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The Management of the Surgically Traumatized Ureter1
THE MANAGEMENT OF THE SURGICALLY TRAUMATIZED URETER1 THOMAS D. MOORE From the Department of Urology, John Gaston Hospital, College of Jlfedicine, University of Tennessee, and the Moore Clinic, Baptist Memorial Hospital, Memphis, Tennessee
Accidental injury of the ureter during the course of pelvic operations is not uncommon. It is generally agreed among surgeons and gynecologists that such injuries may be regarded as the most serious surgical accident with which they contend, with a mortality rate of 33.3 per cent for bilateral and 18.8 per cent for unilateral injuries, according to Bland. In difficult hysterectomies and in the removal of intraligamentous tumors and cysts the normal course of the ureter may be so distorted that it may be unsuspectingly injured. The incidence of such accidents is rather difficult to estimate because unilateral injury may be entirely unrecognized, particularly if simple ligation has occurred. As evidence of this, Newell states that their pathologist has been instructed to pay special attention to the ureters when performing autopsies on gynecological patients; he reports 6 cases of ligated ureters found at autopsy, none of which had been suspected prior to the postmortem examination. Numerous articles have appeared in the literature, particularly in recent years, with reported cases now aggregating more than 800 in number. Pertinent data derived from a survey of this fairly large group may be summarized as follows: The incidence of ureteral ligation as a complication of all operations on the female genital organs may be placed at 1 to 3 per cent. Many cases are not reported and many are not recognized. The proportion of unilateral to bilateral injury is approximately 6 to 1; Bland and Feiner collected a total of 710 cases, of which 601 were unilateral and 109 bilateral. The most common sequelae of ureteral injury are ureterovaginal and ureteroabdominal urinary fistulas. It is further evident from a study of the literature that injury of the ureter may occur in the hands of the most skilled surgeon. Urologists are unanimous in their belief that such injuries are preventable and have persistently and consistently advocated the preoperative insertion of inlying ureteral catheters when difficult pelvic surgery is anticipated in order that they will serve as a guide and that the surgeon may more easily avoid the ureters. It seems that many gynecologists have been loathe to adopt this precautionary measure. Leventhal et al. state: "The value of inserting ureteral catheters as a prophylactic measure is highly questionable. They may give a false sense of security, and by altering the normal position of the ureters, render them more liable to injury. In many instances we have been unable to locate them by palpation 1 Read at annual meeting, Southeastern Section, American Urological Association, Palm Beach, Fla., March 26-29, 1947. 712
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and their mere introduction may give rise to infection, ureteral colic and oliguria, with great possibilities of increasing the postoperative morbidity." On the other hand, Sisk states: "For many years we have routinely inserted catheters in the ureters of such patients for the Department of Gynecology at the Wisconsin General Hospital, and as a result only l ureter has been damaged. In this case serious pathology was unexpectedly encountered and catheters had not been introduced." Of further interest is Barrett's statement: "In the formative days of uterine surgery, Kelly recommended ureteral catheterization preliminary to abdominal hysterectomy, but few gynecologists ever acquired the dexterity in ureteral catheterization attained by Doctor Kelly." He fails to mention enlisting the co-operation of a competent urologist for this purpose. With all due respect for the objections mentioned by Leventhal, which appear exaggerated to say the least, there is an abundance of accumulated evidence indicating that the preliminary insertion of ureteral catheters is a wise precaution, not only in cases where radical surgery is contemplated in the female pelvis but also preliminary to such operations as abdominoperineal resection of the rectosigmoid in either sex. It behooves the urologist to remind his surgical and gynecological confreres from time to time of the value of this precautionary measure. It may be safely assumed that the incidence of accidental ureteral injury would thereby be greatly diminished. Instances of accidental injury of the ureter may be divided into two groups: 1) those in which the injury is recognized immediately, and 2) those in which it is discovered during the postoperative period. Both groups may be further subdivided into those in which the injury is a) unilateral and b) bilateral. Types of injury are as follows: Ligation, occlusion by acute angulation from stitches placed near the ureter, crushing or clamping, incision without severence, severence, and resection of a portion of the ureter. MANAGEMENT OF INJURY WHEN RECOGNIZED IMMEDATELY
Simple ligation of 1 ureter is probably seldom recognized at the time of the operation. If the accident is discovered before the operation is terminated, immediate deligation, followed by the insertion of a ureteral catheter, would appear adequate. Acute angulation may be managed in the same way. Crushing by a clamp is more serious and requires essentially the same treatment as a severed ureter because of the probability of subsequent sloughing or dense cicatricial contracture. Under such circumstances the surgeon may adopt one of several possible solutions of the problem, the governing principle of which should be conservation of the involved kidney. End-in-end anastomosis (Pozzi) has proved to be more satisfactory than end-to-end anastomosis. In the former the proximal stump is introduced into the distal one and secured by a few interrupted sutures of 0000 chromic catgut, designed to attain a water-tight closure. A small opening above the anastomosis through which a ureteral catheter is passed to the renal pelvis and brought out of the flank for temporary diversion of the urine, as advocated by Curtis, may be expected to yield a satisfactory result in a fair percentage of cases. Adams found that of 30 cases so treated 21 (70 per cent)
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had satisfactory results. There were 6 (20 per cent) failures and 3 (10 per cent) deaths. Unfortunately surgeons and gynecologists frequently have not familiarized themselves with the principles of ureteral repair and when confronted with a severed ureter are prone to disregard conservation of the kidney as it is easier to ligate the severed ureter with or without subsequent nephrectomy. A serious objection to uretero-ureteral anastomosis is the probability of the formation of subsequent cicatricial contracture. Many of these patients require frequent and systematic dilatation of the ureter; otherwise slow hydronephrotic atrophy resulting from the ureteral stenosis will in the end necessitate nephrectomy. Good immediate results have undoubtedly been reported from this procedure when the ultimate result was unsatisfactory as illustrated by a case · reported by Nora, in which a ureter was accidently severed during hysterectomy and was repaired by an immediate uretero-ureteral anastomosis. Patency of the ureter was maintained by catheter dilatations over a period of eighteen months and on several occasions the case was presented before medical societies as evidence of a good result from ureterorrhaphy. Seven years later Nora performed a right nephrectomy; the ureter had become abruptly stenosed and there was complete destruction of the renal parenchyma. If the ureter has been severed low in the pelvis probably a better procedure than an attempt at anastomosis of its ends would be its re-implantation into the bladder as low in the base as possible, employing a technic designed to prevent reflux of urine from the bladder. Of 70 collected cases so treated, Adams reported perfect results in 8 (11.4 per cent), fair results (moderate stenosis) in 38 (54.3 per cent), failures in 21 (30.4 per cent) and 3 deaths (4.3 per cent). If the precaution is taken however of dividing the proximal end of the severed ureter 6 or 8 mm. and inserting it at least 1 cm. beyond its entrance into the bladder, subsequent stenosis of the ureteral opening will be less likely to occur. Cutaneous ureterostomy is mentioned only for condemnation although it may be regarded as a conservative measure. Some writers prefer uretero-intestinal anastomosis. A serious objection is the lack of preparation of the patient for such a procedure with special reference to emptying and cleansing the bowel and the employment of modern chemotherapy in the form of intestinal antisepsis. Therefore, an unplanned uretero-intestinal anastomosis undoubtedly would incur greater risk than a planned operation of this type. Ligation under certain circumstances may be the operation of choice; after a difficult and prolonged pelvic operation the patient already may have been on the operating table too long in a state of shock. In this event if palpation of the opposite kidney indicates its healthy state ligation may be considered the best and safest procedure although it is freely admitted that palpation of the opposite kidney can yield only presumptive evidence of its functional condition. While performing a major urological operation recently a surgical confrere called me into an adjoining operating room because of a severed ureter incurred during a difficult hysterectomy. He had taken the precaution to mobilize the ureter in spite of which it had been divided accidentally about 10 cm. above the bladder. The patient had been on the table nearly 2 hours and was in no condition for
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further extensive surgery. It appeared wise to advise secure ligation of the proximal stump after ascertaining by palpation that the opposite kidney appeared sound. The patient made a nice recovery. Temporary ureteral repair might have been considered, however, had I not been engaged with my own patient. If a large segment of the ureter has been excised uretero-ureteral anastomosis or re-implantation into the bladder usually is not possible and one of the following procedures should be considered: transuretero-ureteral anastomosis, ureterointestinal anastomosis, ureterocutaneous anastomosis, ligation and nephrectomy, listed in the order of their choice. Hepler prefers uretero-intestinal implantation in such cases to ligation or nephrectomy, employing the Coffey No. 1 technique. Frequently the extreme condition of the patient prohibits conservative efforts. There should be some temporary measure, less radical than ligation, nephrectomy or cutaneous ureterostomy, which would permit a well-planned conservative operation later when conditions are more favorable. There should be considered for this purpose 1) the passage of a ureteral catheter through the proximal segment of the severed ureter, the distal end of which may be ligated about the catheter employing non-absorbable suture material with extraperitoneal drainage, 2) temporary ureterostomy and 3) temporary nephrostomy. The problem that would then be presented is the same as will be discussed under the second group comprising those injuries discovered in the postoperative period. MANAGEMENT OF INJURY WHEN RECOGNIZED LATE
Unilateral ligation or ureteral occlusion from acute angulation secondary to sutures probably occurs more often than is generally believed. It may be suspected, however, in the postoperative period following pelvic surgery if there is unusual discomfort in either renal area associated with tenderness at the costovertebral angle. A wider employment of excretory urography in such cases undoubtedly would lead to the more frequent detection of such injuries and would render possible the conservation of the involved kidney rather than to permit atrophy of the organ. In many cases the appearance of urinary leakage from the vagina or from the abdominal incision in the early postoperative period is the first evidence of ureteral injury, either unilateral or bilateral. If both ureters have been ligated or otherwise occluded, complete anuria is at once evident and may be erroneously diagnosed as "suppression of urine." Failure to demonstrate urine in the bladder on catheterization 6 to 12 hours following a difficult pelvic operation renders a cystoscopic examination mandatory for the exclusion of obstructed ureters. Too often the patient will be subjected to treatment for suppression of urine for several days and only with the increasing gravity of the case will a urological consultation be requested in an atmosphere of desperation. If cystoscopy confirms the suspicion of bilateral ureteral occlusion an immediate unilateral nephrostomy may prove to be a life saving measure. Lynch and Thompson prefer temporary ureterostomy to bilateral nephrostomy in bilateral injuries because it is technically easier and avoids the
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necessity of changing the position of the patient and redraping, as well as ease in locating the distended obstructed ureters and their ready catheterization. With the abdomen open, however, deligation would appear more practical. Regarding deligation, it is interesting to note from a review of the literature the wide divergence of opinion regarding its advisability. A review of 23 articles dealing with ureteral injury discloses that 8 writers definitely advise against deligation; it is advocated by 11 and 4 do not mention it. Hepler states that "postoperative deligation is a formidable operation with a mortality rate of about 90 per cent." Feiner reports the death of 2 patients following intraabdominal deligation and is of the opinion that nephrostomy with subsequent operation for ureteral anastomosis or re-implantation into the bladder is a safer procedure. Deligation as it is usually practiced by the average surgeon with the patient in a desperate condition, and without the assistance of a urologist, is undoubtedly hazardous in that the abdomen is re-opened and the surgeon carries out an extensive search for offending ligatures, which may be extremely difficult to locate. Enlisting the co-operation of a urologist when the surgeon re-opens the abdomen is of extreme importance, the value of which cannot be overemphasized. With ureteral catheters, preferably of a large caliber (9 or 11 F.), the cystoscopist can literally prod the obstructed points, permitting the surgeon to quickly clip ligatures and also facilitating the detection of more than one ligated point if present. He should not be satisfied until both catheters have passed into the renal pelves. Such active urological assistance should render deligation a far less hazardous procedure. ILLUSTRATIVE CASES
Mrs. H.B., aged 40, was first seen February 19, 1945. She had undergone a difficult hysterectomy by a general surgeon 3 days before. There was 200 cc of urine in the bladder on catheterization 15 hours after the operation and complete anuria since, for which she had been treated for "suppression of urine." By the time of the urological consultation she had moderate generalized edema and was semicomatose. The nonprotein nitrogen content of the blood was estimated at 172.5 mg. per cent and the creatinin estimation was 3.5 mg. per cent. Cystoscopy revealed impassable obstructions of both ureters approximately 7 cm. above the bladder. In my absence from the city one of my associates performed an immediate left nephrostomy, which permitted the drainage of 1800 cc of urine during the following 18 hours. Upon my return 3 days following the nephrostomy I advised immediate deligation. The surgeon re-opened the abdomen; I passed a cystoscope and inserted No. 11 ureteral catheters into each ureter and easily located the ligated points for the surgeon, who clipped sutures at these points releasing the obstructions and permitting the catheters to pass with ease to both renal pelves. The catheters were left in place and the abdomen was quickly closed. Her convalescence was uneventful. The catheters and nephrostomy tube were removed after 7 days and she was discharged from the hospital 16 days following the deligation, at which time the nonprotein nitrogen estimation on the blood was 35 mg. per cent. Eighteen days later a 10 F. bulb was
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passed through each ureter without detecting any evidence of obstruction and there was no abnormal retention of urine in either renal pelvis. Two years later an excretory urogram was obtained, revealing normal bilateral function and outline, including normal ureters (fig. 1). Comment: It is evident that if nephrostomy d,rainage had been depended upon for a longer period that severe ureteral damage from the ligatures would have been inevitable. Cystoscopic assistance when the abdomen was re-opened largely eliminated the risk of deligation and its early accomplishment undoubtedly was the chief factor in the good result obtained.
Fm. L A, Plain film, revealing ureteral catheters and indicating points of complete obstruction in both ureters at level of brim of pelvis. B, Retrograde bilateral pyelograms obtained during second postoperative week after deligation. C, Excretory urogram obtained 2 years later, revealing normal bilateral function and normal ureters.
In those cases in which there is evidence that the ureter has been severed, incised, resected or crushed with subsequent sloughing the development of urinary leakage in the postoperative period may be the first indication of the accident, whether unilateral or bilateral. The problem then resolves itself into conserving the life of the patient as well as conservation of the involved kidney. Extensive urinary extravasation may occur from a severed ureter which was neither recognized nor ligated. Hmvever, in most cases urinary drainage will appear within a few days, either from the incision or from the vagina, with consequent improvement of the patient's status. 1Veeks or months may elapse before a urological consultation is requested because of the hope that spontaneous closure of the fistula will occur. In such instances urologists should determine by cystoscopy or excretory urography, or a combination of both, the extent of the damage and the side affected if unilateral. Some surgeons follow the line of least resistance and perform a nephrectomy, which not only controls the annoying urinary leakage hut diminishes to some extent the prospect of medicolegal complications. The majority of urologists, however, are keenly aware of the desirability of conserving renal tissue and when their assistance is enlisted their efforts as a rule are along conservative lines. It is usually impractical to attempt an end-to-end anastomosis of a severed ureter when it has been discovered late. If the site of the injury is low in the pelvis, the proximal ureter may be mobilized,
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permitting sufficient elongation to enable its re-implantation into the bladder at a site preferably as low in the base as possible and with the distal 3 or 4 cm. of the ureter buried in its musculature before finally emerging through the mucosa, thus preserving valve-like function which is so essential in protecting the kidney from vesical reflux. Mrs. P. M. W., aged 46, was first seen on January 23, 1943. She had undergone a hysterectomy for multiple fibromyomata 3 months before. The immediate postoperative period was stormy and after a few dELys urine began to drain continuously from the vagina, along with profuse purulent drainage from the abdominal incision. Since then urine had not been voided in a normal way. The referring surgeon stated that he was aware that he had accidently severed the left ureter, the proximal stump of which was ligated with catgut. He was unable to account for her inability to void nor the discharge of urine from the vagina. Examination revealed absence of urine in the bladder. There was no secretion from either ureteral orifice, complete obstruction of the left ureter 2 cm. above the bladder and a similar obstruction of the right ureter 4 cm. above the orifice. An excretory urogram proved very informative. The soft tissue shadow of the right kidney appeared essentially normal; several moderately dilated calyces were filled with the medium, but the renal pelvis and ureter could not be visualized. The left ureter ·was open in spite of its having been ligated and the kidney was of essentially normal function, but the urine was draining through the vagina. In view of these findings it was assumed that the right ureter had been ligated 4 cm. above the bladder and in spite of its complete occlusion for 3 months it was astonishing to find that it appeared functionally worth conserving. It was therefore explored first and was found involved in dense scar tissue in the region of the vault of the vagina where it evidently had been incorporated in sutures. Although it was about 1 cm. in diameter above the ligated point, it was amputated at this site and mobilized a distance of 4 or 5 cm., permitting its re-implantation without undue tension low in the right base of the bladder with preservation of a valve-like mechanism. Extraperitoneal rubber tissue drainage was provided through a stab wound and the incision closed. Her convalescence ·was satisfactory and 9 days later an extraperitoneal approach was made to the left ureter, which was found to have been severed at a point opposite the second sacral segment. It was freely mobilized for a distance of 5 or 6 cm. and it was possible to also re-implant it into the bladder without undue tension at a site low in the left base, employing essentially the same technique as ,vas carried out on the opposite side. Continuous catheter drainage of the bladder was provided for 10 days. Her convalescence was uneventful and on the seventeenth day, upon filling the bladder with radiopaque fluid, there was no evidence of ureteral reflux on either side. Indigo carmine appeared from the right in 13 minutes and from the left in 14 minutes in fair concentration. She was dismissed 31 days following the first operation. Twenty-seventh months later she returned for a check-up at our request. The urinalysis was negative. There were no urinary complaints and an excretory urogram disclosed both kidneys of normal function and outline (fig. 2).
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Comment: It is truly remarkable that the right kidney which had evidently been completely occluded for 3 months should display such recuperative ability when release of the obstruction was accomplished. Fortunate indeed was the spontaneous opening of the ligated left ureter, thus providing urinary drainage from 1 kidney and preservation of life. It is worthy of note that the sites of the injuries to the ureters were sufficiently low, aided by mobilization of essentially their lower thirds, to permit re-implantation into the base of the bladder without undue tension and with a good functional result. Althought accidental injury of the ureter is usually incurred in those cases where removal of organs or tissues is necessary it is of interest to note that the ureters may be accidentally damaged in cases where tissues have not been removed, for example in such operations as uterine suspension. Simple ligation
FIG. 2. A, Note catheters in place, indicating sites of ureteral obstruction at level of brim of pelvis on right and at a lower level on left side. B, Excretory urogram, indicating good function and drainage from left and surprisingly good function from right in spite of obstruction. C, Excretory urogram obtained 27 months following re-implantation of both ureters into bladder, indicating normal bilateral function and normal ureters.
or acute angulation from sutures would be the most plausible explanation in such cases. Mrs. R. V. K., aged 27, was first examined on October 12, 194.5. She had undergone a suspension of the uterus by a general surgeon 2 months before. A few days later an almost constant aching pain developed in the left loin. The pain persisted after her return home and 1 month after she left the hospital cystoscopy elsewhere revealed no evidence of function of the left kidney and its removal was advised by the same surgeon. She was also told that there was a stricture of the right ureter. She decided to obtain another opinion before undergoing a left nephrectomy. My examination revealed a point of marked narrowing in the right lower ureter, with ureterectasis and pyelectasis of moderate degree; 7.5 cc of clear urine was aspirated from the right renal pelvis. An obstruction was met in the lower left ureter 4 cm. above the bladder; after considerable effort a No . .5 catheter ·was passed beyond the obstruction and 170 cc of clear urine was aspirated. Pyelography disclosed an extremely narrow point
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near the midline corresponding to the point of obstruction 4 cm. above the bladder, above which an extreme degree of ureterectasis and pyelectasis was visualized. Apparently the left ureter had been completely ligated at the time of the uterine suspension and the right lower ureter had possibly been transfixed or partially ligated at the same time. In spite of the extreme degree of damage incurred on the left side conservation of this kidney was highly desirable because of the hydronephrotic state of the opposite kidney. The scar of the previous laparotomy was excised and an extraperitoneal approach made to the left lower ureter. It was identified at the level of the brim of the pelvis, was about 2 cm. in diameter and was mobilized and traced to a point of dense cicatricial obstruction about 3.5 cm. below the pelvic brim. It was divided above the obstructed point and the distal stump ligated. More extensive mobilization permitted its reaching a point in the left base of the bladder about 2 cm. posterior to the left ureteral orifice, where it ,vas re-implanted without undue tension and with preservation of a valve-like mechanism. Because of the advanced degree of ureterectasis a temporary ureterostomy seemed wise and was accomplished by inserting a 14 F. rubber catheter to the renal pelvis introduced through a small opening immediately above the point of anastomosis. The ureterostomy tube and rubber tissue drains were brought out through a small stab wound in the left lower quadrant and the median incision was closed. The ureterostomy tube was removed on the tenth day. There was no urinary leakage from this site. Her convalescence was satisfactory and seventeen days following the operation the right ureter was dilated to 12 F. The re-implanted left ureter appeared to have healed satisfactorily. She was dismissed on the nineteenth postoperative day. She returned for observation 3 months later, at which time the urinalysis was negative and on cystoscopic examination there was only 5 cc of retention in the right renal pelvis and 8 cc on the left side. Phenolsulfonphthalein appeared after 3 minutes from both sides with an output of 24 per cent from the right and 14 per cent from the left in 15 minutes. There were no urinary complaints and she considered herself well. Seven months later the urinalysis was still negative. Excretory urograms revealed both kidneys of essentially normal outline and normal function (fig. 3). Comment: In spite of the extreme degree of damage incurred by the left kidney from occlusion of the lower ureter of 2 months' duration its return to an essentially normal condition was astonishing and again well illustrates the recuperative ability of the kidney, thoroughly justifiying conservative efforts. Except for the finding of a moderate degree of hydronephrosis on the right side a left nephro-ureterectomy might easily have been considered the operation of choice in this case. When the ureter has been injured at a high level or a segment accidentally resected, or if it has undergone sloughing through extensive injury to the muscularis or through interference with its blood supply, the problem is definitely more complicated. In such cases it appears that the majority of writers mention the following procedures in the order of their desirability: 1) ligation, 2) nephrectomy, 3) cutaneous ureterostomy and 4) uretero-intestinal anastomosis,
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although Hepler believes these should be in the inverse order with preference given to implantation into the bowel, a procedure which is also advocated by McI ver. To this list of available procedures I should like to add transureteroureteral anastomosis. A number of years ago Sharpe demonstrated experimentally on dogs the feasibility of this operation in which 1 ureter is brought across the midline and anastomosed to the opposite one. In 1934 Higgins reported a case in which this operation was performed for the first time on the human. In his case there was an incompetent right ureterovesical valve permitting reflux of urine accompanied by severe pain. The ureter was severed near the bladder and transplanted into the opposite one ·with a brilliant postoperative result. Smith and Smith in 1941 reported the employment of this procedure in 2
FIG. 3. A, Excretory urogram, disclosing point of narrowing of right ureter at brim o pelvis with moderate degree of ureterectasis and pyelectasis. Absence of medium, left. B, Left retrograde pyelogram; marked ureterectasis and pyelectasis secondary to occlusion of lower left ureter. C, Retrograde pyelogram obtained during second postoperative week. Note ureterostomy tube in place and marked recession of left hydronephrosis. D, Excretory urogram obtained 7 months after re-implantation of left ureter into bladder and after dilating right ureteral stricture. Note normal bilateral function and essentially normal ureters.
additional cases. In one an end-to-end anastomosis of the ureter had been performed because of an accidentally severed ureter, for which the patient had required frequent ureteral dilatations. A long period of recumbency because of a severe fracture enforced discontinuance of the dilatations, after which an impermeable stricture had developed. The ureter was severed above the site of stenosis and was anastomosed to the opposite ureter, following closely the technique described by Higgins with the exception that a side-to-side anastomosis was made rather than end-to-side. The same procedure was employed in Smith's second case because of a ureterovaginal fistula resulting from severance of the ureter about 2 inches above the bladder, which occurred during the repair of cervical lacerations. Excellent results were obtained in both cases. I have been unable to discover in the literature any other references to transureteroureteral anastomosis but I am convinced that it should be of definite value as a
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means of conserving the kidney when the ureter has been extensively damaged or severed at a level too high to permit ureterovesical re-implantation. There is good reason to list this operation high in the order of desirability of those procedures available for high ureteral injuries and it was so employed in one of my cases. Miss M. 0., aged 33, was first examined by us on January 10, 1946. She had undergone a total hysterectomy 6 weeks before because of multiple large fibromyomata of the uterus. There had been complete anuria for 3 days when urological consultation elsewhere was requested. Their examination revealed the following data: Upon attempting an excretory urogram there was no evidence of medium in either renal area after 30 minutes. Cystoscopy revealed both ureters completely obstructed about 4 cm. above the left orifice and somewhat higher on the right. The resident urologist performed bilateral pyelostomy, after which her condition steadily improved. Six weeks later I was called in on the case when the catheter in the right pyelostomy had been accidentally removed and could not be replaced, for which I advised a right nephrostomy. Eight days later the catheter in the left pyelostomy was also accidentally removed, at which time the decision was made to attempt re-implantation of the left ureter into the bladder. Cystoscopy at this time indicated the obstruction of the left ureter was sufficiently low probably to permit this procedure. An excretory urogram disclosed good bilateral renal function. Eighty days following the hysterectomy I exposed the lower left ureter through an extraperitoneal approach and on tracing the ureter downward it became completely detached, indicating that it had been completely severed and ligated at the original operation. The stenosed end was removed and the wall of the ureter was divided about 1 cm. It was widely mobilized, after which it could be brought to the region of the trigone without excessive tension. It was re-implanted at this site employing a technique somewhat similar to the Coffey No. 1 for uretero-intestinal anastomosis. The left nephrolumbar urinary fistula promptly closed and convalescence was satisfactory. The right nephrostomy was functioning well and she was permitted to return home for further recuperation. Five months later she was re-admitted to the hospital, having gained in weight and strength. She was extremely anxious to be relieved of the right nephrostomy tube. A right nephrectomy was considered but the idea was abandoned because the verdict of time had not · been rendered on the ultimate functional result of the re-implanted left ureter. Exploration of the occluded right ureter was decided upon. Although it was obstructed 7 cm. above the bladder, there was a possibility that it might be re-implanted into the bladder or into the colon. In the extreme Trendelenburg position the intestines were packed off and the posterior peritoneum over the region of the ureter divided. It was mobilized downward to the point of obstruction where there was evidence that it had been severed and ligated. In spite of wide mobilization the length was insufficient for re-implantation into the bladder. It was found, however, that it WO\lld easily reach the dilated spindle portion of the left mid-ureter and that transuretero-ureteral anastomosis appeared more desirable and less hazardous than uretero-intestinal implantation.
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The mid-portion of the left ureter was exposed through a second incision in the posterior peritoneum and ·with a curved forcep a tunnel beneath the posterior peritoneum was made ncross the spine, through which the free end of the right ureter was drawn. The end of the right ureter was cut obliquely at about 45 degrees and ,YtLS anastomosed to an opening in the left ureter about 12 mm. in length, employing interrupted sutures of 0000 chromic catgut. Through a small opening in the right ureter proximal to the anastomosis a No. 5 ureteral catheter was passed through the anastomosis down the lmver left ureter into the bladder and the upper end was passed into the right renal pelvis and left in place as a splint. The ureterotomy was closed tightly and a small rubber tissue drain ,va:,: passed extraperitoneally through a small stab wound in the left flank. Both posterior peritoneal incisions were closed and the abdominal incision was closed y1·ithout drainage. Following the operation a cystoscope
Fm. 4. A, Excretory urogram, disclosing marked narrowing of lower left ureter and extravasation in pelvis. B, Right nephrostomy tube in place. Note occlusion of right ureter at brim of pelvis. C, Left retrograde pyelogram after re-implantation of left ureter into bladder. D, Film obtained following right transuretero-ureteral anastomosis with inlying catheter coiled in bladder prior to its removal passing into lower left ureter and across to right kidney. Clamp is on right nephrostomy tube. E, Retrograde pyelogram obtained prior to removal of right nephrostomy tube, disclosing right ureter anastomosed to left at level of fifth lumbar vertebra. F, Excretory urogram made 5 months following transuretero-ureteral anastomosis, indicating good bilateral function and absence of stasis.
was passed and the end of the catheter coiled in the bladder was brought out through the urethra. There was evidence of pyelonephritis for the next 20 days with temperature as high as 103° F. at times. Cystoscopy disclosed that this involved chiefly the left kidney, for which an inlying catheter was inserted, combined with chemotherapy, with prompt improvement. The right nephrostomy tube was removed 41 days later with prompt healing of the site and she was dismissed from the hospital on the forty-fourth postoperative day. A recent postoperative check-up, 5 months following operation, revealed a very satisfactory functional result as evidenced by an excretory urogram indicative of good bilateral renal function and absence of ureterectasis or pyelectasis (fig. 4). The nonprotein nitrogen estimation on the blood was 40 mg. per cent. There were no complaints referable to the urinary tract although a catheterized specimen revealed a moderate degree of pyuria. The re-implanted left ureter easily admitted a 11 F. catheter. Comment: As far as I have been able to determine, transurete'ro-ureteral
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anastomosis has been employed in only 4 cases, including the one herewith reported. The functional result in all of them has been eminently satisfactory and the procedure probably deserves more frequent use as a conservative operation with special reference to injuries of the ureter at levels too high above the bladder to permit re-implantation. SUMMARY
The principles governing the management of surgical injury of the ureter are determined to a great extent by their early or late discovery and the nature and site of the injury. In instances of complete anuria following extensive pelvic surgery, the possi bility of bilateral occlusion of the ureters should be considered early rather than the adoption of therapy under the erroneous diagnosis of suppression of urine. In such cases although deligation as has been employed in the past has been attended by a very high mortality rate, it is believed that the active co-operation of a cystoscopist when the abdomen is re-opened would render the operation far more safe. Re-implantation of the ureter into the bladder may be considered preferable to uretero-ureteral anastomosis. The latter with its tendency to cicatricial stenosis at the site of anastomosis often sentences the patient to the necessity of numerous subsequent cystoscopic treatments and ureteral dilatations. vVhen a ureter has been severed or damaged, sacrifice of the involved kidney by ligation or nephrectomy is to be condemned except under most urgent circumstances. Transuretero-ureteral anastomosis may be considered along with ligation, nephrectomy, cutaneous ureterostomy and uretero-intestinal anastomosis as a measure to be adopted when the ureter has been extensively damaged or severed at a high level. Of these procedures transuretero-ureteral anastomosis would appear the most desirable. Four cases are cited from the author's experience illustrative of various measures to be adopted in the conservative treatment of the surgically injured ureter. In all of these both ureters were involved. Late follow-up :findings are included, indicative of satisfactory functional results in all. There was no mortality. 899 JJ1 adison Ave., JJ1 emphis 3, Tenn. REFERENCES ADAMS, T. W.: Ureteral injury during gynecologic surgery. West. Jour. Surg., Obst. and Gynec., 61 : 305-324, 1943. BARRETT, C. W.: The ureters in gynecological surgery. Urol. & Cutan. Rev., 47: 588-591, 1943. BLAND, P. B.: The treatment of accidental occlusion of the ureter. Atlantic Med. J., 27: 341-351, 1923. FEINER, D.: Operative injuries of the ureter. Surg., Gynec. & Obst., 66: 790-796, 1938. HEPLER, A. B.: Management of surgical injuries to the ureter. West. Jour. Surg. & Obst., 48: 486-492, 1940. HIGGINS, C. C.: Transuretero-ureteral anastomosis. Tr. Am. Ass. Gen.-Urin. Surg., 27: 279-285, 1934. LEVENTHAL, M. L., SHAPIRO, I. J. AND PLATT, A. J.: Ureteral injuries in gynecologic surgery. Am. Jour. Obst. & Gynec., 37: 797-809, 1939.
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LYNCH, K. D. AND THOMPSON, R. F.: Injuries to the ureters. South. Med. J., 28: 965-972, 1935. MclvER, R. B.: Injuries to the ureter and their management. J. A. M.A., 124: 1116-1120, 1944. NEWELL, Q. W.: Injury to ureters during pelvic operations. Ann. Surg., 109: 981-986, 1939. NoRA, M., quoted by RuscHE, C. F. AND BACON, S. K.: Injury of the ureter. J. A. M.A., 114: 201-207, 1940. SHARPE, N. W.: Trans-uretero-ureteral anastomosis. Ann. Surg., 44: 687-707, 1906. SrsK, I. R.: Operative injuries of the ureter. Surg., Gynec. & Obst., 60: 857-860, 1935. SMITH, P. G. AND SMITH, D. P.: Ureteral injuries and their management. Tr. Am. Ass. Gen.-Urin. Surg., 33: 175-183, 1941.
Accidental injury of the ureter during the course of pelvic operations is not uncommon. It is generally agreed among surgeons and gynecologists that such injuries may be regarded as the most serious surgical accident with which they contend, with a mortality rate of 33.3 per cent for bilateral and 18.8 per cent for unilateral injuries, according to Bland. In difficult hysterectomies and in the removal of intraligamentous tumors and cysts the normal course of the ureter may be so distorted that it may be unsuspectingly injured. The incidence of such accidents is rather difficult to estimate because unilateral injury may be entirely unrecognized, particularly if simple ligation has occurred. As evidence of this, Newell states that their pathologist has been instructed to pay special attention to the ureters when performing autopsies on gynecological patients; he reports 6 cases of ligated ureters found at autopsy, none of which had been suspected prior to the postmortem examination. Numerous articles have appeared in the literature, particularly in recent years, with reported cases now aggregating more than 800 in number. Pertinent data derived from a survey of this fairly large group may be summarized as follows: The incidence of ureteral ligation as a complication of all operations on the female genital organs may be placed at 1 to 3 per cent. Many cases are not reported and many are not recognized. The proportion of unilateral to bilateral injury is approximately 6 to 1; Bland and Feiner collected a total of 710 cases, of which 601 were unilateral and 109 bilateral. The most common sequelae of ureteral injury are ureterovaginal and ureteroabdominal urinary fistulas. It is further evident from a study of the literature that injury of the ureter may occur in the hands of the most skilled surgeon. Urologists are unanimous in their belief that such injuries are preventable and have persistently and consistently advocated the preoperative insertion of inlying ureteral catheters when difficult pelvic surgery is anticipated in order that they will serve as a guide and that the surgeon may more easily avoid the ureters. It seems that many gynecologists have been loathe to adopt this precautionary measure. Leventhal et al. state: "The value of inserting ureteral catheters as a prophylactic measure is highly questionable. They may give a false sense of security, and by altering the normal position of the ureters, render them more liable to injury. In many instances we have been unable to locate them by palpation 1 Read at annual meeting, Southeastern Section, American Urological Association, Palm Beach, Fla., March 26-29, 1947. 712
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and their mere introduction may give rise to infection, ureteral colic and oliguria, with great possibilities of increasing the postoperative morbidity." On the other hand, Sisk states: "For many years we have routinely inserted catheters in the ureters of such patients for the Department of Gynecology at the Wisconsin General Hospital, and as a result only l ureter has been damaged. In this case serious pathology was unexpectedly encountered and catheters had not been introduced." Of further interest is Barrett's statement: "In the formative days of uterine surgery, Kelly recommended ureteral catheterization preliminary to abdominal hysterectomy, but few gynecologists ever acquired the dexterity in ureteral catheterization attained by Doctor Kelly." He fails to mention enlisting the co-operation of a competent urologist for this purpose. With all due respect for the objections mentioned by Leventhal, which appear exaggerated to say the least, there is an abundance of accumulated evidence indicating that the preliminary insertion of ureteral catheters is a wise precaution, not only in cases where radical surgery is contemplated in the female pelvis but also preliminary to such operations as abdominoperineal resection of the rectosigmoid in either sex. It behooves the urologist to remind his surgical and gynecological confreres from time to time of the value of this precautionary measure. It may be safely assumed that the incidence of accidental ureteral injury would thereby be greatly diminished. Instances of accidental injury of the ureter may be divided into two groups: 1) those in which the injury is recognized immediately, and 2) those in which it is discovered during the postoperative period. Both groups may be further subdivided into those in which the injury is a) unilateral and b) bilateral. Types of injury are as follows: Ligation, occlusion by acute angulation from stitches placed near the ureter, crushing or clamping, incision without severence, severence, and resection of a portion of the ureter. MANAGEMENT OF INJURY WHEN RECOGNIZED IMMEDATELY
Simple ligation of 1 ureter is probably seldom recognized at the time of the operation. If the accident is discovered before the operation is terminated, immediate deligation, followed by the insertion of a ureteral catheter, would appear adequate. Acute angulation may be managed in the same way. Crushing by a clamp is more serious and requires essentially the same treatment as a severed ureter because of the probability of subsequent sloughing or dense cicatricial contracture. Under such circumstances the surgeon may adopt one of several possible solutions of the problem, the governing principle of which should be conservation of the involved kidney. End-in-end anastomosis (Pozzi) has proved to be more satisfactory than end-to-end anastomosis. In the former the proximal stump is introduced into the distal one and secured by a few interrupted sutures of 0000 chromic catgut, designed to attain a water-tight closure. A small opening above the anastomosis through which a ureteral catheter is passed to the renal pelvis and brought out of the flank for temporary diversion of the urine, as advocated by Curtis, may be expected to yield a satisfactory result in a fair percentage of cases. Adams found that of 30 cases so treated 21 (70 per cent)
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had satisfactory results. There were 6 (20 per cent) failures and 3 (10 per cent) deaths. Unfortunately surgeons and gynecologists frequently have not familiarized themselves with the principles of ureteral repair and when confronted with a severed ureter are prone to disregard conservation of the kidney as it is easier to ligate the severed ureter with or without subsequent nephrectomy. A serious objection to uretero-ureteral anastomosis is the probability of the formation of subsequent cicatricial contracture. Many of these patients require frequent and systematic dilatation of the ureter; otherwise slow hydronephrotic atrophy resulting from the ureteral stenosis will in the end necessitate nephrectomy. Good immediate results have undoubtedly been reported from this procedure when the ultimate result was unsatisfactory as illustrated by a case · reported by Nora, in which a ureter was accidently severed during hysterectomy and was repaired by an immediate uretero-ureteral anastomosis. Patency of the ureter was maintained by catheter dilatations over a period of eighteen months and on several occasions the case was presented before medical societies as evidence of a good result from ureterorrhaphy. Seven years later Nora performed a right nephrectomy; the ureter had become abruptly stenosed and there was complete destruction of the renal parenchyma. If the ureter has been severed low in the pelvis probably a better procedure than an attempt at anastomosis of its ends would be its re-implantation into the bladder as low in the base as possible, employing a technic designed to prevent reflux of urine from the bladder. Of 70 collected cases so treated, Adams reported perfect results in 8 (11.4 per cent), fair results (moderate stenosis) in 38 (54.3 per cent), failures in 21 (30.4 per cent) and 3 deaths (4.3 per cent). If the precaution is taken however of dividing the proximal end of the severed ureter 6 or 8 mm. and inserting it at least 1 cm. beyond its entrance into the bladder, subsequent stenosis of the ureteral opening will be less likely to occur. Cutaneous ureterostomy is mentioned only for condemnation although it may be regarded as a conservative measure. Some writers prefer uretero-intestinal anastomosis. A serious objection is the lack of preparation of the patient for such a procedure with special reference to emptying and cleansing the bowel and the employment of modern chemotherapy in the form of intestinal antisepsis. Therefore, an unplanned uretero-intestinal anastomosis undoubtedly would incur greater risk than a planned operation of this type. Ligation under certain circumstances may be the operation of choice; after a difficult and prolonged pelvic operation the patient already may have been on the operating table too long in a state of shock. In this event if palpation of the opposite kidney indicates its healthy state ligation may be considered the best and safest procedure although it is freely admitted that palpation of the opposite kidney can yield only presumptive evidence of its functional condition. While performing a major urological operation recently a surgical confrere called me into an adjoining operating room because of a severed ureter incurred during a difficult hysterectomy. He had taken the precaution to mobilize the ureter in spite of which it had been divided accidentally about 10 cm. above the bladder. The patient had been on the table nearly 2 hours and was in no condition for
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further extensive surgery. It appeared wise to advise secure ligation of the proximal stump after ascertaining by palpation that the opposite kidney appeared sound. The patient made a nice recovery. Temporary ureteral repair might have been considered, however, had I not been engaged with my own patient. If a large segment of the ureter has been excised uretero-ureteral anastomosis or re-implantation into the bladder usually is not possible and one of the following procedures should be considered: transuretero-ureteral anastomosis, ureterointestinal anastomosis, ureterocutaneous anastomosis, ligation and nephrectomy, listed in the order of their choice. Hepler prefers uretero-intestinal implantation in such cases to ligation or nephrectomy, employing the Coffey No. 1 technique. Frequently the extreme condition of the patient prohibits conservative efforts. There should be some temporary measure, less radical than ligation, nephrectomy or cutaneous ureterostomy, which would permit a well-planned conservative operation later when conditions are more favorable. There should be considered for this purpose 1) the passage of a ureteral catheter through the proximal segment of the severed ureter, the distal end of which may be ligated about the catheter employing non-absorbable suture material with extraperitoneal drainage, 2) temporary ureterostomy and 3) temporary nephrostomy. The problem that would then be presented is the same as will be discussed under the second group comprising those injuries discovered in the postoperative period. MANAGEMENT OF INJURY WHEN RECOGNIZED LATE
Unilateral ligation or ureteral occlusion from acute angulation secondary to sutures probably occurs more often than is generally believed. It may be suspected, however, in the postoperative period following pelvic surgery if there is unusual discomfort in either renal area associated with tenderness at the costovertebral angle. A wider employment of excretory urography in such cases undoubtedly would lead to the more frequent detection of such injuries and would render possible the conservation of the involved kidney rather than to permit atrophy of the organ. In many cases the appearance of urinary leakage from the vagina or from the abdominal incision in the early postoperative period is the first evidence of ureteral injury, either unilateral or bilateral. If both ureters have been ligated or otherwise occluded, complete anuria is at once evident and may be erroneously diagnosed as "suppression of urine." Failure to demonstrate urine in the bladder on catheterization 6 to 12 hours following a difficult pelvic operation renders a cystoscopic examination mandatory for the exclusion of obstructed ureters. Too often the patient will be subjected to treatment for suppression of urine for several days and only with the increasing gravity of the case will a urological consultation be requested in an atmosphere of desperation. If cystoscopy confirms the suspicion of bilateral ureteral occlusion an immediate unilateral nephrostomy may prove to be a life saving measure. Lynch and Thompson prefer temporary ureterostomy to bilateral nephrostomy in bilateral injuries because it is technically easier and avoids the
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necessity of changing the position of the patient and redraping, as well as ease in locating the distended obstructed ureters and their ready catheterization. With the abdomen open, however, deligation would appear more practical. Regarding deligation, it is interesting to note from a review of the literature the wide divergence of opinion regarding its advisability. A review of 23 articles dealing with ureteral injury discloses that 8 writers definitely advise against deligation; it is advocated by 11 and 4 do not mention it. Hepler states that "postoperative deligation is a formidable operation with a mortality rate of about 90 per cent." Feiner reports the death of 2 patients following intraabdominal deligation and is of the opinion that nephrostomy with subsequent operation for ureteral anastomosis or re-implantation into the bladder is a safer procedure. Deligation as it is usually practiced by the average surgeon with the patient in a desperate condition, and without the assistance of a urologist, is undoubtedly hazardous in that the abdomen is re-opened and the surgeon carries out an extensive search for offending ligatures, which may be extremely difficult to locate. Enlisting the co-operation of a urologist when the surgeon re-opens the abdomen is of extreme importance, the value of which cannot be overemphasized. With ureteral catheters, preferably of a large caliber (9 or 11 F.), the cystoscopist can literally prod the obstructed points, permitting the surgeon to quickly clip ligatures and also facilitating the detection of more than one ligated point if present. He should not be satisfied until both catheters have passed into the renal pelves. Such active urological assistance should render deligation a far less hazardous procedure. ILLUSTRATIVE CASES
Mrs. H.B., aged 40, was first seen February 19, 1945. She had undergone a difficult hysterectomy by a general surgeon 3 days before. There was 200 cc of urine in the bladder on catheterization 15 hours after the operation and complete anuria since, for which she had been treated for "suppression of urine." By the time of the urological consultation she had moderate generalized edema and was semicomatose. The nonprotein nitrogen content of the blood was estimated at 172.5 mg. per cent and the creatinin estimation was 3.5 mg. per cent. Cystoscopy revealed impassable obstructions of both ureters approximately 7 cm. above the bladder. In my absence from the city one of my associates performed an immediate left nephrostomy, which permitted the drainage of 1800 cc of urine during the following 18 hours. Upon my return 3 days following the nephrostomy I advised immediate deligation. The surgeon re-opened the abdomen; I passed a cystoscope and inserted No. 11 ureteral catheters into each ureter and easily located the ligated points for the surgeon, who clipped sutures at these points releasing the obstructions and permitting the catheters to pass with ease to both renal pelves. The catheters were left in place and the abdomen was quickly closed. Her convalescence was uneventful. The catheters and nephrostomy tube were removed after 7 days and she was discharged from the hospital 16 days following the deligation, at which time the nonprotein nitrogen estimation on the blood was 35 mg. per cent. Eighteen days later a 10 F. bulb was
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passed through each ureter without detecting any evidence of obstruction and there was no abnormal retention of urine in either renal pelvis. Two years later an excretory urogram was obtained, revealing normal bilateral function and outline, including normal ureters (fig. 1). Comment: It is evident that if nephrostomy d,rainage had been depended upon for a longer period that severe ureteral damage from the ligatures would have been inevitable. Cystoscopic assistance when the abdomen was re-opened largely eliminated the risk of deligation and its early accomplishment undoubtedly was the chief factor in the good result obtained.
Fm. L A, Plain film, revealing ureteral catheters and indicating points of complete obstruction in both ureters at level of brim of pelvis. B, Retrograde bilateral pyelograms obtained during second postoperative week after deligation. C, Excretory urogram obtained 2 years later, revealing normal bilateral function and normal ureters.
In those cases in which there is evidence that the ureter has been severed, incised, resected or crushed with subsequent sloughing the development of urinary leakage in the postoperative period may be the first indication of the accident, whether unilateral or bilateral. The problem then resolves itself into conserving the life of the patient as well as conservation of the involved kidney. Extensive urinary extravasation may occur from a severed ureter which was neither recognized nor ligated. Hmvever, in most cases urinary drainage will appear within a few days, either from the incision or from the vagina, with consequent improvement of the patient's status. 1Veeks or months may elapse before a urological consultation is requested because of the hope that spontaneous closure of the fistula will occur. In such instances urologists should determine by cystoscopy or excretory urography, or a combination of both, the extent of the damage and the side affected if unilateral. Some surgeons follow the line of least resistance and perform a nephrectomy, which not only controls the annoying urinary leakage hut diminishes to some extent the prospect of medicolegal complications. The majority of urologists, however, are keenly aware of the desirability of conserving renal tissue and when their assistance is enlisted their efforts as a rule are along conservative lines. It is usually impractical to attempt an end-to-end anastomosis of a severed ureter when it has been discovered late. If the site of the injury is low in the pelvis, the proximal ureter may be mobilized,
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permitting sufficient elongation to enable its re-implantation into the bladder at a site preferably as low in the base as possible and with the distal 3 or 4 cm. of the ureter buried in its musculature before finally emerging through the mucosa, thus preserving valve-like function which is so essential in protecting the kidney from vesical reflux. Mrs. P. M. W., aged 46, was first seen on January 23, 1943. She had undergone a hysterectomy for multiple fibromyomata 3 months before. The immediate postoperative period was stormy and after a few dELys urine began to drain continuously from the vagina, along with profuse purulent drainage from the abdominal incision. Since then urine had not been voided in a normal way. The referring surgeon stated that he was aware that he had accidently severed the left ureter, the proximal stump of which was ligated with catgut. He was unable to account for her inability to void nor the discharge of urine from the vagina. Examination revealed absence of urine in the bladder. There was no secretion from either ureteral orifice, complete obstruction of the left ureter 2 cm. above the bladder and a similar obstruction of the right ureter 4 cm. above the orifice. An excretory urogram proved very informative. The soft tissue shadow of the right kidney appeared essentially normal; several moderately dilated calyces were filled with the medium, but the renal pelvis and ureter could not be visualized. The left ureter ·was open in spite of its having been ligated and the kidney was of essentially normal function, but the urine was draining through the vagina. In view of these findings it was assumed that the right ureter had been ligated 4 cm. above the bladder and in spite of its complete occlusion for 3 months it was astonishing to find that it appeared functionally worth conserving. It was therefore explored first and was found involved in dense scar tissue in the region of the vault of the vagina where it evidently had been incorporated in sutures. Although it was about 1 cm. in diameter above the ligated point, it was amputated at this site and mobilized a distance of 4 or 5 cm., permitting its re-implantation without undue tension low in the right base of the bladder with preservation of a valve-like mechanism. Extraperitoneal rubber tissue drainage was provided through a stab wound and the incision closed. Her convalescence ·was satisfactory and 9 days later an extraperitoneal approach was made to the left ureter, which was found to have been severed at a point opposite the second sacral segment. It was freely mobilized for a distance of 5 or 6 cm. and it was possible to also re-implant it into the bladder without undue tension at a site low in the left base, employing essentially the same technique as ,vas carried out on the opposite side. Continuous catheter drainage of the bladder was provided for 10 days. Her convalescence was uneventful and on the seventeenth day, upon filling the bladder with radiopaque fluid, there was no evidence of ureteral reflux on either side. Indigo carmine appeared from the right in 13 minutes and from the left in 14 minutes in fair concentration. She was dismissed 31 days following the first operation. Twenty-seventh months later she returned for a check-up at our request. The urinalysis was negative. There were no urinary complaints and an excretory urogram disclosed both kidneys of normal function and outline (fig. 2).
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Comment: It is truly remarkable that the right kidney which had evidently been completely occluded for 3 months should display such recuperative ability when release of the obstruction was accomplished. Fortunate indeed was the spontaneous opening of the ligated left ureter, thus providing urinary drainage from 1 kidney and preservation of life. It is worthy of note that the sites of the injuries to the ureters were sufficiently low, aided by mobilization of essentially their lower thirds, to permit re-implantation into the base of the bladder without undue tension and with a good functional result. Althought accidental injury of the ureter is usually incurred in those cases where removal of organs or tissues is necessary it is of interest to note that the ureters may be accidentally damaged in cases where tissues have not been removed, for example in such operations as uterine suspension. Simple ligation
FIG. 2. A, Note catheters in place, indicating sites of ureteral obstruction at level of brim of pelvis on right and at a lower level on left side. B, Excretory urogram, indicating good function and drainage from left and surprisingly good function from right in spite of obstruction. C, Excretory urogram obtained 27 months following re-implantation of both ureters into bladder, indicating normal bilateral function and normal ureters.
or acute angulation from sutures would be the most plausible explanation in such cases. Mrs. R. V. K., aged 27, was first examined on October 12, 194.5. She had undergone a suspension of the uterus by a general surgeon 2 months before. A few days later an almost constant aching pain developed in the left loin. The pain persisted after her return home and 1 month after she left the hospital cystoscopy elsewhere revealed no evidence of function of the left kidney and its removal was advised by the same surgeon. She was also told that there was a stricture of the right ureter. She decided to obtain another opinion before undergoing a left nephrectomy. My examination revealed a point of marked narrowing in the right lower ureter, with ureterectasis and pyelectasis of moderate degree; 7.5 cc of clear urine was aspirated from the right renal pelvis. An obstruction was met in the lower left ureter 4 cm. above the bladder; after considerable effort a No . .5 catheter ·was passed beyond the obstruction and 170 cc of clear urine was aspirated. Pyelography disclosed an extremely narrow point
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near the midline corresponding to the point of obstruction 4 cm. above the bladder, above which an extreme degree of ureterectasis and pyelectasis was visualized. Apparently the left ureter had been completely ligated at the time of the uterine suspension and the right lower ureter had possibly been transfixed or partially ligated at the same time. In spite of the extreme degree of damage incurred on the left side conservation of this kidney was highly desirable because of the hydronephrotic state of the opposite kidney. The scar of the previous laparotomy was excised and an extraperitoneal approach made to the left lower ureter. It was identified at the level of the brim of the pelvis, was about 2 cm. in diameter and was mobilized and traced to a point of dense cicatricial obstruction about 3.5 cm. below the pelvic brim. It was divided above the obstructed point and the distal stump ligated. More extensive mobilization permitted its reaching a point in the left base of the bladder about 2 cm. posterior to the left ureteral orifice, where it ,vas re-implanted without undue tension and with preservation of a valve-like mechanism. Because of the advanced degree of ureterectasis a temporary ureterostomy seemed wise and was accomplished by inserting a 14 F. rubber catheter to the renal pelvis introduced through a small opening immediately above the point of anastomosis. The ureterostomy tube and rubber tissue drains were brought out through a small stab wound in the left lower quadrant and the median incision was closed. The ureterostomy tube was removed on the tenth day. There was no urinary leakage from this site. Her convalescence was satisfactory and seventeen days following the operation the right ureter was dilated to 12 F. The re-implanted left ureter appeared to have healed satisfactorily. She was dismissed on the nineteenth postoperative day. She returned for observation 3 months later, at which time the urinalysis was negative and on cystoscopic examination there was only 5 cc of retention in the right renal pelvis and 8 cc on the left side. Phenolsulfonphthalein appeared after 3 minutes from both sides with an output of 24 per cent from the right and 14 per cent from the left in 15 minutes. There were no urinary complaints and she considered herself well. Seven months later the urinalysis was still negative. Excretory urograms revealed both kidneys of essentially normal outline and normal function (fig. 3). Comment: In spite of the extreme degree of damage incurred by the left kidney from occlusion of the lower ureter of 2 months' duration its return to an essentially normal condition was astonishing and again well illustrates the recuperative ability of the kidney, thoroughly justifiying conservative efforts. Except for the finding of a moderate degree of hydronephrosis on the right side a left nephro-ureterectomy might easily have been considered the operation of choice in this case. When the ureter has been injured at a high level or a segment accidentally resected, or if it has undergone sloughing through extensive injury to the muscularis or through interference with its blood supply, the problem is definitely more complicated. In such cases it appears that the majority of writers mention the following procedures in the order of their desirability: 1) ligation, 2) nephrectomy, 3) cutaneous ureterostomy and 4) uretero-intestinal anastomosis,
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although Hepler believes these should be in the inverse order with preference given to implantation into the bowel, a procedure which is also advocated by McI ver. To this list of available procedures I should like to add transureteroureteral anastomosis. A number of years ago Sharpe demonstrated experimentally on dogs the feasibility of this operation in which 1 ureter is brought across the midline and anastomosed to the opposite one. In 1934 Higgins reported a case in which this operation was performed for the first time on the human. In his case there was an incompetent right ureterovesical valve permitting reflux of urine accompanied by severe pain. The ureter was severed near the bladder and transplanted into the opposite one ·with a brilliant postoperative result. Smith and Smith in 1941 reported the employment of this procedure in 2
FIG. 3. A, Excretory urogram, disclosing point of narrowing of right ureter at brim o pelvis with moderate degree of ureterectasis and pyelectasis. Absence of medium, left. B, Left retrograde pyelogram; marked ureterectasis and pyelectasis secondary to occlusion of lower left ureter. C, Retrograde pyelogram obtained during second postoperative week. Note ureterostomy tube in place and marked recession of left hydronephrosis. D, Excretory urogram obtained 7 months after re-implantation of left ureter into bladder and after dilating right ureteral stricture. Note normal bilateral function and essentially normal ureters.
additional cases. In one an end-to-end anastomosis of the ureter had been performed because of an accidentally severed ureter, for which the patient had required frequent ureteral dilatations. A long period of recumbency because of a severe fracture enforced discontinuance of the dilatations, after which an impermeable stricture had developed. The ureter was severed above the site of stenosis and was anastomosed to the opposite ureter, following closely the technique described by Higgins with the exception that a side-to-side anastomosis was made rather than end-to-side. The same procedure was employed in Smith's second case because of a ureterovaginal fistula resulting from severance of the ureter about 2 inches above the bladder, which occurred during the repair of cervical lacerations. Excellent results were obtained in both cases. I have been unable to discover in the literature any other references to transureteroureteral anastomosis but I am convinced that it should be of definite value as a
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means of conserving the kidney when the ureter has been extensively damaged or severed at a level too high to permit ureterovesical re-implantation. There is good reason to list this operation high in the order of desirability of those procedures available for high ureteral injuries and it was so employed in one of my cases. Miss M. 0., aged 33, was first examined by us on January 10, 1946. She had undergone a total hysterectomy 6 weeks before because of multiple large fibromyomata of the uterus. There had been complete anuria for 3 days when urological consultation elsewhere was requested. Their examination revealed the following data: Upon attempting an excretory urogram there was no evidence of medium in either renal area after 30 minutes. Cystoscopy revealed both ureters completely obstructed about 4 cm. above the left orifice and somewhat higher on the right. The resident urologist performed bilateral pyelostomy, after which her condition steadily improved. Six weeks later I was called in on the case when the catheter in the right pyelostomy had been accidentally removed and could not be replaced, for which I advised a right nephrostomy. Eight days later the catheter in the left pyelostomy was also accidentally removed, at which time the decision was made to attempt re-implantation of the left ureter into the bladder. Cystoscopy at this time indicated the obstruction of the left ureter was sufficiently low probably to permit this procedure. An excretory urogram disclosed good bilateral renal function. Eighty days following the hysterectomy I exposed the lower left ureter through an extraperitoneal approach and on tracing the ureter downward it became completely detached, indicating that it had been completely severed and ligated at the original operation. The stenosed end was removed and the wall of the ureter was divided about 1 cm. It was widely mobilized, after which it could be brought to the region of the trigone without excessive tension. It was re-implanted at this site employing a technique somewhat similar to the Coffey No. 1 for uretero-intestinal anastomosis. The left nephrolumbar urinary fistula promptly closed and convalescence was satisfactory. The right nephrostomy was functioning well and she was permitted to return home for further recuperation. Five months later she was re-admitted to the hospital, having gained in weight and strength. She was extremely anxious to be relieved of the right nephrostomy tube. A right nephrectomy was considered but the idea was abandoned because the verdict of time had not · been rendered on the ultimate functional result of the re-implanted left ureter. Exploration of the occluded right ureter was decided upon. Although it was obstructed 7 cm. above the bladder, there was a possibility that it might be re-implanted into the bladder or into the colon. In the extreme Trendelenburg position the intestines were packed off and the posterior peritoneum over the region of the ureter divided. It was mobilized downward to the point of obstruction where there was evidence that it had been severed and ligated. In spite of wide mobilization the length was insufficient for re-implantation into the bladder. It was found, however, that it WO\lld easily reach the dilated spindle portion of the left mid-ureter and that transuretero-ureteral anastomosis appeared more desirable and less hazardous than uretero-intestinal implantation.
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The mid-portion of the left ureter was exposed through a second incision in the posterior peritoneum and ·with a curved forcep a tunnel beneath the posterior peritoneum was made ncross the spine, through which the free end of the right ureter was drawn. The end of the right ureter was cut obliquely at about 45 degrees and ,YtLS anastomosed to an opening in the left ureter about 12 mm. in length, employing interrupted sutures of 0000 chromic catgut. Through a small opening in the right ureter proximal to the anastomosis a No. 5 ureteral catheter was passed through the anastomosis down the lmver left ureter into the bladder and the upper end was passed into the right renal pelvis and left in place as a splint. The ureterotomy was closed tightly and a small rubber tissue drain ,va:,: passed extraperitoneally through a small stab wound in the left flank. Both posterior peritoneal incisions were closed and the abdominal incision was closed y1·ithout drainage. Following the operation a cystoscope
Fm. 4. A, Excretory urogram, disclosing marked narrowing of lower left ureter and extravasation in pelvis. B, Right nephrostomy tube in place. Note occlusion of right ureter at brim of pelvis. C, Left retrograde pyelogram after re-implantation of left ureter into bladder. D, Film obtained following right transuretero-ureteral anastomosis with inlying catheter coiled in bladder prior to its removal passing into lower left ureter and across to right kidney. Clamp is on right nephrostomy tube. E, Retrograde pyelogram obtained prior to removal of right nephrostomy tube, disclosing right ureter anastomosed to left at level of fifth lumbar vertebra. F, Excretory urogram made 5 months following transuretero-ureteral anastomosis, indicating good bilateral function and absence of stasis.
was passed and the end of the catheter coiled in the bladder was brought out through the urethra. There was evidence of pyelonephritis for the next 20 days with temperature as high as 103° F. at times. Cystoscopy disclosed that this involved chiefly the left kidney, for which an inlying catheter was inserted, combined with chemotherapy, with prompt improvement. The right nephrostomy tube was removed 41 days later with prompt healing of the site and she was dismissed from the hospital on the forty-fourth postoperative day. A recent postoperative check-up, 5 months following operation, revealed a very satisfactory functional result as evidenced by an excretory urogram indicative of good bilateral renal function and absence of ureterectasis or pyelectasis (fig. 4). The nonprotein nitrogen estimation on the blood was 40 mg. per cent. There were no complaints referable to the urinary tract although a catheterized specimen revealed a moderate degree of pyuria. The re-implanted left ureter easily admitted a 11 F. catheter. Comment: As far as I have been able to determine, transurete'ro-ureteral
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anastomosis has been employed in only 4 cases, including the one herewith reported. The functional result in all of them has been eminently satisfactory and the procedure probably deserves more frequent use as a conservative operation with special reference to injuries of the ureter at levels too high above the bladder to permit re-implantation. SUMMARY
The principles governing the management of surgical injury of the ureter are determined to a great extent by their early or late discovery and the nature and site of the injury. In instances of complete anuria following extensive pelvic surgery, the possi bility of bilateral occlusion of the ureters should be considered early rather than the adoption of therapy under the erroneous diagnosis of suppression of urine. In such cases although deligation as has been employed in the past has been attended by a very high mortality rate, it is believed that the active co-operation of a cystoscopist when the abdomen is re-opened would render the operation far more safe. Re-implantation of the ureter into the bladder may be considered preferable to uretero-ureteral anastomosis. The latter with its tendency to cicatricial stenosis at the site of anastomosis often sentences the patient to the necessity of numerous subsequent cystoscopic treatments and ureteral dilatations. vVhen a ureter has been severed or damaged, sacrifice of the involved kidney by ligation or nephrectomy is to be condemned except under most urgent circumstances. Transuretero-ureteral anastomosis may be considered along with ligation, nephrectomy, cutaneous ureterostomy and uretero-intestinal anastomosis as a measure to be adopted when the ureter has been extensively damaged or severed at a high level. Of these procedures transuretero-ureteral anastomosis would appear the most desirable. Four cases are cited from the author's experience illustrative of various measures to be adopted in the conservative treatment of the surgically injured ureter. In all of these both ureters were involved. Late follow-up :findings are included, indicative of satisfactory functional results in all. There was no mortality. 899 JJ1 adison Ave., JJ1 emphis 3, Tenn. REFERENCES ADAMS, T. W.: Ureteral injury during gynecologic surgery. West. Jour. Surg., Obst. and Gynec., 61 : 305-324, 1943. BARRETT, C. W.: The ureters in gynecological surgery. Urol. & Cutan. Rev., 47: 588-591, 1943. BLAND, P. B.: The treatment of accidental occlusion of the ureter. Atlantic Med. J., 27: 341-351, 1923. FEINER, D.: Operative injuries of the ureter. Surg., Gynec. & Obst., 66: 790-796, 1938. HEPLER, A. B.: Management of surgical injuries to the ureter. West. Jour. Surg. & Obst., 48: 486-492, 1940. HIGGINS, C. C.: Transuretero-ureteral anastomosis. Tr. Am. Ass. Gen.-Urin. Surg., 27: 279-285, 1934. LEVENTHAL, M. L., SHAPIRO, I. J. AND PLATT, A. J.: Ureteral injuries in gynecologic surgery. Am. Jour. Obst. & Gynec., 37: 797-809, 1939.
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LYNCH, K. D. AND THOMPSON, R. F.: Injuries to the ureters. South. Med. J., 28: 965-972, 1935. MclvER, R. B.: Injuries to the ureter and their management. J. A. M.A., 124: 1116-1120, 1944. NEWELL, Q. W.: Injury to ureters during pelvic operations. Ann. Surg., 109: 981-986, 1939. NoRA, M., quoted by RuscHE, C. F. AND BACON, S. K.: Injury of the ureter. J. A. M.A., 114: 201-207, 1940. SHARPE, N. W.: Trans-uretero-ureteral anastomosis. Ann. Surg., 44: 687-707, 1906. SrsK, I. R.: Operative injuries of the ureter. Surg., Gynec. & Obst., 60: 857-860, 1935. SMITH, P. G. AND SMITH, D. P.: Ureteral injuries and their management. Tr. Am. Ass. Gen.-Urin. Surg., 33: 175-183, 1941.