URETERAL FISTULAE.
Apart from the conditions already described, a stilliddium of urine from the genitals may be seen when there is an abnormal communi cation between one of the ureters and some portion of the genital tract. The striking peculiarity of these cases is, that, in spite of the constant leakage, urine is passed at regular intervals per vias natu rales. This is due to the fact that while one ureter is abnormally switched off into the interior genital tract, its fellow still retains in tact its connection with the bladder.
Urethral fistulae are observed as congenital malformations, in con sequence of injuries during labor, from operations about the vaginal vault, such as the incising of an abscess, and after the operation of vaginal hysterectomy. These fistulae in the past were quite rare, but they have within recent years become much more common because of the great frequency with which the uterus is removed by the vagina for cancerous disease. The explanation of this fact is that the infil tration of the cervix with the new growth makes it much larger, and shortens the distance between the cervix and pelvic wall, conse quently bringing the ureter, which lies between, much closer to it. On the other hand, also, the necessity of leaving a pedicle, and the natural anxiety of the operator to give the disease as wide a berth as possible, make it remarkable that the ureter is not more frequently involved than it appears to.be from published reports.
The diagnosis of ureteral fistula will be made by noting : first, that although there is a constant escape of urine, the patient still passes urine at regular intervals; second, that upon injection of sterilized milk into the bladder none of it escapes through the vagina, while the urine still escaping from the vagina continues clear; third, that by placing the patient in the dorsal position with elevated pelvis, or in the knee-breast position, the ureters may be catheterized as de scribed, and urine collected from one side while no urine escapes from the other; fourth, that the sound may be readily entered into one ureter and passed back to the posterior wall of the pelvis, while in the other it cannot be pushed in more than a few centimetres; fifth, in the congenital malformation where there is a double ure ter on one side with one of its openings near the urethra, and the other in the bladder, the evidence that the fistula is not vesical will be obtained by the injection of milk. The catheterization of both
ureters will demonstrate also that they are pervious and functionally active. It may also be possible to pass a bougie into the abnormal orifice and push it up through the pelvis behind the abdominal cavity.
The treatment of ureteral fistula is by turning the abnormal ori fice into the bladder by either a vaginal or an abdominal operation. Where there is sufficient room to work in the vagina, and the ureter is long enough to be dissected out and turned in through a slit made in the base or posterior wall of the bladder, the vaginal route is to be preferred. If, on the contrary, the fistula is up in the uterus or is hidden behind scar tissue of the vaginal vault, the better plan will be to open the abdomen and dissect the lower 3 or 4 cm. (1 or 1 in.) of the ureter loose from its attachments. Then sew the ureter into the small opening made into the bladder at the nearest point, with a series of delicate circular sutures. The ureter thus attached must project a slight distance into the cavity of the bladder.
I performed this operation in the fall of 1894, upon a woman who had been operated upon by my assistant some weeks before, for cancer of the cervix. The right ureter had been cut off in the operation, and was draining through the scar tissue into the vaginal vault. After demonstrating on which side the injury lay, by the cystoscopic ex amination and the sound, the abdomen was opened, and the ureter dis sected out of its bed. The ureter thus lifted up was too short to reach the bladder, which was therefore dissected loose from its pelvic wall attachments, anteriorly and laterally and dropped back to the ureter. The ureter was then sutured into a small opening made in the poste rior vesical wall. To avoid tension upon the bladder, in closing the abdomen the lower part of the peritoneal incision was not drawn to gether. The abdominal wall was closed throughout. The operation was rendered difficult throughout by the obesity of the patient, but immediate union was obtained and the urine thereafter was dis charged normally per urethram.