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Ureteral Splints
URETERAL SPLINTS SYLVESTER B. KELLEY, M.D.o STIMULATED by a recent article of Dr. Clyde Deming! in which he pointed out the potential dangers from the use of drainage tubes and splints after plastic procedures on the kidney pelvis and upper ureter, I have reviewed the records of the last forty-three patients operated upon at the Massachusetts General Hospital for hydronephrosis secondary to ureteral obstruction in an effort to determine the common practice of members of our staff, and to evaluate the results of the more . common operative procedures which involve the use of ureteral splints. Inadequate follow-up notes on many of the patients and the wide range in the skill of the sixteen different operators whose work I have gone over eliminate any statistical value of such a report but I have gained a number of impressions which may be of some assistance to others interested in this specialty. Inasmuch as postoperative infection of the urinary tract is of major consideration under these circumstances, I have restricted my study to those cases done during the past seven years when the more effective antibiotic agents have been available. In the multitude of different types of disease encountered in the upper urinary tract there, of course, can be no hard and fast rule governing the use of·aureteral splint. Under certain circumstances it is generally agreed that a splint has a useful purpose, but under other conditions its use is ch~llenged by those who believe that it is superfluous and even harmful if one uses the proper surgical technic. A surgeon must, therefore, use. his own discretion. 1£ an operator possesses the skill and infinite patience to produce a water-tight suture line at a ureteropelvic junction, obviously no splint will be necessary. Few of us possess such ability, but there is no reason why it cannot be developed. By the majority a splint is looked upon as a precautionary measure against the extravasation of urine in case the suture line gives way. In other cases where a long stricture of the ureter is merely incised and then molded part'way around a catheter laid lengthwise between its two ends,· a splint plays the role of a guide for the regenerating mucosa of the new ureter. Since giving up the use of the irritating woven silk ureteral catheters for splints some year~ ago, we have employed soft rubber catheters for this purpose. They have worked fairly satisfactorily. Although vitallium tubes have some theoretical advantages in these situations where freeFrom the Department of Urology, Massachusetts General Hospital, .Boston. o Associate Visiting Urologist, Massachusetts General Hospital, Boston. 1812
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dom from foreign body reaction is so important, we never have utilized such an aid. It has been reported, furthermore, that in certain types of urinary infections even vitallium tubes, are riot immune to the precipitation of calcareous material within the lumen. For the relief of a stenosis at the ureteropelvic junction, a number of plastic procedures were used in this small series of cases. The Foley Y plastic or similar procedure was the most popular. Of these, there were twenty-one cases. Not a single one was attempted without accessory drainage tubes of some sort. In sixteen, both a ureteral splint and a nephrostomy tube were inserted; in two cases, a nephrostomy tube alone was used; in two, a T tube; and in one, a ureteral splint alone. Other methods of repair included one case of a Finney pyloroplasty with both a splint and nephrostomy tube; one case of a Rammstedt operation where no splint or nephrostomy tube was used; and one case of a Gibson pyloroplasty, also accompanied by both a ureteral splint and a nephrostomy tube. There were four additional cases of reimplantation of the ureter into the pelvis where surgeons also used both a splint and a nephrostomy tube. The cautious beginner, performing his :S.rst Foley Y plastic operation, will enjoy a great sense of security by using both a ureteral splint and a nephrostomy tube after the fashion of so many of our staff. It was our custom to insert a number 8, 10 or 12 F. soft rubber urethral catheter through the renal cortex or through an opening on the posterior aspect of the renal pelvis, and thence through our line of anastomosis and on down the ureter for a distance of six or eight centimeters. A second catheter, usually a whistle tip perineal tube, size 24 or 26 F., then was brought through the same opening in the renal cortex beside the ureteral splint into the renal pelvis to serve asa nephrostomy tube. Theoretically this nephrostomy tube facilitated healing of the plastic operation by putting the pelvis at complete rest and later served to ease the strain on the suture line after the ureteral splint was removed. The ureteral splint is left in place anywhere from two to twenty days, the average being 9.6 days. The optimum time for the removal of this splint is determined by the intuition of the surgeon. Experience has shown that at the end of about ten days primary healing of the suture line will have taken place unless severe sepsis, extravasation of urine or extensive bleeding has intervened. In none of the cases were periodic postoperative urograms made before the removal of the splint, as suggested by Henline and Menning2 to demonstrate complete heal'. ing of our suture line. Our nephrostomy tubes were left in place for about:s'fteen d~ys. The general indications for the removal of this supplementary tube include a normal temperature, absence of urinary leakage around, the tube, absence of severe infection of the urine on the affected side and the
1314
SYLVESTER B. KELLEY
prompt passage of dye from the bladder after it was injech'ld through the nephrostomy tube into the newly created renal pelvis. In cases where it seemed unwise to drain the kidney through a nephrostomy, two of our men had satisfactory results with simply a T tube to splint the ureter following a plastic operation at the ureteropelvic junction. The shank of the tube is brought out through an opening in the ureter below the line of anastomosis. One arm of the tube extends upward through the suture line into the kidney pelvis and the other arm extends for a short distance down the ureter. This is left in place for the same time as the other types of ureteral splint-about ten days. This arrangement has its merits in that it spares the kidney from the trauma and likelihood of infection associated with a nephrostomy. Its disadvantage, of course, besides its irritating influence on the suturt line, is that once it is removed nothing can be done in case of leakage through the anastomosis; we no longer have in reserve a nephrostomy to carry us over the temporary embarrassment of a postoperative pyonephrosis. But with our constantly improving technic and means of combating infection we should not anticipate such complications and should feel free to adopt this logical splinting device if we feel the need of additional help. My attempts to appraise the results of our Foley Y plastic operations in the region of the ureteropelvic junction were not entirely satisfactory because of scanty follow-up notes in a number of instances. But it would seem that no calamities were experienced by any of the twentyone patients; there is no record of a secondary nephrectomy or of a persistent sinus at the time of their discharge from the hospital. Five patients were lost after their discharge. Seven showed little or no improvement in the x-ray appearance of the operated kidney by intravenous pyelogram made three months or more after operation. In this group of seven failures, urine reports were available on only six patients; but in all six there was persistence of the infection noted in preoperative studies. With one exception, all nine cases which did show improvement in the postoperative x-ray appearance of the renal pelvis were found to have either negative urine cultures or only two or three white blood cells per high power field in the urinary sediment. The above mentioned exception showed twenty-five white blood cells per high power field in the urinary sediment and a B. pyocyaneus infection in the urinary tract; but he was free of his previous flank pain and his pyelogram demonstrated marked improvement in the appearance of the operated kidney. With available urinary antiseptics we may be able to overcome this complication. Another striking discovery was that the one case where no ureteral splint was used, and where the pelvis presumably was put at rest with a nephrostomy tube after the plastic procedure at the ureteropelvic junction, showed no pus cells postoperatively. Despite the small number of cases in this series, I
URETERAL SPLINTS
1315
Fig. 405.-Comparison of results of two different procedures for correction of ureteropelvic obstruction in a 44 year old woman with bilateral hydronepp.rosis. Top, The preoperative condition. Center, The condition in July, 1943, sixteen months after a Rammstedt operation on the right ureteropelvic junction. Bottom, The condition in October, 1946, nineteen months after a Foley Y plastic operation on left side.
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SYLVESTER B. KELLEY
believe we have a rather striking bit of evidence that persistent infection in the kidney does interfere with satisfactory operative result on the pelvic outlet. ':, Figure 405 enable&, one to compare the results of two different procedures for the c0ir'ection of ureteropelvic obstruction with bilateral hydronephrosis. In" the Rammstedt operation, no splint was used; in the Foley Y pyloroplasty, a ureteral splint and nephrostomy tube were left in place for nine and twenty days respectively. In October 1946, sediment from the right kidney contained two white blood cells per high power field; that from the left side showed three white blood cells per high power field. On the basis of this single case one might infer that a Foley Y pyloroplasty was preferable to the more conservative Rammstedt procedure. In this collection of patients there were four cases where the stenosed ureteropelvic junction was completely excised and the ureter reimplanted in the pelvic wall. The two men who did these operations used both a ureteral splint, and a nephrostomy tube in all four cases. Their follow-up notes are v~ry brief. One patient was lost; one had no improvement by x-ray; ope showed slight improvement by x-ray and one showed marked imp~9vement. Pus cells were present in the two cases with reported urinalyses. Suffice it to say that all four patients left the hospital after their pl~stic operations with both kidneys, healed wounds and relief from their original complaints. Figure 406 illustrates the improvement in a woman whose severe ureteropelvic stenosis,was relieved by a pyloroplasty after the method of Kuster-Lubasch.Here, the stenosed pelvic outlet together with the upper ureter were excised and the upper portion of the ureter then reimplanted in the pelvic wall. Both a nephrostomy tube and a ureteral splint were used. It is very interesting to note the time interval necessary for the dilated renal pelvis to contract following the removal of the obstruction. To this group of plastic operations at the kidney outlet I have added fourteen cases of simple ureterolysis for the relief of angulated ureters in the region of the ureteropelvic junction. Among these, ureteral splints were used in five cases for the purpose of straightening the ureter. These were left in placefol: anywhere between eleven and eighteen days. Eight cases had no splints inserted and in o!1e case a nephrostomy tube was used to drain the renal pelvis after the ureter had been freed. Under these circlirnstances, where I am,unable to visualize the surgeon's conception', of "dense fibrous adhesions" or a "mass of plastic exudate," it is rathef difficult to interpret the results of ureteral splinting. I am obliged, therefore, to base my impressions upon those cases with which I am personally acquainted. When the ureteral obstruction is due to angulation by a few light fibrous bands, and uncomplicated by a ureteral stricture, the use of a
a
URETERAL SPLINTS
1317
Fig. 406.-Results of pyloroplastY after the method .of Kuster-Lubasch in a woman of 31. Top, The preoperative condition of the, left kidney. Center, Three . weeks postoperatively. Bottom, Three months later.
1318
SYLVESTER B. KELLEY
ureteral splint has little influence upon the final outcome. In fact, the better results among these patients seem to have been in those instances where the ureter was not opened at all and where no splint was used. The poor results, on the other hand, were in those situations where the ureter was buried in a dense scar. Even when splints were employed for periods of fifteen days under these circumstances, the ureter shortly afterward became stenosed with a return of the hydronephrosis and urinary infection. When, therefore, the ureter is bound down firmly in a plastic exudate, I believe that the mere lysis of adhesions and the insertion of a splint are futile gestures. It is necessary also to dissect out the surrounding scar tissue if one expects to prevent a recurrence of the ureteral narrowing. In my opinion the elongated strictures of the ureter without extensive periureteral reaction come under a different category. These respond well to the "intubated ureterotomy" procedure described by David M. Davis3 in which the strictured portion of the ureter is simply incised longitudinally and then drawn part way around a ureteral splint. No attempt is made to reapproximate the edges of the ureter. The splint in such cases serves merely as a mold around which the ureteral mucosa regenerates to form the ureteral lumen. Figure 407 illustrates an outstanding case of this kind operated upon by one of our staff. The patient had a relatively clean urine to start with. Here we merely incised a long structure of the left ureter and used a number 10 F. rubber catheter as a splint. For supplementary drainage a medium sized nephrostomy tube was inserted. The splint was left in place fifteen days and the nephrostomy tube for eighteen days. Twelve months after operation the urinary sediment contained only a «rare white blood cell." The patient now is symptom-free. The work of Crabtree and Kontoff4 concerning the microscopic appearance of nontuberculous strictures explains why simple dilatation of the stenosed portion of a ureter is quite inadequate. These gentlemen found that in the region of the stenosis there usually is very little smooth muscle; the ureteral wall consists mainly of dense fibrous tissue and the epithelial lining in the same region tends to be desquamated with only a few shreds attached to the surface. In most cases, then, ureteral dilatation alone merely serves to aggravate the fibrous tissue reaction and actually to make the stricture worse. In attempting to appraise one's efforts to improve renal function by a plastic procedure on the ureter, with or without a ureteral splint, one should realize that the x-ray appearance of the kidney pelvis alone is not indicative of the result of the operation. Very frequently, in cases of long-standing infection and obstruction, the walls of the renal pelvis have been so overstretched, and then fixed by fibrous changes within the pelvic walls and in the perirenal tissues, that they never will shrink down after the obstructive factor has been removed. The
UBETERAL SPLINTS
1319
Fig. 407.-Results of "intubated ureterotomy" in elongated stricture of ureter without extensive ureteral reaction in a young man of 47. Top, The preoperative condition. Bottom, Twelve months after operation.
1320
SYLVESTER B. KELLEY
postoperative pyelogram in such a case would be discouraging. In such cases, therefore, we judge the results of our work not by the disappearance of the hydronephrosis but by the improvement in kidney function and the subsidence of infection. Weighing the results of our plastic operations in the region of the ureteropelvic junction, with and without ureteral splints, I now agree with those urologists who long have advocated that we dispense with splints in such procedures. Many of our results at the Massachusetts General Hospital have been good, but I believe they would have been better had we avoided the use of needless foreign bodies rubbing. the suture line of our anastomosis. Avoidance of infection seems to be one of the important essentials for a successful outcome of these plastic operations. If, therefore, we can prevent the entry of bacteria to our operative field by desisting from preliminary retrograde pyelograms, and then by omitting the use of various catheters and splints, we should create an environment favorable to primary healing of our suture lines and to a successful outcome of our efforts .. In the case of an intubated ureterotomy, a ureteral splint is legitimate; but its use elsewhere seems contrary to the principles of good surgery. SUMMARY 1. Forty-three cases of ureteroplasty have been reviewed with particular reference to the use of ureteral splints. 2. With intubated ureterotomies, ureteral splints are legitimate adjuncts; in most other types of plastic operations at the ureteropelvic junction ureteral splints aggravate infection of the urinary tract. 3. Urinary infection interferes with primary healing of our anastomosis. 4. With meticulous surgical technic in uieteroplasties, ureteral splints should not be necessary for successful results.
REFERENCES 1. Deming, Clyde L.: Modem Conception of Drainage and Irrigation of the Urinary Tract. J. Urol., 57:49 (January) 1947. 2. Henline, Roy B. and Menning, Joseph H.: The Management of Hydronephrosis Due to Ureteropelvic Obstruction. Preliminary Report. J. Urol., 50:1-24, 1943. 3. Davis, David M.: Intubated Ureterotomy. Surg., Gynec. & Obst., 76:513 (May) 1943. 4. Crabtree, E. Granville and Kontoff, H . .A.: End Results of Treatment of Forty Cases of Nontuberculous .UreteraI Stricture. J. Urol., 80:421, 1933.
URETERAL SPLINTS
1313
dom from foreign body reaction is so important, we never have utilized such an aid. It has been reported, furthermore, that in certain types of urinary infections even vitallium tubes, are riot immune to the precipitation of calcareous material within the lumen. For the relief of a stenosis at the ureteropelvic junction, a number of plastic procedures were used in this small series of cases. The Foley Y plastic or similar procedure was the most popular. Of these, there were twenty-one cases. Not a single one was attempted without accessory drainage tubes of some sort. In sixteen, both a ureteral splint and a nephrostomy tube were inserted; in two cases, a nephrostomy tube alone was used; in two, a T tube; and in one, a ureteral splint alone. Other methods of repair included one case of a Finney pyloroplasty with both a splint and nephrostomy tube; one case of a Rammstedt operation where no splint or nephrostomy tube was used; and one case of a Gibson pyloroplasty, also accompanied by both a ureteral splint and a nephrostomy tube. There were four additional cases of reimplantation of the ureter into the pelvis where surgeons also used both a splint and a nephrostomy tube. The cautious beginner, performing his :S.rst Foley Y plastic operation, will enjoy a great sense of security by using both a ureteral splint and a nephrostomy tube after the fashion of so many of our staff. It was our custom to insert a number 8, 10 or 12 F. soft rubber urethral catheter through the renal cortex or through an opening on the posterior aspect of the renal pelvis, and thence through our line of anastomosis and on down the ureter for a distance of six or eight centimeters. A second catheter, usually a whistle tip perineal tube, size 24 or 26 F., then was brought through the same opening in the renal cortex beside the ureteral splint into the renal pelvis to serve asa nephrostomy tube. Theoretically this nephrostomy tube facilitated healing of the plastic operation by putting the pelvis at complete rest and later served to ease the strain on the suture line after the ureteral splint was removed. The ureteral splint is left in place anywhere from two to twenty days, the average being 9.6 days. The optimum time for the removal of this splint is determined by the intuition of the surgeon. Experience has shown that at the end of about ten days primary healing of the suture line will have taken place unless severe sepsis, extravasation of urine or extensive bleeding has intervened. In none of the cases were periodic postoperative urograms made before the removal of the splint, as suggested by Henline and Menning2 to demonstrate complete heal'. ing of our suture line. Our nephrostomy tubes were left in place for about:s'fteen d~ys. The general indications for the removal of this supplementary tube include a normal temperature, absence of urinary leakage around, the tube, absence of severe infection of the urine on the affected side and the
1314
SYLVESTER B. KELLEY
prompt passage of dye from the bladder after it was injech'ld through the nephrostomy tube into the newly created renal pelvis. In cases where it seemed unwise to drain the kidney through a nephrostomy, two of our men had satisfactory results with simply a T tube to splint the ureter following a plastic operation at the ureteropelvic junction. The shank of the tube is brought out through an opening in the ureter below the line of anastomosis. One arm of the tube extends upward through the suture line into the kidney pelvis and the other arm extends for a short distance down the ureter. This is left in place for the same time as the other types of ureteral splint-about ten days. This arrangement has its merits in that it spares the kidney from the trauma and likelihood of infection associated with a nephrostomy. Its disadvantage, of course, besides its irritating influence on the suturt line, is that once it is removed nothing can be done in case of leakage through the anastomosis; we no longer have in reserve a nephrostomy to carry us over the temporary embarrassment of a postoperative pyonephrosis. But with our constantly improving technic and means of combating infection we should not anticipate such complications and should feel free to adopt this logical splinting device if we feel the need of additional help. My attempts to appraise the results of our Foley Y plastic operations in the region of the ureteropelvic junction were not entirely satisfactory because of scanty follow-up notes in a number of instances. But it would seem that no calamities were experienced by any of the twentyone patients; there is no record of a secondary nephrectomy or of a persistent sinus at the time of their discharge from the hospital. Five patients were lost after their discharge. Seven showed little or no improvement in the x-ray appearance of the operated kidney by intravenous pyelogram made three months or more after operation. In this group of seven failures, urine reports were available on only six patients; but in all six there was persistence of the infection noted in preoperative studies. With one exception, all nine cases which did show improvement in the postoperative x-ray appearance of the renal pelvis were found to have either negative urine cultures or only two or three white blood cells per high power field in the urinary sediment. The above mentioned exception showed twenty-five white blood cells per high power field in the urinary sediment and a B. pyocyaneus infection in the urinary tract; but he was free of his previous flank pain and his pyelogram demonstrated marked improvement in the appearance of the operated kidney. With available urinary antiseptics we may be able to overcome this complication. Another striking discovery was that the one case where no ureteral splint was used, and where the pelvis presumably was put at rest with a nephrostomy tube after the plastic procedure at the ureteropelvic junction, showed no pus cells postoperatively. Despite the small number of cases in this series, I
URETERAL SPLINTS
1315
Fig. 405.-Comparison of results of two different procedures for correction of ureteropelvic obstruction in a 44 year old woman with bilateral hydronepp.rosis. Top, The preoperative condition. Center, The condition in July, 1943, sixteen months after a Rammstedt operation on the right ureteropelvic junction. Bottom, The condition in October, 1946, nineteen months after a Foley Y plastic operation on left side.
1316
SYLVESTER B. KELLEY
believe we have a rather striking bit of evidence that persistent infection in the kidney does interfere with satisfactory operative result on the pelvic outlet. ':, Figure 405 enable&, one to compare the results of two different procedures for the c0ir'ection of ureteropelvic obstruction with bilateral hydronephrosis. In" the Rammstedt operation, no splint was used; in the Foley Y pyloroplasty, a ureteral splint and nephrostomy tube were left in place for nine and twenty days respectively. In October 1946, sediment from the right kidney contained two white blood cells per high power field; that from the left side showed three white blood cells per high power field. On the basis of this single case one might infer that a Foley Y pyloroplasty was preferable to the more conservative Rammstedt procedure. In this collection of patients there were four cases where the stenosed ureteropelvic junction was completely excised and the ureter reimplanted in the pelvic wall. The two men who did these operations used both a ureteral splint, and a nephrostomy tube in all four cases. Their follow-up notes are v~ry brief. One patient was lost; one had no improvement by x-ray; ope showed slight improvement by x-ray and one showed marked imp~9vement. Pus cells were present in the two cases with reported urinalyses. Suffice it to say that all four patients left the hospital after their pl~stic operations with both kidneys, healed wounds and relief from their original complaints. Figure 406 illustrates the improvement in a woman whose severe ureteropelvic stenosis,was relieved by a pyloroplasty after the method of Kuster-Lubasch.Here, the stenosed pelvic outlet together with the upper ureter were excised and the upper portion of the ureter then reimplanted in the pelvic wall. Both a nephrostomy tube and a ureteral splint were used. It is very interesting to note the time interval necessary for the dilated renal pelvis to contract following the removal of the obstruction. To this group of plastic operations at the kidney outlet I have added fourteen cases of simple ureterolysis for the relief of angulated ureters in the region of the ureteropelvic junction. Among these, ureteral splints were used in five cases for the purpose of straightening the ureter. These were left in placefol: anywhere between eleven and eighteen days. Eight cases had no splints inserted and in o!1e case a nephrostomy tube was used to drain the renal pelvis after the ureter had been freed. Under these circlirnstances, where I am,unable to visualize the surgeon's conception', of "dense fibrous adhesions" or a "mass of plastic exudate," it is rathef difficult to interpret the results of ureteral splinting. I am obliged, therefore, to base my impressions upon those cases with which I am personally acquainted. When the ureteral obstruction is due to angulation by a few light fibrous bands, and uncomplicated by a ureteral stricture, the use of a
a
URETERAL SPLINTS
1317
Fig. 406.-Results of pyloroplastY after the method .of Kuster-Lubasch in a woman of 31. Top, The preoperative condition of the, left kidney. Center, Three . weeks postoperatively. Bottom, Three months later.
1318
SYLVESTER B. KELLEY
ureteral splint has little influence upon the final outcome. In fact, the better results among these patients seem to have been in those instances where the ureter was not opened at all and where no splint was used. The poor results, on the other hand, were in those situations where the ureter was buried in a dense scar. Even when splints were employed for periods of fifteen days under these circumstances, the ureter shortly afterward became stenosed with a return of the hydronephrosis and urinary infection. When, therefore, the ureter is bound down firmly in a plastic exudate, I believe that the mere lysis of adhesions and the insertion of a splint are futile gestures. It is necessary also to dissect out the surrounding scar tissue if one expects to prevent a recurrence of the ureteral narrowing. In my opinion the elongated strictures of the ureter without extensive periureteral reaction come under a different category. These respond well to the "intubated ureterotomy" procedure described by David M. Davis3 in which the strictured portion of the ureter is simply incised longitudinally and then drawn part way around a ureteral splint. No attempt is made to reapproximate the edges of the ureter. The splint in such cases serves merely as a mold around which the ureteral mucosa regenerates to form the ureteral lumen. Figure 407 illustrates an outstanding case of this kind operated upon by one of our staff. The patient had a relatively clean urine to start with. Here we merely incised a long structure of the left ureter and used a number 10 F. rubber catheter as a splint. For supplementary drainage a medium sized nephrostomy tube was inserted. The splint was left in place fifteen days and the nephrostomy tube for eighteen days. Twelve months after operation the urinary sediment contained only a «rare white blood cell." The patient now is symptom-free. The work of Crabtree and Kontoff4 concerning the microscopic appearance of nontuberculous strictures explains why simple dilatation of the stenosed portion of a ureter is quite inadequate. These gentlemen found that in the region of the stenosis there usually is very little smooth muscle; the ureteral wall consists mainly of dense fibrous tissue and the epithelial lining in the same region tends to be desquamated with only a few shreds attached to the surface. In most cases, then, ureteral dilatation alone merely serves to aggravate the fibrous tissue reaction and actually to make the stricture worse. In attempting to appraise one's efforts to improve renal function by a plastic procedure on the ureter, with or without a ureteral splint, one should realize that the x-ray appearance of the kidney pelvis alone is not indicative of the result of the operation. Very frequently, in cases of long-standing infection and obstruction, the walls of the renal pelvis have been so overstretched, and then fixed by fibrous changes within the pelvic walls and in the perirenal tissues, that they never will shrink down after the obstructive factor has been removed. The
UBETERAL SPLINTS
1319
Fig. 407.-Results of "intubated ureterotomy" in elongated stricture of ureter without extensive ureteral reaction in a young man of 47. Top, The preoperative condition. Bottom, Twelve months after operation.
1320
SYLVESTER B. KELLEY
postoperative pyelogram in such a case would be discouraging. In such cases, therefore, we judge the results of our work not by the disappearance of the hydronephrosis but by the improvement in kidney function and the subsidence of infection. Weighing the results of our plastic operations in the region of the ureteropelvic junction, with and without ureteral splints, I now agree with those urologists who long have advocated that we dispense with splints in such procedures. Many of our results at the Massachusetts General Hospital have been good, but I believe they would have been better had we avoided the use of needless foreign bodies rubbing. the suture line of our anastomosis. Avoidance of infection seems to be one of the important essentials for a successful outcome of these plastic operations. If, therefore, we can prevent the entry of bacteria to our operative field by desisting from preliminary retrograde pyelograms, and then by omitting the use of various catheters and splints, we should create an environment favorable to primary healing of our suture lines and to a successful outcome of our efforts .. In the case of an intubated ureterotomy, a ureteral splint is legitimate; but its use elsewhere seems contrary to the principles of good surgery. SUMMARY 1. Forty-three cases of ureteroplasty have been reviewed with particular reference to the use of ureteral splints. 2. With intubated ureterotomies, ureteral splints are legitimate adjuncts; in most other types of plastic operations at the ureteropelvic junction ureteral splints aggravate infection of the urinary tract. 3. Urinary infection interferes with primary healing of our anastomosis. 4. With meticulous surgical technic in uieteroplasties, ureteral splints should not be necessary for successful results.
REFERENCES 1. Deming, Clyde L.: Modem Conception of Drainage and Irrigation of the Urinary Tract. J. Urol., 57:49 (January) 1947. 2. Henline, Roy B. and Menning, Joseph H.: The Management of Hydronephrosis Due to Ureteropelvic Obstruction. Preliminary Report. J. Urol., 50:1-24, 1943. 3. Davis, David M.: Intubated Ureterotomy. Surg., Gynec. & Obst., 76:513 (May) 1943. 4. Crabtree, E. Granville and Kontoff, H . .A.: End Results of Treatment of Forty Cases of Nontuberculous .UreteraI Stricture. J. Urol., 80:421, 1933.