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Nonopaque ureteral calculus
CASE ANALYSIS
CLINIC
Nonopaque
Ureteral
Calculus
JAMES E. ALLEN, M.D., Columbus, Ohio From tbe Department of Surgery and tbe Division of Urology, Obio State University Medical Center, Columbus, Obio.
E. C., a thirty-nine year old saIes was in good heaIth unti1 four hours prior to admission to the hospita1. WhiIe sitting at his desk three hours after his morning meal, he experienced an acute onset of Ieft sided coIicky pain. The pain originated in the high lumbar area and radiated around the Ieft flank into the Ieft side of the lower abdomen and the Ieft side of the scrotum. The pain was described as excruciating and paroxysma1. The patient became nauseated, weak and paIe and perspired freely. He consuIted the physician at the plant who partiaIIy reIieved the pain by administration of l/d gr. of morphine suIfate. FoIlowing examination, including complete bIood count and urinaIysis, the patient was transferred to the UroIogicaI Service at this hospita1. ATIENT
P engineer,
PHYSICAL
EXAMINATION
The patient was a sIightIy obese white man in no acute distress but compIaining of miId aching pain in the Ieft flank and nausea. He was afebriIe with a puIse of IOO per minute. Abdominal examination reveaIed some tenderness to paIpation in the left costovertebra1 angle and Ieft flank. BoweI sounds were present but hypoactive. The remainder of the examination was not remarkabIe. LABORATORY
DATA
CompIete bIood count was normal; urinaIysis showed numerous red bIood ceIIs and 24 to 30 white bIood ceIIs per high power heId; blood urea nitrogen was 20 mg. per cent; caIcium was 9.9 mg. per cent; phosphorus was 4.3 mg. per cent; uric acid was 4.7 and 5.1 mg. per cent. Am&con
Journal
of Surgery,
Volume
191, February
1961
258
Intravenous pyeIogram showed a norma right upper urinary tract and a miId Ieft hydronephrosis and hydroureter with onIy the upper one-third of the Ieft ureter visuaIizing. No caIculi were seen. On the next day, foIIowing another bout of severe Ieft renaI coIic, intravenous pyeIogram faiIed to show excretion of dye by the Ieft kidney. EARLY
MANAGEMENT
The patient was treated initiaIIy with DemeroI@ hydrochIoride 150 mg. and atropine 0.3 mg. every three hours as needed for pain. SuppIementaI intravenous dextrose in water was administered to maintain fluid intake over 3,000 cc. per twenty-four hours. Urine was strained in search of caIcuIi. Furadantin,@ IOO mg. every six hours, was administered. After the patient had remained free of pain for twelve hours, he had a second and third episode of severe Ieft renaI coIic. These episodes were controIIed with large doses of narcotics. ShortIy after the third episode a uretera catheter was placed in the Ieft upper urinary tract. Approximately IOO cc. of cIear urine was drained. The patient’s symptoms disappeared. No manipulation was undertaken. The catheter was removed in forty-eight hours and the patient remained free of symptoms for an additiona1 tweIve hours. He then experienced his fourth and most severe episode of coIicky pain in the Ieft flank and Iower abdomen. Examination of the urine reveaIed gross hematuria without evidence of infection. Retrograde pyeIography showed the Iower two-thirds of the Ieft ureter to be normaI. The catheter met an obstruction at the junction of the upper and middIe thirds of the ureter and the retrogra.de flow of dye outIined the cauda1
UreteraI
CaIcuIus
aspect of the obstruction. It appeared to be round and smooth, apparently filling the Iumen of the ureter. At operation, through a muscle-sphtting incision in the left Aank, a hard, eroded, yeHowbrown caIcuIus was removed from the left ureter. It measured I cm. in diameter. No sphnting or interna drainage of the ureter was carried out. Postoperative course was uneventfu1 and the patient was discharged on the sixth postoperative day. Urine at that time was clear and intravenous pyeIography performed since that time has shown a normal upper urinary tract biIateralIy. COMMENTS
The caIcuIus weighed I 18 mg. and was composed entirely of uric acid as shown by chemica1 anaIysis. Pure uric acid caIcuIi are noted infrequently. In Iarge caIcuIi a nidus of uric acid surrounded by layers of carbonates and phosphates is often revealed. CaIcuIi composed of uric acid and those of xanthine and cysteine are radioIucent. Uric acid is a norma excretory product of the kidney, amounting to 0.4 to 0.7 gm. in a twentyfour hour specimen. It is usuaIIy present in the urine in the form of the various urates. Derangement of the purine metabolism Ieads to increased excretion of uric acid, a prerequisite to the creation of the “gouty kidney” or uric acid renaI caIcuIi. The Iatter often grow to considerable size in the renaI peIvis without causing difficulty. Acute symptoms occur when a caIcuIus faIIs into the ureter, which passes the calcuIus into the bladder.- PartiaI or complete obstruction of the ureter brings about an easiIy recognizabIe syndrome. Diagnosis and subsequent treatment are somewhat compIicated because the radioIucency of these caIcuIi makes it diffrcuIt to determine the position, size and surface characteristics. Complete investigation is mandatory because unexprained uretera coIic is often due to nonopaque caIcuIus. Retrograde pyeIography in this instance offers the most information. The drawbacks of this diagnostic measure are as foIIows: (I) the reff ux and loss of the caIcuIus into the kidney peIvis and (2) the possibIe introduction of infectious organisms into stagnant urine with subsequent sepsis. Treatment of uretera caIcuIi has three main
259
aspects as foIIows: (I) symptomatic treatment with spontaneous passage; (2) cystoscopic and catheter manipulation and extraction; (3) open operation. Various reports advocate each of these means of treatment in certain circumstances. It is agreed that calculi less than 4 mm. in diameter wiII pass spontaneousIy through a healthy urinary tract. With medium sized caIcuIi (4 to 6 mm. in diameter) spontaneous passage occurs less frequently and onIy with much difficulty and attendant morbidity. Advocates of cystoscopy with catheter extraction present evidence to support this method of removing a11 but large calculi; many procedures are described. It is the beIief in this cIinic that this method is desirable only with smaher caIcuIi and only those that are easily reached in the Iower one-third of the ureter. In most cases when spontaneous passage does not occur open operation is indicated. For calculi in the extreme upper Iimits of the ureter a nephrectomy incision is used. For those in the middIe one-haIf of the ureter a muscIe-splitting incision is made in the flank. For those in the Iower one-third of the ureter either a McBurney or Gibson approach is recommended. Retroperitonea1 exposure of the ureter is carried out. A Iongitudinal incision is made in the ureter and the calculus is removed. FoIlowing Ioose cIosure of the ureter with No. 4-o chromic catgut a smaI1 drain is Ieft in the retroperitoneal space for forty-eight to seventy-two hours. With this type of treatment, hospita1 stay is shortened, the pathologic condition is remedied and morbidity from infection and ureteral damage is decreased. The one prerequisite for this mode of therapy is accurate Iocation of the caIcuIus with the operative incision conforming to this position. With all cases of renaI caIcuIi, appropriate metaboIic studies are undertaken to define the precipitating factors and to institute prophylactic measures as indicated. REFERENCES I. ALLYN, R.
2.
1957. SANDEGOORD,
E. Uric acid calculi. J. Ural., 78: 314, E. Prognosis
of stone in the ureter.
Acta cbir. scandinav., vol. 219, 1956. 3. MARQUARDT, C. R. The management of ureteral stone. Wisconsin M. J., 55: 630, 1956. 4. HORWITZ, S. P. Modern managementtand treatment of uretera calcuIus. Wisconsin M. J., vol. 54, p. 356. 5. TAYLOR, W. W. Personal communication.
CLINIC
Nonopaque
Ureteral
Calculus
JAMES E. ALLEN, M.D., Columbus, Ohio From tbe Department of Surgery and tbe Division of Urology, Obio State University Medical Center, Columbus, Obio.
E. C., a thirty-nine year old saIes was in good heaIth unti1 four hours prior to admission to the hospita1. WhiIe sitting at his desk three hours after his morning meal, he experienced an acute onset of Ieft sided coIicky pain. The pain originated in the high lumbar area and radiated around the Ieft flank into the Ieft side of the lower abdomen and the Ieft side of the scrotum. The pain was described as excruciating and paroxysma1. The patient became nauseated, weak and paIe and perspired freely. He consuIted the physician at the plant who partiaIIy reIieved the pain by administration of l/d gr. of morphine suIfate. FoIlowing examination, including complete bIood count and urinaIysis, the patient was transferred to the UroIogicaI Service at this hospita1. ATIENT
P engineer,
PHYSICAL
EXAMINATION
The patient was a sIightIy obese white man in no acute distress but compIaining of miId aching pain in the Ieft flank and nausea. He was afebriIe with a puIse of IOO per minute. Abdominal examination reveaIed some tenderness to paIpation in the left costovertebra1 angle and Ieft flank. BoweI sounds were present but hypoactive. The remainder of the examination was not remarkabIe. LABORATORY
DATA
CompIete bIood count was normal; urinaIysis showed numerous red bIood ceIIs and 24 to 30 white bIood ceIIs per high power heId; blood urea nitrogen was 20 mg. per cent; caIcium was 9.9 mg. per cent; phosphorus was 4.3 mg. per cent; uric acid was 4.7 and 5.1 mg. per cent. Am&con
Journal
of Surgery,
Volume
191, February
1961
258
Intravenous pyeIogram showed a norma right upper urinary tract and a miId Ieft hydronephrosis and hydroureter with onIy the upper one-third of the Ieft ureter visuaIizing. No caIculi were seen. On the next day, foIIowing another bout of severe Ieft renaI coIic, intravenous pyeIogram faiIed to show excretion of dye by the Ieft kidney. EARLY
MANAGEMENT
The patient was treated initiaIIy with DemeroI@ hydrochIoride 150 mg. and atropine 0.3 mg. every three hours as needed for pain. SuppIementaI intravenous dextrose in water was administered to maintain fluid intake over 3,000 cc. per twenty-four hours. Urine was strained in search of caIcuIi. Furadantin,@ IOO mg. every six hours, was administered. After the patient had remained free of pain for twelve hours, he had a second and third episode of severe Ieft renaI coIic. These episodes were controIIed with large doses of narcotics. ShortIy after the third episode a uretera catheter was placed in the Ieft upper urinary tract. Approximately IOO cc. of cIear urine was drained. The patient’s symptoms disappeared. No manipulation was undertaken. The catheter was removed in forty-eight hours and the patient remained free of symptoms for an additiona1 tweIve hours. He then experienced his fourth and most severe episode of coIicky pain in the Ieft flank and Iower abdomen. Examination of the urine reveaIed gross hematuria without evidence of infection. Retrograde pyeIography showed the Iower two-thirds of the Ieft ureter to be normaI. The catheter met an obstruction at the junction of the upper and middIe thirds of the ureter and the retrogra.de flow of dye outIined the cauda1
UreteraI
CaIcuIus
aspect of the obstruction. It appeared to be round and smooth, apparently filling the Iumen of the ureter. At operation, through a muscle-sphtting incision in the left Aank, a hard, eroded, yeHowbrown caIcuIus was removed from the left ureter. It measured I cm. in diameter. No sphnting or interna drainage of the ureter was carried out. Postoperative course was uneventfu1 and the patient was discharged on the sixth postoperative day. Urine at that time was clear and intravenous pyeIography performed since that time has shown a normal upper urinary tract biIateralIy. COMMENTS
The caIcuIus weighed I 18 mg. and was composed entirely of uric acid as shown by chemica1 anaIysis. Pure uric acid caIcuIi are noted infrequently. In Iarge caIcuIi a nidus of uric acid surrounded by layers of carbonates and phosphates is often revealed. CaIcuIi composed of uric acid and those of xanthine and cysteine are radioIucent. Uric acid is a norma excretory product of the kidney, amounting to 0.4 to 0.7 gm. in a twentyfour hour specimen. It is usuaIIy present in the urine in the form of the various urates. Derangement of the purine metabolism Ieads to increased excretion of uric acid, a prerequisite to the creation of the “gouty kidney” or uric acid renaI caIcuIi. The Iatter often grow to considerable size in the renaI peIvis without causing difficulty. Acute symptoms occur when a caIcuIus faIIs into the ureter, which passes the calcuIus into the bladder.- PartiaI or complete obstruction of the ureter brings about an easiIy recognizabIe syndrome. Diagnosis and subsequent treatment are somewhat compIicated because the radioIucency of these caIcuIi makes it diffrcuIt to determine the position, size and surface characteristics. Complete investigation is mandatory because unexprained uretera coIic is often due to nonopaque caIcuIus. Retrograde pyeIography in this instance offers the most information. The drawbacks of this diagnostic measure are as foIIows: (I) the reff ux and loss of the caIcuIus into the kidney peIvis and (2) the possibIe introduction of infectious organisms into stagnant urine with subsequent sepsis. Treatment of uretera caIcuIi has three main
259
aspects as foIIows: (I) symptomatic treatment with spontaneous passage; (2) cystoscopic and catheter manipulation and extraction; (3) open operation. Various reports advocate each of these means of treatment in certain circumstances. It is agreed that calculi less than 4 mm. in diameter wiII pass spontaneousIy through a healthy urinary tract. With medium sized caIcuIi (4 to 6 mm. in diameter) spontaneous passage occurs less frequently and onIy with much difficulty and attendant morbidity. Advocates of cystoscopy with catheter extraction present evidence to support this method of removing a11 but large calculi; many procedures are described. It is the beIief in this cIinic that this method is desirable only with smaher caIcuIi and only those that are easily reached in the Iower one-third of the ureter. In most cases when spontaneous passage does not occur open operation is indicated. For calculi in the extreme upper Iimits of the ureter a nephrectomy incision is used. For those in the middIe one-haIf of the ureter a muscIe-splitting incision is made in the flank. For those in the Iower one-third of the ureter either a McBurney or Gibson approach is recommended. Retroperitonea1 exposure of the ureter is carried out. A Iongitudinal incision is made in the ureter and the calculus is removed. FoIlowing Ioose cIosure of the ureter with No. 4-o chromic catgut a smaI1 drain is Ieft in the retroperitoneal space for forty-eight to seventy-two hours. With this type of treatment, hospita1 stay is shortened, the pathologic condition is remedied and morbidity from infection and ureteral damage is decreased. The one prerequisite for this mode of therapy is accurate Iocation of the caIcuIus with the operative incision conforming to this position. With all cases of renaI caIcuIi, appropriate metaboIic studies are undertaken to define the precipitating factors and to institute prophylactic measures as indicated. REFERENCES I. ALLYN, R.
2.
1957. SANDEGOORD,
E. Uric acid calculi. J. Ural., 78: 314, E. Prognosis
of stone in the ureter.
Acta cbir. scandinav., vol. 219, 1956. 3. MARQUARDT, C. R. The management of ureteral stone. Wisconsin M. J., 55: 630, 1956. 4. HORWITZ, S. P. Modern managementtand treatment of uretera calcuIus. Wisconsin M. J., vol. 54, p. 356. 5. TAYLOR, W. W. Personal communication.