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In the operation of vesical exclusion the urine stream is deviated from the urinary bladder into the colon, thereby forming a cloaca, or on to the surface of the skin, where a fistula discharging urine is created.
The operation is indicated in all cases of complete or partial vesical exstrophy. It is successfully employed in treating severe cases of vesico-vaginal fistula, whether the result of obstetric injury or the delayed action of radium.
In carcinoma of the urinary bladder, whether primary or secondary, it is practised, frequently preliminary to the operation of total cystectomy.
In cases of persistent vesical systole and in intractable cystitis, it has also been occasionally done.
The immediate operative mortality following transplantation of the ureters into the pelvic colon is largely dependent on the condition for which the operation is performed. In cases of malignant disease it is high: whereas in conditions that are non-malignant it is a relatively safe procedure.
The establishment of a cloaca, particularly in the female, of itself produces no appreciable disability. If the operation has been performed for a congenital or an acquired deformity, and this has been skilfully and successfully carried out and the patient has become stabilized, the expectancy of life should not be appreciably diminished.
The case of a patient, upon whom the operation had been performed twenty-nine years previously, is reviewed and particulars of others in which it was performed fourteen years ago, or later, are referred to.
In the pre-operative preparation, in addition to the usual thorough clinical investigation, an examination by excretion urography is indicated, especially to determine the possible presence of a third ureter or a single functioning kidney. At this period it is also important, particularly in cases of obstetric injury, to be sure that the rectal sphincter is fully competent and that no hæmorrhoids are present.
The operative technique was carried out under twilight sleep and spinal anæsthesia. The vital importance of careful post-operative treatment is emphasized. By the immediate post-operative administration of sodium sulphate, by intravenous injection and attention to other details, bilateral ureteral transplantation carried out in one stage could be safely embarked upon without the fear of anuria developing.
A detailed record of 60 cases, in which the operation of vesical exclusion has been carried out by the author is given.