Posted by CLDing on February 17, 1998 at 10:11:19:
In Reply to: Re: Fistula posted by C S Loh on February 17, 1998 at 05:08:58:
I find it very difficult to buy the story that pelvic sepsis caused the fecal fistula
and the right ureter to fistulate. We all have seen enough of acute pelvic abscesses to
know that they do not burst into the rectum or bladder or ureter or uterus, unless there
was a previous breach of any of these organs.
Remember the classic teaching of cannulating both ureters while operating at the base of
the bladder or doing reimplantation? In a diseased state as in surgical trauma, infection,
etc, it can be shocking how close the 2 ureters are? I do not routinely cannulate but
certainly will if I am unhappy. Often I cannulate the contralateral ureter during a
difficult reimplantation just to make sure I have not rogered it. This is especially so
with repair of vesico-vaginal fistula. I will not be surprised if the injury was sustained
during the first reimplantation. That is why I ask about the dissection. There is a very
wise teaching in reconstructing such injuries - dissect the ureter from the iliac vessel
until the site of injury which is the site you encounter all the tightness and 'cement'
and stop there. Of course if you are doing it on really fresh injuries (within the first 5
days or so, you should try to take down all the stitched up areas and release the
ureter(s).
Trying to get distal to the point of injury invites trouble when you have to go in the 2nd
week or later.
I hope I am not sounding like a grandfather, and my sincere apologies to the chap doing
the first reimplantation for the suspicion raised.