THE URETERLecture delivered at the Royal College of Surgeons of England

on5th October 1954

byJohn Howkins, M.S., F.R.C.S.

Assistant Gynaecological Surgeon, St. Bartholomew's Hospital

THE QUALIFICATIONS OF a gynaecologist to discuss the pelvic portion ofthe ureter might, at first sight, be questioned and his right to trespass onsacred urological ground considered sacrilege. Yet he, above all others,is most intimately acquainted with this short eventful reach of the urinarytract, and sees and feels it more often than the pure urologist. Since it isnow very properly decreed that all hysterectomies must be total, he shouldnever remove the uterus from the abdomen without first recognising andsafe-guarding the ureter; and, even when operating from the vagina toperform a Manchester repair for prolapse or a vaginal hysterectomy,he must beware of ureteric injury or ligation; in removing many pelvictumours, inflammatory and neoplastic, he must beware of the danger ofdamage to the displaced ureter; in treating carcinoma of the cervix bysurgery or radiation, the ureter is constantly at hazard by knife or post-radiation fibrosis. Finally, the modern gynaecological surgeon whoperforms some form of pelvic exenteration for advanced pelvic cancermust be able to make an adequate ureteric transplantation as part of hisoperative repertoire. There is, therefore, no part of the pelvic ureter thatis free from his ministrations.

It is not surprising, therefore, that this association with the ureteroccasionally leads to mutual misunderstanding and ignorance of normaland pathological anatomy may result in regrettable trauma. In fact, thegynaecologist who boasts that he has never damaged the ureter is eitherguilty of understatement or has a small and timid practice.The great surgeons of the golden age were mostly apprenticed as

anatomists and years of dissection made them neat and exact performerswho neither faltered nor fumbled. It is fitting, therefore, that we shouldfirst consider the anatomy of the pelvic portion of the ureter and whereand how it is particularly endangered during the course of pelvicoperations.

(a) The ureter enters the pelvis at the brim, close to the bifurcation ofthe common iliac vessels and runs retroperitoneally along the lateralpelvic wall in close relationship to the internal iliac vessels and theirbranches. It is crossed by the ovarian vessels contained in the ovario-pelvic fold of peritoneum and, while there is a healthy distance fromthese in the normal, in the case of pelvic inflammatory disease or adnexaltumours this is not so and the ureter may be cut or clamped at its veryentry into the pelvis. This is danger point No. 1.

(b) It is an axiom of pelvic surgery that the ureter always clings to theperitoneum and inflammatory or malignant lesions which infiltrate the

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pelvic wall in the region of the ureter may cause a tear when dislodged,though it is more likely that ill-advised attempts to staunch bleeding byblind clamping will result in injury. This is danger point No. 2.

(c) After reaching the region of the ischial spine, the ureter passesdownwards, forwards and medially towards the bladder in the base ofthe broad ligament, to reach the ureteric tunnel in Mackenrodt's ligamentwhere it passes beneath the uterine vessels, 1 5 to 2 cms. from the cervix.Here it is at greatest peril in all hysterectomies and here it is strangledby parametric malignant infiltration. This is danger point No. 3.

(d) After tunnelling through the lateral part of Mackenrodt's ligament,the ureter traverses the anterior part of the same structure, the so-calledpubocervical ligament and here it is in especial danger in all radicaloperations for cancer of the cervix since it has to be dissected quite freefrom the involved parametrium in this region. This is a common butlittle publicised site of injury-danger point No. 4.

(e) A further menace to the ureter almost anywhere in the pelvis is theneedle and suture of the enthusiastic reperitonisation and, even if notpierced or occluded, the tension of a continuous suture to ensure a neatand water-tight peritoneal scar, may kink, compress or embarrass theureter and, more important, its tenuous blood supply. Interrupted tacks,placed without tension, are far better than the continuous stitch whenclosing the pelvic peritoneum.

(f) It is important here to consider the blood supply of the uretersince many surgeons who spare the organ the actual insult of knife,clamp and ligature, mortally injure the blood supply and a fistula resultsfrom ischaemic necrosis in seven to 10 days after operation. This isparticularly the case in the radical operation for cancer of the cervixwhere the ureter must be extensively dissected from the parametrium.The ureter derives its blood supply from the renal, lumbar, iliac, uterine(an important and fairly constant branch) and vesical arteries. Thesevessels anastomose longitudinally up and down the ureter and the ligationof too many of the parent trunks will lead to ischaemia. Equally important,however, is the trauma which results in haematomata in the ureter withthrombosis in the long collaterals. Hence the importance of gentledissection and retraction-and the danger of the ureteric tape whichangulates the ureter under tension. The ureter also derives many finetwigs from the peritoneum and should not be dissected from this structurefurther than is absolutely necessary. Ureteric fistulae will always be arisk of pelvic exenteration since the ligation of the internal iliac artery atits root is an essential step in the operation and deprives the ureter at onefell swoop of the bulk of its pelvic blood supply.

Congenital Abnomalities of the UreterThese are many and varied and some knowledge of them is essential to

the pelvic surgeon. The ureter is developed as a bud from the posterioraspect of the Wolffian duct, close to its entrance into the cloaca. This

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bud eventually forms the kidney pelvis and the ureter proper and comesinto contact with the primitive nephrogenic mass at this stage lying inthe female pelvis. The ureteric bud subsequently divides into the calyces.The primitive kidney now ascends from its pelvic position and, by theeighth week of foetal life, has reached its adult subcostal position. As itascends, it undergoes medial rotation so that the hilum opens mediallyrather than ventrally as in the first instance. This process of rotationexplains why double ureters are usually crossed. During its ascent fromthe pelvis, the kidney receives its blood supply en passant from the variouslarge vessels with which it may come in contact. The kidney may remainin the pelvis permanently or may lie at the pelvic brim. Its blood supplywill, therefore, be anomalous-a point to remember if such a kidney hasto be removed. The opening of supernumerary ureters may occur in thebladder, in the urethra or even in the vagina. In some cases, the ureteris only partially double and bifid in its upper part. It is important toremember the possibility of having two or more ureters since the surgeonmay identify the ureter which opens in the vagina and safeguard it, whilecutting the best ureter with a clear conscience. It is also important toremember that congenital anomalies in one kidney may be associatedwith a rudimentary or aplastic kidney on the other side and this isespecially true of the ectopic pelvic kidney. Not only may such a kidneybe single but it may be associated with developmental defects in Mueller'sduct, such as absence of the vagina. The author well remembers the caseof a young married girl whose main complaint was non-consummationof her marriage; on examination, the vagina was represented by a perinealdimple; on rectal examination, she was found to have a firm pelvictumour and this was thought to be a haematometra due to a failure ofcanalisation of the lower part of Mueller's duct. At operation, it wasfortunately recognised that the haematometra was her only ectopickidney. Removal of such a pelvic tumour would be a disservice to thepatient, and Bland Sutton's famous adage should be constantly borne inmind: " Many people manage well with no brains but you must havepart of one kidney."The possibility of ectopic ureter should always be remembered in

dealing with an obscure case of incontinence. The history is one ofconstant leakage of urine associated with normal periodic micturition.Such patients may be treated for a long time and even operated on forso-called stress incontinence. A full urological investigation wouldquickly establish the correct diagnosis. The aberrant ureter may betransplanted into the bladder or a hemi-nephrectomy or nephrectomycarried out. The exact decision depends upon the importance of theaberrant ureter with regard to kidney drainage and the presence orabsence of infection.The final lesson to be learned from the possibility of ureteric abnor-

mality is that any large pelvic operation in which the ureter is going to bein jeopardy, should never be performed without a complete urological

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investigation so that the surgeon starts his operation forewarned of thedangers which lie ahead.

Ureteric Compression and Obstruction from Extraneous SourcesIt is unfortunately not well recognised by gynaecologists that many

conditions in the female pelvis are associated with moderate degrees ofureteric obstruction:

(a) Uterine prolapse.-In complete procidentia of the uterus, themain supporting structure of that organ, namely, Mackenrodt's ligament,is greatly elongated and, in its descent with the uterus, a loop of theureter is drawn down and lies outside the vaginal orifice. This processcauses an acute angulation of the ureter and it is not surprising that itgives rise to hydro-ureter and hydro-nephrosis. The uterine arteries mayalso compress the ureter as they become elongated by the descent of theuterus. Many of these patients have a chronic urinary infection and this,associated with ureteric obstruction, may seriously impair their renalfunction and render them bad operative risks.

(b) Pelvic tumours.-These may cause compression and obstructionof the ureter and this is especially the case of a tight-fitting myoma whichlies firmly embedded in the pelvis. Ovarian cysts, benign and malignant,and even pelvic inflammatory disease produce the same picture. Suchpatients should have a thorough urological investigation before operationsince roughly half of them would show some ureteric obstruction and thismay well account for a post-operative urinary infection in gynaecologicalpatients. Removal of these tumours will restore the urinary tract to normalin 70 per cent. of cases. The worst offenders are those in which theobstruction is due to pelvic inflammatory disease, where permamentstricture formation has occurred in a segment of the ureter.

(c) Carcinoma of the cervix and other malignant infiltrations of thebroad ligament. Although the ureter is guarded by a tough sheath inthe ureteric canal against actual malignant infiltration, its situation inthis tunnel is a grave danger since it is particularly subject to compression.It is an absolute dictum of the author that no case of cancer of the cervixshould ever be treated by surgery or radiation until a preliminary uro-graphic study has been made. Those cases which show ureteric obstructionhave an infinitely poorer prognosis and it must be remembered that40 per cent. of cases of carcinoma of the cervix die, not of their primarydisease, but of bilateral renal obstruction. In these cases, the surgeon'sknife has been regarded in the past as the great menace to the ureter buteffective radiation of an infiltrated parametrium is an equal if not greatermenace since the resulting fibrosis eventually garrottes the ureter. Thisprocess is not immediate or spectacular and may develop over monthsor even years and the patient may well be cured of the local disease tosuccumb, at a later date, to the urinary obstruction.

(d) Obstruction at the site of a fistula.-Many ureteric fistulae healspontaneously and, while this is a gratifying process to surgeon and

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patient, the net results of such a cicatrix may be disastrous to the affectedkidney. By the same token, uretero-ureteric anastomosis of a uretersectioned too high to be implanted into the bladder, is, unfortunately,too often followed by stricture formation at the site of the junction.Such a patient should be carefully followed up by a competent urologistand frequent pyelograms should control the conduct of the case. Aperiodic dilatation may well save the kidney but many of these patientsend up with a nephrectomy. This was the fate of one of my own casesin whom the ureter was sectioned at the pelvic brim; immediate uretero-ureteric anastomosis was performed over a ureteric catheter and at first,the result was gratifying; a stricture developed, however, followed by ahydro-pyonephrosis and the patient lost her kidney. It is questionablewhether uretero-ureteric anastomosis is a good operation and it is probablybetter to implant a ureter sectioned at a high level straight into the bowelas a primary procedure.

(e) Pregnancy.-Not all general surgeons are conversant with thefact that pregnancy has a profound effect on the ureter and kidney pelvis.This is due to the specific action of progesterone on all smooth musclethroughout the body. The gastro-intestinal tract and gall bladder, themusculature of the veins and the ligaments of the spine and pelvis areall affected. The changes are most remarkable, however, in the urinarytract and appear by the fourth month, to reach a maximum at term.After pregnancy, this process of hydro-ureter slowly involutes andshould have returned to normal at the end of the puerperium, certainlyby the third month. If, however, a severe infection results in a pyelitisor pyelo-nephritis of pregnancy, the process of involution may neverbe completed and permanent damage may ultimately lead to nephrectomyin such a patient. The cause of this ureteric dilatation is not compressionfrom the growing uterus since it occurs before such obstruction canoperate. It is more frequently noticed on the right than the left and isprobably due to some distortion of the ureteric canal by the dextro-rotation and dextro-position of the pregnant uterus which is so frequenta finding at operation such as Caesarean section. This physiologicalhydro-ureter calls for no treatment and is only of interest to us as beinga probable cause of pyelitis of pregnancy.

TraumaIn our anatomical considerations, the various situations in which the

ureter is likely to be damaged have been considered. The knife, scissors,clamp (partially or completely applied), needle, ligature and avascularnecrosis can all operate to the detriment of the ureter. Finally, thesurgeon may deliberately resect a part of the ureter in order to overcomethe risk of leaving a small area of malignant infiltration, or he maydeliberately cut the ureter in order to implant it into the bowel. Allthese accidents and procedures may result in a subsequent fistula. Themost likely cases in which the ureter may be damaged are those of

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carcinoma of the cervix, body and ovary, endometriosis, pelvic inflamma-tory disease (not forgetting tuberculosis) and tumours which haveburrowed into the broad ligament under the ureter and lifted it overthe dome of the tumour or displaced it laterally. Sometimes ovariancysts burrow retro-peritoneally and may actually surround the ureterwhich lies in a tunnel in the cyst. Such cases obviously cause uretericobstruction but the chief danger lies in the distortion of the normalureteric anatomy. The cardinal rule which should never be broken inthese cases is to cut nothing and clamp nothing until the ureter has beenidentified and isolated in its entire extent. An excellent safety measure,when in doubt, is to identify the ureter high up at the brim of the pelviswhere it is readily found, and to follow it down to the bladder. Anothergolden rule is never to cut, clamp or ligature anything in the dangerzone without previously identifying and safeguarding the ureter. Duringthe operation, it frequently happens that large friable veins are tornin the uterine and vaginal plexus. Rapid and alarming haemorrhagewells up in the wound and the surgeon, in his angor animi, may call fora clamp and blindly plunge it into the morass of haemorrhage to staunchthe bleeding vessel. This understandable and momentary aberration onhis part must be strongly condemned and he must remember the lessonhe has learned when the renal pedicle is torn and follow the advice ofa great French urologist, namely, to pack the area firmly and tightlywith dry gauze, exert compression, go away and smoke a cigarette, andcome back in a few minutes, remove the pack and quietly pick up theoffending vessel under direct vision and ligate it without fuss or flurry.A competent pelvic surgeon will almost always recognise that he has

cut the ureter the moment he has done so and, if the position in whichit has been cut is in the region of the uterine vessels, uretero-cystotomyshould be immediately performed and, as a rule, the end results willbe satisfactory although such an anastomosis demands periodic assessmentto obviate the danger of stricture formation. If the ureter is cut toohigh to be implanted in the bladder, the surgeon has a choice of performinguretero-ureteric anastomosis over a ureteric catheter or of implantingthe ureter in a convenient adjacent piece of bowel according to his ownconvictions and the indications of a given case. Drainage to the site ofthe anastomosis in these cases is usually unnecessary, but it is wise toprovide drainage to bladder or bowel by an indwelling catheter for10 to 14 days, until the junction becomes secure. It is important toremember that there must be no tension on the anastomosis whether itbe bladder or bowel and it is better to put a ureter in the bowel withouttension than to place it in the bladder on the stretch.The problem of the immediately recognised injury from cutting or

clamping is, therefore, not a great one and the end results are, on thewhole, satisfactory. Damage from clamp or ligature, however, whetherpartial or complete, may not be recognised at the time and, subsequently,may result in fistula formation. If the ureter has been clamped for a

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short period and this is immediately recognised, removal of the clampand inspection of the area of damage may be all that is required butit is wise to provide separate stab drainage to the site of the injury.Such a ureter is liable to stricture formation and may need subsequentimplantation. If the surgeon is in any doubt as to the viability of theclamped area, he had better cut it proximally and implant it immediately.If a ligature has been passed round the ureter, in a few fortunate cases,the affected kidney, if sterile, will undergo a quiet aseptic necrosis and,apart from a little pain in one loin, little untoward will be noticed. If,however, the disaster is bilateral, the patient will, of course, have completesurgical anuria and exploration will be performed within 24 hours.Attempts to deligate the ureter may be unsuccessful; the operative areais oedematous and the anatomy is obscured by the recent trauma;the removal of the offending ligature may result in severe haemorrhage.In such a case, a quick bilateral nephrostomy may be the safest procedureand this can be followed by a subsequent ureteric transplantation whenthe local reaction has subsided and the anatomy has again become morenormal. The wise surgeon will allow at least three, and preferably sixmonths to elapse before undertaking such a procedure and will onlyconsider it then if full urological investigation is favourable.

The diagnosis of a ureteric fistula should not present great difficulty.The surgeon will have an inkling on which side he was under greatestduress during the operation and cystoscopy should reveal no efflux fromone orifice; he will be unable to pass a ureteric catheter up the offendingside. It is best to postpone a surgical correction of such a fistula for aslong as possible and six months is again a wise interval to wait. Some ofthese fistulae heal spontaneously if left alone and, while awaiting thishappy event, the surgeon can make his patient reasonably comfortableby inserting a large de Pezzer catheter into the vagina and packing it inposition with some vaseline gauze, and connecting the catheter to a lowpressure electric suction pump. This at least keeps the patient reasonablydry and improves her morale considerably. An intravenous pyelogramwill often show moderate hydronephrosis on the affected side and aurinary infection is particularly liable to develop in these patients whichshould be combatted by the usual methods. The subsequent repair ofsuch fistulae is carried out according to the principles already laid down.It is the author's view that, unless the kidney is grossly diseased andinfected, nephrectomy should not be performed in these cases as a primaryoperation and this is especially so if the contralateral kidney shows anyimpairment of anatomy or function.

Ligation of the UreterThis facile and antiquated operation is mentioned only to be heartily

condemned. It is the last resort of a poor surgeon and a dishonest anddangerous short-cut out of difficulty.

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Pelvic ExenterationLargely owing to the pioneer work of Brunschwig (at the Memorial

Hospital, New York), a number of cases of advanced pelvic cancer inwhom the growth is localised to the pelvis, are being treated by some formof pelvic exenteration. This operation is only justifiable in those cases inwhich involvement of the bladder or rectum contra-indicate radiationbecause of the very probable danger of fistula formation. In many ofthese cases, a full course of radiation will have already been performedand the growth found to be radio-resistant. The most suitable cases arethose in which the bladder alone is involved and the uterus, vagina andbladder can be removed in one block with implantation of the ureters intothe large bowel. This operation has been facetiously dubbed the NorthAmerica. The pan-America is the complete evisceration of all the pelviccontents, including the rectum, and postulates some form of wet colostomywhich many surgeons regard as officious and intolerable. There are,however, a few women, performing an active social and domestic life,in whom this operation has at least been temporarily successful and,depending upon the psychological and physical stamina of the patient,it is undoubtedly justified in a small number of cases. The modern trendamongst the pioneers of this advanced pelvic surgery is to form anartificial urine receptaculum from an isolated loop of small or largebowel and to provide a separate colostomy for the colon in the left flank.This gives the patient two artificial stomata but the colostomy can betrained to operate once a day without trouble and the collection of cleanurine from a separate stoma is a less unpleasant and messy business. Awet colostomy, dribbling a dilute mixture of faeces by day and night, canonly be described as a damnable procedure. Moreover, the absorption ofelectrolyte from the colon may leave the patient in a dangerous state ofhyperchloraemic acidosis which necessitates constant correction byalkali.The interest of uretero-colic anastomosis lies in the grave danger of

subsequent stricture formation at the site of the junction with the develop-ment of hydro-pyonephrosis and ultimate renal failure. The followingcase well illustrates a typical case history :-Mrs. F., aged 28, five yearsago received a full course of irradiation for cancer of the cervix; thegrowth was quite radio-resistant and it involved the bladder at the timeshe was seen by the author. An abdomino-vaginal total cystectomy anda pan-hystero-colpectomy and lymphadenectomy was performed, theureters being transplanted into the sigmoid. A study of the pyelogramsbefore operation, at three years and four-and-a-half years shows thatthe right kidney eventually developed a pyonephrosis from occlusionof the ureter by a metabolic stone, which necessitated nephrolithotomyand nephrostomy, and the progressive development of hydronephrosison the left. In spite of all this, however, the patient is extremely well atthe moment of writing and the operation has undoubtedly given her a newlease of five years of life-as such, it is considered justifiable.

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The common hazards to which the ureter may be submitted have beenbriefly traced but one further case history will serve to illustrate how thisinnocent structure may be imperilled, even in obstetric practice: amarried woman, with three children, was having her uterus evacuated bya general practitioner who employed, in the removal of the placenta, atoothed ovum forceps. With this instrument, the right uterine wall wasperforated and the right appendages avulsed. A segment of small bowelprolapsed through the hiatus and was promptly seized and torn offits mesentery. The right ureter next became avulsed from the renal pelvisto the vesical junction. In spite of all this, the patient's general conditionwas reasonably fair, her pulse being in the region of 80. Inspectionof the trophies of the operation, however, showed that what was thoughtto be the umbilical cord was, in actual fact, the ureter and a promptlaparotomy, under blood transfusion, completed an operation whichhad been started through the vagina, with resection of the affected areaof small bowel, a right nephrectomy and a hysterectomy. The patientsurprisingly, recovered and, two years later, is a fit and active woman.

MONTHLY DINNERSMonthly dinners are held in the College on the Wednesday before the

second Thursday of each month. The following are entitled to attend withtheir guests: all Diplomates and students of the College and Members ofthe Associations linked to the College through the Joint Secretariat.It is not necessarily intended that guests should be members of the medicalprofession.The dinners will be held at 7 p.m. on the following Wednesdays:

December 8, 1954, January 12, and February 9, 1955.The cost is £1 10s. Od., which includes cocktails before dinner and wine

at the table. Applications for tickets, accompanied by a cheque for theappropriate amount, must be sent to the Deputy Secretary at least aweek before the date of the dinner. Cheques should be made payable to"Royal College of Surgeons of England." The dress is Lounge Suit.

ROYAL COLLEGE OF SURGEONS OF ENGLAND CLUBFacilities for Dinners.Many medical societies and hospital medical staff associations now

hold their dinners at the College. These take place in the new GreatHall. At the moment it is possible to cater for any number of guests upto two hundred and fifty.The cost of the dinner varies with the menu and wines chosen. The food

is prepared by the College catering staff, and a wide range of the very bestwines is available.

All enquiries should be addressed to Mr. W. F. Davis, Deputy Secretary,at the College. HOLborn 3474.

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