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Related post: wholly relieved of the pain though the stone in the ureter remained. I believe it must be excep- tional to have a stone in the lower end of a disused ureter give trouble. I can call to mind three cases where there is a quiescent stone in the lower end of such a ureter. In each of these cases the kidney, which was destroyed as a result of the unrecognized ureteral stone, had been removed, but the stone itself remained and seemed to cause no symptoms. On another patient in this group I made an at- tempt some years ago to do a plastic operation on a moderate sized hydronephrosis — her kidney held seventy-five c.c. of residual urine. The cause of this hydronephrosis was apparently a definite bandlike narrowing of the ureter just below its junction with the kidney pelvis. There was a mild infection in this patient's kidney pelvis, but as it seemed very mild, a plastic operation was carried out at the site of the ureteral narrowing. The kidney was not drained. This procedure was apparently success- ful, and the patient did very well for the follow- ing two weeks. She then began to have a high temperature with turbid urine and pain in her loin. A secondary nephrectomy was done about a month after her primary operation. The principle of adequate drain- age through a cortical incision, that was discussed when considering the question of pyelolithotomy, was neglected in this case, "and I believe that it was the neglect of this precaution that made it neces- sary to carry out secondary nephrectomy. Another patient in this group was operated upon only a month or so ago; the patient, a young man, had had his left kidney cut down upon two and one half years before, but apparently no procedure on the kidney itself was carried out. He had tem- porary relief only, followed by a recurrence of the pain, frequency, and turbid urine. The excised kidney showed a moderate Nortriptyline Mg grade of pyelonephritis with kidney cortex considerably atrophied. The breaking up of the adhesions or whatever opera- tion had been carried out had not offered the kid- ney sufficient help to permit it to overcome its infection ; another instance in which adequate drain- age was neglected. In another of these cases a man in his forties had first shown painless hematuria a month before an Nortriptyline 10 Mg exploration of the bleeding kidney was carried out. An incision Generic Nortriptyline was made from the cortex to the pelvis without recognizing any evident patho- logical process, a tube was carried down to the pelvis, and the kidney sewed up about this tube. Thirty-six hours after operation this man began to bleed so sharply that secondary nephrectomy was done. The removed kidney showed a large infarct which was believed to be the primary process, though not recognized at the time of operation. The patient made a good recovery. The last case in this group was that of a man with large but movable hypernephroma, on whom an attempt had been made to remove this growth through a loin incision, but because of hemorrhage this had to be given up and the wound packed. Some four months later when the patient learned that his kidney had not been removed he was very- insistent that an attempt be made to do it. The Nortriptyline 25 Mg kidney was exposed by an anterior incision and after considerable trouble was freed, all but at one ])oint, just above the hilum. A clamp was put on here, the adhesions cut, and the kidney removed. In tying off it was found that this clamp was upon the vena cava. Several attempts at tying and sewing were unsuccessful. The clamp was then adjusted so as to control the bleeding with as little obstruction as possible to the lumen of Buy Nortriptyline the vein and was left. There was some oozing following the operation ; he became worse and died some five hours later. As I have previously mentioned, there is no standardized technic for secondary nephrectomy. Some modifications, however, of the technic of jjrimary nephrectomy are required to adapt it to this purpose ; these are made necessary because of the anatomical changes brought about by long standing suppuration. We find a discharging sinus in the loin in a very large proportion of the cases in which we are called upon to do a sec- ondary nephrectomy. The presence of this sinus makes it rather easier to do our various function tests, whether they are color tests, induced polyuria, or simply the collection of the kidney output under normal circumstances. From a surgical point of view, however, the disadvantages of a discharging siiuis far outweigh its advantages. As a general rule, a secondary nephrectomy is harder to do the longer the time that elapses between the primary operation and the secondary one, since the longer the time the denser the in- flammatory adhesions become and the greater the distortion due to their contraction. It is this dis- tortion Nortriptyline 25mg and the loss of the usual anatomical rela- tions that add so much to the difficulty and dangers of the operation. Order Nortriptyline Online The most generally useful incision to employ in secondary nephrectomy, cs])ecially in a ca.se in which there is a sinus, and three fourths of the 934 CHUTE: SECONDARY NEPHRECTOMY. [New Vork Medical Journal. cases have these, is an elliptical one that surrounds the old scar. There are several ways of treating the sinus itself, the object of which is to prevent or minimize the contamination of the operative field by urine or pus. A cuff of tissues may be dissected up immediately surrounding the sinus and clamped or tied as one would fold over or tie a bag; this is rather the most satisfactory plan when it is pos- sible ; it prevents effectually any spilling of pus and urine over the operative field while Nortriptyline 10mg handling the kidney. Another simple way is to plug the sinus with a bit of gauze ; in a few cases where there is very little discharge one need Nortriptyline 25 do nothing more than swab out the sinus with a little Cheap Nortriptyline iodine. In a considerable number of cases, especially long stand- ing ones, the kidney will be found right under the scar of the previous operation and very closely adherent to it, so much so that one recognizes no line of cleavage between the two. An unguarded incision may open into the kidney tissue and start a sharp oozing which obscures the field, if nothing worse. For this reason it is well to make one's el- liptical incision rather wide of the edges of the scar and to carry this down cautiously that one may avoid injury to the kidney substance should it Buy Nortriptyline Online be Related links: cost of retin-a prescription, Aspirin Online, Purchase Serevent Online, Micardis Tablets, Acetate Calcium, buy retin a online no prescription, Order Probenecid Online, protonix buy canada, buy generic lexapro cheap, Dexamethasone Generic
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