THE BLOOD SUPPLY OF THE HlJMAN URETER IN RELATION TO ~ URETEROCOLIC ANASTOMOSIS

By OWEN DANIEL, M.B.. F.R.C.S., and RALPH SHACKMAN, M.B., F.R.C.S. Froni the Depavtnient 0 f Surgery, Post-graduate Medical School of Lunrion

,4s yet no method of ureterocolic anastomosis has proved its superiority i n a large series of cases, and the operation still carries a not inconsiderable morbidity and mortality rate. The evolution of an improved technique is hindered by difficulty in investigating the causes of failure as the clinical manifestations of failure due to all causes are those of local or spreading inflammation and ureteral obstruction. Post-mortem examination is often not possible until a time when precise evidence of the cause of failure is lost in suppuration.

Most methods of ureterocolic anastomosis involve the isolation of 5 to 6 cm. of ureter, and although the risk of ischsmic necrosis of this portion of ureter has been widely recognised (Nitch, 1932 ; Flocks, 1947 ; Cordonnier, 1949), there have been few assessments of the importance of this danger. Harper (1942) concluded that division of the lower ureteral twigs from the inferior vesical and middle rectal arteries would not produce ischlemia and impaired vitality of the duct, but our findings do not support this contention.

We have investigated the blood supply of the human ureter from the standpoint of ureterocolic anastomosis by injection experiments in fifty cadavers chosen at random in autopsy rooms. Forty-eight were adults with an average age of 61 years and two were stillborn female infants. Thirty of the adults were male and eighteen female.

The injection medium consisting of 50 per cent. Micropaque' (a colloidal suspension of barium sulphate) and 15 per cent. gelatine, made up in water, was heated in a water bath and run into the thoracic aorta, through a tube and funnel, at a pressure equivalent to 120 mm. of mercury. The inferior vena cava was divided above the diaphragm to allow free circulation. Bodies which were cold were first warmed by perfusing hot hypertonic saline. Under these conditions the medium flowed freely as far as the capillaries, and when cooling occurred it set into a white radio-opaque jelly.

Our studies confirm the generally accepted description of the blood supply of the ureter (Sampson, 1904). The ureter is supplied by a variable number of '' long arteries " which arise from the aorta or its branches and run close to the peritoneum which they supply with small twigs (Fig. I ) . The long arteries divide into ascending and descending branches which travel up and down in the loose adventitial coverings of the ureter, the descending branch of a long artery above anastomosing with the ascending branch of an artery below. The anastomosing arteries give off secondary branches which form a plexus on the surface of the ureter and this plexus sends small twigs into the substance of the ureter.

Of the 100 ureters examined, eighty-eight received branches from the renal and uterine o r vesical arteries, augmented in sixty-four ureters by one, in twenty ureters by two, and in four ureters by three long arteries which joined the intermediate portion of the ureter. Ten of the 100 ureters received renal and uterine or vesical arteries augmented only by minute peritoneal twigs, and two of the 100 ureters had three long arteries to their intermediate portion but did not receive any branches from the renal, uterine, or vesical arteries. The origin of the long arteries to the intermediate portions of the 100 ureters was the upper half of the abdominal aorta in eighteen, the lower half of the abdominal aorta in twenty-six, the testicular in thirty, the ovarian

Read at the Eighth Annual Meeting of the British Association of Urological Surgeons at London on 26th June 1952.

Made by Damancy & Co. Ltd., Ware, H e m , England. 334

THE BLOOD SUPPLY OF THE HUMAN URETER I N RELATION TO URETEROCOLIC ANASTOMOSIS 335

in eight, the common iliac in twenty-five, and the internal iliac arteries i n fifteen (Fig. 2). The blood supply of the right and left ureters is seldom symmetrical, and there is marked variation between the ureteric blood supply of individuals. This variation is mainly congenital in origin, although in one subject arteriosclerosis of the aorta was associated with thrombosis of a ureteric artery (Figs. 7 and 8). It is surprising that this complication does not occur more often, as 42 per

FIG. 1 Barium gelatine mixture injected into thoracic aor!a and specimen cleared by Spalteholz’s method. The ureters are visible by virtue of

their arterial plexus.

cent. of the men and 25 per cent. of the women had extensive aortic ulceration and calcification (Fig. 4).

Injections made i n ten subjects whose ureters had not been disturbed in any way showed a complete anastomosing blood supply along the whole length of each ureter.

When the injection was preceded by rnobilisation and division of the ureters, as in a Coffey (1931) type of operation, sixteen out of twenty subjects showed a good blood supply to their ureters (Figs. 3 and 4), while four did not (Figs. 5, 6, 7, 8, and 9). I n each of the four subjects with a defective blood supply to their divided ureters the injection was technically satisfactory, since the arteries of the vesical ends of the ureters (Figs. 5 and 6 ) , the contralateral ureters, and .tbdominal organs all filled well. Microscopic examination of serial sections of the ends of the four ureters showed the injection medium in capillaries 5 to 12 mm. beyond the point at which it could be seen on the radiographs. But there was no trace of medium in the terminal 1.3 cm.

336 B R I T I S H J O U R N A L O F U R O L O G Y

of one, 2 cm. of the second, 3.8 cm. of the third, and 6.3 cm. of the fourth. Normal but empty arteries, presumably cut off from their source of supply, were present.

Some ureters may be safely divided at any point because they receive large arteries which anastomose through substantial vessels (Fig. 10, A). Ureters with arteries which anastomose through minute branches can be divided with safety only at or above the vascular anastomosis. Division 2.5 cm. or more below will leave the upper end ischremic (Fig. 10, B and c). When the intermediate portion of a ureter is dependent for its blood supply on minute peritoneal twigs, separation from the overlying peritoneum for more than 2.5 cm. may produce ureteric necrosis.

BLOOD SUPPLY OF HUMAN URETER BAsm ON DISSECTION OF FIFTY SUBJECTS

INCIOEffiE OF

THE BLOOD SUPPLY

VARIOUS SOVRCfS

nr . T Y e l r I I -. I. . .. .-..- FEMALE URETER

COMMON I L I A C

UTERINE-

, OVARIAN A 81. (TESTICULAR 3 0 1 )

V E S I C A L

y/h , INTERNAL I L I A C 15%

I N - UTERINE A

90%

FIG. 2

left summary of findings in fifty subjects. Diagram of blood supply of ureter ; on the right that of a typical female and on the

Sloughing of the tip of the ureter in the lumen of the colon probably causes no trouble. Sloughing of part of the ureter in the submucous tunnel would probably cause inflammation in and about the anastomosis and early or delayed ureteric obstruction ; and sloughing of the ureter above the tunnel would cause failure of the anastomosis, and if the anastomosis is intraperitoneal, peritonitis and death.

If ureters are always divided at the same point, as in the Coffey (1931) or Cordonnier (1949) operations, or always mobilised for more than 2.5 cm., irrespective of their blood supply, troublesome sIoughing of the ureter is likely in some 10 to 15 per cent. of subjects.

THE BLOOD SUPPLY OF THE HUMAN URETER I N RELATION TO URETEROCOLIC ANASTOMOSIS 337

Fig. 3.-Ureters mobilised as i n Coffey operation, with good blood supply to both upper ends. (Woman, aged 80, who died of

heart failure.)

Fig. 4.-The abdominal aorta of tile subject of Fig. 3. The exten- sive atheromatous calcification did not interfere with the blood supply

ol' the ureter.

FIG. 4

338 B R I T I S H J O U R N A L O F U R O L O G Y

FIG. 5 Ureters mobilised as in Coffey operation. The terminal 2 cm. of the upper end of the left ureter contains no injected arteries. The lower end is well injected. and this reciprocity was always found when one end of the divided ureter was not injected. (Man, aged 63, who died

of carcinoma of the bronchus. The aorta showed no sign of atheroma.)

THE BLOOD SUPPLY OF THE HUMAN URETER IN RELATION TO URETEROCOLIC ANASTOMOSIS 339

FIG. 6 Ureters mobilised as in CofYey operation. The terminal 3.8 cm. of the upper end of the left ureter contains no injected arteries although the lower end is well injected. (Woman, aged 58, who died of carcinoma of the breast. The aorta showed no sign of

atheroma.)

4F*

340 B R I T I S H J O U R N A L OF U R O L O G Y

FIG. I Ureters mobilised as in Coffey operation. The left ureter receives a large artery from the lower aorta hut the injection medium has not flowed into this

artery or the terminal 6.3 crn. of ureter.

THE BLOOD SUPPLY OF THE HUMAN URETER IN RELATION TO URETEROCOLIC ANASTOMOSIS 341

FIG. 8 The aorta of the subject of Fig. 7 showing ante-mortem thrombus occluding the mouth of the left long ureteric artery. (Man, aged 65, who dled ten days after a gastric operation.)

FIG. 9 c Ureters mobilised as in Coffey operation. The terminal 1.3 cm. of the right ureter is not injected because the anastornosing branch was damaged when the ureter was

Diagram showing patterns of ureteric blood supply and the mobilised. (Woman, aged 56, who died of cerebral tumour.)

A B FIG. 10

effect of dividing the ureter.

342 B R I T I S H J O U R N A L O F U R O L O G Y

We think there is a safe way of mobilising the ureter without jeopardising the blood supply to the upper cut end and have tested the method on twenty subjects. On the right side

FIG. I 1 Diagram of method of exposing and dividing ureters without

jeopardising blood supply of upper cut ends.

the pelvic portion of the ureter is exposed by raising a large rectangular or U-shaped flap of peritoneum hinged above to preserve its blood supply (Fig. 11). On the left side the ureter is

FIG. 12 Transplantation of ureter completed and site of anastomosis

extraperitonealised.

exposed by reflecting the colon medially after dividing the lateral reflection of peritoneum in the left paracolic gutter for 7.5 cm. above and below the common iliac artery. The arteries to

THE BLOOD SUPPLY OF THE HUMAN URETER IN RELATION TO URETEROCOLIC ANASTOMOSIS 343

the pelvic portions of the ureters are then visible and the ureters divided 2 cm. below the point at which such vessels join them. If there are no such vessels, the division is made 2 cm. below the bifurcation of the common iliac artery. The pelvic portion of the ureter is mobilised from below upwards by dividing the fascia on its medial side, and its vessels which always approach it from the lateral side (Feitel, 1901) are preserved.

We found that the upper end of each of forty ureters mobilised in this way contained well-injected arteries, and although the length of mobilised ureter was often insufficient for a Coffey type of anastomosis it was suitable for a Stiles (191 1) operation or a simple implantation (Brunschwig and Pierce, 1951). Anastomoses made in this way can be extraperitonealised and reinforced, on the right side by turning down the peritoneal flap and suturing it to the bowel and on the left side by replacing the colon and suturing the lateral peritoneal margin to it, in front of the anastomosis (Fig. 12).

SUMMARY

Any method of ureterocolic anastomosis in which the ureter is always dikided at the same point, or mobilised for more than 2.5 cm., irrespective of its blood supply, is liable to failure, due to ischzmic necrosis of the ureter, in 10 to 15 per cent. of subjects.

As the result of a study of the blood supply of the ureters of fifty cadavers it is suggested that ureters may be safely divided 2 cm. below the point of entry of a pulsating, long, ureteric artery, or in the absence of such, 2 cm. below the bifurcation of the common iliac artery.

We are grateful to Professor Ian Aird for constant encouragement ; to Professor J . H. Dible for facilities to start the work ; to Mr J. D. Fergusson and Mr H. K. Vernon for introduction to the Pathology Departments of the Central Middlesex and St James’ Hospitals, where most of the experiments were made, and to Mr E. V. Willmott for the photographs.

REFERENCES

BRUNSCHWIG, G. A., and PIERCE, V. K. (1951). Arch. Surg., 62, 125. COFFEY, R. C. (1931). Brit. J. Urol., 3, 353. CORDONNIER, J . (1949). Surg. Gynec. Ohstet., 88,441. FEITEL, A. (1901). Z . Geburtsh. Gynuk., 46, 269. FLOCKS, R. H. (1947). Cunad. med. Ass. J., 56, 259. HARPER, W. F. (1942). Brit. J . Urol., 14, 63. NITCH, C. A. (1932). Proc. R . Soc. Med., 25, 1412. SAMPSON, J. A. (1904). Johns Hopk. Hosp. Bull., 15, 39. STILES, H. (1911). Surg. Gynec. Ohstet., 13, 127.