The conditions under which nephrec tomy is indicated—for renal calculus, hydronephrosis, tuberculosis, cysts, and suppurative processes—have already been discussed.
After nephrectomy the recurrence of the disease in the other kidney is very rare. In fact, the healthy kidney, re lieved of the presence of the diseased one, is less disposed to be attacked than be fore the operation. Ureteral catheteriza tion, notwithstanding the greatest care, may infect the sound kidney. As to di agnosis, when the abnormal constituents are continuously secreted and the general condition of the patient is good, a bi lateral lesion may be excluded. List of thirty-nine nephrectomies personally per formed with a mortality of 23 per cent., and 16 per cent. among those for pyone phrosis. D'Antona (II l'oliclin., Oct. 15. 1900).
Ureteral fistula', which usually are due to wounds inflicted during operations on the abdominal or pelvic viscera, may necessitate nephrectomy, but the opera tion seems indicated only in case there is great discomfort or the patient is pre vented from following a necessary occu pation. In most cases it would probably be possible to perform a plastic operation on the ureter or, failing in this, to im plant the end of the ureter into the rec tum.
Operation.—As a preliminary to the removal of a kidney measures should be taken to determine as definitely as pos sible whether another kidney exists and whether it is sound or diseased. Numer ous devices have been suggested for the purpose of collecting the urine from each kidney separately, many of them depend ing upon the compression of the ureter by various means, but none of them have proved entirely satisfactory. The cathe terization of the ureters (see AFFECTIONS OF THE URETERS) is the most certain method of obtaining separate urines, but much special skill is required for its suc cessful practice. Moreover, practically its usefulness is restricted to women. M. L. Harris (Jour. Amer. Med. Assoc., Jan. 29, '95) has devised an ingenious instru ment which has been used with satis factory results in a number of cases. Its essential features are: a blade which can be introduced into the rectum or vagina and elevated so as to make a water-shed between the ureteral orifices, and a double catheter, the tubes of which are so hinged that after introduction into the bladder they can be separated and turned down one on each side of the septum formed by the rectal blade; the urine from each side of the water-shed is car ried by them to separate bottles.
In some cases it may seem necessary to lay both kidneys free by lumbar or ab dominal incisions to determine the pres ence of both kidneys or the extent of disease in them, as recommended by Edebohls (Annals of Surg., xxvii, p. 425, '9S).
The kidney may be removed either through a lumbar or an abdominal in cision. Abdominal nephrectomy is usu ally reserved for those cases in which there is great enlargement of the kidney and for cases of injury in which there is haemorrhage into the peritoneal cavity. The lumbar incision gives better oppor tunity for the separation of adhesions, it is extraperitoneal, and permits freer drainage of abscesses if necessary with out serious danger of peritonitis, and the general mortality is considerably less than after abdominal nephrectomy.
Lumbar Nephrectomy. — The length and direction of the incision depend to some extent on the condition of the organ to be removed. In case the kidney is of normal size or but slightly enlarged and is not adherent, the vertical or oblique incision as described under mov able kidney could be used. The incision suggested by Kiinig, beginning half an inch below the last rib near the outer border of the erector spina and con tinued first downward toward the crest of the ilium, then curving forward toward the umbilicus, would give much more space for the removal of an enlarged or adherent kidney.
Bergmann carries his incision from the last rib posteriorly downward and for ward to the middle third of Poupart's ligament. Kocher uses this form of in cision and finds it possible through it to examine the other kidney or the under surface of the liver with his hand in the abdominal cavity. After determining that the other kidney is sound he sews together the opening in the peritoneum and proceeds with the removal of the diseased kidney.