Transplantation of ureters into the bowel

92 American .hrd

of Surgery Stevens-TranspIantation

into the bIadder for drainage. The patient was then pIaced in bed and five days Iater roentgenogram was taken in order possibIy to demonstrate more caIcuIi. The resuItant exposure justified the suspicion in that muItipIe caIcuIi were demonstrated in the left kidney, the Ieft Iower ureter and bIadder. A cystoscopic examination was then made which showed the bIadder sIightIy congested, with tumefaction and edema at the Ieft uretera orifice. There were three smaI1 caIcuIi in the vesica1 cavity.

of Ureters into the BoweI

JANUARY,1929

A renaI functiona test gave a norma appearance time and norma quantitative output from the right uretera orifice. There was no appearance from the Ieft side after fifteen minutes’ observation, and a smaI1 catheter passed to the Ieft renaI pelvis reveaIed no dye, the resuItant secretion being a puruIent fluid. The necessity of nephrectomy, ureterotomy, and cystotomy was apparent, and was successfuIIy performed with the remova of a11 caIcuIi three days Iater.

CASE REPORTS BY DR. A. R. STEVENS* NEW

TRANSPLANTATION OF URETERS INTO THE BOWEL

I

T has seemed to me worth whiIe to show two cases of doubIe impIantation of ureters into the bowe1, done by dif-

ferent tinence causes.

methods, both because but due to different

of inconunderIying

CASE I. A coIored man, aged fifty years, gave a history of having had gonorrhoea severa times. In 1914 he had a perinea1 incision for perinea1 abscess and stricture, and in 1923 an externa1 urethrotomy and resection of perinea1 fistula. In JuIy, 1926, he was admitted to BeIIevue HospitaI because of recurrent fistuIae and partia1 incontinence of urine; in fact he was compIeteIy incontinent whiIe standing but onIy partiaIIy whiIe Iying down. The Wassermann reaction was negative. His spinal ffuid reaction was negative. Sounds up to 30’~. were easiIy passed to the bIadder. He was operated on in the hope first of cIeaning up his perineum. Some of his fistuIae were excised and the others opened up into one common perinea1 cavity. IncidentaIIy, an abscess of the prostate was opened. Hi’s wound remained infected and on August 13, a suprapubic cystoscopy was done, in the hope of hastening the heaIing of the perinea1 wound by keeping it dry. The writer first saw the case September 15, 1926. He had then a Iarge perinea1 wound which * Read

before Section

of Genito-Urinary

Surgery,

YORK

was continuousIy wet, his urethra was open for 3 in., and 1% in. of the urethra had entireIy sIoughed. An attempt at cystoscopy was made but the bIadder wouId not hoId any fluid. The patient was kept around the ward for a Iong time in the hope that by care and frequent cIeansing we couId hea the perinea1 wound and Iater make a plastic perineal repair of the sphincter and urethra. However, he did not seem to make any great headway, and the writer suggested to him that, inasmuch as he couId not work and associate with his friends in his present condition, he have his ureters implanted in the Iower bowe1. On December 17 we operated through a Iow Ieft rectus incision, Iocated his left ureter, exposed that from the promontory downward, freed the peritoneum, stitched it up behind the ureter, and impIanted the Iatter in the sigmoid by the Coffey technique. No catheter was Ieft in the ureter, but a tube was kept in the rectum for about four days. We were very much surprised that there was no kidney pain following this and no temperature above IOO’F. Ten days afterward we injected indigo carmine intravenousIy and obtained a very marked coIor in the urine from the rectum. On January 18, 1927, under spina and genera1 anesthesia, a mid-Iine incision was made, the right ureter was exposed from the promontory to the bIadder. The bIadder was incised and was found to be a rear contracted bIadder with a waI1 I cm. thick. A ring of bladder mucosa was cut away about the uretera orifice New

York

Academy

of Medicine,

May

16,

x928.

NEW SERIES VOL. VI,

No.

I

Cyst

Valentine-Dermoid

T

HERE are four interesting points in this case: (I) Iarge chunks of epitheIium were passed; (2) the patient had no urinary compIaint; (3) he had IeucopIakia in this diverticuIum, and (4) there was a cystoscopic resembIance to carcinoma. There had been onIy two cases of bIadder IeucopIakia containing diverticuIum reported up to the time when Dr. Bughee reported one and the writer reported this at the recent meeting of the American Association of Genito-Urinary Surgeons. The first operation the writer performed on returning from this meeting was another diverticuIum case which presented typica IeucopIakia both grossIy and microscopicaIIy. The patient had a very marked urinary infection and compIained of marked frequency of urination.

CYST OF KIDNEY* NEW

0

NLY a few cases of dermoid cyst of the kidney have been reported in the Iiterature and their pathoIogica1 study is scantiIy recorded. The most recent before

Section

of Genito-Urinary

93

LEUCOPLAKIA IN A BLADDER DIVERTICULUM

J. J, VALENTINE,

*Read

of surgery

two months after his Bergenhem operation, abIe to hoId his urine in the rectum for from two to six hours. For the first few months he had quite a bit of nocturna1 incontinence but graduaIIy gained compIete contro1. He caIIed on me Iast faI1 and at that time was quite abIe to hoId it for from four to six hours and had measured individua1 voidings that were as much as 350 C.C. His phthaIein output in two hours was 25 per cent. He has gone on now about seventeen years and is entireIy comfortabIe and abIe to work and mingIe with his friends.

the bIadder was sewed up and the right ureter implanted by the Coffey technique. A catheter was Ieft in the ureter. In comparison with the operation on the other side, with no catheter in the ureter, there was some fever (up to IO~‘F.) and pain in the corresponding kidney. In both instances a cigarette drain was pIaced at the site of the ureterosigmoida1 anastomosis. About six weeks after this Iast operation the patient was abIe to hold the recta1 contents for about four hours. When he went home on March 16, about two months after his last implantation, he was abIe to hoId his urine from four to six hours. We did a phthaIein test and obtained from the rectum 20 per cent in two hours. His bIood chemistry was normal. His perinea1 wound has not yet closed up. CASE II. The other patient was a case of ectopia vescicae. When the patient first came to the writer in the faI1 of Igr I, he was a boy of sixteen. Three attempts had been made to cIose the bIadder when he was about two years oId. It is not necessary to go into the details of the history; they have ah-eady been published. We catheterized the ureter and proved that there was no infection of either kidney; the phthalein output was 30 per cent in one hour. Operation was performed ApriI 6, IgI I, by the Bergenhem method, that is, both ureters were isolated extraperitoneaIIy from the promontory of the sacrum to the bIadder and cut away with a smaI1 ring of bIadder mucosa attached to each, without either uretera orifice being cut into. These were impIanted into his recta1 waI1 through independent smaI1 holes and were Ieft there without any s’uture. During convaIescence there were attacks of pain in the Ieft kidney, which cIearIy indicated some infection of that side. The patient went home from the hospita1

DERMOID

American JUMI

of Kidney

Surgery,

M.D.,

P.A.C.S.

YORK

contribution seems to be by of CoIumbus, Ohio in Ig 15. he quotes the famous case Paget’ of dermoid tumor of New York

Academy

of Medicine,

J. F. Baldwin In his articIe of Sir James the kidney in

March

21,

1928.