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Intracystic Reimplantation of the Ureter: A New Operative Technique
INTRACYSTIC REIMPLANTATION OF THE URETER A
NEW OPERATIVE TECHNIQUE
ELMER HESS
There have been several operative techniques developed for reimplantation of the ureter into the bladder as a result of our ever-increasing effort to conserve renal parenchyma. One of the common causes of renal or upper urinary tract damage is stricture of the intramural or terminal ureter. Some of these are successfully handled by means of the cystoscope; others require some type of open operative attack. None of the procedures heretofore advocated has provided for a fairly normal oblique reimplantation of the ureter and most of them have required extensive surgery. The technique to be described is a simple, easy surgical procedure which permits the ureter to course through the bladder wall in a fairly normal oblique manner. This utilizes whatever of sphincteric action is exercised by the musculature of the bladder wall and prevents reflux of urine. Satisfactory anchorage of the ureter in the bladder is simple and efficient. The procedure may be used in a small group of cases where the obstruction is in the intramural portion of the ureter or confined to its lower few centimeters. Case report. A 25 year old female had suffered for a long time with repeated severe attacks of renal colic. It was impossible to pass any size catheter or bougie farther than 2½ cm. above the right ureteral meatus. Several attempts at retrograde pyelography had failed, the medium simply flowing back into the bladder. An intravenous urogram then showed some hydronephrosis on the right side, with marked dilatation and tortuosity of the right ureter. Two hours after intravenous injection the right kidney pelvis and ureter were still plainly visible, while the left pyelogram had completely disappeared in 60 minutes. Several days later an attempt was made to get a satisfactory retrograde pyelogram. A No. 6 ureteral catheter was cut off flush, inserted into the meatus and pushed up snugly against the face of the obstruction, 2½ centimeters above the meatus. Neo-iopax was forced through the catheter by an assistant, as the catheter was held under cystoscopic observation against the face of the stricture. If this pressure was not maintained, the solution could be seen flowing swiftly back into the bladder. Ten cubic centimeters were injected without any discomfort to the patient. Figure 1a shows the pyeloureterogram which beautifully demonstrates the stricture. As our clinical 866
INTRACYSTIC REIMPLANTATION OF URETER
867
and laboratory studies revealed that the kidney was in all probability a normal functioning organ and as there was no evidence of infection, the problem resolved itself in hmv to relieve the obstruction and symptoms without sacrificing the kidney
FIG. 1. a, pyeloureterogram made with blunt catheter in intramural portion of ureter. Notice mild nephrosis and mild dilatation of ureter and fine stricture between end of catheter and terminal portion of ureter. b, five months later. A No. 6 catheter has traversed entire ureter to renal pelvis. c, pyeloureterogram taken 5 months later with improvement in nephrosis and dilatation of ureter. ( Compare with a.)
After repeated failures to pass the obstructing area cystoscopically, it was decided to open the bladder suprapubically and attempt dilatation of the stricture directly. If this failed, the technique of von Lichtenberg was considered. "A Reverdin needle is introduced into the ureteral orifice and carried up the ureter for a distance of from 2 to 3 cm., making certain to pass beyond the strictured area and the needle brought through the wall of both ureter and bladder. A heavier suture is then passed by the same route but in the op-
868
ELMER HESS
posite direction. The 2 sutures are tied tightly enough to cause devitalization of the included tissue, with subsequent sloughing. In female patients, the suture ends are brought through the urethra; in male patients, the suture ends
·Urete..r pass . in.r-, lh'.ru bla'aderwall at a ri&.1l an5le. It was itnpc'c>- . '5ible to pas'5 th.is point with. in.'&trume.n.t6 0
Ureter drawn. upward FIG. 2
are brought out through a small suprapubic drain. In 7 or 8 days, the suture will slough out, leaving a normal appearing slit, which functions well as a ureteral orifice and shows no tendency to re-form the stricture." As it was impossible to pass the finest filiform beyond the face of the stricture
869
INTRACYSTIC REIMPLANTATION OF URETER
with the bladder open, this method was discarded. There seemed nothing left to do, if the kidney were to be saved, except the extensive operation of reimplantation of the ureter so ably described by Young, Lowsley and Kirwin,
Lateral wall ot bladder 1n.c'1sed to exoo;se dilated ri~h.1: u~eter
over-
Oritice ot r1Dht ureter
ureler
Vesical orifice FIG. 3
and by Hyman and Leiter, who recently reported some 60 cases of ureteral reimplantation, discussing both the indications and contraindications to the procedure, as well as their operative technique. It suddenly occurred to me that there was a possibility of handling the situa-
870
ELMER HESS
tion a bit differently and, I hoped, simply. Figure 2, 2, shows a schematic drawing of the ureter, stricture and bladder wall. A probe was bent at right angles and inserted into the ureteral meatus to the face of the obstruction
\Ureler d.rawn. downward into bladder ·. .
i\.
'
'
'
,.,·.
'.
'31:ltu:re :placed into iuiiip.cl ureler
~ulure placed lln.der and lh:ru m.uc06a pt tri8one tQ anchor e,tump ohtreter
·.,
Vt"5ica\ orif\'ce
,if~ ureter up ri~ht ure:ter
_n.0.
p~Jw, and downwa:rd and
. .
·· out th.i'u ure:\hra(Ca\h.eter left in for 10 da1e) · FIG. 4
(fig. 2, 1 and 3) and the mucosa split down to the probe and to the face of the obstruction (fig. 3, 1). Again, attempts were made, unsuccessfully, to pass filiforms through the stricture. The bladder wall at the site of the stricture was now grasped by a Babcock forceps. About 7 cm. above and obliquely
INTRACYSTIC REIMPLANTATION OF URETER
871
the bladder wall was grasped by 2 more Babcocks and incised. The bladder wall was now split through its entirety and the lower ureter was grasped another Babcock and carefully dissected and freed from the periureteral There is considerable slack in the pelvic ureter and it was tissues (fig. 3, very easy to completely free the lower 7 or 8 cm. of the ureter and dra,v it in a loose loop into the lumen of the bladder. Then with the entire lower end of the ureter in view and in a straight line it was easy to divulse the stricture (fig. 3, 3). The incision was carried freely through all coats of the ureteral wall beyond the stricture. Then the entire intramural portion of the ureter was freely cut away from all attachment to the bladder wall (fig. 4, 1). This left a large raw area of exposed muscularis. The mucosa over the trigonal area was denuded and the tip of the lower ureter, which had originally been the meatus, was carried under the trigonal mucosa and buried with a suture (fig. 4, 2). A suture was placed through the muscularis and the under surface of the ureter. This further anchored the ureter in place (fig. 4, 3). A No. 8 catheter was placed in the ureter through the newly created meatus, the proximal end was passed out through the urethra and pulled taught, and the walls of the bladder were closed in such a manner by the sutures that the ureter coursed through in its normal oblique fashion (fig. 4, 4). No attempt was made to drain the perivesical space, as it was felt that with the interrupted suturing the ureter itself would act as a drain into the bladder. A retention catheter was next placed through the urethra into the bladder and the suprapubic opening in the bladder was tightly closed. A small cigarette drain into the space of Retzius finished the operative procedure. Measures were taken to keep the infection to a minimum. The retention catheter was removed from the bladder on the sixth day. The retention catheter in the ureter was removed several days later and the patient had a satisfactory convalescence, with complete relief of all of her symptoms. Five months later, the patient was re-examined. She was symptom-free and had gained 15 pounds. The bladder appeared free of infection. The right ureteral meatus was large, functioned normally and was situated on a ridge which extended to and lost itself in the right edge of the trigone. The ureter was easily catheterized. Figure lb shows a No. 6 catheter to the renal pelvis. Figure le shows the improvement in the retrograde pyelogram. I wish to extend my appreciation and thanks to William P. Didusch for the excellent drawings which illustrate this operative procedure, CONCLUSIONS
A simple, easy, surgical technique is presented for the reimplantation of the ureter into the urinary bladder where the obstruction is confined
872
ELMER HESS
to the intramural or lower few centimeters of the pelvic ureter. This simple operation, while done only once, was successful and is offered for consideration. 501 Commerce Bldg., Erie, Pa. REFERENCES HYMAN, A. AND LEITER, H. E.: J. Mount Sinai Hosp., 7: No. 6, (March-April) 1941. L0WSLEY, 0. S. AND KIRWIN, T. J.: Clinical Urology, vol. 2. Williams & Wilkins Co., Baltimore, 1940. YOUNG, HUGH H.: Young's Practice of Urology, vol. 2. W. B. Saunders Co., Philadelphia and London, 1926.
NEW OPERATIVE TECHNIQUE
ELMER HESS
There have been several operative techniques developed for reimplantation of the ureter into the bladder as a result of our ever-increasing effort to conserve renal parenchyma. One of the common causes of renal or upper urinary tract damage is stricture of the intramural or terminal ureter. Some of these are successfully handled by means of the cystoscope; others require some type of open operative attack. None of the procedures heretofore advocated has provided for a fairly normal oblique reimplantation of the ureter and most of them have required extensive surgery. The technique to be described is a simple, easy surgical procedure which permits the ureter to course through the bladder wall in a fairly normal oblique manner. This utilizes whatever of sphincteric action is exercised by the musculature of the bladder wall and prevents reflux of urine. Satisfactory anchorage of the ureter in the bladder is simple and efficient. The procedure may be used in a small group of cases where the obstruction is in the intramural portion of the ureter or confined to its lower few centimeters. Case report. A 25 year old female had suffered for a long time with repeated severe attacks of renal colic. It was impossible to pass any size catheter or bougie farther than 2½ cm. above the right ureteral meatus. Several attempts at retrograde pyelography had failed, the medium simply flowing back into the bladder. An intravenous urogram then showed some hydronephrosis on the right side, with marked dilatation and tortuosity of the right ureter. Two hours after intravenous injection the right kidney pelvis and ureter were still plainly visible, while the left pyelogram had completely disappeared in 60 minutes. Several days later an attempt was made to get a satisfactory retrograde pyelogram. A No. 6 ureteral catheter was cut off flush, inserted into the meatus and pushed up snugly against the face of the obstruction, 2½ centimeters above the meatus. Neo-iopax was forced through the catheter by an assistant, as the catheter was held under cystoscopic observation against the face of the stricture. If this pressure was not maintained, the solution could be seen flowing swiftly back into the bladder. Ten cubic centimeters were injected without any discomfort to the patient. Figure 1a shows the pyeloureterogram which beautifully demonstrates the stricture. As our clinical 866
INTRACYSTIC REIMPLANTATION OF URETER
867
and laboratory studies revealed that the kidney was in all probability a normal functioning organ and as there was no evidence of infection, the problem resolved itself in hmv to relieve the obstruction and symptoms without sacrificing the kidney
FIG. 1. a, pyeloureterogram made with blunt catheter in intramural portion of ureter. Notice mild nephrosis and mild dilatation of ureter and fine stricture between end of catheter and terminal portion of ureter. b, five months later. A No. 6 catheter has traversed entire ureter to renal pelvis. c, pyeloureterogram taken 5 months later with improvement in nephrosis and dilatation of ureter. ( Compare with a.)
After repeated failures to pass the obstructing area cystoscopically, it was decided to open the bladder suprapubically and attempt dilatation of the stricture directly. If this failed, the technique of von Lichtenberg was considered. "A Reverdin needle is introduced into the ureteral orifice and carried up the ureter for a distance of from 2 to 3 cm., making certain to pass beyond the strictured area and the needle brought through the wall of both ureter and bladder. A heavier suture is then passed by the same route but in the op-
868
ELMER HESS
posite direction. The 2 sutures are tied tightly enough to cause devitalization of the included tissue, with subsequent sloughing. In female patients, the suture ends are brought through the urethra; in male patients, the suture ends
·Urete..r pass . in.r-, lh'.ru bla'aderwall at a ri&.1l an5le. It was itnpc'c>- . '5ible to pas'5 th.is point with. in.'&trume.n.t6 0
Ureter drawn. upward FIG. 2
are brought out through a small suprapubic drain. In 7 or 8 days, the suture will slough out, leaving a normal appearing slit, which functions well as a ureteral orifice and shows no tendency to re-form the stricture." As it was impossible to pass the finest filiform beyond the face of the stricture
869
INTRACYSTIC REIMPLANTATION OF URETER
with the bladder open, this method was discarded. There seemed nothing left to do, if the kidney were to be saved, except the extensive operation of reimplantation of the ureter so ably described by Young, Lowsley and Kirwin,
Lateral wall ot bladder 1n.c'1sed to exoo;se dilated ri~h.1: u~eter
over-
Oritice ot r1Dht ureter
ureler
Vesical orifice FIG. 3
and by Hyman and Leiter, who recently reported some 60 cases of ureteral reimplantation, discussing both the indications and contraindications to the procedure, as well as their operative technique. It suddenly occurred to me that there was a possibility of handling the situa-
870
ELMER HESS
tion a bit differently and, I hoped, simply. Figure 2, 2, shows a schematic drawing of the ureter, stricture and bladder wall. A probe was bent at right angles and inserted into the ureteral meatus to the face of the obstruction
\Ureler d.rawn. downward into bladder ·. .
i\.
'
'
'
,.,·.
'.
'31:ltu:re :placed into iuiiip.cl ureler
~ulure placed lln.der and lh:ru m.uc06a pt tri8one tQ anchor e,tump ohtreter
·.,
Vt"5ica\ orif\'ce
,if~ ureter up ri~ht ure:ter
_n.0.
p~Jw, and downwa:rd and
. .
·· out th.i'u ure:\hra(Ca\h.eter left in for 10 da1e) · FIG. 4
(fig. 2, 1 and 3) and the mucosa split down to the probe and to the face of the obstruction (fig. 3, 1). Again, attempts were made, unsuccessfully, to pass filiforms through the stricture. The bladder wall at the site of the stricture was now grasped by a Babcock forceps. About 7 cm. above and obliquely
INTRACYSTIC REIMPLANTATION OF URETER
871
the bladder wall was grasped by 2 more Babcocks and incised. The bladder wall was now split through its entirety and the lower ureter was grasped another Babcock and carefully dissected and freed from the periureteral There is considerable slack in the pelvic ureter and it was tissues (fig. 3, very easy to completely free the lower 7 or 8 cm. of the ureter and dra,v it in a loose loop into the lumen of the bladder. Then with the entire lower end of the ureter in view and in a straight line it was easy to divulse the stricture (fig. 3, 3). The incision was carried freely through all coats of the ureteral wall beyond the stricture. Then the entire intramural portion of the ureter was freely cut away from all attachment to the bladder wall (fig. 4, 1). This left a large raw area of exposed muscularis. The mucosa over the trigonal area was denuded and the tip of the lower ureter, which had originally been the meatus, was carried under the trigonal mucosa and buried with a suture (fig. 4, 2). A suture was placed through the muscularis and the under surface of the ureter. This further anchored the ureter in place (fig. 4, 3). A No. 8 catheter was placed in the ureter through the newly created meatus, the proximal end was passed out through the urethra and pulled taught, and the walls of the bladder were closed in such a manner by the sutures that the ureter coursed through in its normal oblique fashion (fig. 4, 4). No attempt was made to drain the perivesical space, as it was felt that with the interrupted suturing the ureter itself would act as a drain into the bladder. A retention catheter was next placed through the urethra into the bladder and the suprapubic opening in the bladder was tightly closed. A small cigarette drain into the space of Retzius finished the operative procedure. Measures were taken to keep the infection to a minimum. The retention catheter was removed from the bladder on the sixth day. The retention catheter in the ureter was removed several days later and the patient had a satisfactory convalescence, with complete relief of all of her symptoms. Five months later, the patient was re-examined. She was symptom-free and had gained 15 pounds. The bladder appeared free of infection. The right ureteral meatus was large, functioned normally and was situated on a ridge which extended to and lost itself in the right edge of the trigone. The ureter was easily catheterized. Figure lb shows a No. 6 catheter to the renal pelvis. Figure le shows the improvement in the retrograde pyelogram. I wish to extend my appreciation and thanks to William P. Didusch for the excellent drawings which illustrate this operative procedure, CONCLUSIONS
A simple, easy, surgical technique is presented for the reimplantation of the ureter into the urinary bladder where the obstruction is confined
872
ELMER HESS
to the intramural or lower few centimeters of the pelvic ureter. This simple operation, while done only once, was successful and is offered for consideration. 501 Commerce Bldg., Erie, Pa. REFERENCES HYMAN, A. AND LEITER, H. E.: J. Mount Sinai Hosp., 7: No. 6, (March-April) 1941. L0WSLEY, 0. S. AND KIRWIN, T. J.: Clinical Urology, vol. 2. Williams & Wilkins Co., Baltimore, 1940. YOUNG, HUGH H.: Young's Practice of Urology, vol. 2. W. B. Saunders Co., Philadelphia and London, 1926.