Longitudinal suture of ureter. (Hartmann.)
Implantation or invagination of ureter with fixation and then with circular sutures. (Hartmann.)
Longitudinal incision and transverse suture of ureter for stricture, similar to the pyloroplastic method of dealing with pyloric stenosis. (Hartmann.)
Operations upon the Ureters.
—The surgery of the ureters is also quite modern, and has been worked out in the experimental laboratory. That ureteral tissue will heal has been proved by Murphy, who has remarked that “The peritoneum is the only tissue that unites as kindly as does the ureter.” After accidental injuries during other operations the ureter may be sutured almost as though nothing had happened. These sutures should be made with fine round needles, and be placed closely together. They should be made of fine silk or thread.
Not only end-to-end union but lateral anastomosis and even more ingenious methods of transplantation and implantation are now in vogue. [Figs. 645], [646] and [647] illustrate some work in this direction, and show what may be done by work quite similar to that done upon the small intestines or the bloodvessels. More complete instances of transplantation have been effected in connection with exstrophy and carcinoma of the bladder, where, for instance, the ureters individually, or the base of the bladder containing the ureteral orifice, have been dissected out and implanted in the colon or the rectum.[67]
[67] In one case I carried out the following procedure, necessitated by cancer involving the urethra, the base of the bladder, the rectum, and the whole floor of the pelvis, in a female patient, the disease having attained a degree making urination or even catheterization impossible. I opened the abdomen, dissected out the right ureter from the bladder, implanted it into the appendix, and then dissecting the left ureter in the same way implanted it in the right, the intent being to direct the whole urinary stream into the colon and thus spare the bladder. The operation was not finally successful. I afterward found that this method had been tried experimentally by Jacobson, of Toledo, but without success.
CHAPTER LV.
THE BLADDER AND PROSTATE.
Methods of recognition of surgical diseases of the bladder have been vastly improved, as well as complicated, within the past few years. The bladder has now been made accessible not alone to touch, as through the rectum or vagina, or by incisions above or below the pubis, but to sight, through the use of the cystoscope. It is furthermore possible to detect foreign bodies within it by the Röntgen rays. Palpation is chiefly of value in thin persons, or when the bladder is greatly distended; still, infiltration of the base of the bladder can be detected through the vagina or through the rectum, as can also certain foreign bodies. Much of value is learned by both chemical and microscopic examination of the urine. This may be passed by the patient or withdrawn by the catheter. It has already been indicated how much of value can be learned by separating the urine drawn from each kidney. The difficulties of this procedure are greater in the male than in the female, owing to the complications in the requisite manipulation of the instruments. Nevertheless there is no accurate method of such estimation save by ureteral catheterization. The method of Harris, by the use of the so-called segregator, is of occasional assistance, but is never accurate nor always satisfactory. If the catheter alone be used it should be of metal, if it be desired to have it serve the purpose of a probe, as in the search for a foreign body (calculus and the like) or as a means of estimating the size and shape of the bladder. For the latter purpose an ordinary sound will serve as well, preferably one with a short beak, ordinarily known as a stone searcher. In cases of prostatic enlargement it is of great advantage to estimate the amount of residuary urine after the patient has apparently emptied his bladder. This may be withdrawn by a sterile catheter under aseptic precautions. The use of the catheter is also necessary for lavage of the bladder, a measure of great value in many cases.