Experimental Studies on Surgery of the Ureter: Part II. An Experimental Study on Reconstruction of the Ureters by a Tube made from Pedicled Peritoneal Flaps

Choo, Kun Weon; Lee, Hak Song

Abstract

A satisfactory method is needed for reestablishing continuity where the ureteral wall has been lost or compromised over a long segment. Experimental efforts to replace the ureteral segments with grafts of free fascia, skin, blood vessels and a pedicled fallopian tube have been reported; however, the results were not considered satisfactory. In 1943, Lord, Stefko and Stevens attempted to replace ureteral segments with free peritoneal flaps splinted with vitallium tubes. Slough and graft necrosis occurred prior to epithelialization. I believed that this failure was due to a disturbance of the blood supply. With this impression I utilized a pedicled peritoneal flap to develop an adequate blood supply. Mongrel dogs, weighing from 15~20kg, were used without special preoperative preparation. Pentothal sodium was administered intravenously for anesthesia. The right ureter was exposed through a paravertebral incision retroperitoneally. The middle third of the right ureter was mobilized. A 3 to 5 cm segment of the right ureter was removed. A pedicled peritoneal flap was fashioned and threaded on a thin polyethylene tubing the ends of which were then passed into the proximal and distal ureter. The ends of ureter were anastomosed with the ends of peritoneal tube using 4-0 chromic catgut. This procedure was technically difficult due to the extreme thinness of the peritoneal grafts. The wound was closed without drainage (Atlas 1: A,B,C, and D). No urinary diversion was performed. Determination of B.U.N. and creatinine were done preoperatively and just prior to sacrificing the animals. Dog No. 1 exhibited vomiting and a poor appetite on the 14th postoperative day, B.U.N. and creatinine were markedly elevated to 73.0mg% and 3.8mg% respectively on the 21st postoperative day compared with 9.8mg% and 1.4mg% preoperatively. Observations at the time of sacrifice revealed the replaced ureteral segment to be dilated and adherented to the surrounding tissues, leakage of urine into the peritoneum, no epithelialization of the peritoneal graft, and severe hydronephrosis of the right kidney. Dog No. 3 also developed a poor appetite on the 14th postoperative day and was sacrificed on the 20th postoperative day. The B.U.N. and creatinine were elevated to 75mg% and 2.8mg% respectively prior to sacrificing. The replaced segment was adherented to the surrounding tissues and showed abscess formation with leakage of urine. No organisms were found by culture. The right kidney showed marked hydronephrosis. Dog No. 4 was examined by intravenous pyelography on the 20th postoperative day when the B.U.N. elevated to 47.3mg%. There was no visualization of right collecting system at 30 minutes. The dog died on the 30th postoperative day. The replaced segment was shrunken and adherented to the surrounding tissues. Right hydronephrosis and hydroureter was found. Uremia developed in all dogs by the second or third postoperative week and severe adhesions, shrinkage and urinary leakage occurred in association with hydronephrosis and hydroureter.