MCCARTHY ET ALll
LASER SURGERY FOR SUPERFICIAL MALIGNANCY
anaesthetist indicated that positive pressure respiration during the surgery would be more likely to have been the cause. The patient recovered uneventfully. The depth of penetration of the laser is such that penetration of the muscles and pleura would be unlikely unless the laser was used extremely carelessly. The laser will probably not have a large place in routine general surgery; it is more difficult to use than the scalpel, and in those operations where blood loss is not a major factor, offers no specific advantages over the scalpel and diathermy techniques currently in use. The laser does appear to have a specific place in the treatment of superficial malignancy and malignancy of the soft tissues. In these areas it does minimize blood loss and provide good vision for the operator, and does achieve a satisfactory extirpation of the lesion. In addition, there are the potential advantages of lymphatic sealing and destruction of tumour cells
should the line of incision pass through tumour tissue. ACKNOWLEDGEMENTS The surgical laser was purchased by public donation. The assistance of the members of thestaff of Sydney Hospital and a large number of private donors is gratefully acknowledged. A substantial donation from the Kirby Foundation enabled the appeal to be successfully concluded. REFERENCES KETCHAM. A. S., HOYE. A. C. and RIGGLE.G.C. (1967). Surg. Clin. N. Amer., 47: 1249. MCGUFF.P. E., DETERLING. R. A., GOTTLIEB.L. S., FAHIMI. H. D., BUSHNELL. D. and ROCHER. F. (1965), Dis. Chest, 48: 130. R. ., GOTTLIEB.L. S.. FAHIMI,H. D. MCGUFF.P. E.,DETERLING. and BUSHNELL.D. (1964). Ann. Surg., 160: 765. MAIMAN.T. H. (1960), Phys. Rev. Lett., 4: 564. MINTON.J P., MOODY.C. D., DEARMAN. J. R.. MCKNIGHT. W. B. and KETCHAM. A. S. (1965). Surg. Gynec. Obsttt., 121: 5
SUCCESSFUL RECONSTRUCTION OF THE UPPER URINARY TRACT BY A COMBINED BOAR1 FLAP URETEROPLASTY AND TRANSURETEROURETEROSTOMY S. K. SHARMA,B. C. BAPNA AND R. C. RATH Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Acute obstructive uropathy, following an abdominal hysterectomy In a 45-year-old woman, had been temporarily circumvented by bilateral nephrostomy. Reconstructionof the upper urinary tracts, in the face of a small, defunctionallzed bladder, was successfully accomplished by a Boari flap ureteroplasty and transureteroureterostomy.
CLINICALRECORD A 45-year-old woman had required bilateral nephrostomyfor anuria, developing after an abdominal hysterectomy for fibroids. Subsequently, for some unknown reason, the nephrostomy catheters had been removed, and the patient developed urinary leaks per vaginam as well as from the left nephrostomy stoma. At this stage she was referred to us. The patient was grossly emanciated. and pale but alert. Routine investigations, included blood biochemistry, only confirmed the presence of anaemia and low serum protein levels.
Reprints: Dr S. K. Sharrnd. Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh. 160012, India.
AUST N.Z. J. SURG, VOL 48 - No 6,DECEMBER, 1978
High-dose intravenous phyelography (Figure 1) showed bilateral hydroureteronephrosis and a large contrast-filled cavity at the lower end of the right ureter. Keeping i n mind the poor general status of the patient and grossly obstructed upper urinary tracts, a right nephrostomy was reestablished. Following this procedure, the leak per vaginam stopped. She required multiple blood transfusions and a high protein and high caloric diet before she was in a condition to have the formal reconstructive surgery. The patient was explored o n April 4, 1975, exactly three months after her injury. After a difficult but meticulous dissection, it was discovered that the gap between the lower ends of the ureters and the bladder was too large to be easily bridged. A Boari flap ureteroplasty was undertaken on the right side, whereas such a procedure could not be accomplished o n the left side. because the defunctionalized bladder had become
661
PLASTIC RECONSTRUCTION OF UPPER URINARY TRACT
SHARMA ET ALll
small. Therefore a transureteroureterostomy by anastornosing the left ureter to the right over a silastic stent, well above the Boari flap, was undertaken. The postoperative period was complicated by profuse urine leakage, which necessitated left nephrostomy. Following this procedure, the urinary leakage stopped and the patient recovered well. The nephrostomy catheters were removed after pyeloureterography through the nephrostomies had shown free flow of the contrast medium down to the bladder. Intravenous pyelography before the patient's discharge from the hospital (Figure 2) showed the transureteroureterostomy and the Boari flap ureteroplasty, with significant regression of the hydronephrotic changes. The bladder had enlarged to its original size. She has been on regular follow-up and is doing well 34 months after surgery.
DISCUSSION
Bladder-flap ureteroplasty, psoas-hitch procedure, transureteroureterostomy, the use of isolated ileal segments, and renal autotransplantation, are all well-established procedures of repairing large lower ureteric defects. But the problem in bilateral large defects associated with a small defunctionalized bladder is unique in the sense that successful employment of any one of these procedures may not be practicable. A normal bladder capacity is important in that asmall bladder may preclude any type of antireflux or bowel
nGURE 2: Significant regression of the hydronephrotic changes, and the transureteroureterostomy and Boari flap ureteroplasty.
anastomosis (King, 1976). A small defunctionalized bladder, uncomplicated by fibrosis, would usually regain its normal capacity when either a previously diverted urinary tract is rendered undiverted or periodic hydrostatic bladder distention is practised. In the present case, it is a matter of conjecture whether hydrostatic distention therapy would have made bilateral bladder augmentation procedures possible. It is thus suggested that while considering reconstruction of the renal units in such cases, a r e c o u r s e may be h a d t o c o m b i n i n g a transureteroureterostomy with a bladder flap ureteroplasty. Such a procedure may prove to be safer and less formidable. A similar experience has been reported only once before (Weems, 1970).
REFERENCES FIGURE 1: Bilateral hydroureteronephrosis. with a large contrast-filled cavity at the Iower end of the right ureter.
662
KING, L. R. (1976). J. Urol. (Baltimore), 115: 296. WEEMS, W. L. (1970), J. Urol. (Baltimore), 103: 50
AUST.N.Z. J. SURG.. VOL. 48
- No. 6, DECEMBER. 1978
LASER SURGERY FOR SUPERFICIAL MALIGNANCY
anaesthetist indicated that positive pressure respiration during the surgery would be more likely to have been the cause. The patient recovered uneventfully. The depth of penetration of the laser is such that penetration of the muscles and pleura would be unlikely unless the laser was used extremely carelessly. The laser will probably not have a large place in routine general surgery; it is more difficult to use than the scalpel, and in those operations where blood loss is not a major factor, offers no specific advantages over the scalpel and diathermy techniques currently in use. The laser does appear to have a specific place in the treatment of superficial malignancy and malignancy of the soft tissues. In these areas it does minimize blood loss and provide good vision for the operator, and does achieve a satisfactory extirpation of the lesion. In addition, there are the potential advantages of lymphatic sealing and destruction of tumour cells
should the line of incision pass through tumour tissue. ACKNOWLEDGEMENTS The surgical laser was purchased by public donation. The assistance of the members of thestaff of Sydney Hospital and a large number of private donors is gratefully acknowledged. A substantial donation from the Kirby Foundation enabled the appeal to be successfully concluded. REFERENCES KETCHAM. A. S., HOYE. A. C. and RIGGLE.G.C. (1967). Surg. Clin. N. Amer., 47: 1249. MCGUFF.P. E., DETERLING. R. A., GOTTLIEB.L. S., FAHIMI. H. D., BUSHNELL. D. and ROCHER. F. (1965), Dis. Chest, 48: 130. R. ., GOTTLIEB.L. S.. FAHIMI,H. D. MCGUFF.P. E.,DETERLING. and BUSHNELL.D. (1964). Ann. Surg., 160: 765. MAIMAN.T. H. (1960), Phys. Rev. Lett., 4: 564. MINTON.J P., MOODY.C. D., DEARMAN. J. R.. MCKNIGHT. W. B. and KETCHAM. A. S. (1965). Surg. Gynec. Obsttt., 121: 5
SUCCESSFUL RECONSTRUCTION OF THE UPPER URINARY TRACT BY A COMBINED BOAR1 FLAP URETEROPLASTY AND TRANSURETEROURETEROSTOMY S. K. SHARMA,B. C. BAPNA AND R. C. RATH Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Acute obstructive uropathy, following an abdominal hysterectomy In a 45-year-old woman, had been temporarily circumvented by bilateral nephrostomy. Reconstructionof the upper urinary tracts, in the face of a small, defunctionallzed bladder, was successfully accomplished by a Boari flap ureteroplasty and transureteroureterostomy.
CLINICALRECORD A 45-year-old woman had required bilateral nephrostomyfor anuria, developing after an abdominal hysterectomy for fibroids. Subsequently, for some unknown reason, the nephrostomy catheters had been removed, and the patient developed urinary leaks per vaginam as well as from the left nephrostomy stoma. At this stage she was referred to us. The patient was grossly emanciated. and pale but alert. Routine investigations, included blood biochemistry, only confirmed the presence of anaemia and low serum protein levels.
Reprints: Dr S. K. Sharrnd. Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh. 160012, India.
AUST N.Z. J. SURG, VOL 48 - No 6,DECEMBER, 1978
High-dose intravenous phyelography (Figure 1) showed bilateral hydroureteronephrosis and a large contrast-filled cavity at the lower end of the right ureter. Keeping i n mind the poor general status of the patient and grossly obstructed upper urinary tracts, a right nephrostomy was reestablished. Following this procedure, the leak per vaginam stopped. She required multiple blood transfusions and a high protein and high caloric diet before she was in a condition to have the formal reconstructive surgery. The patient was explored o n April 4, 1975, exactly three months after her injury. After a difficult but meticulous dissection, it was discovered that the gap between the lower ends of the ureters and the bladder was too large to be easily bridged. A Boari flap ureteroplasty was undertaken on the right side, whereas such a procedure could not be accomplished o n the left side. because the defunctionalized bladder had become
661
PLASTIC RECONSTRUCTION OF UPPER URINARY TRACT
SHARMA ET ALll
small. Therefore a transureteroureterostomy by anastornosing the left ureter to the right over a silastic stent, well above the Boari flap, was undertaken. The postoperative period was complicated by profuse urine leakage, which necessitated left nephrostomy. Following this procedure, the urinary leakage stopped and the patient recovered well. The nephrostomy catheters were removed after pyeloureterography through the nephrostomies had shown free flow of the contrast medium down to the bladder. Intravenous pyelography before the patient's discharge from the hospital (Figure 2) showed the transureteroureterostomy and the Boari flap ureteroplasty, with significant regression of the hydronephrotic changes. The bladder had enlarged to its original size. She has been on regular follow-up and is doing well 34 months after surgery.
DISCUSSION
Bladder-flap ureteroplasty, psoas-hitch procedure, transureteroureterostomy, the use of isolated ileal segments, and renal autotransplantation, are all well-established procedures of repairing large lower ureteric defects. But the problem in bilateral large defects associated with a small defunctionalized bladder is unique in the sense that successful employment of any one of these procedures may not be practicable. A normal bladder capacity is important in that asmall bladder may preclude any type of antireflux or bowel
nGURE 2: Significant regression of the hydronephrotic changes, and the transureteroureterostomy and Boari flap ureteroplasty.
anastomosis (King, 1976). A small defunctionalized bladder, uncomplicated by fibrosis, would usually regain its normal capacity when either a previously diverted urinary tract is rendered undiverted or periodic hydrostatic bladder distention is practised. In the present case, it is a matter of conjecture whether hydrostatic distention therapy would have made bilateral bladder augmentation procedures possible. It is thus suggested that while considering reconstruction of the renal units in such cases, a r e c o u r s e may be h a d t o c o m b i n i n g a transureteroureterostomy with a bladder flap ureteroplasty. Such a procedure may prove to be safer and less formidable. A similar experience has been reported only once before (Weems, 1970).
REFERENCES FIGURE 1: Bilateral hydroureteronephrosis. with a large contrast-filled cavity at the Iower end of the right ureter.
662
KING, L. R. (1976). J. Urol. (Baltimore), 115: 296. WEEMS, W. L. (1970), J. Urol. (Baltimore), 103: 50
AUST.N.Z. J. SURG.. VOL. 48
- No. 6, DECEMBER. 1978
