A Weekly Journal of Medicine and Surgery. NEW SERIES VOL. L. JANUARY 10, 1903. THE LUMBAR SEGMENT OF THE URETER. BY BYRON ROBINSON, B.S., M.D., The entrance of an organ in the surgical field revives its anatomy as well as its topography. Surgery is the father of practical anatomy. This is especially characteristic of the lumbar ureteral segment. For convenience of anatomic description and surgical application, we will assume (1) the anatomic, and (2) the topographic plan of the lumbar segment. I. ANATOMIC PLAN. First and foremost should be considered the anatomic plan, to become familiar with the following data: The location of the lumbar ureter is in the regio lumbalis, dorsal to the peritoneum and lying on the ventral surface of the psoas muscle. Practically, the lumbar ureter is located between the psoas muscle and the dorsal peritoneum. The division consists of (1) a proximal isthmus or neck; (2) a lumbar spindle; (3) a middle isthmus. The limitations extend from the proximal ureteral isthmus to the middle isthmus. In other words, it begins at the neck and ends at the iliac artery. The direction is obliquely median ward from the proximal isthmus to the middle isthmus. The ureters converge distalward. It has a slight curve, the concavity of which presents externalward. The ureter and psoas muscle muscle cross each other at an acute angle like an italic letter x. The form is that of a fusiform spindle. The proximal end of the lumbar ureter is more elongated, while the distal end is more blunt and is short. The dimensions of the lumbar ureter are: (1) length about four inches; (2) caliber; a, proximal end (neck), onetenth of an inch; b, distal end, one-sev WHOLE VOLUME LXXXIX. enth of an inch; and c, middle, threetenths of an inch. The symmetry of the lumbar ureters is not bilateral in form or location. The right lumbar spindle is shorter in length and greater in diameter than that of the left. The left lumbar ureter is nearer to the median line than the right. The right calices and pelvis located more distalward than the left. The right lumbar ureter is perhaps one-fourth of an inch shorter than the left. The distances of separation of the lumbar ureter are: (a) the proximal ends are separated about three and a half inches; (b) the distal ends are separated about two and a half inches. The tissue matrix consists of a universally areolar bed, having a wide range of mobility, which is of great practical utility in surgical intervention. Though the lumbar ureter lies in a shifting, mobile bed, it is intimately connected with the peritoneum by fibrous strands, and the ureter follows the peritoneum in stripping the one from the other. The fixation apparatus of the lumbar segment is a vast loose mobile cellular bed. A limited number of fibers retain it in relation to the peritoneum. The cellular bed of the lumbar segment is sufficiently important for separate consideration. Its course is in subperitoneal tissue on the ventral surface of the dorsal wall. It passes between fine shiny planes of fibrous cellular tissue lying between the dorsal wall and the peritoneum. (a) The fascia propria ureteris surrounds the ureter. It is a thin fibrous, shiny, fascial envelope which passes proximal ward over the surfaces of the kidney and distalward over the surfaces of the ureter. (b) A transverse fibro-cellular bed sur FIG. 1. (Byron Robinson). Dorsal abdominal wall illustrating the lumbar ureter, its pars renalis, pars infra-renalis, its spindle and proximal ureteral isthmus. B, the ureteral distal pelvis; AA, the proximal arterio-ureteral crossings. The ureter, AB; the vena renalis, the vena cava and ovarian vein as far as A, the crossing of it. Ureter constitutes the uretero-venous triangles of author. 1, middle arterio-ureteral crossing. The lumbar ureter extends from kidney to 1. rounds the ureter. This plane is infiltrated with fat. It is a kind of aponeurosis; one can separate it in several layers. This ureteral fibrous envelope passing proximal ward blends with the panniculus adiposus. This plane becomes gradually lost bilateral to the ureter. It is the thick fatty bed of cellular, fibrous tissue which hides the ureter from view. It emits fibrous bands which become attached to the peritoneum. (c) The dorsal parietal peritoneum forms another important tissue bed for the ureter -very important in surgical intervention. The peritoneum forms the ventral covering of the lumbar ureteral segment, and in all spare subjects the ureter may be observed as a white ribbon-like band lying on the psoas, shimmering through the peritoneum. If one strips the peritoneum from the lumbar ureteral segment, especially at the distal end, the ureter will tend to follow the peritoneum, fine fibrous threads being attached to it. In other words, the ureter adheres to the peritoneum stronger than it does to the tissue of its own bed. This is important in cases of ureteral isolation, as it may become nourished by the peritoneum. In surgical intervention on the lumbar ureteral segment the colon and ureter are forced with the peritoneum toward the median line, but they retain amply sufficient nourishing blood-vessels for the life of the ureter. The peritoneum ventral to the lumbar ureteral segment is extensively mobile; also the lumbar ureter dorsal to the peritoneum is widely mobile in its cellular bed. The lumbar ureter belongs to the subperitoneal fibrous fascia to such an extent that the vessels of tractus intestinalis are situated between the fibrous fascia and peritoneum and form a constituent part of the peritoneum. The plane of fibrous tissue ventral to the lumbar ureter is thin, so that it makes a slight yet pronounced relief in the peritoneum. In fatty subjects this dense fibrous plane infiltrated with fat obscures the ureter from inspection. The ureter is quite independent of the dorsal fatty bed, from which it is easily enucleated; on the contrary, it is united to the peritoneum by strong adhesions - fibrous strands. Too much stress cannot be laid on the anatomic fact that the ureter follows the peritoneum when stripping it, especially when exploring the calices, pelvis and lumbar ureter. To Cabot is due the credit of first writing on this point. II. TOPOGRAPHIC PLAN OF THE The topographic plan is the most sig nificant in diagnosis and surgical intervention. The topography or visceral relation of the lumbar ureteral segment changes with age and function. This is an especial feature more pronounced in the right lumbar ureter. The topography of the lumbar segment will be considered under four heads, viz., holotopy, skeletopy, syntopy and idiotopy. A. Holotopy (relations to general body). (1) The lumbar segment of the ureter is practically symmetrical, and (2) it converges distalward toward the median body line. (3) It has a curve the concavity of which presents externally. (4) The lumbar segment crosses the psoas obliquely from the external proximal end to internal distalward. (5) It extends from the proximal ureteral isthmus or neck to the iliac artery; in general it extends from the distal renal pole to the iliac artery. (6) The lumbar segment lies extra-peritoneally on the dorsal peritoneal surface. (7) The lumbar segment lies in a loose bed of cellular tissue; it has a wide zone of motion. (9) It is about four inches in length. (10) It is a spindle-shaped duct with the most elongated, tapering end proximalward. Its proximal end is two inches from the middle line; its distal end is one and a half inches from the middle line. The lumbar segment has an extensive area of mobility within the zone of health. The right calices and pelvis in about 60 per cent. of subjects lies more distalward than the left. Their more distal position rests on (a) the developing liver in the fetus; (b) the size of the liver in adults; (c) the longer right renal artery; and (d) the shallow right renal bed. (11) B. Skeletopy (relation to osseous skeleton).—(1) The lumbar segment lies almost bilaterally symmetrically and ventral to the transverse processes of the second, third, fourth and fifth lumbar vertebræ. (2) Practically it lies between the twelfth rib and sacro-iliac joint. (3) The distal end lies on the sacro-iliac joint and distal to the iliac crest. (4) It is perhaps the most safely protected of ducts. (5) The left lumbar ureter lies especially at its distal end, nearer to the vertebral column FIG. 2.-Topography of ureter and blood-vessels of lateral pelvic wall and anterior abdominal wall. The cut illustrates the relations of the ureter and the spiral segment of the genital circle. The upper portion of the cut represents a front view, while the under part of the cut represents a side view. It shows the proximal (II), middle (iliac) and distal (17) arterio-ureteral crossing. The spindle shape and curves of the ureters are shown. In this drawing a suggestion from Holl is employed. The genital circle and ureter are shown in their relation, 1, kidney; and 7, ureteral pelvis ; 4 and 8, proximal ureteral isthmus; 5 and 9, proximal ureteral spindle; 6, ureteral calices; 10 and 11, proximal arterio-ureteral crossing; 12, middle arterio-ureteral crossing; 13, ovarian segment; 14 and 15, external iliac vessels; 16, pelvic ureteral spindle; 17, distal arterio-ureteral crossing; 18, left oviduct; 19, uterus; 20, pelvic segment of uterine artery divided by the ureter; 22, vagina; 23, ureteral orificial slit opening into bladder; 24, posterior branch of internal iliac; 25, renal vein receiving the ovarian vein 26; 9, 26, 25, 7, uretero-venous triangle. (Author.) FIG. 3.-(Byron Robinson). Ventral view of the ureters in relation to osseous skeleton (skeletopy). 1, distance between ureteral pelves (four inches). 2, distance between ureters at fourth lumbar vertebra (two and one-half inches). AB, line erected at junction of internal and middle thirds of ligamentum inguinale. Note the ureters in lumbar segment rest on ventral surface of transverse processes. Note that the twelfth rib divides the kidney. (Author.) than the left. (6) The renal artery arises from the aorta in over half of the cases at the level of the intervertebral disc, between the first and second lumbar vertebræ. (7) The calices and pelvis correspond in position to the eleventh and twelfth dorsal and the first, second and third lumbar vertebræ. It is a frequent finding in autopsies to find the distal pole of the right calices. distal to the crista iliaca. C. Syntopy (relations to adjacent viscera). The syntopic relations of the lumbar ureteral segment are significant from diagnosis and surgical intervention. The relation of the ureter in the lumbar segment to adjacent viscera changes with the condition of adjacent viscera and state of splanchnoptosis. It has age and functional relations. The topography of the lumbar ureter will be considered in regard to (I) viscera; (II) muscle; (III) vessels; (IV) nerves; (V) lymph apparatus. I. VISCERAL RADIATIONS OE THE URETER (FACIES VICERALIS A.-The ventral visceral relation of the lumbar ureter is first and foremost with : |