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DISEASES OF THE URINARY SYSTEM (SURGICAL)

(DIAGNOSTIC AND OPERATIVE TECHNIQUES FOR

THE URINARY SYSTEM)

By ELMER BELT
Elmer Belt Urologic Group, Los Angeles, California

In surgery, as in other fields of science, new concepts are created by new

procedures. Advance depends upon the introduction and the progress of new
techniques, which increase our diagnostic acumen, lower mortality and
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morbidity rates, and produce more satisfactory end results. A few of these
innovations are considered here.
Experiments in the perfusion of living organs and tissues with blood cir­
culated by a pulsating mechanical apparatus gradually led to a better under­
standing of the internal environment of the body (1). Failure of the proper
functioning of the kidney, which bears the greatest responsibility for main­
taining this internal environment at its best functioning level, threatens life.
Vividialysis (2) was introduced to substitute for the work of the kidney and
to restore the proper balance of chemicals within the internal environment
of the body. Peritoneal lavage (3), intestinal lavage, and artificial diffusion
through a cellophane membrane, the so-called artificial kidney (4, S, 6), all
have merited and received close attention. Each has been used to help re­
store function through the removal from the body of toxic substances which
would readily have been cleared by normal renal action. In very carefully
selected cases restoration of function has been most frequently accomplished
by the artificial kidney. However, with this instrument there are dangers
from overhydration, from heparin poisoning with resulting hemorrhage, and
from the washing out of essential substances along with the undesirable ones.

TRANSPLANTATION

Better adapted to a surgeon's idea of things is renal homotransplantation

(7). In dogs the duration of functional survival of such homotransplants of
kidneys is about five days with an upper limit of about three weeks. It is gen­
erally thought that antibodies, created in the host by substances in the trans­
planted organ, close the vessels running into the transplant and cause its
death and elimination from the recipient's body. In man the only successful
homotransplants excepting corneal transplants have been from the body of
one identical twin to the other. A recent clinical experiment has renewed in­
terest in the fascinating possibility of renal homotransplantation in man. In
a case report by Gustave J. Dammin and his associates (7), functional sur­
vival in renal homotransplantation is described as having lasted almost six
months. Quoting from their own abstract:
The patient, G.W., was a 26-year-old physician with terminal chronic glomerulone­
phritis. The homotransplant, from an adult patient who died during a cardiac opera-
377
 378 BELT

tion, was inserted into a polyethylene sac and placed subcutaneously into the thigh
with vascular anastomoses to the femoral vessels and with a cutaneous ureteral ori­
fice. Significant function appeared on the nineteenth postoperative day and for five
months the homotransplant excreted between 1,500 to 2,000 m!. of urine per day.
During this period, the patient's condition improved and the blood urea nitrogen
dropped to 33 mg. per cent from an immediate postoperative level of 244 mg. per cent.
The blood pressure remained elevated (220/140), congest ive failure appeared, and
the patient expired six months postoperatively.
Postmortem, the transplanted kidney weighed 340 grams. Vascular anastomoses
were intact and endothelialized. The ureter was slightly dilated and angulated. There
was no pyelone phritis . The host epidermis had grown over the cutaneous portion of
the ureter. The ureter was well vascularized and its smooth muscle intact. No cellular
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reaction was observed at the anastomotic junctions of host and transplant tissues.
Annu. Rev. Med. 1955.6:377-384. Downloaded from www.annualreviews.org

Since the other donor kidney was essentially normal, the advanced atherosclerosis
with luminal narrowing observed in the smaller branches of the renal artery of the
transplant must have developed during its tenure in the recipient.
Microscopically, the glomeruli were normal except for moderate basement mem­
brane thickening. There was advanced atrophy of the tubules particularly in the
cortex . However, some tubules appeared normal or hypertrophied. There was ad­
vanced interstitial edema and moderate lymphocytic infiltration with some mono­
nuclear cells showi ng pyronin ophilia .
The long survival and morphologic cha ng es observed suggest considerable com­
patibility of recipient and donor tissues and suggest that ultimate failure of the trans­
plant resulted from vascular and circulatory changes related to hypertension and
decompensation.

This history-making experiment should greatly stimulate every worker in­

terested in the field o f hom o tra n spla n t a tion and survival through renal
transplants.
DIAGNOSTIC METHODS

A technical achievement attained through the combination of precise

sur g i c al p ro cedure s and e xcel l ent x r ay te chn i qu e is seen in the results ac­
-

complished by combined aortography (8) and retroperitoneal air insufflation.

There is a n e w ly de vi se d method for the presacral inj ection of oxygen for
-

retroperitoneal pneumography (9) in which the needle, through which air is

to be introduced, is passed into the loose areolar tissue betweell the rec tu m
and sacrum. In this method the air travels from that point upward to find
its place within the retroperitoneal spaces around the kidney. This method
is pr oving to be less disturbing to the patient as well as more efficient than
the earlier method of injecting retroperitoneally-placed air or oxygen through
a needle which is passed throu gh the skin into th e p er iren al fo ss a fro m a
point just above the iliac crest. It has as yet brought about no reported
fatalities. With these methods as well as with the aid of laminography,
tumors of the adrenal have been localized and the difficult diagnostic problem
of differentiating between cysts of the kidney which deform the pyelographic
picture and tumors which produce closely similar deformities in the pyelo­
gram has been solved. By means of a o rtogra p hy th e n ormal vasc ular pattern
 URINARY SYSTEM DISEASES 379
can clearly be demonstrated. In renal tumors this pattern is altered in a very
characteristic way. Nodules are revealed in which there are irregularly dis­
tributed masses of vessels. Within some of these nodular areas there are
poorly-defined blurs representing areas of extravasation. Cysts, on the other
hand, appear as round, clear, avascular spaces from which the blood vessels
have been pushed aside by the accumulated fluid which fiIls the cyst. Twelve
per cent of such cysts are associated with malignancies deeply placed in the
base of the cyst itself. Aortography cannot be expected to reveal such areas
of malignancy. By combining aortography with perirenal air insufflation one
more step toward the preoperative diagnosis of renal lesions is accomplished.
Experience with the use of an exploring needle in making aortograms and
in obtaining deep tissue biopsies has brought closer the solution of a similarly
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difficult problem, that of the completely obstructed ureter. Ureteral obstruc­

tions, familiar to the urologist, may arise from stone, tumor, inflammatory
strictures, operative injuries to the ureter, or pressure upou the ureter from
without. If complete occlusion has occurred, intravenous pyelography may
show no excretion of the dye into the renal pelvis. Retrograde pyelography
may also be impossible because the blocked ureter may not permit the up­
ward progress from bladder to kidney of either the ureteral catheter or of in­
jected pyelographic medium, even though the medium is injected under
pressure. The exact degree of ureteral and renal pelvis dilatation above the
point of obstruction and the character and extent of the obstruction there­
fore remain undetermined. The usefulness of percutaneous renal puncture as
a solution for problems of this type has been established (10). The introduc­
tion of a long, large-gauge needle into the renal pelvis directly from the out­
side through the skin and muscles of the back is not difficult. After the proper
placing of the needle into the renal pelvis it is easily possible to pass a plastic
tube into the renal pelvis through such a wide-gauge needle. This effects a
temporary nephrostomy and permits restoration of function to the blocked
kidney by allowing the constant escape of urine through the plastic tube.
Such a tube may be left in place for months. The introduction of a pyelo­
graphic medium (11) through a needle so placed in the renal pelvis permits
pyelography of great clarity as well as ureterography down to the point of
obstruction, allowing a ready and accurate diagnosis to be made in what
would otherwise be an obscure problem. The designation "percutaneous,
needle puncture, antegrade pyelography" to distinguish this procedure from
"retrograde pyelography" and from "intravenous pyelography," terms al­
ready in use, has been introduced by Casey & Goodwin (12) to describe this
procednre of pyelography from above downward by means of a needle in­
serted through the skin and muscles of the back into the kidney pelvis.

SURGICAL TECHNIQUES

Close cooperation between abdominal surgeons and urologists in the

working out and application of newly devised techniques of bowel and
ureteral surgery has resulted in the successful use of isolated lengths of ileum
 380 BELT

(13 to 16) which are substituted for ureters lost through damage or disease.
By this method internal drainage into the bladder is provided for the kidney,
thus avoiding the many disadvantages of external fistulous drainage through
an opening upon the skin.
The production of urinary receptacles for transplanted ureters has pre­
sented an ever-recurring challenge to the resourceful urologist. Transplanta­
tion of the ureters is required in removal of the bladder for vesical carcinoma
and for injuries to the bladder resulting from postirradiation damage which
shrinks the bladder, producing a very painful cystitis. Such changes occur
in the course of treatment of recurrent cancer of the cervix. It is also occa­
sionally necessary to remove the ureters from the bladder because of con­
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genital deformities of the lower urinary tract. Among the current solutions
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for the problem of what to do with ureters removed from their normal posi­
tion is a recently devised operation by which a urinary cloaca is produced
from a short distal segment of a loop colostomy (17). This method has proven
to be very useful, especially for those patients in whom severe postoperative
irradiation cellulitis has followed secondary infection and sloughing of the
intestinal mucosa and in whom vesicovaginal fistulas and vesicorectal
fistulas have formed. This condition necessitates the diversion of the urinary
and fecal streams followed by complete pelvic exenteration. To receive the
ureters in such a patient a short, distal segment of a loop colostomy closed
at its distal end is used. Such a tube of bowel is not traversed by feces. The
ureters entering it are not subjected to the back pressure of fluids and in­
testinal gases as they are when transplanted into the closed bowel, and the
proximal end of the loop which opens on to the abdominal wall comes to lie
close beside the distal end of the colostomy opening which drains the large
bowel. The double colostomy opening is readily covered by a Rutzen bag.
This arrangement does not have the disadvantages produced by mingling
urine and fecal output. Consequently, constant fecal soiling which produces
the foul odor so often associated with a "wet colostomy" is avoided.
Progress in bowel sterilization (18) has continued. With present technics
the large bowel which has been properly prepared may now be opened with­
out fear of peritonitis. Accordingly in the most recently devised method of
ureteral transplantation into the sigmoid (19), the bowel is opened along the
anterior taenia and, through this wide-open aperture made in the wall of the
sigmoid, the inside of the bowel is as clearly visualized as is the inside of the
bladder in a cystotomy (20). The mucosa on the posterior surface of the
sigmoid is then lifted from the muscularis at a site chosen for the transplant
by means of a wheal produced by injecting 1: 10,000 epinephrine in saline
through a needle which pierces the mucosa (21). The elevated mucosa is
incised at this point and a hemostat is passed beneath its surface. With
this instrument a tunnel is created by burrowing the hemostat between
mucosa and muscularis for a distance of 1.5 cm. The hemostat is then turned
laterally, piercing the muscularis of the sigmoid behind the peritoneal attach­
ment. The hemostat is opened. It seizes the distal cut off end of the ureter
 URINARY SYSTEM DISEASES 381
which has previously been detached from the bladder, freed and directed
medially behind the sigmoid. Through the newly-made channel in the bowel
wall the ureter is pulled into the bowel lumen. Delfino Gallo (19) of Mexico,
who was the first to describe this method, also suggests splitting half a
centimeter of the terminal end of the ureter and turning back a cuff of ureter.
This cuff he feels creates a valve and prevents reflux of gas and bowel con­
tent through the ureteral lumen upward into the renal pelvis. The turned­
back mucosal edge of the cuff is attached to the bowel mucosa by means of
interrupted sutures of fine catgut. The opposite ureter is similarly implanted.
The bowel is securely closed. The abdomen may then be closed without
drainage. The use of this method has greatly shortened the hospital stay of
these patients and has lessened the complications which result from leakage
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at the site of the anastomosis. Care in arranging the route of the ureter into
the bowel also prevents angulation of the ureter on its way to the new site
within the bowel lumen. The "French cuff" of Delfino Gallo also lessens
those late complications which result from ureteral reflux of bowel content
into the renal pelvis.
The altered body chemistry resulting from the use of the bowel as a
receptacle for urine has been the subject of intensive study. Early studies
(22) revealed the fact that transplantation of the ureters into the small bowel
invariably produced uremia. The small bowel was shown to be capable of
absorbing anything which the kidneys could excrete. Selective absorption
of some of the constituents of the urine from the large bowel was also seen to
follow ureterosigmoidostomy. Because of the altered chemical composition
of the blood this syndrome became known as "reabsorptive hyperchloremic
acidosis" (23). Women seem to be troubled less by this complication than
are men. Children are best able to adjust to the altered physiology engen­
dered by uretero-intestinal transplantation.
Recent experimental studies on the proper adjustment of food and fluid
intake tend to show a way to prevent unfavorable reabsorption from the
bowel. The irritation brought about by the outpouring of urine into the
mucosa of the large bowel causes the bowel mucosa to excrete sodium into
the gut lumen (24). There is a net higher reabsorption rate from the bowel
lumen for chloride than for sodium. The net water movement follows the
osmotic gradient in direction and rate. The percentage of net reabsorp­
tion of chlorides is found to be low at high total osmotic activity. The
largest percentile net reabsorption of chlorides and urea occurs from the
least concentrated urine specimens. The greatest risk of retention of hy­
drogen ions is present when the amount of hydrogen ions removed from
the body by the formation of a certain quantity of urine is moderate and
especially if it is small in proportion to the total osmotic activity of the urine.
Retention of urea is more apt to occur if the urine poured into the bowel is
hypotonic, and from such dilute urine a greater amount of chloride is ab­
sorbed. Thus, low concentration and moderate acidity of the excreted urine
pr'omote reabsorption which produces hyperchloremic acidosis and elevation
 382 BELT

of the blood urea. To the urologist, used to urging the forcing of fluids to
promote better excretion, this seems paradoxical, but it has been shown
that for patients whose ureters expel their urine into the sigmoid, better
levels of excretion can be obtained by following a regimen which will keep
the urine both concentrated and alkaline in reaction. Reabsorption hyper­
chloremic acidosis may be avoided by observing this simple rule.
It is regrettable that, because of the brevity of this review, there is not
opportunity for full descriptions of new surgical approaches to the kidney.
Intratracheal intubation in anesthesia now permits transthoracic nephrec­
tomies. In some cases in which large renal tumors are to be removed and in
which extensive lymph node dissection may be needed the transthoracic
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route is desirable. The transabdominal transperitoneal approach and the

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transabdominal retroperitoneal approach each permit the exposure of the

pedicle without moving the kidney from its bed, which is a desirable feature
in nephrectomy for renal malignancies. Finally, there is the Nagamatsu (25)
dorsolumbar approach which mobilizes the lower costal cage. In this method
small segments of rib are removed from the twelfth, eleventh, and tenth ribs
near their attachment to the spine. Thus freed from their posterior attach­
ment these ribs may be elevated like a Venetian blind giving an excellent
approach to the kidney or to the adrenal. This approach is especially needed
when an extrapleural retroperitoneal exposure to the kidney is desired as is
the case where the renal pedicle is short, the kidney is high, or a huge calculous
pyonephrosis is to be removed.
Hypospadias.-A plastic operation for the repair of hypospadias has been
presented which can be accomplished simply and in one step (26). It is based
upon the tendency of the mucosa-like epithelium of the underside of the
penis to grow prolifically in covering a defect. An incision extending from the
abnormal urethral hypospadias opening distally to the edge of the glans penis
is made skin d eep on each side of the strip of urethra on the under side of the
-

penis. This strip, lying along the shaft of the penis, is left flat and intact, un­
touched. On each side of it the skin edges ar e deeply undercut and lifted
upward. The undermining and lifting extends also to the skin over the ab­
normal hypospadias opening at the base of the penis. To ease tension in clos­
in g these flaps across the ventral surface of the penis a longitudinal easement
incision, completely through the skin, is made along the full length of the
dorsum of the penis. The denuded raw surfaces of the skin flaps now ap­
proximated on the ventral surface of the penis are brought, raw surface to
raw surface, over the still attached strip of penile skin, now completely
hidden beneath their apposing surfaces. These apposing surfaces are pinned
together with a series of st eel wire sutures which pass through them from
side to side and are held lightly in apposition by the pressure of a bead
against the skin on each side. The bead in turn is kept from slipping by a
section of a small aluminum tube which is crimped onto the suture just be­
yond each bead. The skin edges are then very carefull y sutured into fine ap­
position with a row of minute stitches. Thus, at the end of the operation, onl y
 URINARY SYSTEM DISEASES 383
the roof of the future urethra is present, a roof which lies along the ventral
surface of the penis. In the succeeding days this epithelial tissue will prolifer­
ate rapidly over the raw surfaces which roof it and will form in the recesses
beneath the outer skin a completely intact circular tube or urethra. This
urethra, however, stops at the base of the penis. The new urethra will never
extend onto the glans penis. The operation is easy to perform and accom­
plishes in one step results which are often not obtained by previous methods
in many operative sessions. It has caught the attention of surgeons every­
where.
The principle upon which this hypospadias operation is based, the ready
proliferation of the urethral epithelium, became the basis for an operation
devised for the surgical cure of urethral strictures (27). In this new open
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operation for urethral strictures known as "the buried strip technique" the
urethra is opened throughout its length, exposing the entire urethra from a
point well central to the most proximal of the urethral strictures all the way
to the external urinary meatus. The penile skin of the undersurface of the
penis is now united to the cut edge of the urethral mucosa down each side of
the shaft of the penis along the full length of the newly opened penis. The
urethra now lies widely open. When healing is complete along its entire
length and all edema has disappeared, a wide strip of the urethral mucosa
which previously formed the urethral roof and now is open and exposed on
the under surface of the penis is outlined by incisions running along its full
length just as was done in the hypospadias operation described above. The
edges of the skin which approximate this urethral roof on each side are under­
cut. Their raw approximating surfaces are apposed and pinned together with
steel wire held in place by double stops, a bead and a crimped-on aluminum
tube, over the urethral strip along the full length of the penis. The skin edges
are then carefully and minutely approximated. By proliferation the mucosa
which forms the roof of the urethra grows over the raw surfaces which now
cover it, thus forming a new unstrictured urethra of wide caliber along the
full length of the penis. This urethra, however, stops at the glans penis which,
as in the operation for hypospadias, it does not penetrate. This procedure is
done to remove the necessity of a life-long series of urethral dilatations. It
thus warrants the short period of hospitalization and confinement made
necessary in each of its two steps.
LITERATURE CITED
1. Carrel, A., and Lindberg, C. A., The Culture of Organs (Paul B. Hoeber Inc.,
Medical Book Dept. of Harper & Bros., 221 pp., 1938)
2. Fine, J., Frank, H. A., and Se ligman, A. M., Ann. Surg., 124,857-78 (1946)
3. Ferris, D.O., and Odel, H. M., Proc. Staff Meeting Mayo Clinic, 22, 305-13 (1947)
4. KoHl, W. J., The Artificial Kidney (J. H. Kok N.V. Kampen, Holland, 84 pp.,
1946)
5. Alwall, N., Acta. Med. Scand., Suppl. 133,299-337 (1949)
6. Merrill , J. P., Smith, S. III, Callahan, E. J., and Thorn, G. W., 1. Clin. Invest.,
29,425-38 (1950)
 384 BELT

7. Dammin, G. J., Hume, D. N., Merrill, J. P., Miller, B. F., and Thorn, G. W.,
J. Lao. CUn. Med., 44, 784-85 (1954)
8. Walter, R., and Good win, W. E., J. Urol.,70, 3, 526-37 (1953)
9. Rivas, M. R., Am. J. Roentgenol Radium Therapy, 64, 723 (1950)
10. Weens, H. S., and Florence, T. J., J. Urol., 72, 489-95 (1954)
11. Wickhom, I., Acta Radiol., 41,505-12 (1954)
12. 'Casey, W. C., and Goodwin, W. E., J. Urol. (In press )
13. Davids, A. M., and Lesnick, G. ]., Ann. Surg.,137,289-94 (1953)
14. Rack, F. J., J. Am. Mea. Assoc.,152,516-17 (1953)
15. F oret, J., and Heugshem, C., Lancet, 1,1181 (June 13, 1953)
16. Rack, F. ]., and Simeone, F. A., Ann. Surg.,140,615-22 (1954)
17. Ma ntz,T. P., a nd Kastl, K., West. V. Med. J., 49, (10),279-81 (1953)
18. Poth, E. J.,J. Am. Med. Assoc., 153, 1516-21 (1953)
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19. Gallo, D., and Chacon, J. L. D., Gincologia y Obstetrica de Mexico, 6, (2) (April,
1951)
20. Goodwin, W. E., Harris, A. P., Kaufman, J. J., and Beal, J. M., Surg. Gynecol.
Oostet. 97, 295-300 (1953)
21. Joseph, E. (Personal Communication, Univ. Israel Medical School, Jerusalem,
Israel)
22. Hinman, F., and Belt, E. J. Am. Med. Assoc., 79, 1917-24 (1922)
23. Wilder, C., and Cotton, R., Am. J. Mea., 15,423-30 (1953)
24. Pers, M., Scand. J. Clin. &I Lab. Invest., 6, (3), 189-202 (1954)
25. Nagamatsu, G., J. Urol., 63, (4) 569-77 (1950)
26. Browne, D., Techniques in British Surgery, Chap. 18, 412-18 (W. B. Saunders
Company, Philadelphia, U.S.A., and London England, 1950)
27. Johanson, B., Acta Surg. Scandinavica, 176, 17 (1953)

ADDENDUM
After this review was prepared, the following t wo important works on
renal homotransplantation became available:

1. Miller, B. F., The Problem of Kidney Transplantation in Bradley, S. E., Ed.,

Renal Function: Trans. 5th Conf.,Oct. 14, 15 and 16, 1953, Princeton, N. J.
Uosiah Macy, Jr. Foundation, New Yor k, N. Y., 218 pp., 1954)
2. Hume, D. M., Merrill, J. P., M iller B. F., and Thorn , G. W., J. CUn. Invest., 34,
,

327-382 (1955)