N O T E S O N I N T E R E S T I N G . C A S E S

ACCIDENTAL LIGATION OF BOTH URETERS By DAVID SWARTZ, M.D.(Man.), F.R.C.S.(Edin.).

UROLOGIST, ORACE HOSPITAL, WINNIPEG, AND CIIILDREN’B HOBPITAL, WINNIPEG ; A88ISTANT UROLOQIBT, MISERICORDIA HOSPITAL, WINNIPEG

THE patient, Mrs. E., age 38, white, para ii, gravida ii, had a total hysterectomy and appendectomy performed on October 27, 1938, for degenerating leiomyoma of the uterus.

I saw her for the first time on October 28th, 1938, twenty-four hours following her operation because she had not voided and no urine could be obtained by catheterisation.

Cystoscopic examination and ureteric catheterisation revealed a complete obstruction in the left ureter 14 inches from the vesical orifice, and in the right ureter 2 inches from the orifice. There was no excretion of dye, which had been injected intravenously; and opaque solution injected into the ureteric catheters failed to show up above the points of obstruction,

The patient looked and felt ill ; temperature 101 ; pulse 130. A transfusion of 500 C.C. of citrated blood was given during the afternoon. Catheterisation the same evening resulted in a few C.C. of a cloudy turbid fluid, poor in urea, but rich in epithelial cells and debris; this was evidently bladder secretion.

A description of her operation revealed that twenty-day chromic catgut had been used for sewing in the pelvis, and the surgeon to whom such an accident had never before occurred, felt convinced ‘that the ureters were caught in ligatures rather than cut.

At operation the same night a bilateral lumbar ureterostomy was performed through oblique lumbar incisions. The ureters on both sides were under tension. A No. 12F. rubber catheter was inserted into each ureter as far as the kidney pelvis. These catheters were then fixed to the skin of the loins and connected to a bottle on each side of the bed.

Improvement following the operation was sustained until November loth, 1938, when the left catheter slipped out and could be re-inserted only as far as, but not into the ureter. A few days later the right catheter slipped out. Following these misadventures the convalescence became quite stormy. Dressings would require frequent changes when drainage was good, while on occasions drainage was inadequate and general

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condition of the patient worse. Repeated cystoscopies on November 12th and 22nd revealed no further change.

At this examination, although the ureteric catheters could not be inserted past the points of obstruction, there was an efflux of urine from the left orifice, and indigo carmine given intravenously spurted from the left ureter in

On November 28th another cystoscopy was performed.

Intravenous pyelogram. 16 min.

nine minutes. From this day on the general condition of the patient improved.

Cystoscopic examination on December 7th revealed dye from both kidneys-in good concentration-within five minutes of injection. Both urinary fistulae had already closed completely. She was discharged from hospital on December 16th in good condition.

February lst, 1939.-Cystoscopic findings were the same as 'on December 16th, 1938, and catheters could not be passed above the point where obstruction had been previously nohd.

June Sth, 1939.-Intravenous pyelogram showed both kidneys to be normal (see figure). Urine analysis was nega,tive and specific gravity normal.

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October 16th, 1939.-Cystoscopy revealed both kidneys functioning normally. A catheter could be passed up the left ureter with ease ; this did not apply to the right ureter.

At present Mrs. E. is leading a normal life, has no complaints, and recovery is considered complete.

Discussion

It is quite evident from the course of events that the ureters had been ligated rather than cut. The danger of re-opening the abdomen in this type of accident is too great to warrant the procedure.

It was decided to meet the emergenoy by a method that entailed the least shock, and therefore ureterostomy was chosen. Bilateral nephros- tomy would probably have resulted in much easier post-operative management, and drainage could have been maintained for a longer period of time. For this reason, nephrostomy should be considered the procedure of choice.

In the ultimate recovery of this patient nature played a master r61e. The chromic catgut very conveniently absorbed in its allotted period ; the urinary fistulae closed immediately the ureters became patent ; and this patency was increased by the maintenance of a positive urinary pressure above. Stricture formation on both sides must be minimal in view of the normal state of the kidneys as observed cystoscopically and by pyelogram. Failure to pass catheter up the right ureter is due to a kink rather than stricture and will be checked at a later date.

It is difficult to assess mortality from this type of case because of a natural aversion to reporting accidents.

Bland,* in 1925, collected a series of 441 cases from the literature, of which 81 involved both sides and 361 only one side. Mortality in the former was 33-3 per cent. and in the latter was 18.8 per cent.

Conclusion.-( 1) Ureteral accidents in pelvic surgery are complica- tions of great magnitude and can be readily suspected when the condition is bilateral.

2. Following pelvic surgery, “ suppression of urine ” should never be diagnosed until the ureters have been catheterised.

(3) Pre-operative catheterisation of ureters in difficult cases suggests itself as a procedure of merit.

* Bland, P. B., Med. Journal and Record, April lst, 1926, “Surgicctl Injuries of the Ureter. ”