Reconstruction of the Ureter by Means of Bladder Flaps

Abstract

After operations on the lower one-third of the ureter, strictures usually form despite the most careful efforts to prevent them. Considerable clinical and experimental data indicate the difficulties of securing a satisfactory ureterovesical anastomosis and describe methods which it was hoped would solve the problem.

It seemed to us that a modification of the Janeway gastrostomy would offer a procedure for replacing the resected lower portion of the ureter with a tube constructed from the bladder. The literature revealed that Boari conceived a similar idea but his observations were limited to one dog which lived in apparent good health for 4 years after the operation but was never autopsied. 1

Various procedures were tried, each consisting essentially in turning a flap of bladder wall and constructing a tube of it into which the ureter was placed. The most satisfactory type for the preservation of blood supply to the bladder tube or pouch was to turn a flap from the fundus downward, having its broadest portion attached to the base of the bladder and preferably at a point entered by large blood vessels. Likewise, it was desirable to have the base of the flap slightly broader than the free end.

In dogs, this procedure afforded an easy transplantation of the ureter even after a resection of about 5 cm. of the lower part. If a greater length of ureter were removed, the flap could be turned from the base upward towards the fundus as advocated by Boari. In this instance, however, the blood supply to the flap was less abundant, and the position of the artificial tube or pouch varied with the size of the bladder.

Although one could easily maintain the integrity of the bladder tube and could easily effect an anastomosis, a stricture almost invariably formed at the junction of the ureter and the bladder, which in itself defeated the purpose of the operation.