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Reimplantation of the Ureter into the Bladder by a Flap Method
REIMPLANTATION OF THE URETER INTO THE BLADDER BY A FLAP METHOD ~ELSE F. OCKERBLAD
In many cases when the operation for reimplantation of the ureter into the bladder is considered, several problems arise. One of the most important of these problems is whether or not the injured ureter -1Yill be long enough to reach the bladder to be implanted without tension upon the splice. In 1932 and 1933 very interesting experiments were done on the ureters of dogs in the Department of Urology at the Yale University Medical School. Out of that work came a brief but important note by Spies, Johnson, and \Vilson describing a novel flap operation for reimplanting the ureter into the bladder in dogs. These -workers apparently-were trying to avoid strictures of the ureter which they found frequently formed when surgery was performed upon the lmver one-third of a dog's ureter. They stated that they found a reference to an Italian, A. Boari, who, in 1894 -rrns reported to have done a flap operation on a dog and that the dog -was alive and -well 4 years later. They also had in mind the Janeway gastrostomy method as they carried out this ingenious procedure on the bladder and ureter in dogs. I had read this article and made a mental note of it when a case came to my attention where such a flap operation seemed indicated. CASE REPOR'l'
A 44 year old Yvhite married woman had been operated upon for extensive fibroids, and a radical hysterectomy had been performed. Following the operation the patient had complained of being wet with urine. At first not much attention was paid to her complaints but finally the surgeon concluded that she probably had a vesicovaginal fistula. I was consulted on October 25, 1936. I examined this patient and could find no defect in the vaginal vault suggestive of vesicovaginal fistula, but that urine was leaking into the vagina there was no doubt. Cystoscopy revealed that the right ureter was patent and normal. The left ureter was occluded 5 cm. from the vesical ureteral os. Indigo carmine injected intravenously appeared at the right ureteral orifice in the bladder in 4 minutes, did not appear from the left ureteral orifice, but did show in the vagina in 12 minutes. I advised that an attempt be made to do a ureteral reimplantation into the bladder. On October 30, 193G, I performed this operation. A left rectus incision was made and the ureter and the bladder exposed extraperitoneally. It was found that, while the leak and the obstruction were at the 5 cm. level above the left ureteral orifice, the next few centimeters of ureter above the fistula had so degenerated that, in all, from 8 to 9 cm. of the lower end of the ureter were unusable. Confronted with this situation of a ureteral stump too short to be reimplanted into the bladder, three methods of repair came to mind: l) a nephrectomy, 2) implantation into the bowel, and 3) reim845
846
NELSE F. OCKERBLAD
plantation into the bladder by means of a flap operation that had never before been done on a human being. The latter method seemed best. A tongue or flap of bladder was cut 10 cm. long by 4 cm. wide with the base near the dome of the bladder and on the left lateral aspect of the bladder. The ureter was freed from its bed of scar tissue and the portion that was sure to die was cut away, leaving the freshened end of good tissue with apparently quite normal blood supply. The wound in the bladder was closed ,vith fine interrupted chromic sutures, being careful not to include the mucosa. The ureter was then laid lightly in the tongue of bladder and secured to its mucosal surface by split-
'""'••,=-:,
~ __J
0·--
-~~~~~//'--,~1:r~:~{~7:;;,-:~;~js;·_~~~.~-~==:m F,j :::,. Fm. 1. Diagrams showing steps in development of bladder flap. flap with ureter secured into it.
3, Showing finished
ting the end and securing each split portion by a plain catgut suture. This method was suggested by Vermooten. The tongue of bladder was then closed over the end of the ureter by a double row of interrupted fine chromic catgut sutures. The serosa of the ureter was secured to the serosa of the tubed tongue of bladder at the point of entrance by four fine chromic sutures. When this finished plastic fancy work was dropped back into the pelvis it lay flaccid and relaxed without the slightest sign of tension on the splice. One small cigaret drain was placed near but not touching the splice and the wound was closed in layers. Silk sutures in the form of a running mattress closed the skin and on
REIMPLANTATION OF URETER IN'.rO BLADDER
847
this was placed a petrolatum gauze strip. Dressings were applied and the patient taken back to bed. She made a fine recovery and soon left the hospital. After an interval of a year in which the patient had no trouble_, a pyelogram was made which showed a normal kidney pelvis and a normal ureter down to the splice. Below the splice the tube of bladder at that time appeared ·widened like an elongated narrow diverticulum. There was no infection present and there was every evidence that the kidney was perfectly normal. Now, on September 17, 1946, ten years after the operation, another pyelogram shows the kidney and the kidney pelvis are both quite normal (fig. 2). The kidney now excretes indigo carmine, which ,vas injected intravenously in good concentration, in 3½ minutes. One interesting observation is that the tubed tongue or bladder flap has shrunk, so that it is now not much larger than a slightly dilated ureter.
FIG. 2. Pyelograrn of reimplanted ureter made 10 years after operation COMMENT
I believe I was the first to make use of this ingenious flap method of performing a ureteral implantation into the bladder in a human being. It is a method which is practical and can be used whenever the ureter is too short to be implanted by any of the better known procedures. It does not seem to matter how the bladder flaps are made, nor just where the base of the flap is located, nor yet the direction the flap may take. The flap should not be too narrow as it will shrink. There seems to be ample blood supply. 1530 Professional Bldg., Kansas City, Mo.
REFERE::S.:CES WrLSo;,;: Reconstruction of the ureter by means of bladder flaps. Proc. Soc. Exper. Biol. & :\feel., 30: 425, 1933. VERMOOTEN SPIES AND Nm:sWANGER: Transplantation of the lower encl of clog's ureter, an expe;·irnental study. J. urol., 32: 261, HJ34.
SPIES, ,JoHNSON A:-iD
In many cases when the operation for reimplantation of the ureter into the bladder is considered, several problems arise. One of the most important of these problems is whether or not the injured ureter -1Yill be long enough to reach the bladder to be implanted without tension upon the splice. In 1932 and 1933 very interesting experiments were done on the ureters of dogs in the Department of Urology at the Yale University Medical School. Out of that work came a brief but important note by Spies, Johnson, and \Vilson describing a novel flap operation for reimplanting the ureter into the bladder in dogs. These -workers apparently-were trying to avoid strictures of the ureter which they found frequently formed when surgery was performed upon the lmver one-third of a dog's ureter. They stated that they found a reference to an Italian, A. Boari, who, in 1894 -rrns reported to have done a flap operation on a dog and that the dog -was alive and -well 4 years later. They also had in mind the Janeway gastrostomy method as they carried out this ingenious procedure on the bladder and ureter in dogs. I had read this article and made a mental note of it when a case came to my attention where such a flap operation seemed indicated. CASE REPOR'l'
A 44 year old Yvhite married woman had been operated upon for extensive fibroids, and a radical hysterectomy had been performed. Following the operation the patient had complained of being wet with urine. At first not much attention was paid to her complaints but finally the surgeon concluded that she probably had a vesicovaginal fistula. I was consulted on October 25, 1936. I examined this patient and could find no defect in the vaginal vault suggestive of vesicovaginal fistula, but that urine was leaking into the vagina there was no doubt. Cystoscopy revealed that the right ureter was patent and normal. The left ureter was occluded 5 cm. from the vesical ureteral os. Indigo carmine injected intravenously appeared at the right ureteral orifice in the bladder in 4 minutes, did not appear from the left ureteral orifice, but did show in the vagina in 12 minutes. I advised that an attempt be made to do a ureteral reimplantation into the bladder. On October 30, 193G, I performed this operation. A left rectus incision was made and the ureter and the bladder exposed extraperitoneally. It was found that, while the leak and the obstruction were at the 5 cm. level above the left ureteral orifice, the next few centimeters of ureter above the fistula had so degenerated that, in all, from 8 to 9 cm. of the lower end of the ureter were unusable. Confronted with this situation of a ureteral stump too short to be reimplanted into the bladder, three methods of repair came to mind: l) a nephrectomy, 2) implantation into the bowel, and 3) reim845
846
NELSE F. OCKERBLAD
plantation into the bladder by means of a flap operation that had never before been done on a human being. The latter method seemed best. A tongue or flap of bladder was cut 10 cm. long by 4 cm. wide with the base near the dome of the bladder and on the left lateral aspect of the bladder. The ureter was freed from its bed of scar tissue and the portion that was sure to die was cut away, leaving the freshened end of good tissue with apparently quite normal blood supply. The wound in the bladder was closed ,vith fine interrupted chromic sutures, being careful not to include the mucosa. The ureter was then laid lightly in the tongue of bladder and secured to its mucosal surface by split-
'""'••,=-:,
~ __J
0·--
-~~~~~//'--,~1:r~:~{~7:;;,-:~;~js;·_~~~.~-~==:m F,j :::,. Fm. 1. Diagrams showing steps in development of bladder flap. flap with ureter secured into it.
3, Showing finished
ting the end and securing each split portion by a plain catgut suture. This method was suggested by Vermooten. The tongue of bladder was then closed over the end of the ureter by a double row of interrupted fine chromic catgut sutures. The serosa of the ureter was secured to the serosa of the tubed tongue of bladder at the point of entrance by four fine chromic sutures. When this finished plastic fancy work was dropped back into the pelvis it lay flaccid and relaxed without the slightest sign of tension on the splice. One small cigaret drain was placed near but not touching the splice and the wound was closed in layers. Silk sutures in the form of a running mattress closed the skin and on
REIMPLANTATION OF URETER IN'.rO BLADDER
847
this was placed a petrolatum gauze strip. Dressings were applied and the patient taken back to bed. She made a fine recovery and soon left the hospital. After an interval of a year in which the patient had no trouble_, a pyelogram was made which showed a normal kidney pelvis and a normal ureter down to the splice. Below the splice the tube of bladder at that time appeared ·widened like an elongated narrow diverticulum. There was no infection present and there was every evidence that the kidney was perfectly normal. Now, on September 17, 1946, ten years after the operation, another pyelogram shows the kidney and the kidney pelvis are both quite normal (fig. 2). The kidney now excretes indigo carmine, which ,vas injected intravenously in good concentration, in 3½ minutes. One interesting observation is that the tubed tongue or bladder flap has shrunk, so that it is now not much larger than a slightly dilated ureter.
FIG. 2. Pyelograrn of reimplanted ureter made 10 years after operation COMMENT
I believe I was the first to make use of this ingenious flap method of performing a ureteral implantation into the bladder in a human being. It is a method which is practical and can be used whenever the ureter is too short to be implanted by any of the better known procedures. It does not seem to matter how the bladder flaps are made, nor just where the base of the flap is located, nor yet the direction the flap may take. The flap should not be too narrow as it will shrink. There seems to be ample blood supply. 1530 Professional Bldg., Kansas City, Mo.
REFERE::S.:CES WrLSo;,;: Reconstruction of the ureter by means of bladder flaps. Proc. Soc. Exper. Biol. & :\feel., 30: 425, 1933. VERMOOTEN SPIES AND Nm:sWANGER: Transplantation of the lower encl of clog's ureter, an expe;·irnental study. J. urol., 32: 261, HJ34.
SPIES, ,JoHNSON A:-iD