The Surgery of the Ureters 
and Kidneys. 
By Hunter Roiiu, M. I). 
Prof, of Gynaecology, Western Reserve 
University. TIIE SURGERY OF THE URETERS AND KIDNEYS. 
BY HUNTER ROBB, M. D. 
Prof, of Gynaecology, Western Reserve University. 
Tauffer of Buda-Pesth, has an article of some seventy 
pages in the Archiv fiir Gymecologie, Vol. XL VI., Part 3, in 
which he gives an account of our present knowledge upon 
the subject of the surgery of the ureters and kidneys to which 
he himself has contributed most important additions. It will 
be remembered that the author was associated with Hegar 
in the now classical case of uretero-abdominal fistula in which 
he succeeded in connecting the ureter with the bladder and 
thus saved the patient’s kidney. At that time Simon’s case 
of resection of the kidney stood alone in the literature. 
These two cases together with that of Nussbaum, supplied 
the ground work upon which the immense advances in the 
subject since that time have been mainly based. But al- 
though in the last fifteen years the literature has become 
quite abundant, the various questions which have neces- 
sarily arisen have by no means been settled. The author 
says, “ Since the appearance of Olshausen’s classical work 
upon “The Diseases of the Ovaries,” the surgery of the 
uterine adnexa? has been put upon a scientific basis, and it is to 
be hoped that in a short while we shall be able to say the same 
for the surgery of the ureters and kidneys. He adds, “In 
the meanwhile, we are still living in the time of detail work, 
and it is just now that the contributions of the experienced 
workers may be of great service in clearing up obscure 
points. I therefore consider it opportune to put before you 
my experiences in order that I may do my share in making 
this one of the questions of the day in our medical researches.” 
After giving an account of his work and of the various 
cases wdiich have come into his hands, he ends by summing 2 
Robb: The Surgery of the Ureters and Kidneys. 
up under four heads the conclusions to which his own ex- 
perience and the consideration of that of others have led him. 
A. The Surgery of the Ureters. 
1. The existence of an uretero-abdominal fistula is 
generally considered an absolute indication for nephrectomy. 
The study both from a clinical and pathological standpoint 
of injuries to the ureter occurring during operations for large 
abdominal tumors is as yet by no means complete. 
2. In cases of accidental injury to the ureter every effort 
must be made to adopt some measure which will bring the 
ureter again into connection with the bladder before recourse 
is had to nephrectomy. The possibility of a plastic operation 
by which the cut ends of the ureter can be united is demon- 
strated by my cases. 
3. Subperitoneal tumors which grow deep down in the 
pelvis and push before them the neighboring organs, not in- 
frequently displace the ureter en masse so that the organ is 
often found in an abnormal position, and is exposed to the 
danger of an accidental wound. The danger becomes 
greater when the tumor has pushed itself up between the 
bladder and the ureter, and has separated these organs from 
one another. 
4. The arteria ureterica, a branch of the renal artery 
the existence of which has up to the present time been almost 
ignored, is, in my opinion, of the greatest importance, 
because in trying to stop a hemorrhage deep down in the 
pelvis and in the neighborhood of the dislocated but un- 
recognized ureter we are liable to tie or cut through this 
organ. 
5. In severe operations, the ureter is often freed from 
its connections for a distance of from 10 to Id cm., and lies 
free in the pelvis. In these cases, this part of the organ 
depends for its nourishment entirely upon the arteria ureterica 
which is intimately connected with the fibrous capsule of the 
ureteral wall. Robb : The Surgery of the Ureters and Kidneys. 
3 
6. After difficult laparotomies, especially when stitches 
or ligatures have been laid deep down in the pelvis, it is of 
the utmost importance, before the abdominal wound is 
closed, to make sure that neither of the ureters has been 
ligated. Such an accident may be diagnosed by finding a 
cylindrical mass about as thick as the finger, which is formed 
by the ureter in which the urine is dammed up. In such 
cases the impediment must at all costs be removed. 
7. The accidental ligation of the ureter produces a 
hydro-nephrosis, and later on; on account of the pressure 
of the sterile urine, to atrophy of the substance of the kidney. 
It does not necessarily endanger life. 
8. In the presence of an uretero-vaginal fistula, it is 
advisable to first make an artificial vesico-vaginal fistula after 
which a plastic operation for direct closure is indicated. 
This at any rate must be first attempted before any more 
serious procedure is decided upon. 
9. When a third ureter exists, and when this super- 
numerary ureter empties into the urethra or into the vault of 
the vagina, we should see whether it does not for some dis- 
tance in its course run quite close to the bladder. If this 
is found to be the case, by an epievstotomy, it can be con- 
nected directly with the bladder after which the peripheral 
portion can be destroyed by means of the Paquelin cautery. 
B. Nephrotomy and Nephrectomy. 
1. The most recent researches in the surgery of the 
kidneys point to the necessity of conservative procedures. 
2. My experience goes to support Favre’s theory, that 
when the function of one ureter is interfered with by com- 
pression or ligation, the other kidney can gradually become 
accustomed to compensatory work, so that later on the ex- 
tirpation of one kidney can be well borne, or in other words 
a single kidney can finally do the work of two. 
3. The cause of death after the extirpation of one 
kidney before the other kidney has had time to accustom 4 
Robb : The Surgery of the Ureters and Kidneys. 
itself to the increased work is almost always an acute 
parenchymatous nephritis. 
Other experiments are necessary before we can allow 
the truth of Favre’s theory, that this acute nephritis is due 
to a previous special intoxication of the blood with ptomaines. 
4. Should Favre’s theory be confirmed by future experi- 
mental work, as well as by clinical experience, the extirpation 
of the kidney at a second operation will be indicated. 
5. Whenever in the course of a severe operation in the 
abdominal cavity, the ureter be accidentally cut, extirpation 
of the kidney on that side is not indicated at the time. If it is 
impossible to connect the ureter directly with the bladder an 
artificial uretero-abdominal fistula should be made and 
nephrectomy should be performed later. 
6. Even with a utero-abdominal fistula, under ideal 
circumstances, it might be possible for the corresponding 
kidney to remain absolutely sound. Experience, however, 
shows that owing to an ascending infection, a pyelitis or 
even a nephritis usually follows. Consequently in the case 
of an uretero-abdominal fistula, nephrectomy is indicated. 
7. It has been noticed that through a portion of the 
ureter 10 cm. long, fastened to the abdominal wound, the 
urine is evacuated in peristaltic rhythm. This would justify 
the conclusion that under normal circumstances the 
rhythmical flow of the urine takes place, and as a conse- 
quence of rhythmetical contractions occurring not in the 
ureter, but in the pelvis of the kidney. 
C. Tumors of the kidney. 
1. In the differential diagnosis between renal tumors, 
especially hydro- and pyonephrosis and ovarian tumors, 
errors are not uncommon. Definite clinical signs which 
might aid us are often absent. 
2. A hydronephrotic sack can often empty itself 
entirely without any apparent cause, (intermittent, temporary 
hydronephrosis.) Robb: The Surgery of the Ureters and Kidneys. 
5 
3. A peritonitis following upon a puncture of a renal 
tumor owing to which fluid has escaped into the abdominal 
cavity and the consequent adhesions may render a differential 
diagnosis impossible. 
4. A hydronephrotic sack can easily be freed from the 
connective tissue which holds it, provided that there has 
been no inflammatory complication, or that the inflammation 
has been confined to the peritoneum. If, however, the in- 
flammatory process has been perirenal, the enucleation of 
the sack will sometimes present insuperable difficulties. 
5. The contents of a hydronephrotic sac may become 
purulent in consequence of an ascending catarrhal infection 
of the bladder. In these cases, if the ureter closes, the 
catarrh of the bladder may get well, and thus no proof may 
remain that the infection came originally from the bladder. 
6. In the walls of a hydronephrotic sack of moderate 
size, renal tissue still capable of functioning can often be 
found, the preservation of which is often of the greatest im- 
portance to the patient. 
7. In doubtful cases, an exploratory laparotomy is 
indicated. Such an operation does not necessarily exclude 
the possibility of nephrectomy through a lumbar incision, 
if such be indicated. 
8. When the renal tumor is combined with a retro- 
peritoneal abscess, the operation through the peritoneum may 
be dangerous since the abscess cavity lies close to the 
abdominal cavity. It will not always be possible to recog- 
nize this complication early enough even after a preliminary 
laparotomy, so that whenever such a condition is suspected, 
the lumbar incision should be preferred. 
9. In dealing with hydro- or pyonephrotic tumors, the 
utmost conservatism is to be recommended. The spon- 
taneous cure of such a sack, even after the elapse of months, 
(in our case after 27 months,) may be expected and the 
patient be left with a useful kidney. 6 
Roms: The Surgery of the Ureters and Kidneys. 
10. Tumors of the kidney developing with pregnancy, 
have at present been but little studied. The hydro- and 
pyonephrosis caused by compression of the ureter can eventu- 
ally give rise to a parenchymatous nephritis. Under these 
circumstances the induction of premature labor is indicated. 
11. In the diagnosis of renal tumors, the cystoscope 
plays an important role, more especially with reference to 
the side on which the sound or diseased kidney is situated. 
D. Nephrolithiasis, Renal tuberculosis, Malignant 
tumors of the kidney and Nephrorraphy. 
1. Calculus in the pelvis of the kidney may exist with 
symptoms of an ordinary pyonephrosis. It may have 
existed for many years without giving rise to any character- 
istic symptoms. 
2. In cases of renal calculus nephrolithomy is indicated. 
3. In any case in which a laparotomy is performed for 
an abdominal tumor, it is advisable to palpate both kidneys 
directly, and more when there has been any 
history pointing to the existence of a renal calculus, even 
although the symptoms may have occurred many years before. 
4. In connection with the question of nephrolithotomy, 
it must be remembered that the formation of a calculus in the 
kidney is not infrequently bilateral, and that a successful 
operation may not therefore cure the patient. 
5. The diagnosis of unilateral primary tuberculosis of 
the kidneys is very difficult since both the clinical and the . 
bacteriological examinations are often unreliable. 
6. The justifiability of operation in cases of unilateral 
primary tuberculosis of the kidney is to-day undeniable. 
7. In cases of unilateral tuberculosis of the kidney, 
nephrectomy is indicated. 
8. It may sometimes happen that in the attempt to 
perform a nephrotomy we may encounter an uncontrollable 
hemorrhage coming from the kidney tissue. In these cases, 
we must perforce proceed to a nephrectomy. Robb: The Surgery of the l'refers ami Kidneys. 
7 
9. The high degree of mortality (75%) which has 
been observed after operation for malignant tumors of the 
kidney is attributable to two causes, (1) to the technical 
difficulties encountered during the operation, (2) to meta- 
static infection. Better results can be looked for from (a) 
an early diagnosis and (£) from greater perfection in our 
operative technique. 
10. With respect to the frequency of the occurrence of 
floating kidney, the views of the authorities are at variance. 
In deciding how far the symptoms complained of by the 
patient are attributable to this condition, much depends on 
the opinion of the particular physician. Hence the frequency 
with which some proceed to operation. (Nephrorraphy.) 
11. In cases of floating kidney, fixation is the result 
which should be aimed at, the exact position, i. e., whether 
the kidney should be fastened a little higher up or a little 
lower down, seems to be of but slight importance. 
12. For laying bare the kidney, the lumbar operation 
according to Czerny’s method, seems to be the best. This 
is especially appropriate for the fixation of the kidney since 
the upper surface of the organ, when partially separated 
from its capsule, can be sutured dirpctly to the lumbar fascia 
which has been freed from its fat.