NEPIIROPEXY, OR NEPIERORRIIA Y, AND NEPIIROLITHOTOMY, being only in dicated in special disorders, are described above under the heading of the latter.
Surgery of the Ureters.
Ureterectomy.—The term has been ap plied not only to the total extirpation of the ureter, but to resections of more than two or three inches of this organ. The operation is indicated in certain cases of tuberculosis of the ureter, hydrops of the ureter, suppuration in a dilated ureter, and in case of lumbar fistula due to the presence of a diseased ureter after ne phrectomy has been performed.
The operation may be primary, when the ureter is removed simultaneously with the kidney; or secondary, when the ureter is removed by a subsequent opera tion. The extraperitoneal method is usu ally chosen, through the incision de scribed under methods of examination.
Uretero-Ureteral Anastomosis. — This operation is employed to restore the con tinuity of the duct after accidental di vision or division during abdominal or pelvic operations; after resection for stricture, ulceration, or sloughing caused by any cause particularly calculus; and after rupture or other injuries due to ex ternal violence.
Four methods have been successfully used: direct end-to-end anastomosis; Poggi's end-to-end invagination of the upper into the lower portion of the ureter; oblique end-to-end anastomosis as practiced by Bovee; and lateral im plantation, as suggested by Van Hook. End-to-end union has been performed seven times with four cures and three deaths due to other causes than the ureteral operation. Van Hook's method has been used successfully in three cases, by different operators in each case. It is most readily and rapidly performed and is the operation which is now gen erally preferred. Bovee's method might be employed in case there was great loss of substance. in case more than a third of the circumference of the duct is in volved by an injury division and anas tomosis would be the preferable method of treatment.
By Van Hook's method the lower end of the ureter is ligated and a longitudinal incision twice as long as the diameter of the ureter is made in its wall V, inch (6 millimetres) below the ligature. The
upper end is slit up inch (6 millime tres) and two very small sewing needles threaded on one fine suture of sterilized catgut are passed through its wall from within outward, inch (3 millimetres) from its extremity, and inch (1.5 millimetres) apart. These needles are carried through the slit in the lower end of the ureter into and down the tube for inch (13 millimetres), and are then pushed through its wall side by side. By traction on the catgut loop the upper end of the duet is drawn into the lower portion and the ends of the loop are tied. Although catgut was originally used be cause its early absorption lessened the danger of the formation of calculus, silk is to be regarded as a safer mate rial and no bad results have been reported from its use.
The site of the union is then envel oped in peritoneum, which is stitched in place about it.
Ureteral implantation into the blad der, into some portion of the intestine, and on to the skin have been suggested by many operators and by numerous methods. Such operations are under taken for the cure of ureteral fistuhu, the prevention of fistul2 in ease too great injury has been done to the ureter to permit of anastomosis, in case of ex strophy of the bladder, and for uretero uterine and uretero-vaginal fistula In cases of uretero-vaginal fistuhe 'Kelly recommends making a vesico-vag inal fistula near by, then inclosing both fistula; in a circular denudation and su turing the sides together.
Urelero-eystotomy.—In this procedure the abdomen is opened and the end of the ureter is freed. An incision is made at a suitable place in the bladder-wall; long forceps are introduced into the bladder through the urethra and are used to pull the ureter through the blad der incision, into which it is sutured by fine-silk interrupted sutures.