Part 19 (1/2)

Sampson stated that from August, 1889, to January, 1904, the uterus was removed 156 times for cancer of its neck at the Johns Hopkins Hospital, Baltimore, and the ureters were injured nineteen times. The injuries were of various kinds, such as 'ligating, clamping, cauterizing, cutting.'

In abdominal hysterectomy for fibroids the risk of injuring a ureter is not great. Thus Deaver writes that in the course of 250 abdominal hysterectomies he injured the ureter once, but the accident entailed the death of the patient.

I have performed hysterectomy on 1,000 occasions and injured the ureter once; my patient had a narrow escape for life and lost a kidney.

I have been present on five occasions when a ureter was injured. Four of the operations were for the removal of the uterus on account of fibroids, and one was an ovariotomy. Four of the patients died.

The injuries to which the ureters are liable in the course of hysterectomy are as follows:--

1. One or both ureters have been included in the ligatures applied to the uterine arteries.

2. One or both ureters have been cut or completely divided with scissors, or knife, in removal of the uterus.

3. A segment of a ureter 7 centimetres in length has been accidentally exsected.

4. One or both ureters have been compressed by clamps applied to restrain bleeding in the course of v.a.g.i.n.al hysterectomy, and subsequently sloughed.

5. Ureters exposed in the course of 'radical' operations for cancer of the neck of the uterus often slough.

6. A ureter is sometimes transfixed by a needle and thread when sewing the layers of the broad ligament together in the course of a subtotal hysterectomy.

The most dangerous injury to the ureters occurs in the course of a subtotal hysterectomy, especially if it is not recognized at the time of the operation. In such circ.u.mstances the urine will slowly leak into the connective tissue of the broad ligament and form an extravasation extending into the loin.

In some cases the fluid will leak directly into the pelvis, and a sinus will form in the abdominal wound and allow the urine to escape; this may be the first intimation that a ureter has been injured, whereas when a ureter has sustained damage in the course of a total abdominal or a v.a.g.i.n.al hysterectomy, the leakage of urine along the v.a.g.i.n.a will quickly apprise the surgeon of the accident.

There is another form of injury to the ureter which should be mentioned.

Occasionally a fibroid, but more often a cyst or tumour arising from the base of the broad ligament, will involve the corresponding ureter and carry it upwards in such a way that, when the layers of the broad ligament are reflected, the ureter will be found crossing the crown of the tumour like a strap. In such a case the pressure has usually exerted a ba.n.a.l influence on the kidney, and it is often in the condition known as sacculation. In a case under my own care in which I attempted to remove a malignant tumour of the broad ligament, and in which the ureter ran over its upper pole in this way, thinking it was an adhesion, traction was made upon it, and the ureter came away with a portion of the renal pelvis. At the post-mortem examination the kidney was merely a thin-walled sac with purulent contents.

In all cases in the course of an abdominal hysterectomy it is useful for the surgeon to inform himself of the condition of the kidneys. Whilst performing a subtotal hysterectomy, one of the fibroids burrowed deeply between the layers of the left broad ligament; when all the bleeding was checked, I looked carefully to determine that the ureter was safe, and found it kinked by the ligature applied to the corresponding uterine artery; it was at once removed. On palpating the kidneys I found the right kidney small, and shrunken, and useless. Fortunately the woman recovered.

The method of treating an injured ureter varies greatly and will depend not only on the extent of the damage, but also on the time at which it is recognized. For example, if the surgeon recognizes the injury in the course of the operation, he will be able to deal with it at once. This we may term _immediate_ treatment. The more difficult cases are those in which the injury is unrecognized at the time of the operation and only becomes obvious in the course of convalescence; the treatment in such circ.u.mstances may be called _secondary_.

The primary treatment of an injury to a ureter in the course of a pelvic operation will depend in a large measure on the ability, judgment, and experience of the surgeon, as well as on the extent of the injury. For example, if the ureter be partially divided, the opening may be closed with sutures of thin silk; when the duct is completely divided, the cut ends may be inv.a.g.i.n.ated, the upper into the lower, and retained in position by suture. When five or more centimetres of the ureter have been accidentally exsected, none of these methods is applicable; in such circ.u.mstances several plans have been tried. Of these the simplest is ligature of the proximal end with the hope of inducing atrophy of the kidney; in several recorded instances this has proved successful. The surgeon who adopts this method should satisfy himself that the patient has another kidney, and that it is, as far as he can ascertain at the time, healthy. Some surgeons who have divided a ureter have promptly removed the corresponding kidney; others have secured the proximal end in the upper angle of the abdominal incision and removed the kidney subsequently.

[Ill.u.s.tration: FIG. 27. THE RELATION OF PARTS AFTER RICARD'S OPERATION OF URETERO-CYSTO-NEOSTOMY (after Lutaud). A, the proximal end of the ureter with the mucous membrane reflected. B, the walls of the bladder, showing the mode of fixing the ureter to its walls. 1 and 2, sutures.]

It has been suggested that when a portion of a ureter has been resected and the proximal end cannot be engrafted into the wall of the bladder, it should be turned into the caec.u.m or the sigmoid flexure, according to its position, and thus preserve to the patient the kidney and save her the distress of a urinary fistula. This method has not found favour with practical surgeons. The most promising procedure consists in engrafting the proximal end of the cut ureter into the bladder. This is known as uretero-cysto-neostomy, an operation which has been made the subject of a valuable thesis by Dr. Lutaud. This thesis appears to have been inspired as a result of two successful operations performed by Ricard.

The principle of this method is as follows:--

The abdomen is opened by the usual median sub.u.mbilical incision, and the peritoneum covering the damaged duct is incised and its proximal end exposed: the mucous membrane of the ureter is reflected like a cuff. An opening is made in the bladder wall in a situation convenient for making the junction, and two centimetres of the ureter are allowed to project freely into the vesical cavity, 'a la facon d'un battant de cloche.' The ureter is secured by sutures to the vesical mucous membrane, and to the muscular coat of the bladder. The sutures should be of thin catgut and must not perforate the bladder or the ureteral walls. The bladder itself near the junction should be attached by sutures to the adjacent peritoneum to prevent dragging (Fig. 27).

Lutaud significantly points out that we know little of the subsequent fate of ureters which have been engrafted into the bladder. The immediate results have been successful, but there is good reason to believe that when a ureter has been engrafted into the bladder, its walls become sclerosed by a chronic ureteritis, and its lumen is gradually stenosed. These changes take place slowly and cause little or no discomfort in connexion with the kidney or the bladder, so that they pa.s.s unnoticed.

If the opinion expressed by Lutaud, that the ureter becomes stenosed after uretero-cysto-neostomy, is found to be a constant, or even a frequent, sequel to the transplantation of a ureter into the bladder, it will cause surgeons to be careful, and not follow too literally the advice given by some writers to the effect that in performing the 'radical operation' for cancer of the cervix, if the ureters are implicated these ducts may be divided and their proximal ends engrafted into the bladder.

Lockyer, in removing a burrowing fibroid, wounded the bladder and divided the right ureter; he sutured the vesical incision and removed the right kidney. During the twenty-four hours following the operation there was anuria. The abdomen was reopened and then it was found that the left ureter had also been divided. The proximal end of this ureter was engrafted into the bladder through the wound which had been already sutured. Convalescence was disturbed by a urinary fistula. The woman recovered and reported herself in good health three years later.

It has happened that after nephrectomy for the cure of a ureteral fistula, the sequel of a 'radical operation', the remaining ureter became thoroughly blocked by recurrent growth and the patient died from anuria.

In the cases where the injury to a ureter has been overlooked in the course of the operation many difficulties arise before the true conditions are appreciated. In some instances they soon become obvious; for example, Purcell in 1898 performed an abdominal hysterectomy, next day the patient had complete anuria. The abdomen was reopened fifty-eight hours later; a distended ureter was easily recognized behind the ligatures applied to the right and left uterine artery respectively. The ligatures were removed, the swelling quickly subsided, and urine reached the bladder. The woman recovered.

When a ureter is injured in the performance of total hysterectomy, urine escapes by the v.a.g.i.n.a, and at first there may be some doubt whether the leak is due to an injury to the bladder or to the ureter. In such conditions the quant.i.ty of urine voided from the bladder is compared with that which escapes from the v.a.g.i.n.a; if the quant.i.ties are equal, or nearly equal, the leak is in a ureter. A more reliable method is to inject a solution of methylene blue into the bladder through the urethra. If the coloured fluid escapes from the v.a.g.i.n.a, the leak is in the bladder; if not, it is in the ureter. When a v.a.g.i.n.al leakage occurs a few days after a v.a.g.i.n.al hysterectomy, it is probably due to necrosis and sloughing of a ureter, or the duct may have been included in a ligature which has separated by sloughing.