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Transplantation of the Lower End of the Dog’s Ureter: An Experimental Study III. The Function of the Uretero-Rectal Valve
TRANSPLANTATION OF THE LOWER END OF THE DOG'S URETER: AN EXPERIMENTAL STUDY Iff THE FUNCTION OF THE URETERO-RECTAL VALVE VINCENT VERMOOTEN From the Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
Anatomically we find that the ureter passes obliquely through the vesical wall just as Stenson's duct does through the cheek and the common bile duct through the duodenum. In 1909 Coffey (2) transplanted the common bile duct of dogs directly into the duodenum with subse-quent resultant dilatation of the duct and at times even of the entire biliary system. When this was repeated and the duct transplanted obliquely there was no evidence of dilatation. This led him to suggest that a similar situation might very readily hold for the transplantation of the ureter into the rectum. In reviewing the literature on experimental transplantation of the ureter into the rectum we find that Steinke (5) in 1909, summarizing all the previous work says, "Of the unilateral type there were twenty-six recoveries and :fifty-one deaths, or a mortality of about sixty per cent. Of the bilateral cases there were one hundred and seventeen deaths or a mortality of over eighty-seven per cent." Death in most instances was due to peritonitis, pyelonephritis or an association of the two conditions. In reviewing these results we find that in the records in which the cause of death was given, 102 out of 129 died from peritonitis, while only 27 died later from pyelonephritis or were sacrificed; that is, an immediate mortality of 80 per cenL In the instances in which the exact cause of death was not given, we find that 83 out of 95 (87,5 per cent) died within the first week after operation. Presuming that this was due to peritonitis, we must infer that out of the 224 dogs operated upon, 185 died from this cause, a mortality of over 82 per cent. Steinke himself had a 50 per cent mortality from peritonitis. This tremendous mortality from peritonitis even in Steinke's own experiments was very surprisingly diminished or entirely absent in Coffey's work and in the work of other investigators who have attempted one or more of Coffey's submucous methods of transplantation. In Coffey's original article (3) this fact is very effectively illustrated. Of the 6 dogs in which transplantation by the direct method was carried out 5 died 273
274
VINCENT VERMOOTEN
from peritonitis (just over 83 per cent). This corresponds with the above results. Of the 9 dogs in which he used his new "physiologic implantation" only 2 died from peritonitis, or a mortality of 22 per cent, a striking improvement. Working with Kirwin (4) we did bilateral ureteral transplantation in a series of 38 dogs. Various methods were used. No matter how careful our technique or what method we used, we were not able in any single instance to find , at the time of sacrifice, a normal kidney. Recently, in another series of 26 dogs, the ureter was transplanted into either the small or the large intestine. Coffey's three techniques were used as well as the direct method of transplantation (7) which we had used in our experiments for reimplanting the ureter into the bladder. In the instances of direct transplantation 2 dogs died from peritonitis and 2 lived. In the 2 that died we had left the uretero-vesical valve as well as a small portion of the bladder attached to the lower end of the ureter. This evidently tore too large an opening through the wall of the bowel with a resultant leak. In the 2 that lived, urine fin,t appeared in the rectum during the twenty-four hours immediately following the operation. At autopsy four weeks later the kidneys and ureters showed pathologic changes differing in no way from those observed in dogs that had had the ureter transplanted submucously. After these four experiments we found that Beaver and Mann (1) had described a somewhat similar technique. They claim that in dogs in which the "simple method of transplantation" was used the results were very satisfactory. "Some of our animals have lived several years with transplanted ureters .. . .. We have found, however, that the kidney is rarely normal after transplantation of the ureter, regardless of the method used." In a previous communication (6) we have shown that in the ureter an incompetent valve, whether the result of a direct reimplantation into the bladder or the result of complete division or excision, does not lead, as Coffey has presumed, to a ureteral dilatation. This finding seems to be confirmed in the case of transplantations of the ureter into the rectum. This becomes apparent when we take into account the results of the submucous transplantation and compare these with our few dogs that had had direct implantation and with Beaver and Mann's results following their direct transplantation method. In 7 of our dogs, at the time of sacrifice, we tried to determine the efficacy of the valve which we had made by the submucous transplanta-
FT.TNCTION O:F URETERO-RECTAL VALVE
275
tion, This was carried out in the following manner: With the dog under a general anaesthetic the peritoneal cavity was opened and the rectum clamped a short distance above and below the site of the transplantation,
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''R1,:C1'0C1ni1" OF DoG
277
SHOWJNG _RFGPRGI'L\TTO's OF TlH Ol'A()ll]c \]FJ)](')I (;l'
nm
URETEH
This dog liacl had a snlnnucous ureternl trnnsp1anlation done six weeks Jm'viously. The ureter in this instance was found at autopsy to lie subrnucously for a distance of three centi meters and a "ureteral bud" prolrnckd into the rectal lumen.
'rhis portion of the rectum was removed together with lhe ureter and kidney and then distended with a warm 20 per cent solution of sodium iodide at a pressurt' of 2 feet of water A radiograph was taken imnw
276
VINCENT VERMOOTEN
diately to see if any of the opaque medium had regurgitated up the ureter. This occurred in 1 of the 7 dogs (fig . 1) . In this particular dog, when the specimen was later examined it was found that the ureter lay submucously for a distance of fully 3 cm. Microscopically the kidney and ureter showed only a minimal amount of infection. I These findings concur with those following reimplantation into the bladder (7) in which regurgitation was present in 31out of 10 ureters reimplanted by the direct method and in 1 of the 10 reimplanted submucously. The striking feature about all our work is that of 64 dogs in which 102 ureters were transplanted by various submucous methods, only 10 dogs (15.6 per cent) died from peritonitis in contrast to Steinke's finding of over 80 per cent. Of the 4 dogs in which direct implantation was done , 2 died from peritonitis as a result of a leak at the site of the anastomosis. The reason that we devised the special "needle" technique for reimplanting the ureters into the bladder was that our first dogs had died from urine peritonitis as a result of a leak at the site of the transplantation when done by the ordinary methods as used on human beings. The dog's bladder is an intra-peritoneal organ and so has to be tightly closed. In addition, suprapubic or urethral catheter drainage can not be used to keep the bladder at rest while the anastomosis heals. The above findings lead us then to the amazing conclusion that Coffey's greatest contribution to the technique of ureteral transplantation into the rectum is not so much the formation of a valve (for , as we have shown, valve action does not always occur and is in reality not essential and apparently of relatively little importance), but that the submucous method is a very excellent method for preventing peritonitis. Before Coffey's introduction of the method of submucous transplantation, peritonitis, experimentally at least and probably clinically also, was one of the gravest complications of the operation . Now it is very seldom even considered as a possibility. SUMMARY
Submucous transplantation of the ureter into the rectum does not necessarily result in a competent uretero-rectal valve. Direct transplantation of the ureter into the rectum, when properly carried out; leads to no worse sequelae than those of submucous transplantation . The chief advantage of the submucous method of transplantation is
F'UNCTJON OF URETKRO-RECTAL VAL\'E
277
the prevention of peritonitis from a leak at the site of the transplantation, and not, as has been supposed, the formation of a valve. 132 Lister Johannesburg, South REFERENCES (1) (2) (3) (4) (5) (6) (7)
M. G. \ND MANN, F. C.: Ann. Surg., 1932, xcv, 621. R. C.: Ann. Surg., 1909, 1, 1238. COFFEY, R. C.: Jour. Amer. Med. Assoc., 1911, !vi, 397. KIRWIN, T. J.: Amer. Jour. Surg., 1930, viii, 1. STEINKE, C.: Univ. Penna. Med. Bull., 1909, xxii, 110. VERMOOTF:N, V. AND NEuSWANGER, C.H.: Jour. Urol., (in press). VERMOOTEN, v., SPrns, J. w i\Nll NEUS\VANGER, C.H.: Jour. Urol., (in press).
BEAVER,
COFHY,
Anatomically we find that the ureter passes obliquely through the vesical wall just as Stenson's duct does through the cheek and the common bile duct through the duodenum. In 1909 Coffey (2) transplanted the common bile duct of dogs directly into the duodenum with subse-quent resultant dilatation of the duct and at times even of the entire biliary system. When this was repeated and the duct transplanted obliquely there was no evidence of dilatation. This led him to suggest that a similar situation might very readily hold for the transplantation of the ureter into the rectum. In reviewing the literature on experimental transplantation of the ureter into the rectum we find that Steinke (5) in 1909, summarizing all the previous work says, "Of the unilateral type there were twenty-six recoveries and :fifty-one deaths, or a mortality of about sixty per cent. Of the bilateral cases there were one hundred and seventeen deaths or a mortality of over eighty-seven per cent." Death in most instances was due to peritonitis, pyelonephritis or an association of the two conditions. In reviewing these results we find that in the records in which the cause of death was given, 102 out of 129 died from peritonitis, while only 27 died later from pyelonephritis or were sacrificed; that is, an immediate mortality of 80 per cenL In the instances in which the exact cause of death was not given, we find that 83 out of 95 (87,5 per cent) died within the first week after operation. Presuming that this was due to peritonitis, we must infer that out of the 224 dogs operated upon, 185 died from this cause, a mortality of over 82 per cent. Steinke himself had a 50 per cent mortality from peritonitis. This tremendous mortality from peritonitis even in Steinke's own experiments was very surprisingly diminished or entirely absent in Coffey's work and in the work of other investigators who have attempted one or more of Coffey's submucous methods of transplantation. In Coffey's original article (3) this fact is very effectively illustrated. Of the 6 dogs in which transplantation by the direct method was carried out 5 died 273
274
VINCENT VERMOOTEN
from peritonitis (just over 83 per cent). This corresponds with the above results. Of the 9 dogs in which he used his new "physiologic implantation" only 2 died from peritonitis, or a mortality of 22 per cent, a striking improvement. Working with Kirwin (4) we did bilateral ureteral transplantation in a series of 38 dogs. Various methods were used. No matter how careful our technique or what method we used, we were not able in any single instance to find , at the time of sacrifice, a normal kidney. Recently, in another series of 26 dogs, the ureter was transplanted into either the small or the large intestine. Coffey's three techniques were used as well as the direct method of transplantation (7) which we had used in our experiments for reimplanting the ureter into the bladder. In the instances of direct transplantation 2 dogs died from peritonitis and 2 lived. In the 2 that died we had left the uretero-vesical valve as well as a small portion of the bladder attached to the lower end of the ureter. This evidently tore too large an opening through the wall of the bowel with a resultant leak. In the 2 that lived, urine fin,t appeared in the rectum during the twenty-four hours immediately following the operation. At autopsy four weeks later the kidneys and ureters showed pathologic changes differing in no way from those observed in dogs that had had the ureter transplanted submucously. After these four experiments we found that Beaver and Mann (1) had described a somewhat similar technique. They claim that in dogs in which the "simple method of transplantation" was used the results were very satisfactory. "Some of our animals have lived several years with transplanted ureters .. . .. We have found, however, that the kidney is rarely normal after transplantation of the ureter, regardless of the method used." In a previous communication (6) we have shown that in the ureter an incompetent valve, whether the result of a direct reimplantation into the bladder or the result of complete division or excision, does not lead, as Coffey has presumed, to a ureteral dilatation. This finding seems to be confirmed in the case of transplantations of the ureter into the rectum. This becomes apparent when we take into account the results of the submucous transplantation and compare these with our few dogs that had had direct implantation and with Beaver and Mann's results following their direct transplantation method. In 7 of our dogs, at the time of sacrifice, we tried to determine the efficacy of the valve which we had made by the submucous transplanta-
FT.TNCTION O:F URETERO-RECTAL VALVE
275
tion, This was carried out in the following manner: With the dog under a general anaesthetic the peritoneal cavity was opened and the rectum clamped a short distance above and below the site of the transplantation,
}'11;,
L
''R1,:C1'0C1ni1" OF DoG
277
SHOWJNG _RFGPRGI'L\TTO's OF TlH Ol'A()ll]c \]FJ)](')I (;l'
nm
URETEH
This dog liacl had a snlnnucous ureternl trnnsp1anlation done six weeks Jm'viously. The ureter in this instance was found at autopsy to lie subrnucously for a distance of three centi meters and a "ureteral bud" prolrnckd into the rectal lumen.
'rhis portion of the rectum was removed together with lhe ureter and kidney and then distended with a warm 20 per cent solution of sodium iodide at a pressurt' of 2 feet of water A radiograph was taken imnw
276
VINCENT VERMOOTEN
diately to see if any of the opaque medium had regurgitated up the ureter. This occurred in 1 of the 7 dogs (fig . 1) . In this particular dog, when the specimen was later examined it was found that the ureter lay submucously for a distance of fully 3 cm. Microscopically the kidney and ureter showed only a minimal amount of infection. I These findings concur with those following reimplantation into the bladder (7) in which regurgitation was present in 31out of 10 ureters reimplanted by the direct method and in 1 of the 10 reimplanted submucously. The striking feature about all our work is that of 64 dogs in which 102 ureters were transplanted by various submucous methods, only 10 dogs (15.6 per cent) died from peritonitis in contrast to Steinke's finding of over 80 per cent. Of the 4 dogs in which direct implantation was done , 2 died from peritonitis as a result of a leak at the site of the anastomosis. The reason that we devised the special "needle" technique for reimplanting the ureters into the bladder was that our first dogs had died from urine peritonitis as a result of a leak at the site of the transplantation when done by the ordinary methods as used on human beings. The dog's bladder is an intra-peritoneal organ and so has to be tightly closed. In addition, suprapubic or urethral catheter drainage can not be used to keep the bladder at rest while the anastomosis heals. The above findings lead us then to the amazing conclusion that Coffey's greatest contribution to the technique of ureteral transplantation into the rectum is not so much the formation of a valve (for , as we have shown, valve action does not always occur and is in reality not essential and apparently of relatively little importance), but that the submucous method is a very excellent method for preventing peritonitis. Before Coffey's introduction of the method of submucous transplantation, peritonitis, experimentally at least and probably clinically also, was one of the gravest complications of the operation . Now it is very seldom even considered as a possibility. SUMMARY
Submucous transplantation of the ureter into the rectum does not necessarily result in a competent uretero-rectal valve. Direct transplantation of the ureter into the rectum, when properly carried out; leads to no worse sequelae than those of submucous transplantation . The chief advantage of the submucous method of transplantation is
F'UNCTJON OF URETKRO-RECTAL VAL\'E
277
the prevention of peritonitis from a leak at the site of the transplantation, and not, as has been supposed, the formation of a valve. 132 Lister Johannesburg, South REFERENCES (1) (2) (3) (4) (5) (6) (7)
M. G. \ND MANN, F. C.: Ann. Surg., 1932, xcv, 621. R. C.: Ann. Surg., 1909, 1, 1238. COFFEY, R. C.: Jour. Amer. Med. Assoc., 1911, !vi, 397. KIRWIN, T. J.: Amer. Jour. Surg., 1930, viii, 1. STEINKE, C.: Univ. Penna. Med. Bull., 1909, xxii, 110. VERMOOTF:N, V. AND NEuSWANGER, C.H.: Jour. Urol., (in press). VERMOOTEN, v., SPrns, J. w i\Nll NEUS\VANGER, C.H.: Jour. Urol., (in press).
BEAVER,
COFHY,