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round the ureteral fistula, denuded outside of this, and closed the fistula.

e. Pozzi's Method.-Pozzi used the flap-splitting method in a case of uretero-vesico-vaginal fistula. He placed the patient in the kneechest position, made a transverse incision extending half an inch beyond the borders of the vesico-vaginal fistula and a perpendicular at each end so as to form an H. Next he dissected the two flaps off to a distance of half an inch, brought them together over the openings of both fistula with three deep silver-wire sutures and three superficial

sutures,

B. Implantation of the Ureter in the Bladder (Uretero-cystostomy). -This may be accomplished by the intraperitoneal or by the extraperitoneal method.

a. The Intra-peritoneal Method. The abdomen is opened in the median line as in other laparotomies. The ureter is dissected out, and an opening made in the posterior wall of the bladder by cutting down on a closed forceps introduced through the urethra. A thin flexible catheter is introduced into the ureter and pulled out through the urethra. The ureter is then fastened to the wall of the bladder by means of interrupted silk sutures. A self-retaining soft-rubber catheter is inserted through the urethra into the bladder beside the ureteral catheter; and finally the abdomen is closed.

b. The Extra-peritoneal Method.—In order to avoid the dangers of intestinal occlusion if the ureter forms a cord drawn through the cavity of the pelvis, a method has been invented by which the ureter is displaced, and the bladder drawn up toward it outside of the peritoneum. The patient is placed in Trendelenburg's position. Median laparotomy is performed. Next, a small incision is made through the peritoneum where the ureter crosses the bifurcation of the iliac artery (p. 81), in doing which the surgeon must, however, bear in mind that the ovarian vessels lie in front of the ureter at this place. By pulling on the ureter here he makes its lower course apparent, and makes a second small incision through the broad ligament about the middle of its height. Through this he pulls the ureter out, ties it with a double ligature, and cuts it across on a little pad. The protruding mucous membrane of the lower end is cut off, the peritoneum sutured over the opening, and the stump dropped. The upper end of the severed ureter is pushed behind the peritoneum up to the upper opening, where it is seized with a long narrow forceps, which is carried from the side of the bladder, outside of the peritoneum, above the ilio-pectineal line, and from where it is pulled down. Next, the two small openings in the peritoneum and the incision in it in the median line are closed with fine catgut. The bladder, distended with a small quantity of boric-acid solution, 1 Pozzi, Traité de Gynécologie clinique et opératoire, Paris, 1890, p. 934. 20. Witzel of Bonn, Centralbl. für Gynük., 1896, vol. xx. No. 11, p. 290.

is now easily drawn up toward the ureter until they are in contact in the length of an inch and a half. The end of the ureter is cut slantingly, and a small hole is made in the wall of the bladder by cutting down on a catheter introduced through the urethra, and the mucous membrane of the ureter is stitched with fine catgut to that of the bladder, and then the wall of the ureter is stitched to the sides of the hole in the wall of the bladder. The bladder is raised in two folds above and below the ureter, and these folds are stitched together over it, so as to form an oblique canal one and a half inch long, simulating the normal obliquity of the course of the ureter through the wall of the bladder. A small drain is left in an opening cut through the skin corresponding to the place of union between bladder and ureter. Finally, the abdominal wound is closed, and a catheter left in the bladder for four days.

C. Nephrectomy. (See below, under Uretero-uterine Fistula.)

Of these three operations the closure of the fistula, as the safest and simplest, should first be tried. The implantation of the ureter in the bladder has given good results in several cases, and should be preferred to the mutilating nephrectomy.

4. Vesico-uterine Fistula.—Fistulous communication between the urinary system and the uterus can only take place in the cervix. The other end of the fistula may be in the bladder or in the ureter, and it is of vital importance to distinguish between these two conditions. Common for both is the discharge of urine from the os uteri. The vesico-cervical fistula forms a small round hole opening in the middle of the cervix, a condition which has been brought about by imperfect healing of a tear through the anterior wall of the cervix and the base of the bladder.

Diagnosis. Sometimes a probe can be brought from the bladder through the fistula into the cervical canal, where it comes in contact with a uterine sound held there. Milk injected into the bladder will come out of the os uteri. If the cervical canal is plugged with a laminaria tent, no systemic disturbance will result, while acute hydronephrosis is developed if it is a uretero-cervical fistula.

Prognosis.-This kind of fistula has an unusual tendency to spontaneous healing, which probably is due to the thickness of the wall in which it is situated.

Treatment. This tendency to spontaneous closure may be furthered by cauterization. If that does not succeed, closure by suture may be attempted in different ways.

a. Emmet's Method. The anterior lip of the cervix is split open in the median line, so as to reproduce a condition similar to that obtaining when the injury was fresh. In this way the fistula is reached, and pared, and the wound united by silver-wire sutures from side to side. b. Folet's Method. The urethra is dilated so as to admit the index

finger, and the cervix is pulled down to the vaginal entrance. A transverse incision is made in front of the cervix, the bladder dissected off, and the opening in the bladder closed, the finger in the urethra aiding the introduction of the sutures.

It seems that even the somewhat risky dilatation of the urethra (p. 142) may be dispensed with.'

As a last resort the cervix may be turned into the bladder by suturing it to the borders of a hole cut from the vagina into the bladder.

5. Vesico-utero-vaginal Fistula.-This fistula goes from the bladder through the anterior lip of the cervix and ends in the vagina.

Treatment. If there is left enough of the anterior lip of the cervix a denudation is made here and stitched together with a correspondingly pared surface on the anterior wall of the vagina.

If there is not tissue enough left in front the posterior lip of the cervix is pared and brought together with the anterior lip of the opening in the bladder. By this procedure the cervix is turned into the bladder, and the menstrual flow is secreted with the urine through the urethra.

6. Uretero-uterine Fistula.-In this variety, as in the vesico-uterine, urine flows from the os, but the exact condition can be made out in different ways. Milk injected into the bladder will not come out through the os. If the cervical canal is plugged there will soon appear symptoms of acute hydronephrosis, such as pain in the lumbar region, vomiting, and fever. The most conclusive test is, however, that of Bérard. The bladder is emptied with catheter, and the patient is placed on a vessel that will collect all the urine coming from the vagina. At the end of two hours the urine is again drawn from the bladder by means of a catheter. The amount obtained will equal that which has flowed from the vagina, each being the secretion of one ureter. The ureter may perhaps be felt swollen (p. 167). That it should be possible to introduce a ureter-catheter into the uterus from the bladder (p. 165) is very unlikely.

This variety of fistula is exceedingly rare.

Treatment. The cervix must be turned into the bladder as described above. As the lower portion of the ureter is usually obliterated, it is not allowable simply to close the os uteri, apart from the trouble that might be anticipated by the stagnation of urine in the

uterus.

Another method more dangerous, but offering the advantage of not interfering with fertility, consists in nephrectomy; that is, the removal of the corresponding kidney through an incision made in the lumbar region (Simon).

7. Uretero-vesico-vaginal Fistula.—When the ureter has been partly 1 A. Benckisser, Centralblatt f. Gynäk., 1893, vol. xvii. p. 847.

destroyed at the same time as a vesico-vaginal fistula is formed, the opening of the former is found somewhere on the edge of the latter. We have seen above how this condition may be cured, either with or without slitting up the ureters.

Genital Cleisis.-When it is impossible to close a fistula, relief from the troublesome, constant escape of urine may be afforded by closing the genital canal below the seat of the fistula, an operation called cleisis, or closure.

We have already alluded to the closure of the uterine os (hysterocleisis), the turning in of the cervix into the bladder (hystero-cystocleisis). The vulva may be made the seat of the closure (episio-cleisis), but this is a very objectionable procedure, since it not only renders impregnation impossible, but prevents coition, causes stagnation of urine, and may give rise to the formation of stone in the lower part of the vagina. The most common seat of this closure is the vagina (colpocleisis). In performing this operation the operator should always keep in view the desirability of preserving as much of the depth of the vagina as possible. Closure should therefore not be made at a lower point than necessary, and often much can be gained by giving the line of union a slanting direction.

The patient is placed in Simon's position (p. 368). A narrow strip is cut off from the mucous membrane of the vagina in such a way that the denuded part of the anterior wall fits to that of the posterior. These are now brought together by sutures according to general rules. During the insertion of sutures on the anterior wall a sound is kept in the bladder, and while working on the posterior wall the operator uses a finger in the rectum as a guide.

Through the development of better methods for the direct closure of urinary fistula, the use of genital cleisis has become more and more rare. Still, the operation is yet occasionally indicated in cases of great loss of substance, when there is much cicatricial tissue around the fistula partly adherent to the bone, when the bladder is inverted and filled with part of the intestine, and especially in certain cases of uretero-uterine and vesico-utero-vaginal fistula. (See above.)

When the urethra had been lost or its lower edge was too weak to be pared and stitched, Von Nussbaum combined cleisis with the formation of an artificial supra-pubic urethra. He punctured the bladder above the symphysis, and left the canula in place for two weeks. Then the patients were allowed to get up, and directed to empty the bladder every two or three hours with a female catheter. At the end of a few months the catheter could be dispensed with, the urine being driven out at will, in a jet, by contraction of the abdominal muscles. In the interval the recti and pyramidales muscles kept the little opening closed.

Urinals. If for some reason or other no operation can be per

formed, the patient may derive more or less comfort from the use of a urinal. These may be divided into two classes, the extra- and intra-vaginal. To the first belong rubber bags with a wide opening covering the vulva, and fastened to the pelvis and the thigh. To the second belong the ingenious apparatus of Bozeman and Jay. Bozeman's consists in a flat pear-shaped receiver of silver with a number of holes on the side that comes in contact with the anterior vaginal wall. The urine enters through one or more of these holes, and is led through a tube to a rubber bag attached to the thigh. Jay's consists in a strong soft-rubber ring, to which is attached a bag of the same material, ending in a tube which is compressed by a shut-off. The ring is introduced into the vagina where it stays by its own expansion. The patient takes a daily sitz-bath, and slips the nozzle of a syringe into the exit-tube and fills the urinal repeatedly with warm soap-suds.'

I have, however, found that patients, for different reasons, such as pain, excoriations, lack of coaptation, get tired of wearing urinals and prefer to protect themselves with towels.

FIG. 227.

Operations for Incontinence.-It happens sometimes, after a complete closure of a fistula, that the patient continues having a constant dribbling of urine, which now escapes involuntarily through the urethra. This condition may be due to the loss of the sphincter muscles of the urethra, or to traction being exercised on the urethra, by which it is kept open, or simply to the habit of contraction acquired by the bladder while the fistula was open. Sometimes a spontaneous cure takes place by shrinkage of a cicatrix running across the neck · of the bladder; but this is at best slow work. Pawlik has devised an operation by which the condition is remedied at once (Fig. 227). The patient is placed in knee-elbow position. The urethra is pulled to one side with a tenaculum as far as possible (a). N、 The limits of the fold thus formed are marked on the mucous membrane. From these points two parallel lines are drawn up and made to converge at their upper end near the subpubic ligament. Next the meatus is pulled as far as possible toward the clitoris without using undue force, and that point marked (b). The lines of incision are now continued in a slightly convergent direction to b. The

12

b

H

Pawlik's Operation for Incontinence: H, urethra; A, denudation; a, point to which the urethra can be pulled to a side; b, point to which it can be pulled in the direction of the clitoris.

thus circumscribed tissue is cut out in the shape of a wedge, and the

John C. Jay, Jr., New York Medical Record, Aug. 28, 1886, vol. xxx. p. 251. The urinal is made by Parker, Stearns & Sutton, 228 South street, New York. Pawlik, Wiener Med. Wochenschrift, 1883, Nos. 25–26, p. 772, and Zeitschrift für Geburtshilfe und Gynäk., 1882, vol. viii. p. 38.

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