[Reprinted from the American Gynaecological and Obstetrical Journal 
for October, 1896.] /V 
SURGICAL INJURIES TO THE URETERS* 
J. M. Baldy, M. D., Philadelphia. 
Injuries to the ureters are by no means uncommon accidents, 
even though few of them ever find their way into print. The ques- 
tion of the repair of a severed ureter within certain accepted limits 
was a few years ago unsolved, while to-day we stand upon substan- 
tial surgical grounds in saying that the subject is settled beyond 
peradventure. It is true there yet remains some few details in the 
technique to clear up, but the main proposition is accomplished. 
The adoption of such makeshifts as ligation of the severed ends, 
formation of a urinary fistula, or nephrectomy, is ancient history. 
To-day we have but two propositions to consider—uretero-ureteral 
anastomosis and uretero-cystostomy (bladder implantation J). Both 
these procedures have been demonstrated as feasible, first by ex- 
perimentation (Van Hook,J Paoli,# and Busachi) upon dogs, and 
subsequently by various surgeons upon the human subject. There 
are now upon record seven successful operations of this character, 
and it is not too early, I think, to make a comparison between the 
two methods for the purpose of determining which is the better or 
in what class of cases each is applicable. It has been contended 
by some surgeons that these two procedures are not rivals in the 
same field, but are applicable to distinctly different classes of cases. 
In this matter, however, I am compelled to dissent, and the facts 
as well as theories seem to uphold my position. Experience seems 
to demonstrate more and more that bladder implantation is applica- 
ble to a much larger group" than is uretero-ureteral anastomosis, 
* Read before the American Gynaecological Society, May 28, 1896. 
f Baldy, American Gynecological and Obstetrical Journal, November, 1894. 
\ Journal of the American Medical Association, December 16, 1893. 
# Ann ales des Maladies des Organes Gen. Utine., 1888. 
Copyright, 1896, by J. D. Emmet, M. D. 2 
J. M. Baldy, M. D 
and, if any choice must be made between the two methods, this is 
the method of election. In this connection several points present 
themselves for consideration, a careful study of which will materially 
aid us in arriving at an intelligent conclusion. 
It is necessary for the purpose of performing uretero-ureteral 
anastomosis— 
That the two ends of the ureter be perfectly free and easily 
brought together. 
That the bladder end be more patulous (or capable of being 
made so) than the kidney end. 
That the injury to the ureter be sufficiently high in the pelvis 
to enable the surgeon to readily carry out the necessary manipula- 
tions. 
In the case of uretero-cystostomy but one point is necessary— 
That the injury be not too high in the pelvis to enable the kidney 
end of the ureter to be approximated with the bladder. 
Theory is a very good method by which to arrive at a conclu- 
sion if facts be wanting, but where facts are at hand theory is no 
longer of consequence. Applying this axiom to the matter under 
consideration, it will be recalled that seven operations are on record 
for the repair of severed ureters. Of this number two (Kelly and 
Bache Emmett) were of the method uretero-ureteral anastomosis; 
five (Novaro, Kelly, Krug, Penrose, and Baldy) were by the method 
uretero-cystostomy. A careful study of this group of operations 
discloses several important facts: Five of the seven procedures were 
bladder implantations, and in no one of the five could the end-to- 
end anastomosis have been accomplished. Of the two cases of 
end-to-end anastomosis one at least (Kelly *) could have been cor- 
rected with equal success by bladder implantation. In the second 
case (Bache Emmett f) the tear was at an unusually high level, the 
case, in fact, almost unique in this respect. Even in this case it is 
not stated in the report that the bladder and ureter could not be 
approximated. It is therefore evident, as far as practical experi- 
ence demonstrates anything, that uretero-cystostomy can be per- 
formed in almost all these accidents. . 
Analyzing the five cases of uretero-cystostomies, it at once be- 
comes evident, as has been pointed out, that in not a single one 
* Annals of Surgery, January, 1894. 
f American Journal of Obstetrics, April, 1595. Surgical Injuries to the Ureters. 
3 
of them was uretero-ureteral anastomosis possible. The operation in 
the cases of Novaro* and Kelly j- were performed some weeks after 
the original injury, and at a time when the bladder end of the ureter 
was irretrievably lost. In the Penrose £ case the bladder end was 
cancerous, and in both Krug’s # and my own case (| the lower end 
was lost in masses of inflammatory deposits; in addition, the kidney 
end in Krug’s case showed such thickening and friability from in- 
flammatory changes that a uretero-ureteral anastomosis would 
have been impossible, as dilatation of the bladder end could not 
have been made even if it could have been found. Emmett’s state- 
ment, then, that “ it (uretero-ureteral anastomosis) is certainly feasi- 
ble in every case in which there is no loss in continuity, and prob- 
ably in those even in which quite a portion of ureter might be lost,” 
is clearly theoretical, and has no basis in fact. 
The facts established are, therefore, that in the great majority 
of cases uretero-cystostomy is possible. In but a small portion of 
the cases can uretero-ureteral anastomosis be successfully per- 
formed; even where this operation is feasible, in the great majority 
of cases uretero-cystostomy is equally practicable. If this be true, 
and as far as the facts are to be relied upon it is unquestionable, 
uretero-cystostomy is generally the operation of necessity. As to the 
operation of election, where the possibility of both methods present, 
the facts are not so decisive. However, the indications as far as they 
go seem to favor uretero-cystostomy. The points which have been 
considered in this connection are— 
The ease with which each operation may be performed in any 
given case. 
The danger of immediate obstruction. 
The danger of future obstruction. 
The danger of kidney infection. 
As to the first point. Any injury to the ureter at the base of the 
broad ligament or thereabout forces the surgeon in case he desires 
to perform a uretero-ureteral anastomosis to work so low in the 
depths of the pelvis as to render the necessary manipulations very 
difficult, if not impossible; on the other hand, if the injury be at or 
* Centralblatt fur Chirurgie, No. 27, 1893. 
f Johns Hopkins Hospital Reports, February, 1895. 
\ Medical News, April 28, 1894. 
# American Gynecological and Obstetrical Journal, November, 1894. 
|| Baldy, American Journal of Obstetrics, vol. xxxiii, No. 3, 1896. 4 
/. M. Baldy, M. D. 
above the level of the ileo-pectoneal line it is exceedingly difficult 
if not impossible to closely approximate the end of the ureter and 
the bladder. Therefore, within these limitations it is manifest 
that there can be no manner of rivalry between these two methods ; 
it matters not what objection may obtain in either case, we are 
forced to adopt that which is feasible. A3 a matter of fact, how- 
ever, in the vast majority of cases the injury occurs between these 
two points and at a position which allows of the approximation of 
the desired points with more or less ease. In the case of most 
neoplasms (intraligamentary cysts and uterine fibroids), where the 
ureter is severed at a very considerable distance from the bladder, 
it will be found that it is greatly elongated, sufficiently so to com- 
pensate for the high level of the injury and to render it easily 
brought in contact with the bladder. This is oftener true within 
these limits than that the bladder end is found, or if found, is in a 
condition to be used. Of the seven cases reported, uretero-cystos- 
tomy was performed or was feasible in six, and it is not recorded 
that it was not so in the seventh. Therefore, even if the statement 
that “ it (uretero-cystostomy) can only be applied to those cases in 
which the injury is very close to the bladder ” were true, practical 
facts demonstrate that as a rule these injuries occur at a point at 
which this operation is readily performed. Even though there be 
some little difficulty in easily approximating the ureter and bladder, 
such difficulty may be readily overcome, as was done in Kelly’s 
case, by dissecting the bladder to a greater or less extent free’from 
its attachments to the pubis, or by fastening the bladder to some 
fixed point on the pelvic wall by several stout sutures, as was re- 
sorted to in my own case. In neither of these cases was there any 
subsequent trouble either in the bladder, ureter, or kidney, and any 
criticism from that point of view is based purely on theory. The 
danger of immediate obstruction in the two operations does not 
seem to be great. In no one of the seven cases reported has this 
effect been noted, and it would seem that this complication does not 
form a very great element of danger. 
Secondary obstruction would, however, appear as a possible 
defect, although as far as noted no such condition has occurred. In 
view of this possibility the criticism has been offered in the case of 
uretero-cystostomy that “ the ureter is placed directly through the 
walls of the bladder instead of slantingly, as it is in Nature. This 
natural entrance is peculiarly well fitted to guard against a con- Surgical Injicries to the Ureters. 
5 
striction of the canal ; the opening through the viscus is oblong, 
the contraction of the muscular fibers of the bladder is spread over 
an oval length of the ureter, and closure of its lumen is thus made 
impossible.” The objection is again altogether theoretical. The 
arrangement and action of the muscular fibers is quite different 
than as stated, and I think none of the gentlemen who have per- 
formed uretero-cystostomy will for a moment concede that the 
ureter passes naturally more obliquely through the bladder wall 
than it is made to do by the operation. The practical test again 
settles the matter finally. I have personally had opportunity to ex- 
amine two of these cases repeatedly with the cystoscope since their 
operations, one of which was performed about two years ago, and 
there is as yet no signs of stenosis, nor does the flow of urine from 
the ureteral opening in any way different from that of the non-in- 
jured side. In fact it would be well-nigh impossible to tell which 
side had been injured, except for the abnormal position of the open- 
ing on the side on which the operation had been performed. The 
simple precaution of splitting one side of the end of the ureter which 
is implanted into the bladder adds greatly to the certainty of non- 
stenosis. On the other hand, it stands to reason that there is no 
little danger of obstruction in an organ of such small caliber, where 
the opening in one end is (necessarily) narrowed by its forcible in- 
troduction into the other. Should by any possibility stenosis follow 
either operation, is there any one who doubts the greater ease with 
which it could be detected and treated in the case of uretero-cys- 
tostomy ? 
The dangers of kidney infection have been urged against ure- 
tero-cystostomy, but the arguments are too fallacious to stand for 
one moment the test of the facts. The statement is made that 
“ the natural opening of the ureter into the bladder is valvelike, 
which is only patent when the ureter contracts upon its contents 
to force them into the bladder. Under new conditions it is at times 
constricted by the muscular fibers ; it is at other times gaping. 
How can it then stand as a guard to the kidney ? It must allow a 
back pressure when the bladder is full, and more positively still 
when this viscus contracts to empty itself.” There are three propo- 
sitions advanced in this statement, and all three are incorrect. In 
the first place, is the natural opening of the ureter valvelike? I 
conceive not, unless we are to consider that the ureter being more or 
less collapsed throughout its whole length acts in this way as a 6 
J. M. Baldy, M. D. 
valve. In this case the same thing holds true on the injured side. 
Again, I have never heard any one who has had the privilege of see- 
ing through a cystoscope the seat of the operation say that the 
opening was gaping. I have myself seen three of these cases, and 
in none of them did this occur. Finally, the position of the new 
opening, high up on the fundus of the bladder, eminently protects 
it from the chances of septic invasion, and particularly from the 
back pressure caused by the contraction of the bladder on its con- 
tents. Finally, in not a single one of the five operations has kidney 
infection resulted. 
To sum up then, it is clearly evident that in the large majority 
of cases of torn ureter during the course of an operation the injury 
will occur below the level of the ileo-pectoneal line, in which case 
it is amenable to treatment by uretero-cystostomy. 
The danger of stenosis in uretero-cystostomy does not obtain. 
The dangers of kidney infection are mythical. 
All things considered, where the question of choice between the 
two operations arises, if there be any difference, it lies in favor of 
uretero-cystostomy.