Historical Contribution: 1942, Jewett, New Method of Ureteral Reimplantation

1942
Jewett. A new method of ureteral transplantation for cancer of the bladder. Journal of Urology, 1942: (48), 489-513.

 
In the early 1940's, the mortality for extirpative bladder cancer surgery and reconstruction hovered around 50%. The mainstay for urinary diversion was the ureterosigmoidostomy, which was fraught with complications related to obstruction of the freshly implanted ureter. In the discussion, Dr. Lawrence Wharton comments that, "in spite of 65 or so techniques now available, [ureteral anastomosis] is still a dangerous operation and should never be done…" However, it was recognized that there are several circumstances, including iatrogenic ureteral injuries in addition to bladder cancer, where no other option is left and foregoing urinary diversion condemned the patient to certain death.

 
In this manuscript, Dr. Hugh J. Jewett describes 15 cases of a two-stage ureterosigmoidostomy. Without a viable option for urinary divesion, Jewett knew that patients would succumb to renal failure or be so debilitated by chronic obstruction and infection that they would be unable to survive radical cystectomy. For this operation, Jewett expanded upon a two-stage surgical technique from the 1930's – and developed a special cutting electrode to facilitate the operation. Briefly, the operation included:

Stage 1: submucosal implantation of both ureters into the sigmoid colon without a lumen-to-lumen connection. This preserved ureteral blood supply and allowed the ureter to safely anastamose to the colon. Importantly, Jewett covered the ureterocolonic anastomoses in omentum and peritoneum to preserve/enhance blood supply and healing.

 
Stage 2: Maturation of the ureterosigmoidostomies. Three or four weeks later, Jewett would take the patient back to the operating room to complete the ureterosigmoidostomy. The distal ureter was divided, giving Jewett access to the anastomosis of the ureters to the colon. Using his cutting electrode, the lumen of the bowel could be joined to the ureter, completing the anastomosis in a safe, well-vascularized fashion.

 
Outcomes
All patients had invasive urothelial cancer of the bladder. Thirteen of the fifteen patients proceeded to cystectomy after urinary diversion. Nine of the 15 were alive 1.5 years after surgery. Three died during the recovery period and three died after discharge from the hospital. All of the patients, except one, died with adequate urinary drainage and good renal function. One patient, who Jewett attributed to a technical error, died of urinary obstruction as an early electrode caused significant damage to the anastomosis. Four patients required subsequent operations due to: bowel complications, urine leak and/or abdominal infection. No patient developed an ascending pyelonephritis.

 
While recognizing that his operation carried significant morbidity and mortality, Jewett noted in his conclusions,

"In the cases which I have reported, the condition of the majority of the patients was considered hopeless, and every form of therapy had been tried elsewhere before the patient was subjected to transplantation of the ureters. In a group of patients representing better surgical risks, I believe the mortality could be considerably reduced."

 
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HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy!