F

ROM there
DETROIT, the early days of kidney surgery, has been dissatisfaction among A surgeons with nephrectomy as the invariable treatment of hydronephrosis. It, of course, reheved the symptoms, but frequentIy at the expense of functioning kidney tissue. When the opposite kidney was normaI, this was of IittIe consequence, but when the other kidney was absent or markedIy diseased, it was disastrous.
ROM there
So it is not surprising that quite earIy in the modern era attempts were made to devise pIastic operations which wouId give an ahernative to nephrectomy or permanent nephrostomy.
ROM there
The first attempt of this kind was by TrendeIenburg in 1886, but it remained for Kuster, in I 891, to demonstrate that such operations couId be successful, and he made the prediction that in time such operations would become the usua1 and accepted method of treatment for hydronephrosis. His success encouraged others to similar efforts, chief among them being Israel, Albarran, RiedeI and KiimmeII. In rgo8, Kroiss was abIe to find in the literature 102 instances of pIastic operations on the peIvis, of which seventy were considered successful by the standards of the time, and three years This fact argues for unfamiliarity on the part of the profession in genera1 with the methods which can be empIoyed; for the Iack of confidence in pIastic operations as a remedy for hydronephrosis; or possibIy for a lack of agreement as to the preferabIe type of operation and Iack of standardization of procedure. Moreover, it is objected that in some cases reported as successfu1, the evidence of success is inconcIusive, and there seems to be an impression current Ormond-Hydronephrosis ing well. WiIdboltz used Kuster's operation on a large infected traumatic hydronephrosis and twenty years Iater it stiIl showed some function, and in the meantime had been symptom free. In another instance he performed a Fenger operation on a hydronephrosis the size of a child's head, and found sixteen years later, that there was onIy slightIy Iess function on this side than on the other. In two other cases there were good resuIts sixteen years after pyeloneostomy. Von Lichtenburg, sixteen years after pyelo-uretero-neostomy, removed the kidney for carbuncIe and found it functioning. He aIso had another case in which the other kidney was removed sixteen years later, and the patient survived.
ROM there
These isoIated reports sureIy prove that permanent success of pIastic operations is possible, but indicate nothing as to the frequency of success. A review of the resuIts obtained in a Iong series of such attempts by many different operations is necessary to the appraisal of the chances of sucCess, the determination of the indications and contra-indications for operation, and for decision as to the best methods of operation.
ROM there
The Iongest series is reported from the Mayo CIinic. Walters, Cabot, and PriestIy report seventy-one pIastic operations in sixty four patients, with fifteen secondary nephrectomies and two deaths. AI1 these were done in the past few years, and in 89 per cent there were satisfactory foIIow-up reports. They regard 70 per cent of their resuIts as at least satisfactory, and report diminution in the size of the peIvis in a large portion of their patients. They favor resection of the peIvis and reimpIantation of the ureter into the portion of the peIvis remaining, though they have used other methods.
ROM there
They have used the spIinting catheter and nephropexy in most instances.
ROM there
From Those who have practiced section of the ureter with reimpIantation, have had no more faiIures than those who preferred uretero-pyeIopIasty.
ROM there
The evidence seems to be hostiIe to the theory of renal CounterbaIance, unless it may be construed as evidence in its favor that solitary kidney or biIatera1 hydronephrosis seem to offer the most favorabIe opportunity for successfu1 pIastic operation.
ROM there
There is difference of opinion as to the value of resection or pIication of the pelvis. On one hand, it is argued that no resection or pIication can restore power to an overstretched and atrophied peIvic muscIe; on the other hand, it is admitted that either procedure wiI1 diminish the residua1 reservoir, which may be worthwhiIe. On the whole, the evidence seems to favor resection, even though it adds to the Iength of operation and to the amount of manipuIation invoIved. I have tried it just once, in a case in which the ensuing failure couId not be bIamed on this procedure.
ROM there
The baIance of opinion and the evidence is rather strongIy against the Fenger operation.
ROM there
It is a seductive procedure-it Iooks simple, but in reaIity it requires finer judgment than the other operations. If the incision through the stricture is a shade too Iong, or if the stricture is long, suturing in the reverse direction may cause puckering and a reformation of the obstruction it set out to remedy. It seems to have been a favorite with those who have undertaken pIastic operations onIy once or twice and this may expIain their discouragement with piastic surgery. Nevertheless, there are those who feel that this operation has a pIace, and who have used it with satisfaction. Two of my faiIures were with this type of operation.
ROM there
The operations of uretera reimpIantation and uretero-pyeIoplasty seem equalIy successfu1 in the hands of those who use them. My own preference is for reimpIantation, for it does not necessitate the section of a vascuIar band, and is as appIicabIe to stricture and high uretera impIantation as is uretero-pyeIopIasty.
ROM there
It seems to me simpIer; to require Iess manipulation; and to make Iess demand on the judgment. This however, is onIy a persona1 opinion, and certainry the resuIts obtained by Foley and Creevy speak for themseIves.
ROM there
Three methods of reimpIantation have been mentioned: one in which a smaI1 coIIar of peIvic tissue is excised with the ureter and reimpIanted into the pelvis; the second in which the ureter is aIIowed to project into the pelvis for a short distance, the peIvic waI1 being sutured about it Iike a cuff; and the third in which the ureter is sutured to the peIvic opening with accurate apposition of the cut edges. The evidence of their value is confhcting, and it is possibIe to give onIy a persona1 preference. I prefer the third. It seems to me that it wouId be possibIe to overIook a stricture or vaIve at the juncture, in the first method, and that it would be possibIe to create a vaIve by the second. This Iatter has been reported. However, von Lichtenburg has used the second method with satisfaction and it is possible that Lubash's recentIy described method may eIiminate danger of vaIve formation.
ROM there
I have had two faiIures using the second method, remedied Iater by reoperation with suture in accurate apposition. This successfu1 resuIt, however, may have been due to the Iong continued spIinting of the ureter.
ROM there
There was bridged around a splinting catheter which was Ieft in pIace for a long time, with compIete restoration of the ureter.
CONCLUSIONS
In arriving at fina concIusions, a11 the above facts, opinions, and arguments must be considered, and in addition due weight must be given to the foIIowing: the specia1 importance of conservation of renaI function in certain cIasses of patients-particuIarIy in young women in the chiId bearing age; the fact that with one good kidney, the importance of the other varies inverseIy with the age or directIy with the life expectancy; and the factor of expense and Ioss of time.
CONCLUSIONS
Giving a11 of these their proper weight, it seems to me that the foIIowing fina concIusions are justified : A.
B.
c.
B.
PIastii surgery is indicated in chiIdren and young aduIts, especiaIIy in young women in the chiId-bearing age. Nephrectomy is the preferabIe procedure after the age of 30. In the middIe years, decision should be based primariIy on the experience of the surgeon in this type of surgery; and secondariIy, on the financial status of the patient;
B.
for faiIure means increased expense and a Iengthened period of disability-matters of serious import to the vast majority of patients.
B.
3. If pIastic surgery is decided on, one of the proven methods of ureteropyeIopIasty, or section and reimpIantation, shouId be chosen, rather than the Fenger operation.

{'paper_id': '72023094', 'title': 'End-results of plastic operations on the kidney pelvis for hydronephrosis', 's2_url': 'https://api.semanticscholar.org/CorpusID:72023094', 'source': 'S2ORC'}