A System of Operative Surgery, Volume 4 (of 4)

by Unknown

4. One or both ureters have been compressed by clamps applied to restrain bleeding in the course of vaginal 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 circumstances 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 vaginal hysterectomy, the leakage of urine along the vagina 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 banal 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 circumstances 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 invaginated, 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 circumstances 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.