HYDRONEPHROSIS.
The treatment of an accumulation of fluid in the dilated pelvis of the kidney consists in the early removal of the cause. Thus in Glenard's disease or where the floating condition of the kidney exists the hydro nephrosis is at first intermittent, disappearing as soon as the normal position of the kidney is restored and the kinking of the ureter removed. The prevention of further attacks may be achieved by the use of suitable abdominal supports, as described under Glenard's Disease; when these fail, the surgeon should resort to the operation of fixation of the kidney, and if necessary also of the liver.
The most serious cases are those where the ureter has become blocked by an impacted calculus. Where the blocking is of recent occurrence and the tumour not very tense, the simple operation of manipulating it through the abdominal walls should have a fair trial. With the ana tomical position of the kidney and ureter and their relations to other organs in the abdomen before the surgeon's mind, he may try a series of massage and pressure movements with the view of dislodging the calculus or causing the fluid to flow past it into the bladder. This manceuvre is worthy of a trial, and before commencing it the patient's abdomen should he freely poulticed or swathed in warm water bandages covered by a piece of stout mackintosh for 48 hours—a local hot pack. It is needless to say that undue force should not be employed.
Aspiration or tapping must he resorted to when the tumour is tense and of large dimensions. it may be the only means of prolonging life where the opposite kidney has been previously destroyed by an old impaction or where the hydronephrosis is bilateral, and the tapping may be repeated as often as necessary. The site of the puncture is of im portance. The sac should be entered from behind, midway between the last rib and the iliac crest at the outer border of the erector spinve muscle. On the left side the best spot is one just in front of the interval between the last two floating ribs. All the fluid should be removed through a moderately fine and long needle, and it may not again accumulate owing to the previous destruction of the entire secreting structure of the kidney, or the tapping may, by relieving or removing the pressure and irritation, cause the descent of an impacted calculus into the bladder, or it may be followed by subsequent discharge of hydronephrotic fluid into the bladder without the descent of any obstruction. These results, though very improbable, have been recorded in isolated instances, and justify the operation of tapping before resorting to more severe and dangerous measures. An attempt may be made to establish drainage by inserting
a fine rubber tube into the sac through the canula or hollow needle before withdrawal, but the establishment of a permanent fistula is most unsatis factory and should if possible be avoided.
The best routine surgical procedure is to expose the kidney by a lumbar incision, tap the sac and draw the organ out through the wound, where it should be freely incised along its convex border so as to thoroughly explore its pelvis. If the obstruction is found to depend upon the formation of a valvular septum at the entrance of the ureter, the valve should be slit vertically and its edges sutured in the transverse direction. Should an impacted calculus in the upper part of the ureter be found, it should he removed by forcing it back into the renal pelvis, from which it can easily be extracted through the wound.
Where the obstruction is found to be the result of old adhesions between the ureter and the outer surface of the pelvis, these should be carefully dissected out, and it may be necessary to divide the duct and insert its lower end into the most dependent portion of the dilated pelvis by the operation of uretero-pyelo-nephrostomy, or a lateral anastomosis may be effected. A very large sac may sometimes be successfully reduced by removing a portion of its walls or by infolding them by a series of sutures after transplanting the orifice of the ureter into the lowest part of the cavity. Drainage of the kidney in all cases is necessary till the distended pelvis has time to contract before the removal of the tube. Where a fistula fails to close owing to the continuous discharge of urine, the only resource left to the surgeon is to perform nephreetomy and excise the organ, and this may be obviously found necessary when the exploratory incision reveals an advanced stage of disorganisation of the gland. Such a procedure cannot, however, be entertained unless the opposite kidney is known to be functioning in a normal manner.
In some cases the history and nature of the case will show that the nephrectomy should be carried out through an anterior incision made as in ordinary laparotomy for the removal of an ovarian cyst; a necessary preliminary in all such operations is catheterisation of the ureters from the bladder in order to establish proof of the integrity of the kidney on the opposite side.
When the incision of the sac reveals a purulent condition of its con tents, the pyonephrosis should be dealt with by free drainage or nephrec tomy, as described under Pyonephrosis.