TRANSPLANTATION OF URETERS FOR INOPERABLE VESICOVAGINAL FISTULA A
KEPORT OF TWO CASES *
By HERSCHEL C. ALDRICH, b.a., m.d. (Ohio State Univ., U. S. A.) American Methodist Mission Hospital, Nadiad Coffey (1911) and Stiles (1911) described somewhat similar techniques for the transplantation of ureters. Operations for transplantation previous to this date, suggested by various surgeons, were not satisfactory, and resulted in a high mortality rate. Coffey modified his first technique, designating it as Coffey II (1927), and Coffey III (1931). It is not until quite recently that more than a few cases have been operated on successfully for the transplantation of ureters to the rectum. Turner (1929) reported 17 cases by the Stiles' technique. Woodman (1936) reported a series of cases also by the Stiles' technique. Orr (1937) reported a series of 13 cases (5 cases by Coffey II, 1 case by Coffey III, high transplantation 1 case, and 6 In this series of cases by the Stiles' technique). 13 cases, the 5 cases done by the Stiles' technique were entirely successful, whereas those done by the other methods were unsatisfactory for various reasons.
Essentials are
[Oct., 1939
THE INDIAN MEDICAL GAZETTE
604
for
a
successful
transplantation
:?
(1) The anal sphincter must be undamaged and in good condition, in order that the urine may be retained in the rectum without leaking. (2) The ureters must be transplanted one at a time, with a sufficient interval between the two operations to permit the first kidney to recover from the temporary incapacity accompanying the pyelo-nephritis that invariably sets in immediately following the implantation of the ureter into the septic rectal field.
or 3 inches of the have some suitable transplanted drain placed within its lumen to prevent a coffi' a plete destruction of kidney function from blockage of the lumen, which might occur if were not done, because of the rather sharp reaction, with oedema, that must occur from tin
(3) The distal 2^ inches ureter
must
sepsis.
Vesicovaginal fistula is a very common condition in India; where, as a rule, most cases afe delivered in their homes by untrained dalSar? Many of these cases of vesicovaginal fistula
totally beyond repair surgically, as frequently the whole bladder trigone, together with tn sphincter and a portion of the urethra are completely torn out. In such cases the transplant^" tion of the ureters to the rectum or sigm01 preferably by the Stiles' technique, is to strongly recommended. Where this is not done, the woman is outcaste by her husband an '
friends. She is put to no end of discomfort frp the excoriation and irritation of skin, and tn foul smell, which are a part of the continuous^ dripping urine. Following a successful trans plantation, the woman is completely freed fro ' this inconvenience, and can live a normal n* once again taking her place in the family.
reporting the two following cases operated by the Stiles' technique; f?11 separate operations in all. Both these wome^ are very pleased with the outcome of the ?Peraa We
are
on
One of them has now been at home f?r period of about a year and a half; the | has recently been discharged from the hospita tion.
?
W Case 1.?Female, 17 years of age, Hindu, Patel This 'woman first presented herself at our ^ pital on 24th June, 1937, with the history of having*n a forceps delivery in another hospital soine months ago; following this there was a contin^ ^ ? dripping of urine, and a partial paralysis of both 1 Patient could only walk with the greatest of difficU g This was her first pregnancy, and the child delivered at term. .
caste.
On examination the patient was found to have rather markedly contracted pelvis. Vaginal ^ tion:?The entire base of the bladder, together the sphincter, urethra, and lower portion ^
^
exaDQvjtb
triangular ligament completely torn out. The sphincter was found to be in good condition, normal control. This patient was operated on 01| j.ed August, at which time the right ureter was transplaP into the rectum by the Stiles' technique. '
fjfl
Following this operation, for 7 days there WJl? al. irregular temperature ranging from a 104?F. to n? The temperature on the 8th day was normal, remained so until the second operation on the v\tj0U September (transplantation of left ureter and 'r'^jpg of tubes to prevent further pregnancies). Foil? ^re this second operation, there was a rise of tempe'a, ^ to 101.8?F. on the second day, and an irregular j fever ranging between normal and 99?F., for a P n? of some five days, following which it was again After each operation, there was a rather 111'h. oO decrease in the output of urine from the kidney^.^ ^ the side operated upon, during the first 48 hours, j however, soon returned to normal after this mte This patient was discharged on the 29th of lC ber, 1937, with full control of the urine per and with no complaints. ,
0ct.; 1939]
SUBTOTAL HYSTERECTOMY
We have since heard from occasions. We saw Months after the operation a came to the hospital bringing She was so well satisfied with Previous operation, having she had nothing to say concern we
from her
inquired
SZAMEK
605
six ^ time she ther patient, resUlt of the that
personally
different
until
:
?-
joints,
yier 0wn case ^QW s\ie was from*^liis patient
as
getting along. We again heard
through her husband over a and he reported operation, and happy with no complamts.
^
y
waS
c
&e well
-o +ol bv caste, in?3 2.?-Female, aged 25, Pa ^ on 26th April presented herself at our n^inence of urine, 1938, with a history of having ^ months ag the the She had had birth of pregnancies 1 six previous un with three njnation, the entn children living. base of the -,1, th sphincter, and a together with the torn Portion of bladder, the urethra, were dripping of urine and there was a contm found to be through the vagina. The cervi purulent moderate somewhat soft, and there was , operation on discharge. The patient was 2nd May, ^ opened, time the ab of and the 1938, at which appearance uterus was found to have ?, cjrcum-about a two months' pregnancy. stances, we did not feel justified P ee and : q{ ^ chlld. the del instructed This she did to return after 1939, with about one year latei, the term, which of having delivered a history y_ died was transshortly birth. The^ rip. Planted to theafter tech q e on 14th April, Stiles rectum by and at this to preVent time both tubes future pregnancv. wfr,, S this operation The reaction foUova-,n
KEPORT OF TWO CASES *
By HERSCHEL C. ALDRICH, b.a., m.d. (Ohio State Univ., U. S. A.) American Methodist Mission Hospital, Nadiad Coffey (1911) and Stiles (1911) described somewhat similar techniques for the transplantation of ureters. Operations for transplantation previous to this date, suggested by various surgeons, were not satisfactory, and resulted in a high mortality rate. Coffey modified his first technique, designating it as Coffey II (1927), and Coffey III (1931). It is not until quite recently that more than a few cases have been operated on successfully for the transplantation of ureters to the rectum. Turner (1929) reported 17 cases by the Stiles' technique. Woodman (1936) reported a series of cases also by the Stiles' technique. Orr (1937) reported a series of 13 cases (5 cases by Coffey II, 1 case by Coffey III, high transplantation 1 case, and 6 In this series of cases by the Stiles' technique). 13 cases, the 5 cases done by the Stiles' technique were entirely successful, whereas those done by the other methods were unsatisfactory for various reasons.
Essentials are
[Oct., 1939
THE INDIAN MEDICAL GAZETTE
604
for
a
successful
transplantation
:?
(1) The anal sphincter must be undamaged and in good condition, in order that the urine may be retained in the rectum without leaking. (2) The ureters must be transplanted one at a time, with a sufficient interval between the two operations to permit the first kidney to recover from the temporary incapacity accompanying the pyelo-nephritis that invariably sets in immediately following the implantation of the ureter into the septic rectal field.
or 3 inches of the have some suitable transplanted drain placed within its lumen to prevent a coffi' a plete destruction of kidney function from blockage of the lumen, which might occur if were not done, because of the rather sharp reaction, with oedema, that must occur from tin
(3) The distal 2^ inches ureter
must
sepsis.
Vesicovaginal fistula is a very common condition in India; where, as a rule, most cases afe delivered in their homes by untrained dalSar? Many of these cases of vesicovaginal fistula
totally beyond repair surgically, as frequently the whole bladder trigone, together with tn sphincter and a portion of the urethra are completely torn out. In such cases the transplant^" tion of the ureters to the rectum or sigm01 preferably by the Stiles' technique, is to strongly recommended. Where this is not done, the woman is outcaste by her husband an '
friends. She is put to no end of discomfort frp the excoriation and irritation of skin, and tn foul smell, which are a part of the continuous^ dripping urine. Following a successful trans plantation, the woman is completely freed fro ' this inconvenience, and can live a normal n* once again taking her place in the family.
reporting the two following cases operated by the Stiles' technique; f?11 separate operations in all. Both these wome^ are very pleased with the outcome of the ?Peraa We
are
on
One of them has now been at home f?r period of about a year and a half; the | has recently been discharged from the hospita tion.
?
W Case 1.?Female, 17 years of age, Hindu, Patel This 'woman first presented herself at our ^ pital on 24th June, 1937, with the history of having*n a forceps delivery in another hospital soine months ago; following this there was a contin^ ^ ? dripping of urine, and a partial paralysis of both 1 Patient could only walk with the greatest of difficU g This was her first pregnancy, and the child delivered at term. .
caste.
On examination the patient was found to have rather markedly contracted pelvis. Vaginal ^ tion:?The entire base of the bladder, together the sphincter, urethra, and lower portion ^
^
exaDQvjtb
triangular ligament completely torn out. The sphincter was found to be in good condition, normal control. This patient was operated on 01| j.ed August, at which time the right ureter was transplaP into the rectum by the Stiles' technique. '
fjfl
Following this operation, for 7 days there WJl? al. irregular temperature ranging from a 104?F. to n? The temperature on the 8th day was normal, remained so until the second operation on the v\tj0U September (transplantation of left ureter and 'r'^jpg of tubes to prevent further pregnancies). Foil? ^re this second operation, there was a rise of tempe'a, ^ to 101.8?F. on the second day, and an irregular j fever ranging between normal and 99?F., for a P n? of some five days, following which it was again After each operation, there was a rather 111'h. oO decrease in the output of urine from the kidney^.^ ^ the side operated upon, during the first 48 hours, j however, soon returned to normal after this mte This patient was discharged on the 29th of lC ber, 1937, with full control of the urine per and with no complaints. ,
0ct.; 1939]
SUBTOTAL HYSTERECTOMY
We have since heard from occasions. We saw Months after the operation a came to the hospital bringing She was so well satisfied with Previous operation, having she had nothing to say concern we
from her
inquired
SZAMEK
605
six ^ time she ther patient, resUlt of the that
personally
different
until
:
?-
joints,
yier 0wn case ^QW s\ie was from*^liis patient
as
getting along. We again heard
through her husband over a and he reported operation, and happy with no complamts.
^
y
waS
c
&e well
-o +ol bv caste, in?3 2.?-Female, aged 25, Pa ^ on 26th April presented herself at our n^inence of urine, 1938, with a history of having ^ months ag the the She had had birth of pregnancies 1 six previous un with three njnation, the entn children living. base of the -,1, th sphincter, and a together with the torn Portion of bladder, the urethra, were dripping of urine and there was a contm found to be through the vagina. The cervi purulent moderate somewhat soft, and there was , operation on discharge. The patient was 2nd May, ^ opened, time the ab of and the 1938, at which appearance uterus was found to have ?, cjrcum-about a two months' pregnancy. stances, we did not feel justified P ee and : q{ ^ chlld. the del instructed This she did to return after 1939, with about one year latei, the term, which of having delivered a history y_ died was transshortly birth. The^ rip. Planted to theafter tech q e on 14th April, Stiles rectum by and at this to preVent time both tubes future pregnancv. wfr,, S this operation The reaction foUova-,n
