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Experiences with Ureteral Calculi1
EXPERIENCES WITH URETERAL CALCULI 1 HENRY S. BROWNE
This study is based on a series of 200 cases of ureteral calculi. No urological condition can give more grief nor spectacular success than ureteral calculi. Fortunately, the percentage of success is far greater than that of grief. I shall not burden you with a detailed analysis of the symptoms or methods of diagnosis. The x-ray and cystoscope, with intravenous and retrograde urography, have made the diagnosis certain in practically every case. We are all familiar with the small stone in the lower ureter which is nonopaque to the x-ray, or lies invisible against the bony pelvis. Intravenous urography in such cases often shows no function on the affected side due to a temporary blocking of the kidney but the cystoscope and a retrograde pyeloureterogram will reveal the stone. Except for acute retention of urine, there is nothing that will make a patient seek a doctor quicker than a ureteral colic. Women often tell me the pain is worse than a labor pain. The average doctor is now much more cognizant than formerly of the possibility of a calculus causing abdominal pain, and we are called in much more frequently to rule out the possibility of stone. This is sometimes possible without a complete urological examination, for in ureteral calculi the onset is violent, the pain radiates downward, and is often both in front and behind. Red blood cells are usually found in the urine and there is usually no fever. One is impressed with the gastrointestinal symptoms, chiefly nausea and vomiting, that accompany ureteral colic. As the stone moves lower frequency and burning on urination increase. When there is infection present and the ureter is blocked by the stone, there may be high temperature and severe prostration. Having made the diagnosis we come to the treatment. We must remember that many stones will pass unaided, which occurred in 17 cases, or 8.5 per cent of my series. This is a much lower percentage than most others report, perhaps because I have been quick on the cystoscopic trigger and manipulated some stones that would have passed without instrumentation. However, I believe that such manipulation shortened materially the time of passage into the bladder. No stone in the upper and middle ureter passed spontaneously. All required manipulation or operation. I have not had much success with injecting oil or anesthetics above the stone, or giving drugs by mouth, to aid the passage of calculi, and I believe I have used all that have been recommended at various times. It is certainly a waste of time to give drugs when the stone is impacted. In the nonoperative treatment 141, or 70 per cent, were recovered by various cystoscopic maneuvers. Seven cases were lost track of. The simple passage of a catheter by the stone caused its prompt delivery in the majority of cases. If this did not, one or more catheters were passed up to the kidney and left in for two or more days. Usually, following this, the stone was passed in 24 hours 1 Presidential address read at annual meeting, South Central Branch, American Urological Association, Oklahoma City, Okla., September 26, 1942.
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or crumbled from the hard catheter lying against it. Crowell first popularized this method and he once told me he ordinarily did not confine his patients to to bed but let them walk around town with a catheter dripping into a bottle strapped to their leg. Some advocate irrigation to keep the catheter open but I believe this is to be condemned because of the danger of introducing infection into the kidney. If the catheter becomes plugged the urine will escape around it anyway. Sulfathiazole is given continuously in these cases to prevent infection which is my greatest fear. Some stones impacted in the bladder wall have been removed by enlarging the ureteral orifice with a Turner electrode, then passing a metal bougie by the stone, thus, engaging and removing it. I do not use this instrument any more for fear of tearing through the ureteral wall. I have tried the Councill extractor, but, in my hands, it is too rigid to pass any distance up the ureter without fear of injuring it. An instrument I have used with great satisfaction is the Johnson wire basket bougie, usually under an anesthetic. At our meeting in Denver in 1940 King Wade showed a film in which one of the wires of this basket was broken, requiring operative removal. Remembering this, I always inspect it carefully before using. It is almost as flexible as a catheter and if passed by a small stone will engage it on withdrawal and deliver it into the bladder. It should be used, however, only on stones in the lower ureter. I once engaged a stone in the midureter with it and could not budge the stone, even with traction for 6 hours. At operation the stone was easily found and was firmly embedded in the ureteral wall. If this bougie is passed immediately after removing indwelling catheters, the stone is easily delivered while the ureter is thus relaxed. In open operations on the lower ureter I always have the bougie handy, and, in one case it was extremely helpful, converting what bid fair to be a formidable operation into an easy one. The ureter was firmly bound down to the iliac vessels by concretelike adhesions which could not be broken up without danger of tearing these vessels. Besides, the ureter was greatly thickened so that the stone could not be palpated. An incision was made in the ureter, the bougie was passed down it and the calculus was removed easily. Thirty-four cases of this series required operative removal: 12 out of 17 cases in the upper ureter; 5 out of 12 cases in the mid-third; and 17 out of a total of 158 cases in the lower ureter. I have used the lateral incision, parallel to Poupart's ligament, in removing calculi from the lower ureter, because the ureter can be found easily above the bifurcation of the common iliac artery. From this point the ureter is readily followed until the stone is felt and if it is very deep in the pelvis, the incision can be extended to, and through, the rectus sheath, thus, giving ample exposure. And, if necessary, the bladder can be opened. This was done in 1 case. In 2 cases vaginal ureterolithotomy was carried out. These stones were very low, and palpable through the vaginal wall. Lower and also Shaw have especially recommended this approach and I am sorry we cannot use it more often. There need be no fear of a fistula for a urinary fistula will not stay open if there is no obstruction below it. There were 2 stones removed in which there was only 1 kidney; 1 case with
EXPERIENCES WITH URETERAL CALCULI
303
anuria present for 48 hours and the other had had anuria for 24 hours the previous week. Notwithstanding this, it required a lot of sales talk to convince these 2 men that they had to be operated on at once, for both had lost the other kidney by bungling surgery. There was 1 other case of anuria with a stone in the lower right and in the upper left ureter. The first was removed by cystoscopic means and the latter by operation. There were 4 cases with a stone in l kidney and 1 in the other ureter. In these the ureteral calculi were removed first, being the more dangerous. Three cases had stones in the kidney and ureter of the same side. There were multiple ureteral calculi in only 4 cases. An industrial case, complaining of pain in his back and side, was found to have a ureteral calculus. He became angry when told this was the cause of the pain and I never saw him again. This proves to us that in industrial cases with back pain the possibility of calculi must always be considered. There was 1 operative death in a man aged 72. His non-protein nitrogen was 60 and he had had a high septic temperature for two weeks from a blocked kidney. The diagnosis was made from a plain film and intravenous urography. A small stone was removed from the upper third and the ureteral incision left open. However, he continued to have a high septic temperature and died on the eighth postoperative day. This emphasizes the point that, with an impacted calculus and a blocked kidney with infection and a septic temperature, operation should be carried out without delay. As time goes on I find that I am using manipulation less and operating more. If, after 3 trials with the cystoscope, the stone fails to pass and shows evidence of impaction, I recommend operation. If the patient is symptomless and there is no infection, and the stone is small, he is kept under observation and very often in the course of time the stone will pass.
Medical Arts Bldg., Tulsa, Okla.
This study is based on a series of 200 cases of ureteral calculi. No urological condition can give more grief nor spectacular success than ureteral calculi. Fortunately, the percentage of success is far greater than that of grief. I shall not burden you with a detailed analysis of the symptoms or methods of diagnosis. The x-ray and cystoscope, with intravenous and retrograde urography, have made the diagnosis certain in practically every case. We are all familiar with the small stone in the lower ureter which is nonopaque to the x-ray, or lies invisible against the bony pelvis. Intravenous urography in such cases often shows no function on the affected side due to a temporary blocking of the kidney but the cystoscope and a retrograde pyeloureterogram will reveal the stone. Except for acute retention of urine, there is nothing that will make a patient seek a doctor quicker than a ureteral colic. Women often tell me the pain is worse than a labor pain. The average doctor is now much more cognizant than formerly of the possibility of a calculus causing abdominal pain, and we are called in much more frequently to rule out the possibility of stone. This is sometimes possible without a complete urological examination, for in ureteral calculi the onset is violent, the pain radiates downward, and is often both in front and behind. Red blood cells are usually found in the urine and there is usually no fever. One is impressed with the gastrointestinal symptoms, chiefly nausea and vomiting, that accompany ureteral colic. As the stone moves lower frequency and burning on urination increase. When there is infection present and the ureter is blocked by the stone, there may be high temperature and severe prostration. Having made the diagnosis we come to the treatment. We must remember that many stones will pass unaided, which occurred in 17 cases, or 8.5 per cent of my series. This is a much lower percentage than most others report, perhaps because I have been quick on the cystoscopic trigger and manipulated some stones that would have passed without instrumentation. However, I believe that such manipulation shortened materially the time of passage into the bladder. No stone in the upper and middle ureter passed spontaneously. All required manipulation or operation. I have not had much success with injecting oil or anesthetics above the stone, or giving drugs by mouth, to aid the passage of calculi, and I believe I have used all that have been recommended at various times. It is certainly a waste of time to give drugs when the stone is impacted. In the nonoperative treatment 141, or 70 per cent, were recovered by various cystoscopic maneuvers. Seven cases were lost track of. The simple passage of a catheter by the stone caused its prompt delivery in the majority of cases. If this did not, one or more catheters were passed up to the kidney and left in for two or more days. Usually, following this, the stone was passed in 24 hours 1 Presidential address read at annual meeting, South Central Branch, American Urological Association, Oklahoma City, Okla., September 26, 1942.
301
302
HENRY S. BROWNE
or crumbled from the hard catheter lying against it. Crowell first popularized this method and he once told me he ordinarily did not confine his patients to to bed but let them walk around town with a catheter dripping into a bottle strapped to their leg. Some advocate irrigation to keep the catheter open but I believe this is to be condemned because of the danger of introducing infection into the kidney. If the catheter becomes plugged the urine will escape around it anyway. Sulfathiazole is given continuously in these cases to prevent infection which is my greatest fear. Some stones impacted in the bladder wall have been removed by enlarging the ureteral orifice with a Turner electrode, then passing a metal bougie by the stone, thus, engaging and removing it. I do not use this instrument any more for fear of tearing through the ureteral wall. I have tried the Councill extractor, but, in my hands, it is too rigid to pass any distance up the ureter without fear of injuring it. An instrument I have used with great satisfaction is the Johnson wire basket bougie, usually under an anesthetic. At our meeting in Denver in 1940 King Wade showed a film in which one of the wires of this basket was broken, requiring operative removal. Remembering this, I always inspect it carefully before using. It is almost as flexible as a catheter and if passed by a small stone will engage it on withdrawal and deliver it into the bladder. It should be used, however, only on stones in the lower ureter. I once engaged a stone in the midureter with it and could not budge the stone, even with traction for 6 hours. At operation the stone was easily found and was firmly embedded in the ureteral wall. If this bougie is passed immediately after removing indwelling catheters, the stone is easily delivered while the ureter is thus relaxed. In open operations on the lower ureter I always have the bougie handy, and, in one case it was extremely helpful, converting what bid fair to be a formidable operation into an easy one. The ureter was firmly bound down to the iliac vessels by concretelike adhesions which could not be broken up without danger of tearing these vessels. Besides, the ureter was greatly thickened so that the stone could not be palpated. An incision was made in the ureter, the bougie was passed down it and the calculus was removed easily. Thirty-four cases of this series required operative removal: 12 out of 17 cases in the upper ureter; 5 out of 12 cases in the mid-third; and 17 out of a total of 158 cases in the lower ureter. I have used the lateral incision, parallel to Poupart's ligament, in removing calculi from the lower ureter, because the ureter can be found easily above the bifurcation of the common iliac artery. From this point the ureter is readily followed until the stone is felt and if it is very deep in the pelvis, the incision can be extended to, and through, the rectus sheath, thus, giving ample exposure. And, if necessary, the bladder can be opened. This was done in 1 case. In 2 cases vaginal ureterolithotomy was carried out. These stones were very low, and palpable through the vaginal wall. Lower and also Shaw have especially recommended this approach and I am sorry we cannot use it more often. There need be no fear of a fistula for a urinary fistula will not stay open if there is no obstruction below it. There were 2 stones removed in which there was only 1 kidney; 1 case with
EXPERIENCES WITH URETERAL CALCULI
303
anuria present for 48 hours and the other had had anuria for 24 hours the previous week. Notwithstanding this, it required a lot of sales talk to convince these 2 men that they had to be operated on at once, for both had lost the other kidney by bungling surgery. There was 1 other case of anuria with a stone in the lower right and in the upper left ureter. The first was removed by cystoscopic means and the latter by operation. There were 4 cases with a stone in l kidney and 1 in the other ureter. In these the ureteral calculi were removed first, being the more dangerous. Three cases had stones in the kidney and ureter of the same side. There were multiple ureteral calculi in only 4 cases. An industrial case, complaining of pain in his back and side, was found to have a ureteral calculus. He became angry when told this was the cause of the pain and I never saw him again. This proves to us that in industrial cases with back pain the possibility of calculi must always be considered. There was 1 operative death in a man aged 72. His non-protein nitrogen was 60 and he had had a high septic temperature for two weeks from a blocked kidney. The diagnosis was made from a plain film and intravenous urography. A small stone was removed from the upper third and the ureteral incision left open. However, he continued to have a high septic temperature and died on the eighth postoperative day. This emphasizes the point that, with an impacted calculus and a blocked kidney with infection and a septic temperature, operation should be carried out without delay. As time goes on I find that I am using manipulation less and operating more. If, after 3 trials with the cystoscope, the stone fails to pass and shows evidence of impaction, I recommend operation. If the patient is symptomless and there is no infection, and the stone is small, he is kept under observation and very often in the course of time the stone will pass.
Medical Arts Bldg., Tulsa, Okla.