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Columbus Medical Journal.
URETERO-URETERAL ANASTOMOSIS, WITH A
BY J. WESLEY BOVEE, M. D., WASHINGTON, D. C.,
I trust I may be pardoned for bringing this subject to the attention of the Society, after the able and carefully prepared contributions to the surgery of the ureters by Van Hook, Fenger, Kelly and2 Cabot (6) in this country, and the classical works of Glantenay, Liaudet (24), Tuffier (40) and others in Europe.
It is, however, not an old subject and, thanks to the pioneer work of Pawlik and Kelly, we are rapidly brushing away the clouds from the pathology and treatment of diseases of the upper urinary tract.
These organs are so intimately associated with the female generative organs, both in position and function, that the interest of the gynecologist must be drawn to their abnormal conditions. The work of the specialist cannot be limited to the reproductive organs. The rectum and bladder have already claimed his attention and the ureters and kidneys are also applicants for the same honor. I believe it is the gynecologist that is destined to enlighten the profession on the diseases and treatment of these organs. Kelly, Pawlik, Fenger, Kuster, Van Hook and others have started us in the right direction and we will rapidly increase our knowledge. of the yet unknown functions and pathology of the ureters and kidneys.
1 Author's Abstract from Annals of Surgery January, 1897, of paper read in Ninth Annual Meeting of The Southern Surgical and Gynecological Society, Nashville, Nov. 10, 1896.
2 The figures in parentheses refer to the Bibliography at the end of the article.
DEFINITION. Our conception of uretero-ureteral anastomosis is the approximation of adjacent portions of the ureter so as to remove the interruption of its function due to partial or complete section of this organ by accident or otherwise. This meaning does not contemplate such cases as have been reported by Kuster (26), Mynter (26) and Fenger (13), in which they have done such excellent work on the portion of the duct adjoining the pelvis of the kidney. While the kidney pelvis is of the same anatomical structure and function, it has not the same shape and size as the uterer and, therefore, surgical treatment of it is more easily executed and without the danger of stricture or fistula remaining. Nor do we allude to such vaginal work as has been done by Emmet (12), Parvin (28) and others; or even to the lowest two inches of the organ, for it would probably be too difficult to be carried out, transperitoneally, in this portion. Besides, the vesical graft is probably more advantageous here, notwithstanding the difficulty of making a proper duct-ending by that operation. Nor can it be applied when a considerable extent of the duct is destroyed. It is scarcely necessary to state that uretero-ureteral anastomosis does not comprise the implantation of this organ into vagina, rectum, ileum or even to the surface of the body. Kelly has given to this operation the name "Uretero-ureterostomy," a term of whose propriety we do not feel confident. Yet, as no critical objections to it are apparent, its use would seem to be warranted by its convenience.
So far as we could learn from the Library of the Surgeon General's office, the operation has been very rarely attempted on man, and never previous to Schepf's case (34), in 1886. We have found recorded eleven cases, and wish to place on record one that occurred in our own experience. We are obliged to think that many more cases have been recorded, but not under titles indicating them, thus making them nearly inaccessible. For instance, Cushing's case (8) was found by reading a report by him of "Rare Forms of Myomectomy," in one case of which he was obliged to repair in this manner, a cut ureter. Probably many have occurred, both successful and otherwise, that have not been reported. So that it will be seen that this extremely important part of ureteral work has been neglected. This is readily apparent, when we remember the great work done by Pawlik, Kelly and others in
the treatment of constrictions, inflammations and calculi in this duct. Perhaps more striking would it appear if we call attention to the many kidneys that have been sacrificed for injuries to this tube.
ANATOMY.-For the better understanding of the matter under consideration we will mention a few points in the anatomy of this duct.
The uterers are two small elastic tubes that convey the urine from the kidneys to the bladder. They are continuations of the pelves of the kidneys and have the mucous lining, the muscular layers, longitudinal and circular, and a fibrous external covering that is quite intimately attached to the peritoneum throughout its whole extent. They have a diameter of three to four mm., with a lumen somewhat less, and are about twelve inches long. They are abundantly supplied with lymphatics and blood vessels that promote rapid healing. The ureter at first passes obliquely downward and inward from the kidney to enter the cavity of the true pelvis at a point about the intersection of a line connecting the anterior superior iliac spines by one drawn vertically from the pubic spine. In this portion its convexity has been toward its opposite fellow, but now it dips down into the pelvis and follows the pelvic wall, making its convexity toward the wall of the pelvis, and thus in its whole extent inscribing a figure that might be called a reversed "S." It penetrates the wall of the bladder very vertically and, according to Bell (2), travels between the muscular and mucous coats one-half to three-fourths inches. This latter author (p. 178) has carefully studied the anatomy and function of the bladder and ureter and describes a musculature which he calls "the muscles of the ureters," and which have been mentioned by other writers since his time. They have the power
to prevent regurgitation of urine into the ureters.
ANATOMICAL RELATIONS.-The ureter rests upon the psoas muscle in its upper portion and is crossed obliquely from within outward, below the middle of this muscle, by the spermatic vessels, which descend in front of it. The right ureter is close to the inferior vena cava. Lower the ureter passes over the common or external iliac vessels, behind the termination of the ileum on the right and the sigmoid or its vessels on the left. nears the bladder in the male, it is crossed on the inner side by
the vas deferens, which passes down between the ureter and2 bladder. In the female the ureter runs along the side of the cervix uteri and upper part of the vagina before reaching the bladder. Kelly has shown us the dangerous relations of it to the ovarian vessels which cross it at about the middle of the abdominal portion and accompany it to the pelvis along its outer side, recrossing it here. The uterine artery crosses inward just above it as it nears the cervix.
Glantenay (15, p. 47) mentions a fold at the junction of the mucous membranes of the bladder and ureter that is formed by them and which acts as a valve to the opening. The urine is forced along the ureter by two influences: the peristaltic action of the tube and the force of gravity, but this latter does not act when the patient is in a horizontal position while the first is constantly acting. Smith (37) and other abdominal surgeons have had excellent opportunities for studying this vermicular action.
The following class represents the cases of uretero-ureteral anastomosis that have been reported:
1. Schopf (34). Operated for broad ligament cyst; dense and universal adhesions that were divided by thermo-cautery; ureter divided in this manner accidentally and closed by eight silk sutures that did not penetrate the lining membrane; died of tuberculosis seven weeks afterward; autopsy showed both apices to be surrounded by fibrous tissue, several small abscesses in left upper lobe; spleen decaying; left kidney, amyloid degeneration; right one size hen's egg, parenchyma contracted and pelvis distended; right ureter at seat of injury is embedded in: dense fibrous tissue.
2. Pawlik (29). Removal of papillomatous cysts of broad' ligaments (ovarian?); cut ureter in separating adhesions; passed elastic uretal catheter down into bladder and up into upper portion of ureter; sewed ureteral ends over it with silk (Lembert stitch) in two courses; closed peritoneum over it and no drainage used; left ureter catheter in place; but slipped out owing to restlessness of patient, who died fourteen hours later. Autopsy demonstrated imperviousness of sutured wall.
3 and 4. Tauffer (38). In tying off blood supply of tumors in two cases, ligated and severed ureter; in each case closed wound by six fine intestinal silk sutures, and both cases completely recovered.
5. Fritsch (14), on pp. 264 and 265 of his work reports case in which he cut the ureter while operating for a tumor. Did not recognize the duct and passed a uterine sound into the bladder and a uteral sound into the lower part of the cut ureter; as both sounds came into direct contact in the bladder, it demonstrated it to be the ureter. With fine intestinal sutures the ends were brought together and healed perfectly.
6. Hochenegg (16). Sacro-peritoneal hysterectomy for cancer, during which resection of bladder and left ureter was necessary; ureter sutured end-to-end and bladder sutured. On twentieth day fatal hemorrhage from granulating wound; ureter and bladder sutures intact; origin of hemorrhage could not be lo.cated.
7. Kelly (20). Hystero-myomectomy, May 1, 1892, for removal of large tumor; divided large (hydro) ureter for a large vein and closed it by Van Hook method; iodoform gauze drainage; union by first intention; recovery.
8. Cushing (8). In removing large soft myoma cut one ureter; ends united by two fine silk sutures and one of catgut; discharge of a little urine from the wound for two weeks; but fistula promptly closed. Both ureters were distended and tortuous; recovery.
9. Emmet (11). In removing a large uterine fibroid cut ureter in two at level of fifth lumbar vertebra; closed it by Van Hook's method, notwithstanding the upper portion was much distended; recovery.
10. Doherty (10), of Georgia, quoted by Van Hook, sent to the latter a report of a case like Kelly's and patient recovered completely.
II. A. W. Mayo Robson (32). "In removing a large myoma uteri, which weighed twenty-five pounds, and which had raised the peritoneum from the floor of the pelvis, I found I had taken two inches out of the ureter. Instead of performing nephrectomy, or establishing a ureteral fistula, I anastomosed the proximal into the distal end by splitting the lower end and drawing the upper into the lower. Recovery was uninterrupted, and the amount of urine was never diminished. The patient remains well six months later."
12. Author's. In removing a badly adhered tubo-ovarian abscess, we tied ureter with ovarian vessels and cut it off. After