral ligament, the pre- rectal peritoneum, the right utero-sacral ligament, the round ligaments and the vesico-uterine peritoneum anteriorly. Laparoscopic view of a McCall culdeplasty done by vaginal route shows where the stitch pass in the utero-sacral ligament and how the ureters are kept at reasonable distance from the suture. The results of this technique, published in a retrospective study concerning 185 patients showed very good anatomic results without any ureteral kinking (3).

1) Kasturi S, Bentley-Taylor M, Woodman P.J, Terry C, Hale D.S (2012) High uterosacral ligament vaginal vault suspension: comparison of absorbable vs. permanent suturefor apical fixation. Int Urogynecol J 23 :941-945
2) Chan R.C, Fletcher S, Antosh D, Khavari R, Stewart J, Chen J, Zurawin J, Flores J, Reeves K (2014). Randomized controlled trial of prophylactic ureteral stent placement during uterosacral ligament suspension. Int Urogynecol J 25 (Suppl 1) :S30
3) Chene G, Tardieu A.S, Savary D, Krief M, Boda C, Anton-Bousquet M.C, Mansoor A. (2008) Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and vaginal vault prolapse after vaginal hysterectomy. Int Urogynecol J 19 :1007-1011