URETEROSTOMY IN SITU' By ANTHONY WALSH, F.R.C.S.I.

Department of Urology, Jeruis Street Hospital, Dublirz

DESPITE its disadvantages, nephrostomy has been the accepted method of draining the upper urinary tract for almost a century. The purpose of this communication is to suggest that ureteros- tomy in silu is often a more satisfactory procedure. By ureterostomy in situ is meant the open insertion into the ureter of a catheter which is passed up to the renal pelvis. The name is perhaps a little cumbersome, but i t serves to distinguish the procedure from other types of ureterostomy, e.g. cutaneous.

There is astonishingly little reference in the literature to this simple operation. I n a search through many urological textbooks the only relevant passage appears to be that in Campbell's Urology (1954). He mentions the operation briefly and suggests that i t might be useful but " not for long as the tube may become incrusted and once removed it cannot be replaced " although, as will be seen later, there is no problem when plastic catheters are used.

My attention was first drawn to ureterostomy in situ at the 1956 meeting of the British Association of Urological Surgeons. In the discussion on the use of the intestine i n urology, Wilfrid Adams advocated ureterostomy in situ as an easy and effective procedure.

Technique.-The operative technique is very simple. Through a small gridiron incision in the iliac fossa the peritoneum is exposed but not opened. The peritoneum is pushed medially by a large swab which is then held in place by a self-retaining retractor. This manceuvre is the key to easy exposure of the ureter.

It is best to lead the catheter through a separate stab incision below the medial end of the wound, so that i t runs to the ureter in a gentle curve. The ureter is then opened and the catheter passed up to the renal pelvis. The catheter is immediately attached to the skin by a silk stitch so that it does not become dislodged while the wound is being closed.

Catheter.-In the usual case where the ureter is dilated, I use the 18F, whistle-tip, sliding- flange modification of the Gibbon catheter (Walsh, 1960). Where the ureter is not dilated I use an ordinary Gibbon catheter of suitable size which is cut to a convenient length so that the tip lies in the renal pelvis when the flange is attached to the skin.

Other catheters may be used, but I think it is important that they should be made of polyvinyl chloride (P.V.C.) to minimise the risk of inflammatory reaction in the ureter through chemical irritation or allergy and also to provide the largest lumen i n relation to the external diameter of the catheter.

Yeates has recently (1967) advocated ureterostomy in situ i n the emergency treatment of a damaged ureter. He favours a T-tube, but 1 think i t is better to use a simple catheter which runs, as described above, in a gentle curve from the skin to the ureter. I prefer this to the T-tube because it is extremely easy to change the catheter, and in a large number of personal cases since 1959 I have never regretted not using a T-tube. If the first catheter is left i n for two or three weeks, the track becomes well established and the catheter can easily be changed by a nurse. The correct length of the new catheter is determined by comparison with the old one.

When eventually the source of the ureteric obstruction is removed, the catheter is simply withdrawn: provided that no obstruction remains, there is seldom any leakage of urine from the catheter track.

1 Read at the Twenty-third Annual Meeting of the British Association of Urological Surgeons in London, June 1967.

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Comparison with Nephrostomy.-The advantages of this operation compared with nephros- tomy are as follows: Firstly, it is a very simple, easy, and quick procedure which involves little muscle trauma: this may be very important in patients with renal failure in whom muscle trauma and bleeding add a considerable metabolic load to a struggling kidney. Although it is occasionally possible to perform nephrostomy by a stab or trocar method, full exposure of the kidney is often necessary, with accompanying renal damage and bleeding. Secondly, infection seems to be unavoidable with nephrostomy, but is seldom a problem with ureterostomy in situ. Thirdly, it is often difficult to change a nephrostomy tube-a problem partly overcome by Tresidder’s ( I 957) ingenious manaeuvre, but this is somewhat complicated. Finally, the ureterostomy catheter emerges at a site which is much more comfortable for the patient than the usual nephrostomy tube.

Indications.-The primary indication for this operation is the urgent relief of obstruction in the lower ureter and in this connection i t is particularly valuable in the treatment of acute pyo- nephrosis. It is astonishing how often in cases where the kidney seems merely a bag of pus, the fluid draining from the ureterostomy becomes clear in a matter of days and, as described else- where (Walsh, 1964), there is often considerable recovery of function.

I have frequently used ureterostomy in situ as a safety device after operations such as pyelo- plasty. In most cases, using the Anderson-Hynes operation, no form of drainage is necessary, but i t occasionally happens that one is not entirely happy about the immediate result of a pyelo- plasty and then, especially when operating on a solitary kidney, i t is a simple matter to pass a Gibbon catheter into the ureter below the operation site and up through the anastomosis into the renal pelvis: this gives a great sense of security in doubtful cases. In excising difficult strictures of the ureter it may be helpful to start by performing ureterostomy in situ and then completing the anastomosis over the catheter. This is often unnecessary but may be very valuable in some cases, particularly as in a recent personal case of a very difficult stricture in a ureter draining a solitary and heavily infected kidney.

Complications.-Only one complication has been encountered in over 150 cases. Bilateral ureterostomy in situ was carried out in a young woman with a severe post-irradiation vesico- vaginal fistula and was maintained for some months until repair of the fistula was completed. She subsequently developed a mild stricture of the upper 1 cm. of the ureter on both sides, and 1 have little doubt that this was due to using catheters which were too large.

Ureterostomy in situ may be maintained for many months. The longest period in my own series was nine months i n a man whose right kidney had been destroyed by tuberculosis and who had a tiny contracted bladder with a large tuberculous prostatic abscess and an impassable stricture of the lower 10 cm. of the left ureter. He subsequently had a colocystoplasty.

Conclusion.-Ureterostomy in situ is very simple and easy to manage and in many cases is preferable to nephrostomy for drainage of an obstructed kidney.

REFERENCES

ADAMS, A. W. (1956). Br. J . Urol., 28, 414. CAMPBELL, M. (1954). “ Urology ”, Philzdelphia: Saunders Vol. 111, p. 1853. TRESIDDER, G. C. (1957). 3r. J. Urol., 29, 130. WALSH, A. (1960). Lancet, 1, 708. _- (1965). XIII Congr. int. SOC. Urol., London 1964, Vol. 11, p. 243. Edinburgh: Livingstone. YEATES, W. K. (1967). Lancet, 1, 499.