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The Incidence of Urinary Tract Obstruction in Renal Calculus Formation1
THE INCIDENCE OF URINARY TRACT OBSTRUCTION IN RENAL CALCULUS FORMATION1 JOSEPH C. BIRDSALL
During the past 10 years there has been such a vast amount of data assembled and published as a result of research studies and clinical observations in an attempt to discover the etiological factors concerned in the formation and prevention of recurrences in renal lithiasis, that the urologist has been quite at his wits end in an endeavor to crystalize the various theories and formulate a working hypothesis for the successful management of these cases. Geographic distribution, heredity, climate, vitamin deficiency diets, metabolic diseases, renal injury, focal infections, colloidal imbalance, and hyperparathyroidism, primary and secondary, may be accessory causative factors of renal calculus formation in few instances but they are not entirely the responsible agents in the great majority of cases. While it is of academic and scientific interest to observe that there are numerous stone areas in different parts of the world and it is apparent that a definite deficiency in the diets of the inhabitants of those districts actually exists, the problem which confronts most of us is how to manage the calculi in our own baliwick where all the proper vitamins, fresh fruits and vegetables may be had at the corner grocery the year around. Many experimenters have shown that a large percentage of rats placed on a Vitamin A and D free diet will develop stones in the urinary tract in a variable number of days. However, the practical application of the principles of this diet in causing a diminution in size or disappearance of renal calculi and also in the prevention of the formation of new stones, has been most disappointing in our test cases as there has been no diminution in the size noted and new stones have continued to form during the period the patients were on the diet. Since Barney and Mintz and Albright and Bloomberg emphasized the frequency of the presence of hyperparathyroidism in renal calculus disease, we have had many of our cases subjected to careful studies of the calcium and phosphorus content of the blood and our results have been for the most part extremely negative, and while these observers conclude hyperparathyroidism is responsible for 4-5 per cent of the cases of renal 1 Read before annual meeting, American Urological Association, White Sulphur Springs, W. Va., May 29, 1939. 917
918
JOSEPH C. BIRDSALL
lithiasis, a review of the cases of urinary lithiasis at the Mayo Clinic and at the Cleveland Clinic show that hyperparathyroidism was found to be an etiological factor in 0.2 and 0.1 per cent of their cases, respectively. The recent experimental studies on rats by Pappenheimer and his associates and also the production of experimental renal insufficiency in dogs by Highman and Hamilton, have shown that renal insufficiency may give rise to hyperparathyroidism, hyperplasia and hyperfunction. These observations are of considerable value as they suggest that pnmary
FIG.1
Frc. 2
FrG.1. Combined cystoscopicand pyelographic table, equipped with electric motor driven raising mechanism, adjustable Bucky diaphragm and tube stand with indicator for centering, and adjustable leg supports for all positions. First pyelogram taken with table in this position. FIG. 2. Combined cystoscopic and pyelographic table with attached extension and standing platform for patient. Second pyelogram taken with table in this position.
renal insufficiency produced experimentally has stimulated the parathyroids to develop bony lesions comparable to osteitis fibrosa cystica, and also that the calcium content of the residual renal tissues has shown an increase in proportion to the parathyroid enlargement. A stimulus for the study of the incidence of obstruction in upper urinary tract calculus disease was received several years ago when we were studying 400 cases of urinary tract obstruction in its relationship to the various types of renal infection.
919
OBSTRUCTION IN RENAL CALCULUS FORMATION
Classification of 400 cases ,eith urinary obstruction I
NUMBER OF
-- -1--(~~=~-~-~ ----" N ephroptosis. Hydronephrosis. Pyonephrosis. Pyelitis .. Pyelonephritis. Total ..
INFECTED
NON-INFECTED
PER CE.c\'T lN.FECT.ED
- - - - - - - - - -
220 110 30
162
25
25
15
15
400
323
91 30
58 19
77
73.6 82.7 100 100 100
80. 7
During this investigation, the great frequency of the presence of renal and ureteral calculus was noted with such impressive regularity that a study of the various obstructive processes associated with calculus formation was undertaken. The subject matter of this paper comprises a study of 150 cases of renal calculi and 61 cases of ureteral calculi, totaling 211 cases of upper urinary tract lithiasis, from the urologic services at the Graduate and Presbyterian Hospitals. Each case was subjected to roentgenological examination and pyelograms, retrograde or excretory, were made of the kidneys and ureters with the patient in the recumbent and erect positions (figs. 1 and 2). Classification of obstructions in 211 cases of renal and ureteral calculi number of
cases
:Nephroptosis .. Bands-adhesions. Stricture of ureter .. Vessels .. Anomalies-duplication-horseshoe-polycystic. Trauma .. Cancer of ovary. No demonstrable obstruction. Hydronephrosis present .. Total.
141 34
17 8
4 3
1 3
211
Nephroptosis with angulation of the ureter was the most frequently encountered type of urinary tract obstruction in the association of which renal and ureteral calculi were found. In many cases comparatively small calculi were demonstrated, by pyelographic studies, to be located in the minor calices, giving evidence of having been formed on the renal papillae. Many other types of obstruction, such as bands, vessels, stricture of the ureter, and various types of anomalies, renal duplication, crossed ectopia, horseshoe kidneys and polycystic disease were the
920
JOSEPH C. BIRDSALL
underlying cause of hydronephrosis, stasis of urine and calculus formation. In 3 cases there was a history of trauma, immediate hematuria and on subsequent examination, calculi were discovered. In one case cancer of the left ovary was the obstructive lesion. In 3 cases no definite demonstrable type of obstructive lesion could be found, although in all of the 3 cases there was well developed hydronephrosis. As a result of the pyelographic studies, hydronephrosis was found to be present in 179, pyonephrosis in 23 and pyelonephritis in 9 cases. Infection also played an important role and was found in 168 cases, 43 of which were in cases of ureteral calculus and 125 in cases of renal calculus, and the organisms in order of their frequency were, B. coli, Staphylococcus aureus and albus, B. proteus and non-hemolytic streptococci. All of these bacteria except B. coli, belong to the class of urea splitting organisms. Age, sex and site incidence in 211 cases of upper urinary tract calculi AGE
NUMBER
SITE
NUMBER
years
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 Not stated Total. ........
2 5 32 54 51 37 18 7 5 211
Right kidney. Left kidney .. .... Bilateral. ..................... Right ureter. Left ureter .. . . . . . .... Bilateral. .. Kidney and ureter. . .... . . . . . . '
.
61 70 19 27 33 1 12
SEX
Males. Females.
..... .
....
135 76
Treatment of 150 cases of renal calculi number of
cases
Pyelolithotomy with incision of bands and vessels. N ephrolithotomy ... N ephrectomy. Heminephrectomy. Non-operated. Total. Nephropexy. Recurrences . Calyectasis. Bands-adhesions. Horseshoe kidneys, obstruction not corrected.
45 25 40 3
37 150 42 9 4 3
2
921
OBSTRUCTION IN RENAL CALCULUS FORMATION
number of
cases
Deaths-pre-operative. post-operative. Septicemia. Uremia. Cardiac. Pneumonia. Peritonitis. Cancer. Pulmonary embolism.
9
12 3 3
2
Treatment of 61 cases of 11reteral calculi nztmber of cases
Ureterolithotomy-lumbar .. Ureterolithotomy-Gibson. N ephrectomy. N ephropexy. Passed after instrumentation. Extracted. Refused operation .. Died before treatment. Total .. Deaths .. Uremia. Cardiac. Recurrences. Calyectasis. N ephroptosis-not corrected.
17 8
7 10
21 6
1 61 4 3
1 3
2
The problem of recurrences of renal and ureteral calculi has been a most difficult but interesting one. In 3 cases of horseshoe kidneys with renal calculi, there have been recurrences in 2 cases. In both there was such large calyectasis that adequate correction of the stasis of urine was impossible. In the third case, the isthmus was separated and each kidney suspended. There has been no recurrence of stones in this case over a 3 year period. In 6 cases, stones reformed in dilated calices in which the stasis of urine could not be corrected by nephropexy. In 3 cases in which partial nephrectomy was performed for calyectasis, there has been no recurrence over 5, 3 and 2 year periods. In certain selected cases of renal lithiasis with well developed calyectasis or partial hydronephrosis and in which correction of the nephroptosis or the obstructing vessel or band cannot correct the stasis of urine in the dilated calyx, partial or heminephrectomy must be a considered procedure for the prevention of recurrence. Post-operative formation of adhesions at the uretero-pelvic outlet has been found in three cases at the
922
JOSEPH C. BIRDSALL
second operation to be the responsible factor in the causation of unrelieved stasis of urine and infection with rapid calculus reformation. The management of cases of urinary lithiasis from a practical standpoint consists in studying each case individually, including history, blood chemistry and urinalysis. Roentgenograms and visualization of the kidneys and ureters either by excretory urography or by retrograde pyelography and in two positions is most essential. Retrograde pyelography has two advantages. First, the examiner obtains a specimen of urine from each kidney and, secondly, a better visualization of the renal pelves, calices, and ureters in cases of poor renal function. The
FIG.3
FIG.4
FIG. 3. Case 1. Plain x-ray showing dendritic calculus in right kidney, 2 calculi in left kidney and 1 calculus in pelvic portion of left ureter. FIG. 4. Case 1. Retrograde pyelogram in recumbent position showing hydronephrosis and calyectasis of left kidney.
following cases illustrate the important part played by obstruction in renal calculus formation and when properly and adequately corrected, recurrences have not occurred. Case 1. W. F. (figs. 3 to 7) age 50, a white man, was admitted to the Urologic Service, Presbyterian Hospital, June 1, 1934, with a chief complaint of sharp knife-like attacks of pain above crest of ileum on both right and left sides, and pus i:n the urine. X-ray study: Plain film showed large, dense shadow present in the right kidney pelvis filling practically the entire pelvis and calices. Three shadows were present in the region of the left kidney.
FIG. 5. Case 1. Retrograde pyelogram m erect position with catheters withdrawn, showing marked bilateral nephroptosis.
FIG.
6
FIG.
7
6. Case 1. Plain x-ray film taken 3½ months after pyelolithotomy and nephropexy of left kidney. Film shows many calculi which have reformed in pelvis of left kidney. FIG. 7. Case L Plain x-ray taken 4 years after right nephrectomy and second operation on left kidney in which pyelolithotomy was performed and adhesions removed from ureteral pelvic site. No recurrence of stone. Urinalysis normal. FIG.
923
924
JOSEPH C. BIRDSALL
Second study: Retrograde pyelography: After injection, both kidney pelves were well filled, stone in right pelvis indicated by mottled appearance, rather sharply demarcated from the dye in lower portion of pelvis. Right ureter was greatly dilated for very nearly its entire length. Left kidney pelvis was tremendously dilated, calices blunted, outline globular. Left ureter sharply kinked, lower calyx of right kidney opposite lower border of third lumbar vertebra, lower calyx of left kidney 1½ cm. below this level. Third study (standing): Catheters withdrawn, right kidney had emptied its dye and ureter collapsed. Left still retained greater portion and the ureter was moderately dilated but not kinked badly. Lower calyx of right kidney was opposite the upper border of the fifth lumbar vertebra, lower calyx of left kidney was at about the same level. Urinalysis: Light amber; specific gravity 1.010; albumin, a dense cloud; no sugar. Microscopic examination: each field loaded with pus cells with 150-200 red blood cells per field. Blood calcium: 10.4 mg. per 100 cc. Blood phosphorus: 3.8 mg. per 100 cc. Wassermann and Kahn tests: negative. Culture of urine: B. proteus. On June 4 one of the calculi in the left kidney passed down the ureter and this necessitated an operation on the left kidney first. On June 6, the left kidney was exposed and a pyelolithotomy and ureterolithotomy performed. An incision was made into the pelvis of the kidney and 2 calculi removed. The calculus in the ureter was also removed per incision in ureter at pelvic brim. The incisions in the ureter and in the renal pelvis were closed with continuous sutures of No. 00 plain catgut, the kidney was then suspended by 3 triple mattress sutures of No. 1, 20-day chromic catgut, a rubber tube drain was placed in the incision and the wound closed. Patient placed on increased vitamin A intake and Acid Ash diet. Patient was advised to have his right kidney operated upon but inasmuch as he was ready to leave the hospital August 1, and he was eager to spend the month of August at the seashore he decided to come back September 1 for his other operation. However, on August 9, he had to be re-admitted having had several attacks of severe pain again in both kidney regions, especially on the left side. On cystoscopic examination, streams of pus were observed to come from both ureteral orifices and indigocarmin intravenously did not appear from either ureter in 30 minutes. X-ray taken on day after admission showed 4 small stones reformed in the left kidney pelvis. While patient was in the hospital, August 13 to September 18, he passed 12 stones varying from B.B. shot to pea size. On September 18, x-ray of the kidney showed 15 to 17 stones in the left renal pelvis. Culture from the urine on several occasions showed B. proteus and also B. coli. This patient was presented at this time before the American College of
OBSTRUCTION IN RENAL CALCULUS FORMATION
925
Surgeons in Philadelphia for discussion. The concensus of opinion was that the case was hopeless and further surgery would be of no benefit. With the recurrence of stones I could not help but feel that there was recurrence of obstruction. Therefore, after blood transfusions and ureteral cathe-
FIG. 9
FIG.10
FlG.
H
FIG. 8. Case 2. Plain x-ray film showing shadow in region of right kidney. FIG. 9. Case 2. Retrograde pyelogram showing shadow obiiterated by pyelographic medium. Hydronephrosis and calyectasis of kidney. FIG. 10. Case 2. Retrograde pyelogram in erect position showing third degree ptosis. Shadow has descended with kidney. FIG. 11. Case 2. Retrograde pyelogram 6 years after pyelolithotomy and nephropcxy. No recurrence of calculus.
terization with lavage of the kidneys, the right kidney was operated on December S, 1934, at which time the right kidney was found to be so markedly diseased that nephrectomy was performed for calculus pyonephrosis. On January 16, 1935, the left kidney was re-operated upon and 6 calculi were removed from the pelvis of the left kidney. Bands had formed from the pre-
926
JOSEPH C. BIRDSALL
vious operation and constricted the ureter at the uretero-pelvic junction. These were removed and the renal pelvis drained with gall bladder duct T-tube type of drain, one arm of the tube being placed in the ureter, the other arm in the pelvis of the kidney. The patient made an excellent recovery. Follow-up: The patient has been in excellent health since last operation in January 1935, with no history of recurrences of pain or passing of stones. X-ray checkup in April, 1939, revealed no opacities in the region of the kidney, ureter or bladder. Urinalysis was normal. Case 2. J. T. (figs. 8 to 11) a white woman, age 54, was admitted to Graduate Hospital on August 6, 1929, with history of attacks of pain in epigastrium, eructation of gas, nausea and vomiting for 10 years. The pain did not radiate. Urinalysis showed many leukocytes and few erythrocytes. Plain x-ray film showed an almond-shaped opaque shadow immediately above the right transverse process of the third lumbar vertebra. Retrograde pyelogram in recumbent position showed moderate hydronephrosis and calyectasis of the right kidney. The lower portion of the renal pelvis was on the level of upper border of the fourth lumbar vertebra. The pyelogram in the erect position showed third degree nephroptosis of the right kidney. The inferior calyx was at lower border of the fifth lumbar vertebra. Pyelolithotomy and nephropexy performed in October 1929. The patient has been seen several times during the past 10 years. Plain x-ray film in 1935 showed no recurrence of stone and pyelogram in erect position showed good position of suspended kidney. She also stated that her indigestion had disappeared. Case 3. L. G. (figs. 12, 13, 14) a white woman, age 43, was admitted to Graduate Hospital April 11, 1939, with chief complaint of attacks of pain in her right side. Previous history elicited that she had had a very severe attack of right sided pain in 1934. Pain lasted 3 hours and she apparently passed a calculus at that time. Thorough urologic study failed to show a calculus but retrograde pyelograms showed complete duplication of left ureter and kidney, bilateral hydronephrosis and third degree nephroptosis. Preliminary x-ray film on present admission showed 2 small opacities in right kidney region, one at level of superior pole and one at level of inferior pole. Retrograde pyelograms revealed calculus in the superior calyx and one in the inferior calyx of the right kidney. The study also revealed bilateral hydronephrosis and bilateral nephroptosis. Culture of urine from right kidney showed Staphylococcus albus, non-hemolytic and B. coli. The culture from the urine of the upper left renal pelvis showed diphtheroids and from the lower left renal pelvis B. coli. Microscopic examination of the urine showed each field to be loaded with leukocytes. Operation, April 14, 1939: nephrolithotomy and bilateral nephropexy.
OBSTRUCTION IN RENAL CALCULUS FORMATION
FIG. 12. Case 3. of right kidney.
927
Plain x~ray film showing small calculi in superior and inferior calices
FIG. 13
FIG. 14
FIG. 13. Case 3. Retrograde pyelogram showing double type of pelvis right kidney, complete duplication of ureters and kidneys on left side. FrG. 14. Case 3. Pyelogram in erect position showing marked bilateral nephroptosis with bilateral hydronephrosis.
928
JOSEPH C. BIRDSALL
FIG.15 FIG.16 FIG. 15. Case 4. Plain film showing calculus in pelvic portion of right ureter. FIG. 16. Case 4. Pyelogram in erect position showing hydro-ureter, hydronephrosis and marked nephroptosis of right ureter and kidney. Ureterolithotomy and nephropexyno recurrence of stone over 10 year period.
FIG. 17. E. B. Case 5.
Plain x-ray film showing bilateral renal calculi
OBSTRUCTION IN RENAL CALCULUS FORMATION
FIG.
18
929
FIG.19
FIG. 18. E. B. Case 5. Retrograde pyelogram in recumbent position showing bilateral hy"' dronephrosis and partial hydronephrosis of the superior and inferior calices of the right kidney. FIG. 19. E. B. Case 5. Pyelogram in the erect position showing marked bilateral nephroptosis. Refused operation.
Frc. 20. F. B. Case 6.
Plain x-ray film showing 4 shadows in the region of the right kidney
930
JOSEPH C. BIRDSALL
Case 7. W. C., a white male, age 67, was. seen in 1928 with a chief complaint of attacks of left renal pain which fa:d:iated to bladder. He had a similar attack in 1914 with the passing of a calculus, and in 1927 he had 3 attacks, one in April, one in November and a third in December. On each occasion a calculus was passed. From the time of his first visit in January, 1928, until March of that year, he was quite prolific in the formation and passing of stones, contributing in all 11. In 1929 an attack of pain was followed by the passing of a stone and there were no more symptoms until
FIG. 21
FIG. 22
FIG. 21. F. B. Case 6. Retrograde pyelogram of right kidney in recumbent position showing hydronephrosis with a constriction at the ureteral pelvic site. FrG. 22. F. B. Case 6. Retrograde pyelogram in erect position showing second degree nephroptosis with hydronephrosis and a definite constriction at the ureteral pelvic site. Operation showed small vessel and band at ureteral pelvic site. Pyelolithotomy, incision of vessel and band and nephropexy performed. No recurrence of stone over 4 year period.
September, 1937, when patient had several severe attacks of pain with chills and fever. Patient was admitted to the hospital. Urinalysis: Cloudy; acid; specific gravity 1.015; sugar, negative; albumin, faint trace; acetone, negative. Microscopic examination: occasional hyaline cast, occasional squamous and renal epithelial cells, amorphous urate crystals and each field was loaded with pus cells. X-ray study showed in left pelvis, opposite the last sacral segment, a dense, ovoid smooth shadow. Excretory urography: The left kidney showed a moderate degree of hydro-
OBSTRUCTION IN RENAL CALCULUS FORMATION
931
nephrosis and ureterectasis. In antero-posterior view the ureter on left side ,vas right in line with the density in pelvis. In the erect position, the pelvis of the left kidney was at the level of the interspace between the third and fourth lumbar vertebrae. A No. 11 F. Garceau catheter was passed up left ureter and left in situ for 48 hours and a seventeenth calculus was passed 24 hours after removal of catheter. This case is illustrative of frequent recurrences of calculi in presence of urinary tract obstruction. Case 8. R. C., a white man age 32, was seen in May 1932, and was referred to Urologic Service, Graduate Hospital, for study. Chief complaint: Attacks of pain in region of left kidney with radiation to left testicle. In 1916 he passed sandy substance in his urine without distinct pain except burning and irritation of the urethra on urination. In 1920 he had an attack of severe pain in left renal area and passed 3 stones. In 1925 he had another severe attack of pain lasting 10-12 days, at which time he passed 3 stones. One month ago had several attacks of pain in left renal area and passed 30 small stones. Present attack began with pain in left kidney which radiated to left testicle, so severe that a hypodermic was required to control it. Nausea was marked and patient vomited several times. Patient noticed blood in his urine. Complained of frequency of urination, 16 to 20 times a day. Urinalysis: Yellow; acid; specific gravity 1.015; trace of albumin; sugar, negative. Microscopic examination: no casts; each field loaded with pus cells; amorphous urate crystals present. X-ray study showed an opaque calcareous shadow about 15 mm. in length and 10 mm. in width, located in the region of the upper end of the left ureter. There was no other evidence of opaque lithiasis in the tract. Cystoscopic examination: Indigocarmin 5 cc of a 0.4 per cent solution intravenously appeared from the right ureteral orifice in 3 minutes and there was no appearance from the left ureteral orifice in 12 minutes. A No. 6 F. x-ray ureteral catheter was passed up the left ureter 27 cm. and dye was obtained per catheter in 20 minutes. A specimen of urine was obtained and 18 cc of 12½ per cent solution of sodium iodide was injected per catheter into pelvis of the left kidney. Pyelograms were made in the recumbent and erect positions. X-ray report: Hydronephrosis with considerable distention of the calices of the left kidney-normal degree of ptosis of the kidney-urine from the left kidney showed many pus cells and few red blood cells. Operation June 6, 1932: Pyelolithotomy, left kidney. After exposure of kidney and pelvis a large vessel was observed to come from perirenal fat and
932
JOSEPH C. BIRDSALL
enter region of vascular pedicle. Vessel crossed ureter at uretero-pelvic junction and pelvis containing stone was dilated down to this point. Vessel was severed and ligated. Pelvis of kidney incised and calculus removed. A No. 11 F. Garceau catheter was then passed down ureter and into bladder, without meeting any• obstruction. A rubber tube drain was placed near opening in renal pelvis and the wound closed. Follow-up: Patient was seen several times during 5 year period following operation. There has been no recurrence of the calculus. Seven years after operation a plain x-ray showed no recurrence of the stone and the function of this kidney is normal. Pelvis and calices also appear normal. CONCLUSIONS
Every case of calculus in upper urinary tract should be subjected to thorough urologic study. The incidence of obstructive lesions, demonstrated by pyelographic study, is extremely high in upper urinary tract lithiasis. The presence of infection, particularly with the urea splitting type of organisms, was found in 89 per cent of cases. Adequate correction of obstruction with elimination of its associated stasis of urine and infection, is most essential in the prevention of recurrence of stone. I am indebted to my associates, Dr. F. G. Harrison and Dr. L. F. Milliken, for many of their cases which are included in this series, and also to Dr. George C. Poore for his complete resume of the 211 case histories.
1900 Spruce St., Philadelphia, Pa. REFERENCES ALBRIGHT, F., AND BLOOMBERG, E.: Tr. Am. Assn. Genito-urin. Surg., 27: 195, 1934. BARNEY, J. D., AND MINTZ, E. R.: J. A. M.A., 103: 741, 1934. GRIFFIN, M., OSTERBERG, A. E., AND BRAASCH, w. F.: J. A. M.A., 3: 683, 1938. HIGGINS, C. C.: Urinary Lithiasis, Surg., Gynec. and Obst., 392-405, 1939. Idem.: J. Urol. 29: 157, 1933. HIGHMAN, w. J., JR., AND HAMILTON, B.: J. Clin. Investigation, 16: 103, 1937. JARRETT, W. A., PETERS, H. L., AND PAPPENHEIMER, A. M.: Proc. Soc. Exper. Biol. and Med., 32: 1211, 1935. KEYSER, L. D.: South. Med. J., 26: 1031, 1932. LIVERMORE, GEO. R.: J. Urol. 41: 310, 1939. PAPPENHEIMER, A. A.: J. Exper. Med. 64: 965, 1936. RANDALL, A.: Am. Surg., 106: 1009, 1937. WINSBURY-WHITE, H.P.: Brit. J. Urol., 6: 142, 1934.
During the past 10 years there has been such a vast amount of data assembled and published as a result of research studies and clinical observations in an attempt to discover the etiological factors concerned in the formation and prevention of recurrences in renal lithiasis, that the urologist has been quite at his wits end in an endeavor to crystalize the various theories and formulate a working hypothesis for the successful management of these cases. Geographic distribution, heredity, climate, vitamin deficiency diets, metabolic diseases, renal injury, focal infections, colloidal imbalance, and hyperparathyroidism, primary and secondary, may be accessory causative factors of renal calculus formation in few instances but they are not entirely the responsible agents in the great majority of cases. While it is of academic and scientific interest to observe that there are numerous stone areas in different parts of the world and it is apparent that a definite deficiency in the diets of the inhabitants of those districts actually exists, the problem which confronts most of us is how to manage the calculi in our own baliwick where all the proper vitamins, fresh fruits and vegetables may be had at the corner grocery the year around. Many experimenters have shown that a large percentage of rats placed on a Vitamin A and D free diet will develop stones in the urinary tract in a variable number of days. However, the practical application of the principles of this diet in causing a diminution in size or disappearance of renal calculi and also in the prevention of the formation of new stones, has been most disappointing in our test cases as there has been no diminution in the size noted and new stones have continued to form during the period the patients were on the diet. Since Barney and Mintz and Albright and Bloomberg emphasized the frequency of the presence of hyperparathyroidism in renal calculus disease, we have had many of our cases subjected to careful studies of the calcium and phosphorus content of the blood and our results have been for the most part extremely negative, and while these observers conclude hyperparathyroidism is responsible for 4-5 per cent of the cases of renal 1 Read before annual meeting, American Urological Association, White Sulphur Springs, W. Va., May 29, 1939. 917
918
JOSEPH C. BIRDSALL
lithiasis, a review of the cases of urinary lithiasis at the Mayo Clinic and at the Cleveland Clinic show that hyperparathyroidism was found to be an etiological factor in 0.2 and 0.1 per cent of their cases, respectively. The recent experimental studies on rats by Pappenheimer and his associates and also the production of experimental renal insufficiency in dogs by Highman and Hamilton, have shown that renal insufficiency may give rise to hyperparathyroidism, hyperplasia and hyperfunction. These observations are of considerable value as they suggest that pnmary
FIG.1
Frc. 2
FrG.1. Combined cystoscopicand pyelographic table, equipped with electric motor driven raising mechanism, adjustable Bucky diaphragm and tube stand with indicator for centering, and adjustable leg supports for all positions. First pyelogram taken with table in this position. FIG. 2. Combined cystoscopic and pyelographic table with attached extension and standing platform for patient. Second pyelogram taken with table in this position.
renal insufficiency produced experimentally has stimulated the parathyroids to develop bony lesions comparable to osteitis fibrosa cystica, and also that the calcium content of the residual renal tissues has shown an increase in proportion to the parathyroid enlargement. A stimulus for the study of the incidence of obstruction in upper urinary tract calculus disease was received several years ago when we were studying 400 cases of urinary tract obstruction in its relationship to the various types of renal infection.
919
OBSTRUCTION IN RENAL CALCULUS FORMATION
Classification of 400 cases ,eith urinary obstruction I
NUMBER OF
-- -1--(~~=~-~-~ ----" N ephroptosis. Hydronephrosis. Pyonephrosis. Pyelitis .. Pyelonephritis. Total ..
INFECTED
NON-INFECTED
PER CE.c\'T lN.FECT.ED
- - - - - - - - - -
220 110 30
162
25
25
15
15
400
323
91 30
58 19
77
73.6 82.7 100 100 100
80. 7
During this investigation, the great frequency of the presence of renal and ureteral calculus was noted with such impressive regularity that a study of the various obstructive processes associated with calculus formation was undertaken. The subject matter of this paper comprises a study of 150 cases of renal calculi and 61 cases of ureteral calculi, totaling 211 cases of upper urinary tract lithiasis, from the urologic services at the Graduate and Presbyterian Hospitals. Each case was subjected to roentgenological examination and pyelograms, retrograde or excretory, were made of the kidneys and ureters with the patient in the recumbent and erect positions (figs. 1 and 2). Classification of obstructions in 211 cases of renal and ureteral calculi number of
cases
:Nephroptosis .. Bands-adhesions. Stricture of ureter .. Vessels .. Anomalies-duplication-horseshoe-polycystic. Trauma .. Cancer of ovary. No demonstrable obstruction. Hydronephrosis present .. Total.
141 34
17 8
4 3
1 3
211
Nephroptosis with angulation of the ureter was the most frequently encountered type of urinary tract obstruction in the association of which renal and ureteral calculi were found. In many cases comparatively small calculi were demonstrated, by pyelographic studies, to be located in the minor calices, giving evidence of having been formed on the renal papillae. Many other types of obstruction, such as bands, vessels, stricture of the ureter, and various types of anomalies, renal duplication, crossed ectopia, horseshoe kidneys and polycystic disease were the
920
JOSEPH C. BIRDSALL
underlying cause of hydronephrosis, stasis of urine and calculus formation. In 3 cases there was a history of trauma, immediate hematuria and on subsequent examination, calculi were discovered. In one case cancer of the left ovary was the obstructive lesion. In 3 cases no definite demonstrable type of obstructive lesion could be found, although in all of the 3 cases there was well developed hydronephrosis. As a result of the pyelographic studies, hydronephrosis was found to be present in 179, pyonephrosis in 23 and pyelonephritis in 9 cases. Infection also played an important role and was found in 168 cases, 43 of which were in cases of ureteral calculus and 125 in cases of renal calculus, and the organisms in order of their frequency were, B. coli, Staphylococcus aureus and albus, B. proteus and non-hemolytic streptococci. All of these bacteria except B. coli, belong to the class of urea splitting organisms. Age, sex and site incidence in 211 cases of upper urinary tract calculi AGE
NUMBER
SITE
NUMBER
years
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 Not stated Total. ........
2 5 32 54 51 37 18 7 5 211
Right kidney. Left kidney .. .... Bilateral. ..................... Right ureter. Left ureter .. . . . . . .... Bilateral. .. Kidney and ureter. . .... . . . . . . '
.
61 70 19 27 33 1 12
SEX
Males. Females.
..... .
....
135 76
Treatment of 150 cases of renal calculi number of
cases
Pyelolithotomy with incision of bands and vessels. N ephrolithotomy ... N ephrectomy. Heminephrectomy. Non-operated. Total. Nephropexy. Recurrences . Calyectasis. Bands-adhesions. Horseshoe kidneys, obstruction not corrected.
45 25 40 3
37 150 42 9 4 3
2
921
OBSTRUCTION IN RENAL CALCULUS FORMATION
number of
cases
Deaths-pre-operative. post-operative. Septicemia. Uremia. Cardiac. Pneumonia. Peritonitis. Cancer. Pulmonary embolism.
9
12 3 3
2
Treatment of 61 cases of 11reteral calculi nztmber of cases
Ureterolithotomy-lumbar .. Ureterolithotomy-Gibson. N ephrectomy. N ephropexy. Passed after instrumentation. Extracted. Refused operation .. Died before treatment. Total .. Deaths .. Uremia. Cardiac. Recurrences. Calyectasis. N ephroptosis-not corrected.
17 8
7 10
21 6
1 61 4 3
1 3
2
The problem of recurrences of renal and ureteral calculi has been a most difficult but interesting one. In 3 cases of horseshoe kidneys with renal calculi, there have been recurrences in 2 cases. In both there was such large calyectasis that adequate correction of the stasis of urine was impossible. In the third case, the isthmus was separated and each kidney suspended. There has been no recurrence of stones in this case over a 3 year period. In 6 cases, stones reformed in dilated calices in which the stasis of urine could not be corrected by nephropexy. In 3 cases in which partial nephrectomy was performed for calyectasis, there has been no recurrence over 5, 3 and 2 year periods. In certain selected cases of renal lithiasis with well developed calyectasis or partial hydronephrosis and in which correction of the nephroptosis or the obstructing vessel or band cannot correct the stasis of urine in the dilated calyx, partial or heminephrectomy must be a considered procedure for the prevention of recurrence. Post-operative formation of adhesions at the uretero-pelvic outlet has been found in three cases at the
922
JOSEPH C. BIRDSALL
second operation to be the responsible factor in the causation of unrelieved stasis of urine and infection with rapid calculus reformation. The management of cases of urinary lithiasis from a practical standpoint consists in studying each case individually, including history, blood chemistry and urinalysis. Roentgenograms and visualization of the kidneys and ureters either by excretory urography or by retrograde pyelography and in two positions is most essential. Retrograde pyelography has two advantages. First, the examiner obtains a specimen of urine from each kidney and, secondly, a better visualization of the renal pelves, calices, and ureters in cases of poor renal function. The
FIG.3
FIG.4
FIG. 3. Case 1. Plain x-ray showing dendritic calculus in right kidney, 2 calculi in left kidney and 1 calculus in pelvic portion of left ureter. FIG. 4. Case 1. Retrograde pyelogram in recumbent position showing hydronephrosis and calyectasis of left kidney.
following cases illustrate the important part played by obstruction in renal calculus formation and when properly and adequately corrected, recurrences have not occurred. Case 1. W. F. (figs. 3 to 7) age 50, a white man, was admitted to the Urologic Service, Presbyterian Hospital, June 1, 1934, with a chief complaint of sharp knife-like attacks of pain above crest of ileum on both right and left sides, and pus i:n the urine. X-ray study: Plain film showed large, dense shadow present in the right kidney pelvis filling practically the entire pelvis and calices. Three shadows were present in the region of the left kidney.
FIG. 5. Case 1. Retrograde pyelogram m erect position with catheters withdrawn, showing marked bilateral nephroptosis.
FIG.
6
FIG.
7
6. Case 1. Plain x-ray film taken 3½ months after pyelolithotomy and nephropexy of left kidney. Film shows many calculi which have reformed in pelvis of left kidney. FIG. 7. Case L Plain x-ray taken 4 years after right nephrectomy and second operation on left kidney in which pyelolithotomy was performed and adhesions removed from ureteral pelvic site. No recurrence of stone. Urinalysis normal. FIG.
923
924
JOSEPH C. BIRDSALL
Second study: Retrograde pyelography: After injection, both kidney pelves were well filled, stone in right pelvis indicated by mottled appearance, rather sharply demarcated from the dye in lower portion of pelvis. Right ureter was greatly dilated for very nearly its entire length. Left kidney pelvis was tremendously dilated, calices blunted, outline globular. Left ureter sharply kinked, lower calyx of right kidney opposite lower border of third lumbar vertebra, lower calyx of left kidney 1½ cm. below this level. Third study (standing): Catheters withdrawn, right kidney had emptied its dye and ureter collapsed. Left still retained greater portion and the ureter was moderately dilated but not kinked badly. Lower calyx of right kidney was opposite the upper border of the fifth lumbar vertebra, lower calyx of left kidney was at about the same level. Urinalysis: Light amber; specific gravity 1.010; albumin, a dense cloud; no sugar. Microscopic examination: each field loaded with pus cells with 150-200 red blood cells per field. Blood calcium: 10.4 mg. per 100 cc. Blood phosphorus: 3.8 mg. per 100 cc. Wassermann and Kahn tests: negative. Culture of urine: B. proteus. On June 4 one of the calculi in the left kidney passed down the ureter and this necessitated an operation on the left kidney first. On June 6, the left kidney was exposed and a pyelolithotomy and ureterolithotomy performed. An incision was made into the pelvis of the kidney and 2 calculi removed. The calculus in the ureter was also removed per incision in ureter at pelvic brim. The incisions in the ureter and in the renal pelvis were closed with continuous sutures of No. 00 plain catgut, the kidney was then suspended by 3 triple mattress sutures of No. 1, 20-day chromic catgut, a rubber tube drain was placed in the incision and the wound closed. Patient placed on increased vitamin A intake and Acid Ash diet. Patient was advised to have his right kidney operated upon but inasmuch as he was ready to leave the hospital August 1, and he was eager to spend the month of August at the seashore he decided to come back September 1 for his other operation. However, on August 9, he had to be re-admitted having had several attacks of severe pain again in both kidney regions, especially on the left side. On cystoscopic examination, streams of pus were observed to come from both ureteral orifices and indigocarmin intravenously did not appear from either ureter in 30 minutes. X-ray taken on day after admission showed 4 small stones reformed in the left kidney pelvis. While patient was in the hospital, August 13 to September 18, he passed 12 stones varying from B.B. shot to pea size. On September 18, x-ray of the kidney showed 15 to 17 stones in the left renal pelvis. Culture from the urine on several occasions showed B. proteus and also B. coli. This patient was presented at this time before the American College of
OBSTRUCTION IN RENAL CALCULUS FORMATION
925
Surgeons in Philadelphia for discussion. The concensus of opinion was that the case was hopeless and further surgery would be of no benefit. With the recurrence of stones I could not help but feel that there was recurrence of obstruction. Therefore, after blood transfusions and ureteral cathe-
FIG. 9
FIG.10
FlG.
H
FIG. 8. Case 2. Plain x-ray film showing shadow in region of right kidney. FIG. 9. Case 2. Retrograde pyelogram showing shadow obiiterated by pyelographic medium. Hydronephrosis and calyectasis of kidney. FIG. 10. Case 2. Retrograde pyelogram in erect position showing third degree ptosis. Shadow has descended with kidney. FIG. 11. Case 2. Retrograde pyelogram 6 years after pyelolithotomy and nephropcxy. No recurrence of calculus.
terization with lavage of the kidneys, the right kidney was operated on December S, 1934, at which time the right kidney was found to be so markedly diseased that nephrectomy was performed for calculus pyonephrosis. On January 16, 1935, the left kidney was re-operated upon and 6 calculi were removed from the pelvis of the left kidney. Bands had formed from the pre-
926
JOSEPH C. BIRDSALL
vious operation and constricted the ureter at the uretero-pelvic junction. These were removed and the renal pelvis drained with gall bladder duct T-tube type of drain, one arm of the tube being placed in the ureter, the other arm in the pelvis of the kidney. The patient made an excellent recovery. Follow-up: The patient has been in excellent health since last operation in January 1935, with no history of recurrences of pain or passing of stones. X-ray checkup in April, 1939, revealed no opacities in the region of the kidney, ureter or bladder. Urinalysis was normal. Case 2. J. T. (figs. 8 to 11) a white woman, age 54, was admitted to Graduate Hospital on August 6, 1929, with history of attacks of pain in epigastrium, eructation of gas, nausea and vomiting for 10 years. The pain did not radiate. Urinalysis showed many leukocytes and few erythrocytes. Plain x-ray film showed an almond-shaped opaque shadow immediately above the right transverse process of the third lumbar vertebra. Retrograde pyelogram in recumbent position showed moderate hydronephrosis and calyectasis of the right kidney. The lower portion of the renal pelvis was on the level of upper border of the fourth lumbar vertebra. The pyelogram in the erect position showed third degree nephroptosis of the right kidney. The inferior calyx was at lower border of the fifth lumbar vertebra. Pyelolithotomy and nephropexy performed in October 1929. The patient has been seen several times during the past 10 years. Plain x-ray film in 1935 showed no recurrence of stone and pyelogram in erect position showed good position of suspended kidney. She also stated that her indigestion had disappeared. Case 3. L. G. (figs. 12, 13, 14) a white woman, age 43, was admitted to Graduate Hospital April 11, 1939, with chief complaint of attacks of pain in her right side. Previous history elicited that she had had a very severe attack of right sided pain in 1934. Pain lasted 3 hours and she apparently passed a calculus at that time. Thorough urologic study failed to show a calculus but retrograde pyelograms showed complete duplication of left ureter and kidney, bilateral hydronephrosis and third degree nephroptosis. Preliminary x-ray film on present admission showed 2 small opacities in right kidney region, one at level of superior pole and one at level of inferior pole. Retrograde pyelograms revealed calculus in the superior calyx and one in the inferior calyx of the right kidney. The study also revealed bilateral hydronephrosis and bilateral nephroptosis. Culture of urine from right kidney showed Staphylococcus albus, non-hemolytic and B. coli. The culture from the urine of the upper left renal pelvis showed diphtheroids and from the lower left renal pelvis B. coli. Microscopic examination of the urine showed each field to be loaded with leukocytes. Operation, April 14, 1939: nephrolithotomy and bilateral nephropexy.
OBSTRUCTION IN RENAL CALCULUS FORMATION
FIG. 12. Case 3. of right kidney.
927
Plain x~ray film showing small calculi in superior and inferior calices
FIG. 13
FIG. 14
FIG. 13. Case 3. Retrograde pyelogram showing double type of pelvis right kidney, complete duplication of ureters and kidneys on left side. FrG. 14. Case 3. Pyelogram in erect position showing marked bilateral nephroptosis with bilateral hydronephrosis.
928
JOSEPH C. BIRDSALL
FIG.15 FIG.16 FIG. 15. Case 4. Plain film showing calculus in pelvic portion of right ureter. FIG. 16. Case 4. Pyelogram in erect position showing hydro-ureter, hydronephrosis and marked nephroptosis of right ureter and kidney. Ureterolithotomy and nephropexyno recurrence of stone over 10 year period.
FIG. 17. E. B. Case 5.
Plain x-ray film showing bilateral renal calculi
OBSTRUCTION IN RENAL CALCULUS FORMATION
FIG.
18
929
FIG.19
FIG. 18. E. B. Case 5. Retrograde pyelogram in recumbent position showing bilateral hy"' dronephrosis and partial hydronephrosis of the superior and inferior calices of the right kidney. FIG. 19. E. B. Case 5. Pyelogram in the erect position showing marked bilateral nephroptosis. Refused operation.
Frc. 20. F. B. Case 6.
Plain x-ray film showing 4 shadows in the region of the right kidney
930
JOSEPH C. BIRDSALL
Case 7. W. C., a white male, age 67, was. seen in 1928 with a chief complaint of attacks of left renal pain which fa:d:iated to bladder. He had a similar attack in 1914 with the passing of a calculus, and in 1927 he had 3 attacks, one in April, one in November and a third in December. On each occasion a calculus was passed. From the time of his first visit in January, 1928, until March of that year, he was quite prolific in the formation and passing of stones, contributing in all 11. In 1929 an attack of pain was followed by the passing of a stone and there were no more symptoms until
FIG. 21
FIG. 22
FIG. 21. F. B. Case 6. Retrograde pyelogram of right kidney in recumbent position showing hydronephrosis with a constriction at the ureteral pelvic site. FrG. 22. F. B. Case 6. Retrograde pyelogram in erect position showing second degree nephroptosis with hydronephrosis and a definite constriction at the ureteral pelvic site. Operation showed small vessel and band at ureteral pelvic site. Pyelolithotomy, incision of vessel and band and nephropexy performed. No recurrence of stone over 4 year period.
September, 1937, when patient had several severe attacks of pain with chills and fever. Patient was admitted to the hospital. Urinalysis: Cloudy; acid; specific gravity 1.015; sugar, negative; albumin, faint trace; acetone, negative. Microscopic examination: occasional hyaline cast, occasional squamous and renal epithelial cells, amorphous urate crystals and each field was loaded with pus cells. X-ray study showed in left pelvis, opposite the last sacral segment, a dense, ovoid smooth shadow. Excretory urography: The left kidney showed a moderate degree of hydro-
OBSTRUCTION IN RENAL CALCULUS FORMATION
931
nephrosis and ureterectasis. In antero-posterior view the ureter on left side ,vas right in line with the density in pelvis. In the erect position, the pelvis of the left kidney was at the level of the interspace between the third and fourth lumbar vertebrae. A No. 11 F. Garceau catheter was passed up left ureter and left in situ for 48 hours and a seventeenth calculus was passed 24 hours after removal of catheter. This case is illustrative of frequent recurrences of calculi in presence of urinary tract obstruction. Case 8. R. C., a white man age 32, was seen in May 1932, and was referred to Urologic Service, Graduate Hospital, for study. Chief complaint: Attacks of pain in region of left kidney with radiation to left testicle. In 1916 he passed sandy substance in his urine without distinct pain except burning and irritation of the urethra on urination. In 1920 he had an attack of severe pain in left renal area and passed 3 stones. In 1925 he had another severe attack of pain lasting 10-12 days, at which time he passed 3 stones. One month ago had several attacks of pain in left renal area and passed 30 small stones. Present attack began with pain in left kidney which radiated to left testicle, so severe that a hypodermic was required to control it. Nausea was marked and patient vomited several times. Patient noticed blood in his urine. Complained of frequency of urination, 16 to 20 times a day. Urinalysis: Yellow; acid; specific gravity 1.015; trace of albumin; sugar, negative. Microscopic examination: no casts; each field loaded with pus cells; amorphous urate crystals present. X-ray study showed an opaque calcareous shadow about 15 mm. in length and 10 mm. in width, located in the region of the upper end of the left ureter. There was no other evidence of opaque lithiasis in the tract. Cystoscopic examination: Indigocarmin 5 cc of a 0.4 per cent solution intravenously appeared from the right ureteral orifice in 3 minutes and there was no appearance from the left ureteral orifice in 12 minutes. A No. 6 F. x-ray ureteral catheter was passed up the left ureter 27 cm. and dye was obtained per catheter in 20 minutes. A specimen of urine was obtained and 18 cc of 12½ per cent solution of sodium iodide was injected per catheter into pelvis of the left kidney. Pyelograms were made in the recumbent and erect positions. X-ray report: Hydronephrosis with considerable distention of the calices of the left kidney-normal degree of ptosis of the kidney-urine from the left kidney showed many pus cells and few red blood cells. Operation June 6, 1932: Pyelolithotomy, left kidney. After exposure of kidney and pelvis a large vessel was observed to come from perirenal fat and
932
JOSEPH C. BIRDSALL
enter region of vascular pedicle. Vessel crossed ureter at uretero-pelvic junction and pelvis containing stone was dilated down to this point. Vessel was severed and ligated. Pelvis of kidney incised and calculus removed. A No. 11 F. Garceau catheter was then passed down ureter and into bladder, without meeting any• obstruction. A rubber tube drain was placed near opening in renal pelvis and the wound closed. Follow-up: Patient was seen several times during 5 year period following operation. There has been no recurrence of the calculus. Seven years after operation a plain x-ray showed no recurrence of the stone and the function of this kidney is normal. Pelvis and calices also appear normal. CONCLUSIONS
Every case of calculus in upper urinary tract should be subjected to thorough urologic study. The incidence of obstructive lesions, demonstrated by pyelographic study, is extremely high in upper urinary tract lithiasis. The presence of infection, particularly with the urea splitting type of organisms, was found in 89 per cent of cases. Adequate correction of obstruction with elimination of its associated stasis of urine and infection, is most essential in the prevention of recurrence of stone. I am indebted to my associates, Dr. F. G. Harrison and Dr. L. F. Milliken, for many of their cases which are included in this series, and also to Dr. George C. Poore for his complete resume of the 211 case histories.
1900 Spruce St., Philadelphia, Pa. REFERENCES ALBRIGHT, F., AND BLOOMBERG, E.: Tr. Am. Assn. Genito-urin. Surg., 27: 195, 1934. BARNEY, J. D., AND MINTZ, E. R.: J. A. M.A., 103: 741, 1934. GRIFFIN, M., OSTERBERG, A. E., AND BRAASCH, w. F.: J. A. M.A., 3: 683, 1938. HIGGINS, C. C.: Urinary Lithiasis, Surg., Gynec. and Obst., 392-405, 1939. Idem.: J. Urol. 29: 157, 1933. HIGHMAN, w. J., JR., AND HAMILTON, B.: J. Clin. Investigation, 16: 103, 1937. JARRETT, W. A., PETERS, H. L., AND PAPPENHEIMER, A. M.: Proc. Soc. Exper. Biol. and Med., 32: 1211, 1935. KEYSER, L. D.: South. Med. J., 26: 1031, 1932. LIVERMORE, GEO. R.: J. Urol. 41: 310, 1939. PAPPENHEIMER, A. A.: J. Exper. Med. 64: 965, 1936. RANDALL, A.: Am. Surg., 106: 1009, 1937. WINSBURY-WHITE, H.P.: Brit. J. Urol., 6: 142, 1934.