J.M. Gil-Vernet

The Ileocolic Segment in Urologic Surgery

When, in 1957, we wrote on ileocystoplasty versus colocystoplasty we started a controversy about which of the two intestinal segments would be the more appropriate for enterocystoplasty. The sigmoid colon seems to be the more advantageous for total or partial bladder substitution. This fact has been proven by clinical results. The ileum, because of its urine-conveying properties, apparently is more suitable for ureteral substitution. We have used the sigmoid colon in 158 cases of vesicoplasty and the ileum in 33 cases of ureterojjlasty. A logical eagerness to improve omresults induced us to use the ileocolic segment. In 1956, together with Arandes Adan,^ ^ we reported a case of contracted bladder, ureteritis and a solitary kidney. This was the first time that the ileocolic segment was utilized to enlarge a small bladder and also provided a substitute for the ureter. Since then we have amended and extended the indications for this operation in many vesical and ureteral lesions. When techniques 1 and 2 for construction of a functioning ai-tificial bladder were described,^ we stated that uieteral reflux almost always followed the procedure. However this type of reflux tends to disappear with time, and usually does not result in upper urinary tract infection. Instead, the reflux causes dilatation of the pyelocalyceal system from which secondary infection may develop or calculi may form, although the latter possibility has not been observed.

Orthotopic Renal Transplant and Results in 139 Consecutive Cases

Although a commonly performed technique, heterotopic renal transplantation may be a cause of late graft failure owing to ureteral stenosis, urinary fistula and vesicoureteral reflux secondary to the immune response. The new retroperitoneal lumbar approach to the splenic vessels has allowed the orthotopic technique to be developed using the splenic artery or aorta, the renal vein and a pyelo-pyelic anastomosis. In this manner the renal graft is located in an anatomical position that is well protected, and with the recipient urinary tract the normal physiology is preserved with comparatively low complication and mortality rates. A third transplant attempt also is simplified. This method is the only alternative in some cases. Transplant ureter pathology symptoms are not observed. The results of 139 consecutive cases are presented.

New surgical approach for treatment of complex vesicovaginal fistula.

Complex vesicovaginal fistulas still represent a management problem, since most of the cases have been operated on previously and because of the lack of a completely successful surgical technique. A new procedure for vesical autoplasty is presented. A flap is obtained from the posterosuperior bladder wall that slides down to cover large lesions, even in low capacity reservoirs. The technique has shown excellent long-term results in 42 consecutive complicated cases.

Urogenital Diaphragm Raising Maneuver

The urogenital diaphragm raising maneuver, a procedure to facilitate membranous urethral surgery, is described. The technique shortens operating time by permitting easy identification and exposure of the severed urethral ends, thus, allowing for precise re-establishment of urinary tract continuity. Selective membranous urethral surgery can be performed with ease, preserving external sphincter integrity. This maneuver represents an advance over any other technique by almost eliminating the risk of stenosis, urinary fistula and incontinence owing to failure of precise reapproximation of the membranous urethra.

New Approach to the Splenic Vessels

The transperitoneal approach is used systematically for an arterial or a venous splenorenal anastomosis. However, this approach is associated with high morbidity and mortality rates. Because of our anatomical and surgical findings we have used the retroperitoneal approach to the splenic hilus by means of the lumbar region. The first splenorenal arterial anastomosis with this approach was done in 1972. The approach has proved to be less aggressive since it avoids the danger of damaging the pancreas, it is a more direct approach to the splenic vessels and it provides better exposure and facilitates the anastomosis. In addition, the loss or infection of ascitic fluid in cirrhotic patients is avoided with this approach, as well as intraoperative hemorrhaging caused by the great surplus circulation. There has been neither mortality nor complications in the 13 cases of arterial and venous splenorenal anastomoses that we have done with this method.

Descent of The Right Renal Vein

A new operation is described, in which the right renal vein outlet is moved to a lower level on the vena cava, helping to decrease the distance between the kidney and the bladder. This procedure permits treatment of extensive obstructive wounds of the pyeloureteral junction or lumbar ureteral junction, caused by lithiasis and ureteral and renal operations, that cannot be treated with conventional operations. Renal circulation is not altered with this procedure. The operation is simple, does not cause complications and provides excellent results.

Advances in Intraoperative Renal Radiography: 3-dimensional Radiography of the Kidney

A renal contact chassis that allows for the discovery of the smallest calculi and calcifications is described. The corrected images are far superior to commercially available plates and there is less radiation exposure to the patient and staff of the operating room. The bases have been established for intraoperative, 3-dimensional radiographic exploration of the kidney, which presently has not been achieved and is no doubt of great significance in operations for lithiasis. The technique represents a decisive aid for the intraoperative localization of residual calculi that allows for complete removal with a minimum of trauma to the kidney.

Functional Results of an Artificial Bladder. Section II

Similar to the heart, the bladder is a hollow muscle cavity which presents its successive stages of systole and diastole. The smooth muscle is capable of responding before a stimulus. Vertebrates do not have an exclusively muscular bladder; but lower vertebrates do. In the latter group, there are some muscular structures which have no nerve supply and which respond from a direct environmental stimulus. We can understand the idea of a human bladder without any nerve supply and which is reacting from a natural surrounding, such as the urine, which it holds and must expel. The specific and physiological stimulus of the vesical muscular fibers is to distend. An exclusively muscular bladder would react slowly and its sensitiveness would be thus restricted. There is a need for complete efficiency, the intervention of a governing element to adjust its activities. The presence of an intrinsic nerve root in the bladder results in co-ordination in the action of the various muscular bundles, as well as an increase in sensitiveness of the bladder thus creating an organ capable of efficacious and autonomous activity. The neuromuscular mechanisms of the original type exist and persist in men. They form the metasympathetic or local autonomous system, which is also found in the heart, blood vessels, gastrointestinal tract and genitourinary organs. It should be mentioned here that the bundles and muscular systems are disposed in such a way that direct stimulus would be sufficient to promote micturition with tightening of the detrusor and opening the sphincters. This explains why a completely disconnected bladder can work as an autonomous organ. In order to establish solidarity and harmony between the vesical function and the rest of the body, the existence of a superstructure of the nervous type is necessary. Such a superstructure is centralized in the medulla spinalis. To the central medullary reflexes arrive the afferent fibers which transmit the impulses from the bladder. From these centers depart the efAccepted for publication July 30, 1961. ferent fibers which in turn go through the hypogastric plexus innervating the bladder and thus forming the vesical plexus. The vesical nerve plexus forms the terminal medium from which the vesical musculature is induced by the neuro-vegetative system. But it is also necessary to distinguish the vesical plexus from the intrinsic pseudo-nervous plexus. The nerve endings of the vesical plexus are not acting directly upon the muscular elements, but through the local autonomous system. Thus, we can understand why, although a complete denervation of the bladder promotes some transient distrubances, there is not much delay in the return of micturition to normal or almost so. The tone control and the detrusor capacity to accommodation are not located in a diencephalic center, but are independent from the axial nervous centers. It is a fundamental error to believe that vesicourethral muscular activity is controlled by pathways similar to those that control striated musculature. If this were true, one could not understand how voiding could take place after disconnecting the bladder from the medullary centers by total sectioning of the erectae and presacral nerves. Yet, one could much less explain the functioning of the new intestinal bladder which bears no connection whatsoever with the medullary centers.

Lowering of the Left Renal Artery

AbstractA new operation to lower the aortic anastomosis of the renal artery is described. This procedure allows the left kidney to be lowered enough to enable repair after resections of the upper urinary tract. Renal hemodynamics were not altered and good results were obtained with no complications.

New surgical technique for balanitic hypospadias correction.

Most techniques for treatment of balanitic hypospadias cannot be considered entirely satisfactory because they are too complex, necessitate several repair procedures or involve complications such as fistulas, strictures and necrosis. Because of these circumstances and because of the possibility of poor results, most surgeons believe that correction of this condition is not necessary since micturition and the caliber of the meatus are usually normal. However, this is not our point of view. Although we agree that the disturbances produced by balanitic hypospadias do not affect the patient somatically, they obviously affect him mentally. A boy at school suddenly realizes that he does not urinate as the other children and this anomaly might produce a complex which will affect the boys personality. The method we use to correct balanitic hypospadias is based upon the reconstruction of the urethra by means of rotating the skin flap taken from the penis.