THE KIDNEYS. 43 i 



" Cunningham's Anatomy"). The left ureter is a little the longer because the left 

 kidney is the higher. They are flattened tubes with a lumen of 3 mm. (^ in.) 

 and possess muscular and fibrous walls. The contraction of the marked muscular 

 walls explains the intensity of renal colic. The back-flow of urine from the bladder 

 in diseased conditions may distend the ureters until they approach in size the small 

 intestine. Course. The ureter is in two parts, an abdominal, extending to the brim 

 of the pelvis, and a pelvic part, which is about 2.5 cm. (i in.) longer than the 

 abdominal. The abdominal portion extends from 4 cm. ( i ^2 in. ) to the outside of 

 the median line opposite the second lumbar vertebra to 3 cm. ( i ^ in. ) outside of the 

 median line on a line joining the anterior superior spines of the ilia. It descends 

 on the psoas muscle almost parallel to the median line but inclining a little inward 

 and crosses the brim of the pelvis at the bifurcation of the common iliac artery (the 

 right being sometimes a little lower). It will be observed that at this point the 

 right ureter lies immediately to the inner side of the base of the appendix. There 

 are three narrowed parts; the first or superior isthmus is 7 cm. (2^ in.) below the 

 hilum, where the ureter turns forward on the psoas muscle; the second or inferior 

 isthmus is at the pelvic brim; and the third is where it enters the bladder. Calculi 

 may lodge at any of these points. If this occurs at the brim in the right ureter the 

 case may be. mistaken for one of appendicitis, for the location of the two affections 

 would be almost identical. The abdominal ureter does not possess as distinct a 

 sheath as does the pelvic ureter. It is stuck, however, by fibrous tissue to the peri- 

 toneum, so that when the latter is raised it comes up with it. The ureters are 

 crossed about their middle and accompanied by the spermatic or ovarian vessels. 

 Just below the middle of the abdominal portion of the ureters the genitocrural nerve 

 emerges from the psoas muscle and passes beneath the ureters from within out. 

 This explains the genital pain in cases of calculi. 



Operations.- The abdominal portion of the ureter can be reached for operative 

 purposes by prolonging the oblique incision used in kidney procedures downward. 

 It should pass about 2. 5 cm. ( i in. ) in front of the anterior spine and the same distance 

 above Poupart's ligament. Access to the ureter through the abdominal cavity is not 

 satisfactory because of the presence of the duodenum and, when distended, the 

 ascending colon on the right side and the sigmoid and distended descending colon 

 on the left. The surest way of recognizing the ureter in operations is to follow it 

 downward from the hilum of the kidney or to have it contain an ureteral catheter 

 introduced upward into it from the bladder. 



The ureter (with the kidney) is most often excised for tuberculous disease; there- 

 fore, instead of its having its normal size of 5 mm. (^ in.) when distended, its diam- 

 eter may be increased to 12 mm. or 18 mm. (^- to ^ in.). Excision has been 

 most often done in women, as in them the pelvic portion is much more accessible. 

 It can be reached through an incision in the anterior vaginal wall at its upper portion 

 instead of using an oblique incision through the abdominal muscles. Konig advised 

 a transverse incision between the lower edge of the ribs and the crest of the ilium. 

 Bovee {Journal of Am. Med. Assoc., Oct. 23, 1909) gives the following technic: 

 The cervix uteri is to be drawn downward with a volsellurn. On the anterior vaginal 

 wall, at the uterovesical juncture, a small dimple will be seen. From the outer side 

 of this dimple an incision from one to one and a half inches in length is made down- 

 ward and outward. By careful blunt dissection the ureter can be exposed, brought 

 down with a hook, and traction made to liberate it as it passes through the broad 

 ligament. Its lower end may then be ligated and divided. At this stage of the 

 operation the pelvic portion of the ureter may be resected or not as desired. Then 

 a transverse incision, four inches or longer, is made through the extraperitoneal 

 portion of the abdominal wall, opposite the lower pole of the kidney (Konig) ; its 

 inner end need not go beyond the semilunar line. Through this wound the kidney 

 is liberated and brought out and the ureter separated by gentle traction and freeing 

 with the fingers. 



