Hook " in a valuable paper on the surgery of the ureters takes exception to the performance of nephrectomy, a practice which has hitherto had some advocates, in cases where the duct has been acci-_ dentally divided, as, for instance, in the course of a laparotomy. He observes further : " Kidneys are not to be sacrificed for fistuloe, partial obstruction by valvular folds causing intermittent hydronephrosis, and strictures of the ureter that interfere to a greater or less extent with the functional activity of the ducts, without exhausting every effort to correct the morbid condition." This principle finds forcible and successful illustration in a case recorded by Kiister," where, in a boy who; by congenital defect, pos sessed but one kidney, a ureteral fistula was closed and the urine compelled to traverse its natural channel. This was effected by ex posing the kidney by a posterior incision. The ureter, on being opened below the sacculated gland, disclosed a stricture which was resected and the tube was then implanted into the hydronephrotic sac. A lumbar fistula remained for several months, but was finally cured by a secondary operation.
The circumstances under which it may be necessary for the sur geon to make an attempt by exploration to secure the repair of one of these ducts and thus to avert, immediately or more remotely, the sacrifice of a kidney, seem to be limited to those instances where the evidence is reasonably conclusive that the ureter is, or is likely to become, impermeable to urine. In a severe abdominal injury, as a crush or a squeeze, though there is a possibility of such an occur rence, the practitioner would hardly feel justified in proceeding with either a lumbar or an abdominal exploration on a mere undemonstrated suspicion of ruptured ureter, and in the absence of other lesions re quiring it.
A persistent hemorrhage of apparently renal or ureteral origin, with or without a cystitis due to retained blood-clots, as in the case recorded in my account of ruptured kidney, or the presence of a lum bar or post-peritoneal swelling due to the pressure of extravasated blood or pus in increasing amount or to urinous effusion or extrava sation, as mentioned in connection with the symptoms of rupture of a ureter, either of these would certainly more than justify an explora tion from the loin of the kidney and its ureter. The latter are, as a rule, outside the peritoneum, and, in the locality where ruptures of these viscera most frequently happen, an exploration is attended with no additional risk. If the ureter is discovered to be ruptured an at tempt to effect its immediate repair, with the objects of saving the kidney and maintaining the efficiency of the entire urinary apparatus, would then be entertained.
Again, after a severe injury to the side, when, though at the time it was quite possible but not proved that rupture of a ureter had occurred, the subsequent development of a hydronephrosis would warrant the exploration of the corresponding ureter with a view to undertaking its repair. In illustration of this I will mention a case of Fenger's which is thus epitomized by Van Hook: "Traumatic stricture of the ureter close to its entrance into the pelvis of the kid ney; intermittent hydronephrosis. The patient, forty-seven years of age, had sustained an injury thirty-four years previously. After ten years the hydronephrosis developed. Operation of lumbar ne phrotomy disclosed no calculi. The ureteral entrance could not be found through the renal opening. The dilated pelvis was opened, but still the passage through the ureter could not be discovered. The ureter was now isolated and its upper end found to be imbedded in cicatricial tissue for half an inch. Lower clown, though small in calibre, the duct was normal. A longitudinal incision one centimetre in length was now made in the ureter just below the cicatriN. The
stricture was one centimetre long. It was incised upward into the pelvis. The ureteral wound was now stitched longitudinally, after the manner of the Heineke-Mikulicz procedure for the treatment of pyloric strictures. No Bougie was left in place. The patient made a good recovery without return of the hydronephrosis." In the next place an attempt to secure direct repair in preference to at once proceeding with a nephrectomy, would be open to the sur geon, who in the performance of an abdominal operation accidentally severed or wounded a ureter. Several published instances of this accident in the hands of competent operators will be met with.
The possibility that a person was born with, or that circum stances have brought about the existence of, a single working ureter, upon the integrity of which the existence of the individual absolutely depended, must not be lost sight of in connection with severe abdom inal lesions where total suppression of urine immediately following the injury is a prominent feature. A ruptured ureter might ac count for this and call for a prompt exploratory operation, otherwise a speedily fatal result would be unavoidable.
Under such conditions, and possibly some others, the exploration of a ureter may be undertaken with the view of repairing it if found to he injured. We may now proceed to notice in detail the modes which have been adopted to secure the continuity of so small a tube. Van Hook thus refers to observations on several points connected with die ureters (in woman) which he considers are not correctly or fully stated in some text-books: "Upon examining the ureters of over twenty bodies he never found one over fifteen inches long, the average being between ten and twelve inches in length. The ureter when stripped from the peritoneum may be drawn out from two to four inches. The curvature of the abdominal ureter has its convexity di rected inward, while the convexity of the pelvic portion is turned out ward. The pelvic portion of the ureter describes a very strong curve, almost the arc of a circle, since the duct hugs the bony wall of the pel vis very closely. Hence the portion of the ureter opposite the uterus is at some distance from that organ, and as the ureter approaches the base of the bladder (which it enters at a point near the middle of the distance between the urinary meatus and the cervix), it curves rather sharply forward and inward, so that the point in the duct nearest the cervix is below and behind the posterior lip. It must not be forgotten that the ureter has three points of diminution of calibre which may give rise to mistakes in the search for pathologic stenoses. The first is between one and a half and two and a half inches from the pelvis of the kidney, according to Dr. Tanquary's measurements. The second is at the junction of the pelvic and vesical portions. The third when present (found in three out of five subjects) is just where the ureter crosses the iliac artery." Referring to the modes of approaching the ureters for surgical purposes the same author observes : "The extra-pelvic portion of the ureter is most readily and safely accessible for exploration and surgical treatment by the retro-peritoneal route. Hence all opera tions upon the ureters above the crossing of the iliac arteries should be performed retro-peritoneally, excepting those cases in which the necessity for the ureteral operation arises during laparotomy. The intra-pelvic portion may be reached by incision through the ventral wall, the bladder, the rectum, the vagina in the female, the perineum in the male, or by IiIraske's sacral method." The processes of dealing with a wounded or a stenosed ureter may be described as (1) by suture, and (2) by external or internal implantation, the former being sometimes utilized for merely tempo rary purposes.